CAP at 75 - Leading Through Transformation

Julie McDowell:

Welcome to our latest episode of the CAPcast 75th anniversary series where we ask past presidents to provide a glimpse behind the curtain of leadership and share their insights on leading the profession and a major organization like the CAP.

This episode's discussion features doctors Richard Friedberg and Bruce Williams. Serving back-to-back terms. Dr. Friedberg was president from 2015 to 2017, and Dr. Williams was president from 2017 to 2019.

The two of you joined the board around the time of the market collapse in 2008. Dr. Friedberg, you joined in 2007 and Dr. Williams, you joined in 2009. Given the backdrop of the market collapse, what was your focus at the time and what changes did you notice in the board's thinking? Dr. Friedberg, can we start with you?

Dr. Richard Friedberg:

Sure, sure. One thing we noticed early on was the increased concern about the budget and the reserves. Since I joined in 2007, we had its CEO transition early on in my tenure there. And by the time the 2008 crash came along, we were very concerned about the reserves the college had, where the market was going and what the image was of pathologists spending time.

And so the biggest issue of the market collapse was what is it going to mean? Are we going to recover from this quickly? Is there going to be a transition? How are the customers, physicians, the hospitals, how are they all going to be affected moving forward? There's a lot of uncertainty.

Julie McDowell:

Dr. Williams, how about you? What's your perspective on this?

Dr. Bruce Williams:

Sure. I came in on the board after the market collapse. And the one thing that I need to say is that the college is in the fortunate position of being a large enough organization that we can have first class consultants aid us in our needs as we see them coming up.

At the time, and still to this day, Bob Shear was our financial consultant. And he was extremely beneficial in going over our portfolios and making sure that we were invested in the right things that would last through this downturn and turn positive. I must say that because of his guidance over the years, we came out of it very well.

The board was very concerned about it. Bob was very reassuring and actually led us through several meetings where we thought about our investments, how we could rearrange them and keep them in a good position. And he did that and we came out of that very well. I do think that that did have a longer term impact though on the college and pathology in general.

At that time, there was a group of physicians getting ready to retire that because of their retirement funds decreased in value, decided to stay around longer to work while their earnings came back, their investments came back and they could continue earning some money. And because of that, the job market in the United States for pathologists shrunk because the people that were leaving should been leaving, were not leaving.

This actually became a mini crisis in pathology in that the residents found that there was no jobs available and the word got back to medical students who then did not go into pathology. And I think that's led to our current status of having a decreased number of pathology candidates because of that market collapse.

It was a big point of interest of the college about this. It was of keen interest to the board to investigate this lack of retirement and what it was doing to the pipeline. And actually a prior president, Dr. Stan Robboy, had a years long look at the pipeline issue for a pathologist and published several articles about this. And I must say that in the long term, the outcomes of the predictions of his committee and those publications have come true, that there would be a retirement cliff sometime in the future, and it's happening now.

But because of the concern about pathology residents not being able to get jobs easily back in the early part of the teens, that then this has led to decreased pathology residency pool who are graduating has led to somewhat of a shortage. This is something that's gone on over the years though. I think, Richard, you've probably seen and I've seen it, of where there's not enough pathologists out there. Word goes from the residents to the medical students. Boy, I get a job anywhere.

A lot of the medical students go into pathology residency. And after a while there's so many there that they're saying, "I can't get any." And they feed back to the medical students say, "Whatever you do, don't go into pathology because there's no jobs out there." And therefore, then there's nobody goes into it. And then the cycle starts all over again. Have you noticed that, Richard?

Dr. Richard Friedberg:

Yeah, yeah, that's absolutely true. And one point, just to preface Bruce's entirely correct comments about the pathologists not retiring. In 2005, 2006 right before I joined the board, there was a double year of residents coming out because the American board had changed it from a five-year residency to a four-year residency. We had double the number of residents coming out in 2005 or 2006.

And so by the time 2007 was up, they were still being brought into the system, so there's more people looking. And then when the pathologists stopped retiring and start working longer, you end up with what's in essence what seems to be an oversupply of pathologists. But all you're really doing is you're hitting the doubly high part of a curve. And there's an echo later on with just an insufficient number of pathologists, which is where many of us believe we are now.

Dr. Bruce Williams:

And one other thing happened. That led to a lot of residents getting two fellowships. Before then most pathologists could go directly from residency into a practice. About that time it was becoming more popular to get a single fellowship, to have a subspecialty training, but because they couldn't get a job, a lot of residents went into a second fellowship.

And so for years, there has been a tendency of a lot of graduates going into practice that they would've two fellowships. I think because of the shortage, this has now gone back to one and maybe even some people going directly from residency into practice. That also is another effect from that.

Julie McDowell:

Also, during your times on the board, transparency and participative leadership were a focus. I'd like to hear from each of you about how the entire board was really engaged in this process. Dr. Williams, can we start with you?

Dr. Bruce Williams:

Well, sure. I think it had already started when I was on there because from the very beginning, the board really wanted to make sure that the entire membership of the college understood their reasoning behind the actions they were taking. They had communications to the membership and they wanted to increase participation of members into the different committees and councils of the college.

One way to do that, and that really occurred all the way through both Richard and my time on the board, and then really accelerated when Richard was president and I followed in his footsteps, is that many times there were some people that were very active to join the college. And they'd get on one committee and then somebody else said they were really good and they'd get on another committee. And they'd be on three or four committees. And effectively, that kept fewer people from being able to participate in college committees and councils because one person was filling a lot of spots.

I know when Richard was president, he made a specific effort to look at the number of committees and councils people were on. And to try to keep him on one, of the most two in order that participation could increase. It did tremendously during his presidency and during mine. I followed in the same footsteps and even cut back more on the number of duplicate members in different committees so that we could expand that.

One of the things about that was happened with COVID is that there is a more participation in committees and councils via electronic means. And there's some talk now that there's even still a tremendous demand. We could never get all the people who wanted to be on a committee, on a committee.

And the other thing that we did was if somebody applied for two or three years in a row, we made sure those were the people that got on the committee. They showed a history of being persistent about trying to get on the committees.

And both Richard and I did that. But even now, there's more people trying to get on committees than there are. And because of a lot of meetings are electronically able to be joined, that we can have more people on the committees without paying for airfare and travel and hotel and food, and it costs very little to have more people participate. I think the entire time I've been on the board, there's been an effort to increase transparency and participation.

Julie McDowell:

Dr. Friedberg, what's your perspective?

Dr. Richard Friedberg:

Yeah, I think Bruce hit the nail on the head there. I remember Mary Case at one point in time said that it may have been Tom Sutherland, one of the presidents who preceded me. There were so few open spots for them to appoint, and there's so many people who wanted to join.

And so, we made a considered effort to try to make sure that people had specific six year terms on boards, and that when it came time to rotate off, they would rotate off and let some fresh blood in. And I think it did a world of good to get more and more people involved because it's a lovely problem to have when people are complaining about not being able to be on as many committees as they want to be.

Julie McDowell:

Now also during this time, the CAP strategic planning process really shifted to more of a longer term process. Can you tell us a little bit about the changes in this strategic planning process? Dr. Friedberg, can we continue with you?

Dr. Richard Friedberg:

Yeah. When I joined the board, the strategic planning committee had always been appointed by the president-elect. And the strategic planning committee was in essence that president's group of people to help him or her anticipate and plan out their time as president.

And so, I was actually on the strategic planning committee for Jared Schwartz when he was president of the CAP. When I came on the board and shortly thereafter, when we got a new CEO with Charles on board, we transitioned the strategic planning committee to really be a longer term operation so we weren't having two-year cycles of this set of policies and that sets of policy.

We were really taking a longer term look at really strategic planning. And it was a much more official process around planning for the future, anticipating the problems, having a risk management committee that really looked at where the risks and rewards and the benefits and the hassles and the issues would be for us moving forward. And so we took a much longer look at strategic planning and growth instead of allowing a change every two years of focus.

Julie McDowell:

Dr. Williams, you want to share your thoughts on this?

Dr. Bruce Williams:

Sure. I think Richard's exactly right. I was on a strategic planning committee that involved a president-elect. And it was a good process, but it did result in emphasis changing of the CAP every two years. And that was not really to the best benefit of the members.

And Charles did a lot of good things, I think, for the college. And one of the things he did was to say that we needed to change the way the board worked and to look at it more as a strategic implement of the college. And that happened. After we started thinking about how we should go forward in a strategic manner I had some of the older or more senior board members say that it really did change. Because back before then, sometimes they'd sit around the board meetings and look at the expenses of individual pathologists on their travel expenses going to meetings and things, which is obviously a waste of time for the board to do.

But under the new circumstance, we really did change to strategic effort on the part of the board in a lot of different areas. And I think we were looking forward to the future of pathology. And because of that, we were able to create new committees and even some new councils. And look at the way pathology might be in the future, and how could the college support pathologists to get to that future.

I think, and Richard and I talked about this. I must say, first of all, it was an honor to serve as president-elect and to Richard. I think he was the best president possible for me because he enabled me to do things and gave me jobs to do that got me ready to be president. Even after six years on the board, you're not always ready, I think, to take over and there's still more to learn. And the two years I spent as president-elect under Richard were very beneficial to me to be able to do what I was able to do when I was president.

But during that time, we both talked about how to make the board more strategic. And he set goals and agendas that really reflected the strategic goal of the board. And I was able to try to recapitulate that when I was president. I just followed his lead in making sure that the agendas, which really drive the board discussion had a lot of strategic items in it, as well as some operational items and some housekeeping items that you had to have in there. But I really credit Richard with really leading on that strategic goal setting.

Dr. Richard Friedberg:

They're very kind words from Bruce, Julie, and I appreciate them. I think it's important to recognize that as the CAP grew and became a more complex organization and a more professionally run and managed organization, the board needed to be part of the strategy and not part of the... In the weeds paying too much attention to the minutiae and missing the overall picture.

And so, we would have healthy discussions at the board about the bigger picture kind of questions, not the smaller issues as to whether one committee was spending too much money by going to this spot or that spot. There were ways for those things to be handled. We didn't need to have the board handling that. The board needed to be a much more involved in the strategy and operational side of the strategy and not in the real day-to-day business parts of running the organization.

Julie McDowell:

Keeping along this same theme of strategy along this topic, both of you were involved in the creation of the CAP's first brand strategy, which was all encompassing, involving clarifying the CAP's target audience and messaging, as well as creating brand standards and a new expression system. As well as a new logo, which is a major thing for any entity, any business, any organization. And obviously signified the modernization and the evolving of the CAP.

I'd like to hear both of you talk about why it was so important for the board to be involved in this and really driving this. And why it was important to even do this and modernize the CAP and distinguish the association from other organizations. Dr. Williams, you want to start us off on this discussion?

Dr. Bruce Williams:

Sure. I mentioned before that the CAP was getting large enough to get good consultants. And Rich has already mentioned the professionalization of our staff. And I think one of the highlights of that was hiring Elizabeth Usher to take over the marketing area of the college in that she'd had extensive brand research and expansion in another medical field in a commercial side. But was well established in the ways to do this and the needs to do this.

The reason for the update I think was several. One, as far as the logo went, it was a stylized Erlenmeyer flask, which a lot of people thought looked like a bent coat hanger. And those of us, like Richard and I, knew very well what Erlenmeyer flask was, but it had been years since those had really been used in a clinical lab to any great extent. And it was felt that because the logo was not up-to-date, that a lot of people might feel the college was not up-to-date.

I think the other emphasis though, was even a little bit different than that. The board had made a strategic decision at one point in time to take out of the vision mission statement that CAP would be the leader of pathology worldwide. And they took out worldwide strategically because of they thought that we ought to be emphasizing the practice of pathology in the United States.

The board that Richard and I were on actually voted to put that back in the mission statement because we really felt that we had a lot of knowledge and expertise that could affect patient care worldwide. And that if we could promote quality in a worldwide manner, that we would have a beneficial effect on the practice of medicine throughout the world.

And I think that's true. I think we made the right decision. I think with the improvements that we make through PIPs and PAPs and PTs and inspections and education that we have made a positive worldwide impact on the practice of pathology that's raised the practice of medicine throughout the world. And the Erlenmeyer flask did not reflect a up-to-date worldwide organization. It looked like a behind the times, stodgy organization.

I think it actually did make a change. I think people look at the college differently. I think members looked at the college differently. I think the board looked at the college differently, and I think people around the world did. Richard and I were both in a position fortunately to travel around the world to represent the college at various international meetings.

And I must say the reception that you get from pathologists and laboratorians worldwide to what the college meant, what the college did, and how the college promoted the practice of pathology was overwhelming. I had some of my most amazing talks with international pathologists that were at a meeting outside the United States. And many of them said, "I cannot describe to you what the college means to me as a pathologist or means to the practice or the means to the patients in my country of what you've been able to do to increase the quality." And I think the new brand really reflected our worldwide effect, and I think it was the right thing to do.

Julie McDowell:

Dr. Friedberg, can we hear from you?

Dr. Richard Friedberg:

Yeah, I think Bruce made some very important points there. One of the pleasures that I had as president-elect and president was to do a lot of talking around the US and internationally. I think I spoke at somewhere around maybe a half or a third of all the medical schools and residency programs in the country in my time on the board.

And it was interesting to talk to the residents and the fellows about what the CAP logo was. And you'd hear them arguing about whether it was a coat hanger. They didn't know what else it might be. Maybe it was a triangle, maybe we were trying to talk about stability because of the stable triangle. It was when I'd say it's an Erlenmeyer flask, I got this quizzical look, which they knew they'd heard about it, but they weren't really sure whether that was the one that had the thing out of its neck or just the open hole on the top.

It was a non-sequitur. It was an anomaly for the time. And when we talked about the new logo, the residents and fellows universally accepted it right away. They were getting to interesting discussions about whether the pattern of the colors and the sizes of the dots meant anything and whether this was... The ones in heme were saying, "Well, it's clearly a blood smear." And the more traditional AP guys were saying, "No, it's clearly one of these."

And it was an interesting chuckle to get to because they saw this as something relevant to what they were doing. They saw this as an image of little bits of data coming in from multiple different parts are all being synthesized together to make the diagnosis. And not just some irrelevant piece of glassware that didn't have a real foundation to what they had.

We had a new logo, we had a standardized color scheme, standardized the fonts just to keep things consistent. And we had some very interesting arguments about what should be capitalized and what shouldn't be capitalized, and whether the word American was good or bad. Because is Canada American, is Mexico American, or is this just international? We would have the discussions about the international aspects as we realized how at that time especially, how big the international aspects was for our growth.

Obviously with COVID, some of these things have been reassessed just because of the logistics that are tied into that. But we expanded very significantly worldwide, and I think it was right to have an up-to-date image that reflected us as some part of the new digital approach to how medicine was being aggregated and delivered and not just a arcane piece of glassware that belongs on a Jeopardy question.

Dr. Bruce Williams:

I think Richard's right about the dots. The board actually got the final decision about which logo it would be. And I think one of the things that attracted me and some of the other people to it also was that you could make the dots into whatever you want it to be.

It was round, and I did think of a global image on that, but digital bits and bytes would be possible. Immunohistostains, blood smears. You could make it into whatever you wanted to. And in the long run, I must admire Elizabeth for guidance through it and giving us a choice. And I think the board made the right choice of the options given them as far as what the future logo would be.

Julie McDowell:

Well, thank you both for this great discussion. CAP members can download the 75th anniversary history book authored by past president Dr. Paul Bachner on the CAP website. Please visit cap.org and type in 75th anniversary into the search function to find the link to the book download page on the CAP's e-store.

Thank you for listening to this CAPcast. To listen to our other episodes, find us on the MyCAP app, available for CAP members as well as SoundCloud, Apple Podcasts, Stitcher, Google Podcasts, Spotify, and Amazon Music. Just search for CAPcast from the College of American Pathologists on these apps. Once you find our podcast, be sure to click the subscribe button so you don't miss new CAPcast episodes.

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