Teaching Laboratory Management Principles and Practices Through Mentorship and Graduated Responsibility: The Assistant Medical Directorship

Abstract

With the changing landscape of medicine in general, and pathology in particular, a greater emphasis is being placed on laboratory management as a means of controlling spiraling medical costs and improving health-care efficiency. To meet this challenge, pathology residency programs have begun to incorporate formal laboratory management training into their curricula, using institutional curricula and/or online laboratory management courses offered by professional organizations. At the University of Utah, and its affiliated national reference laboratory, ARUP Laboratories, Inc, interested residents are able to supplement the departmental lecture-based and online laboratory management curriculum by participating in assistant medical directorship programs in one of several pathology subspecialty disciplines. The goals of many of the assistant medical directorship positions include the development of laboratory management skills and competencies. A survey of current and recent assistant medical directorship participants revealed that the assistant medical directorship program serves as an excellent means of improving laboratory management skills, as well as improving performance as a fellow and practicing pathologist.

Full text

Regular Article
Teaching Laboratory Management
Principles and Practices Through
Mentorship and Graduated Responsibility:
The Assistant Medical Directorship
Timothy Hanley, MD, PhD
1
, Aleksandra M. Sowder, MD
1
,
Cheryl Ann Palmer, MD
1,2
, and Ronald L. Weiss, MD, MBA
1,2
Abstract
With the changing landscape of medicine in general, and pathology in particular, a greater emphasis is being placed on laboratory
management as a means of controlling spiraling medical costs and improving health-care efficiency. To meet this challenge,
pathology residency programs have begun to incorporate formal laboratory management training into their curricula, using
institutional curricula and/or online laboratory management courses offered by professional organizations. At the University of
Utah, and its affiliated national reference laboratory, ARUP Laboratories, Inc, interested residents are able to supplement the
departmental lecture-based and online laboratory management curriculum by participating in assistant medical directorship
programs in one of several pathology subspecialty disciplines. The goals of many of the assistant medical directorship positions
include the development of laboratory management skills and competencies. A survey of current and recent assistant medical
directorship participants revealed that the assistant medical directorship program serves as an excellent means of improving
laboratory management skills, as well as improving performance as a fellow and practicing pathologist.
Keywords
competencies, graduated responsibility, laboratory management, pathology residency
Received August 17, 2016. Received revised October 14, 2016. Accepted for publication October 21, 2016.
Introduction
In the rapidly changing field of health care, the scope of prac-
tice of new-age pathologists is rapidly expanding. New-in-
practice pathologists are required not only to have pathology
diagnostic skills and clinical knowledge but to possess labora-
tory management skills and serve as leaders and stewards of
clinical laboratory utilization.
1-3
Although the skills needed to
become a diligent laboratory manager and an effective labora-
tory leader have been continuously stressed as essential for
pathologists in a wide body of literature for almost 25 years,
practicing pathologists and prospective employers continu-
ously cite this as the area with the lowest trainee preparation
rating.
2,4-7
In a 2005 survey performed under the auspices of
the College of American Pathologists (CAP), it was noted that
one-third of recent hires were only somewhat or slightly pre-
pared to enter practice.
6
Common categories of deficiencies
noted by respondents included skills in management, interper-
sonal interactions, regulatory and compliance issues, and bill-
ing and reimbursement procedures. Skills such as clinical
1
Department of Pathology, School of Medicine, Huntsman Cancer Institute,
University of Utah, Salt Lake City, UT, USA
2
ARUP Laboratories, University of Utah, Salt Lake City, UT, USA
Corresponding Author:
Cheryl Ann Palmer, Department of Pathology, Huntsman Cancer Institute,
University of Utah, 1950 Circle of Hope Drive, N3105, Salt Lake City, UT
84112, USA.
Email: cheryl.palmer@path.utah.edu
Academic Pathology
Volume 3: 1–10
ªThe Author(s) 2016
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knowledge, laboratory management, clinical consultation, and
informatics were often cited as essential skills required for a
community pathologist; however, with the shift toward a more
‘‘value-based’’ health-care system, a focus on more concrete
skills has emerged.
8,9
These skills now include test selection
strategies and utilization management techniques, knowledge
of quality assurance procedures and inspection processes, and
strategic laboratory planning including budgeting, personnel
management, coding, billing, revenue collection, and contract
negotiations.
9-11
A significant impetus to create lasting and effective changes
to residency training program curricula was initiated when, in
2013, after several years of planning, the Accreditation Council
for Graduate Medical Education (ACGME) introduced the
Next Accreditation System (NAS) for use in all residency pro-
grams. The ACGME is the regulatory body that oversees US
residency education in all disciplines and, as part of the NAS,
designed educational outcomes termed ‘‘milestones’’ in all spe-
cialties to assess and provide feedback on resident progress in
many areas of competence. Pathology milestones, designed by
a pathology working group, were developed to provide uniform
training goals for pathology residents.
12
These include many
areas of evaluation in laboratory administration and manage-
ment, in addition to the baseline competencies that residency
programs traditionally focus on (patient care, medical knowl-
edge, practice-based learning and improvement, interpersonal
and communication skills, professionalism [PROF], and
systems-based practice [SBP]).
13
In this study, we describe a program used at the University
of Utah to give interested residents the opportunity to engage in
assistant medical directorships (AMDs) with an emphasis on
augmenting the laboratory management training included in
the residency training program, and we also present the results
of a survey of current and recent participants in the AMD
program.
Methods
Description of the Assistant Medical Directorship
Program
The AMD Program in the University of Utah’s Department of
Pathology and its ARUP Laboratories is designed as an elective
longitudinal experience generally occupying 12 months during
which the trainee functions as an apprentice medical director in
one of a number of different subspecialty areas. The elective
involves work in addition to the core training activities and is
thus considered ‘‘moonlighting’’ for the purposes of ACGME
time keeping.
The AMD activities available to interested and qualified
residents at the University of Utah are listed in Table 1.
Descriptions of several representative examples are found in
Tables 2 to 8. Four of these AMD assignments are based on the
subspecialty disciplines of clinical chemistry, surgical pathol-
ogy, and transfusion medicine and have a strong quality assur-
ance theme in their list of responsibilities (see Tables 4-6
and 8). Two AMDs in informatics (Tables 2 and 3) afford
opportunities to participate primarily in postanalytic activities,
including the development of enhanced laboratory result
reports, laboratory utilization management, and knowledge
content development to aid laboratory users, particularly
health-care providers, in more informed use of laboratory ser-
vices. Given the growing interest in and use of digital imaging
in pathology, the digital pathology AMD activities involve the
resident in projects directed at integrating digital imaging into
educational activities as well as process workflow improve-
ments and patient-directed uses. The AMD in hematologic flow
Table 1. Available Assistant Medical Directorships (AMD).
AMD, Anatomic pathology
AMD, Automated core laboratory
AMD, Hematologic flow cytometry laboratory
AMD, Informatics
AMD, Website medical content management, assistant editor
AMD, Transfusion services
AMD, Anatomic pathology slide photographer for outside
departments
AMD, Endocrinology laboratory
AMD, Digital pathology
Table 2. Assistant Medical Director (AMD), Informatics.
General description: Moonlighting opportunity in informatics for a
pathology resident, subject to the standard departmental and
institutional requirements governing moonlighting
Time commitment: Anticipated averaging 4 to 5 hours per week
Reporting to the medical director of informatics
Responsibilities include 1 or more of the following
Developing enhanced laboratory reports. For each particular
test, report development will involve discussion with the
medical director and technical managers responsible for the test
in order to determine the report requirements. The next step is
coordination with the information technology (IT) department
and the technical writer for charting to implement these
requirements and then test for acceptability
Analyzing test ordering patterns (ATOP). This service involves
review of client test order patterns in order to advise our
clients’ pathologists about possible misordering by their local
physicians. The AMD could help conduct some of these reviews.
He/she could also develop new disease topics to add to the
service line; this would involve literature searching and
discussion with ARUP medical directors
Knowledge base for the pathologist on call service.
Consideration has long been given to the potential for a
knowledge base (possibly in a Wikipedia-style format) on
ARUP’s network that would support residents and fellows as
they take call. This would involve compiling ‘‘frequently asked
questions’’ that come up on call into an easily searchable format.
Residents and fellows could then add to this over time as new
topics come up, knowledge evolves, and so on. The IT aspects of
this project would not be complicated—the software is off the
shelf—but the AMD could help organize and review content as
it went into the application
2Academic Pathology

cytometry affords the resident the opportunity to participate in
graduated responsibilities in clinical service. Here, the AMD
integrates into the weekend (generally every fourth weekend,
Saturday and Sunday) sign-out schedule with the fellows in
hematopathology in their support of the attending hemato-
pathologist who covers that weekend. The anatomic pathology
(AP) slide photographer for outside departments is uniquely
different from the other AMD assignments in that it was
designed to fill the need in meeting slide photography requests
from outside the department of pathology, particularly from
faculty and house staff from other clinical departments. The
assistant medical director reviews these requests, clarifies their
purpose (eg, for publication or lectures), and provides the photo-
graphs to the requestors. For photography not related to publi-
cation, requestors are charged a fee for each photography session
prior to release of the photographs. If intended for publication,
the resident will ask to be included on the manuscript as the
pathologist-of-record with appropriate content review responsi-
bilities. In doing so, the requestor is provided the photographs at
no fee, and the resident becomes a cited author on the manu-
script. Of note, a number of AMD positions stress the manage-
ment competencies outlined in phase II of the NAS inspection
program of the ACGME.
13
Examples of multiple milestones and
management competencies that map to the AMD assignments in
the automated core laboratory, endocrinology laboratory, and
surgical pathology in our program are described in Table 9.
Moonlighting Status and Compensation
Assistant medical directorships are considered to be moonlight-
ing activities by the graduate medical education (GME) office.
Table 3. Assistant Medical Director: Website Medical Content Man-
agement, Assistant Editor.
General description: Moonlighting opportunity for a pathology
resident, subject to the standard departmental and institutional
requirements governing moonlighting, to assist with the
development and review of content for ARUP Consult
Time commitment: Negotiated in advance but not to exceed allowable
limits set by the graduate medical education office and the
department of pathology
Reporting: Directly to the managing editor of the informatics decision
support team and indirectly to the medical director of informatics
Responsibilities include
Interact with ARUP medical directors and other staff to assist in
identifying information needs with respect to laboratory testing
Review medical literature, particularly with regard to practice
guidelines and evidence-based medicine related to laboratory
testing
Assist with research to the study the effectiveness of ARUP
information services
Table 4. Assistant Medical Director, Automated Core Laboratory.
General description: Moonlighting opportunity in the chemistry
division for a pathology resident, subject to the standard
departmental and institutional requirements governing
moonlighting
Time commitment: Negotiated in advance but not to exceed allowable
limits set by the graduate medical education office and the
department of pathology
Reporting: Medical director of the automated core laboratory
Responsibilities include
Read, evaluate, and summarize the scientific literature pertaining
to specific issues identified by the medical director or arising
from clinician requests, problems, or recommendations
Review validation data of new assays and instruments
Review standard operating procedures and modify, when
appropriate, with supervision of the medical director
Plan and supervise the evaluation of new assays and
instrumentation in the laboratory, as assigned by the medical
director
Review CAP proficiency testing results
Review the monthly QC summary and suggest any needed
improvements
Attend the ARUP Chemistry Division QA meetings when other
rotation responsibilities permit
Attend the ARUP Automated Core Laboratory meetings when
other rotation responsibilities permit
Contribute to continuing education efforts for the automated
core laboratory staff
Abbreviations: CAP, College of American Pathologist; QA, quality assurance;
QC, quality control.
Table 5. Assistant Medical Director, Endocrinology Laboratory.
General description: Moonlighting opportunity in the chemistry
division for a pathology resident, subject to the standard
departmental and institutional requirements governing
moonlighting
Time commitment: Negotiated in advance but not to exceed allowable
limits set by the graduate medical education office and the
department of pathology
Reporting: Medical director of the endocrinology laboratory
Responsibilities include
Laboratory responsibilities may include testing performed in the
following laboratories: automated endocrinology, manual
endocrinology, electrophoresis and manual endocrinology, mass
spectrometry 1 & 2, and automated core laboratory.
Responsibilities may be adjusted based on individual interests
Read, evaluate, and summarize the scientific literature pertaining
to specific issues identified by the laboratory director or arising
from clinician requests, problems, or recommendations
Review standard operating procedures identified by the annual
review process and suggest improvements or clarifications
Plan and supervise the evaluation of new assays and
instrumentation in the laboratory, as assigned by the medical
director(s). Evaluate data generated premove and postmove if
instrumentation has been moved within a laboratory
Review CAP, New York State Department of Health and other
agency proficiency testing results
Review monthly QC summaries and suggest any needed
improvements
Attend ARUP Chemistry Division QA meetings as able
Attend endocrinology laboratory staff meetings as able
Contribute to continuing education efforts for the
Endocrinology laboratory staff
Abbreviations: CAP, College of American Pathologist; QA, quality assurance;
QC, quality control.
Hanley et al 3

Moonlighting is considered patient care activities external to
the educational program that residents engage in at sites used
by the educational program and other health sites. As such,
residents must have permission to participate from both the
relevant medical director and the residency program director.
They must also have a valid Utah medical license. Moonlight-
ing activities cannot take place while the residents are on call,
must be entered into the E*Value tracking system, and must
count toward the duty hour limitations of the ACGME and
participating institution. The length of moonlighting activities,
Table 6. Assistant Medical Director, Surgical Pathology.
General description: Moonlighting opportunity for a pathology
resident, subject to the standard departmental and institutional
requirements governing moonlighting, who is interested in surgical
pathology and who has demonstrated outstanding performance
during their anatomic pathology rotations
Time commitment: Estimated 4 hours per week but not to exceed
allowable limits set by the graduate medical education office and the
department of pathology
Reporting: Medical director, surgical pathology
Responsibilities include
Perform a QA review of 20 negative biopsy cases per week.
Rank each case as (1) no discrepancy, (2) minor discrepancy (no
difference in clinical management), (3) major discrepancy
(unknown effect on clinical management), or (4) major
discrepancy (significant effect on clinical management)
Review all frozen section diagnoses and compare them with the
final diagnoses. Rank each case 1 to 4, as above and review with
the medical director
Review all corrected reports, deciding if any of these should
have resulted in report addenda and reviewing these with the
medical director
Review all addenda reports for any clinically significant errors,
deciding if any of these should have been directly reported to the
clinician and reviewing these with the medical director
Review all overread diagnoses and rank each case 1 to 4, as
above and review with the medical director
Compile a list of ‘‘prior outside pathology not reviewed’’ cases
and review with the medical director.
Compile a list of all ‘‘major discrepancies’’ identified above and
document their appropriate follow-up by the responsible
pathologist(s) and ensure that follow-up occurs
Attend the monthly QA meeting
Abbreviation: QA, quality assurance.
Table 7. Assistant Medical Director, Digital Pathology.
General description: Moonlighting opportunity for a pathology
resident, subject to standard departmental and institutional
requirements governing moonlighting
Time commitment: Negotiated in advance but not to exceed the
allowable limits by the graduate medical education office and the
department of pathology
Reporting: Medical director of digital pathology
Responsibilities include
Works with the medical director to integrate, educate,
promote, and improve the use of digital technologies within the
diagnostic services of anatomic pathology, microbiology,
chemistry, hematopathology, genetics, and other pathology
sciences.
Works with the medical director to identify and coordinate the
resolution of problems in order to improve pathologist,
scientist, and laboratory professional staff satisfaction regarding
digital pathology issues
Be actively involved in research and development projects
related to digital imaging, in advising students and faculty, and in
participating in academic activities related to digital imaging
Be involved in the initiation and development of continuing
education programs for laboratory professional staff within the
department of pathology as well as outside the institution
through invited seminars, symposia, and teleconferences
Table 8. Assistant Medical Director, Transfusion Services.
General description: Moonlighting opportunity in transfusion
medicine for a pathology resident, subject to the standard
departmental and institutional requirements governing
moonlighting
Time commitment: Negotiated in advance but not to exceed allowable
limits set by the graduate medical education office and the
department of pathology
Reporting: Medical director, transfusion services
Responsibilities include
Daily duties: Check departmental voice mail and e-mail for
requests for assistance and carry a pager at all normal duty times
in case of blood drive questions or blood donor questions
Weekly: Contact blood donors, review all donor reactions and
donor deferrals, meet with the management staff of Transfusion
Services, review all AABB faxnet communications and relevant
FDA guidance documents as soon as possible, and contact the
therapeutic apheresis staff to review scheduled procedures
Quarterly: Provide educational presentation to other house
staff, students, and nursing staff and attend the Transfusion
Committee meeting
At least annually: Review all SOPs and QA documentation for
the blood donor collection and donor processing departments
Other activities: These may include a review and evaluation of
any new workflow processes and/or methodologies/
instrumentation as well as any new software implementations in
the department
Abbreviation: FDA, Food and Drug Administration; QA, quality assurance.
Table 9. Examples of Pathology Milestones and Competencies
Addressed in Assistant Medical Directorships.
Automated Core Laboratory; Endocrinology Laboratory AMD
SBP4: Laboratory management: quality, risk management, and
laboratory safety. Levels 2-4
SBP6: Laboratory management: technology assessment. Levels 1-4
ICS1: Intradepartmental interactions and development of leadership
skills. Levels 1-3
ICS2: Interdepartmental interactions and communications. Levels 1-3
Surgical Pathology AMD
SBP4: Lab management: quality, risk management, and laboratory
safety. Levels 2-4
PBLI1: Recognition of errors and discrepancies. Levels 2-4.
ICS1: Intradepartmental interactions and development of leadership
skills. Levels 1-3
Abbreviations: ICS, interpersonal communication skill; PBLI, practice-based
learning improvement; SBP, systems-based practice.
4Academic Pathology

including the AMD, usually runs on the academic year calen-
dar, but shorter time intervals can be considered. Each new
resident participating in an AMD must complete the Moon-
lighting Authorization Form for the GME office and the depart-
ment of pathology.
Compensation for these AMD activities falls under the
guidelines of the GME office and the department of pathology.
Specific compensation is determined by the responsible faculty
member and may be provided on a continuous or as-needed
basis. Rates include those on a per-request basis (photography,
US$30 per request), an hourly basis (US$40/hour for the infor-
matics AMD duties), or on a fixed basis per pay period (range:
US$165-US$375/pay period).
Survey of Previous Assistant Medical Directors
We contacted 39 former residents who served in AMDs at the
University of Utah and ARUP Laboratories, Inc, over the past
10 years. We surveyed them (Table 10) regarding their expe-
rience in an AMD and the impact that the AMD program had
on their practice of pathology, with an eye toward using their
feedback to improve the experience for future AMDs and to
describe their collective experience for others in academic
pathology.
We queried the former assistant medical directors regarding
their experience in AMDs, whether the AMD helped them
secure a fellowship or attending pathologist position, whether
the AMD prepared them for the laboratory management por-
tion of in-service and board examinations, and whether the
position prepared them to perform their duties as fellows and
practicing pathologists. We also asked the former assistant
medical directors to assess the perceived influence that their
participation in an AMD had on those interviewing them for
fellowship and practice positions and the perceived role the
AMD played in them acquiring these positions.
Results
Of the 39 former assistant medical directors contacted, 23
replied for a response rate of 59.0%. The most common AMDs
were hematologic flow cytometry (7 respondents) and AP (6
respondents). Four respondents had served in AMDs in the
automated core laboratory and 3 each had served in AMDs in
informatics and transfusion services. Fewer respondents served
in AMDs in slide photography (2), infectious disease labora-
tory (1 and no longer offered), and website medical content
management (1). Most respondents served in AMDs during
their third year of residency (19 of 23, 83%), although some
served during their fourth (15 of 23, 65%) and second years (3
of 23, 13%). More than half (13 of 23, 56%) of the respondents
had served in AMDs during more than 1 year of residency,
most commonly during both their third and fourth years.
Although most of these respondents served in the same AMD
during both years, there were 3 respondents who served in
different AMDs during the course of their residencies.
We asked the former assistant medical directors about how
their experience prepared them for their future roles as fellows
and practicing pathologists. More than two-thirds (18 of 22,
82%) of the respondents were satisfied or very satisfied that
the goals of their AMD had been achieved, and a similar num-
ber (18 of 23, 78%) felt that the AMD improved their manage-
ment skills. Despite the fact that most respondents felt that
serving in an AMD improved their management skills, a minor-
ity (approximately one-third) felt that the experience helped
prepare them for the laboratory management portions of Amer-
ican Society for Clinical Pathology (ASCP) Residency In-
Service Examination (RISE) and board examinations (Table
11).
There was almost universal agreement among former assis-
tant medical directors that their experience made them more
competitive fellowship and job applicants (Table 11). Respon-
dents felt that the AMD was an important to very important
factor in helping them secure fellowship and practicing pathol-
ogist positions. Similarly, the majority of respondents felt that
the AMD experience was helpful in allowing them to perform
their duties as fellows and practicing pathologists. Areas in
which the AMDs were rated as deficient included preparation
for leadership roles in professional societies, preparation for
acting as a mentor to trainees, and, for those residents who did
not participate in the informatics AMD, preparation for medi-
cal informatics duties.
Finally, the majority of respondents noted that fellowship
program directors and job interviewers commented favorably
on their participation in an AMD (Table 11). Although most
respondents reported that participation was rarely a deciding
factor in being offered a position, 2 respondents reported that
their participation in an AMD was mentioned by fellowship
program interviewers as a deciding factor in being offered a
position and more than a quarter of former AMDs reported that
their participation in an AMD was mentioned by job inter-
viewers as a deciding factor in being offered a position.
Discussion
Having identified laboratory management and leadership skills
as a necessary, but a generally deficient, aspect of residency
training, numerous strategies arose to introduce laboratory
management curricula into residency training programs.
14-16
These strategies ranged from informal interactions with labora-
tory medical directors during required rotations to formal man-
agement courses. Approaches included management rotations,
lectures from laboratory managers and business people,
assigned textbook and procedure manual reading assignments,
and formal examinations. Other programs chose to use more
involved methods such as requiring trainees to participate in
laboratory management research and/or quality improvement
projects, participation in laboratory inspections, or shadowing
medical directors or laboratory managers during some or all of
their daily activities.
In addition to institution-specific training programs, several
tools are currently available to encourage the use of a more
Hanley et al 5

Table 10. Survey of Previous Assistant Medical Directors.
1. Did you participate in an assistant medical directorship (AMD)?
Yes/No (If no, please skip to question #31)
2. If yes, in which of the following did you participate? (select all that apply)
Anatomic pathology
Automated core laboratory
Hematologic flow cytometry
Informatics (joint with consult editor)
Medical content management, assistant editor for ARUP consult
Hourly analytic client work
Transfusion services
Slide photographer (for outside departments)
Endocrinology
Digital pathology
Other (please specify)
3. In which year of residency did you participate? (select all that apply)
PGY1
PGY2
PGY3
PGY4
PGY5
4. How satisfied were you that the goals of the AMD were achieved?
5—Very satisfied, 4—Satisfied, 3—Neutral, 2—Dissatisfied, 1—Not at all satisfied
5. Do you feel that participation in an AMD improved your management skills?
Yes/No
6. If yes, by how much?
5—Very much, 4—Some, 3—Neutral, 2—Very little, 1—Not at all
7. Do you feel that participating in an AMD prepared you for the management portion of the RISE and/or board exams?
Yes/No (If no, skip to question #9)
8. If yes, by how much?
5—Very much, 4—Some, 3—Neutral, 2—Very little, 1—Not at all
9. Do you feel that participating in an AMD made you a more competitive fellowship applicant?
Yes/No/Not applicable
10. Do you feel that participating in an AMD helped you secure a fellowship position?
Yes/No (If no, please skip to question #12)/Not applicable (If not applicable, please skip to question #14)
11. If yes, how important a factor do you believe the AMD was in helping you secure a fellowship position?
5—Very important, 4—Important, 3—Neutral, 2—Not that important, 1—Not at all important
12. Do you feel that participating in an AMD helped you perform your duties as a fellow?
Yes/No (If no, please skip to question #14)/Not applicable (If not applicable, please skip to question #14)
13. If yes, by how much?
5—Very much, 4—Some, 3—Neutral, 2—Very little, 1—Not at all
14. Do you feel that participating in an AMD made you a more competitive job applicant?
Yes/No (If no, please skip to question #17)/Not applicable (If not applicable, please skip to question #17)
15. Do you feel that participating in an AMD helped you secure a job?
Yes/No (If no, please skip to question #17)/Not applicable (If not applicable, please skip to question #17)
16. If yes, how important a factor do you believe the AMD was in helping you secure a job?
5—Very important, 4—Important, 3—Neutral, 2—Not that important, 1—Not at all important
17. Do you feel that participating in an AMD helped you perform your duties as a pathologist?
Yes/No (If no, please skip to question #19)/Not applicable (If not applicable, please skip to question #19)
18. If yes, by how much?
5—Very much, 4—Some, 3—Neutral, 2—Very little, 1—Not at all
19. How well did the AMD prepare you to act as a medical director in the following areas:
Administrative/leadership 5—Very well, 4—Well, 3—Neutral, 2—Poorly, 1—Not at all
Educational responsibilities 5—Very well, 4—Well, 3—Neutral, 2—Poorly, 1—Not at all
Delegation of tasks 5—Very well, 4—Well, 3—Neutral, 2—Poorly, 1—Not at all
Regulations and liabilities 5—Very well, 4—Well, 3—Neutral, 2—Poorly, 1—Not at all
20. How well did the AMD prepare you for quality assurance/quality control activity?
5—Very well, 4—Well, 3—Neutral, 2—Poorly, 1—Not at all
21. How well did the AMD prepare you for medical informatics?
5—Very well, 4—Well, 3—Neutral, 2—Poorly, 1—Not at all
(continued)
6Academic Pathology

standardized curriculum approach to laboratory management.
17
In 2013, the ASCP and the American Pathology Foundation
introduced Laboratory Management University (LMU), a suc-
cessful, self-paced certificate program wherein participants learn
practical laboratory management and leadership skills through a
series of online modules and quizzes.
18
The LMU is now used in
a number of pathology residency training programs, including
our own, to supplement instruction and firsthand experience in
laboratory management techniques. The American Association
for Clinical Chemistry also offers an online certificate program
in laboratory management.
19
These programs allow laboratories
and training programs (in clinical laboratory sciences and
pathology) to tailor the courses to their needs. The College of
American Pathologists offers the Clinical Pathology Improve-
ment Program, which teaches the principles of laboratory man-
agement through 12 involved case studies.
20
Beyond training in the fundamentals of laboratory manage-
ment, pathology residency programs can also use graduated
responsibility to reinforce these knowledge and skill sets.
Mentor-based teaching is a cornerstone of clinical medicine
and surgery, with bedside rounds and participation in surgical
cases a staple in medical student rotations and medical/surgical
residencies. However, students entering residencies in pathol-
ogy often fall into a passive learning style with diminished
clinical responsibilities and patient contact.
2
Passive training
environments can lead participants to lack confidence, dimin-
ish their expertise, and affect their lifelong learning skills.
Well-designed graduated responsibility systems can do much
to counter these difficulties. However, graduated responsibility
is often difficult to achieve in pathology residency programs,
given restrictions on billing as well as ACGME rules and reg-
ulations regarding supervision. All resident activities relating
to patient care must ultimately be reviewed by attending
faculty, lessening the ability of pathology residents to engage
in decision-making.
Pathology faculty in academic institutions should continue
to seek opportunities for residents to take responsibility for
diagnostic decisions with progressively less oversight.
21
Rota-
tions in specific laboratories should emphasize graduated
responsibility for clinical consultations and interpretation of
unusual results, with residents serving as junior practitioners.
Pathology residents should have the opportunity to both see and
practice the application of management principles they learn.
10
Creating graduated responsibility opportunities for pathol-
ogy residents is an important means to augment more tradi-
tional approaches to knowledge and skills development in AP
and clinical pathology (CP).
21
This includes clinical laboratory
management training. As our health-care delivery system
undergoes medical, technological, and structure changes,
pathologists new to practice are in a better position to enter
practice with necessary knowledge and skill sets for all aspects
of their practice and better prepared to meet the challenges of
future medical practice. With laboratory management, in par-
ticular, a recent workforce analysis by the CAP presented sur-
vey data that showed that 44%of pathologists younger than 40
years and 32%of those older than that ‘‘expect to devote more
of their time to medical direction of clinical laboratories in the
immediate future.’’
22
22. How well did the AMD prepare you to act as a mentor to trainees?
5—Very well, 4—Well, 3—Neutral, 2—Poorly, 1—Not at all
23. How well did the AMD prepare you for a leadership role in professional societies?
5—Very well, 4—Well, 3—Neutral, 2—Poorly, 1—Not at all
24. How well did the AMD prepare you for the following:
Management of and communication with staff 5—Very well, 4—Well, 3—Neutral, 2—Poorly, 1—Not at all
Communication with leadership 5—Very well, 4—Well, 3—Neutral, 2—Poorly, 1—Not at all
Involvement in departmental/institutional meetings 5—Very well, 4—Well, 3—Neutral, 2—Poorly, 1—Not at all
Communication with clients 5—Very well, 4—Well, 3—Neutral, 2—Poorly, 1—Not at all
Development of strategic goals 5—Very well, 4—Well, 3—Neutral, 2—Poorly, 1—Not at all
Project management 5—Very well, 4—Well, 3—Neutral, 2—Poorly, 1—Not at all
25. When applying for fellowship positions, did interviewers comment on your participation in an AMD?
Yes/No (If no, please skip to question #27)/Not applicable (If not applicable, please skip to question #27)
26. If so, were the comments favorable?
Yes/No
27. If offered a position, did program directors or interviewers specifically mention the AMD as a deciding factor?
Yes/No/Not applicable
28. When applying for jobs, did interviewers comment on your participation in an AMD?
Yes/No/Not applicable
29. If so, were the comments favorable?
Yes/No
30. If offered a position, did program directors or interviewers specifically mention the AMD as a deciding factor?
Yes/No/Not applicable
31. Please feel free to include any additional comments about the Assistant Medical Director program at the University of Utah/ARUP
Laboratories.
(Free-text response)
Abbreviations: PGY, postgraduate year; RISE, Residency In-Service Examination.
Hanley et al 7

Table 11. AMD Survey Results.
Do you feel that participation in an AMD improved your
management skills?
Yes No
18 5
If yes, by how much? Very much Some Neutral Very little Not at all
7000 1
Do you feel that participating in an AMD prepared you for the
management portion of the RISE and/or board exams?
Yes No
815
If yes, by how much? Very much Some Neutral Very little Not at all
5000 1
Do you feel that participating in an AMD made you a more
competitive fellowship applicant?
Yes No NA
22 1 0
Do you feel that participating in an AMD helped you secure a
fellowship position?
Yes No
14 8
If yes, how important a factor do you believe the AMD was in helping
you secure a fellowship position?
Very important Important Neutral Not that
important
Not important
at all
5020 0
Yes No NA
Do you feel that participating in an AMD helped you perform your
duties as a fellow?
13 2 6
If yes, by how much? Very much Some Neutral Very little Not at all
6000 0
Do you feel that participating in an AMD made you a more
competitive job applicant?
Yes No NA
17 2 4
Do you feel that participating in an AMD helped you secure a job? Yes No NA
12 5 3
If yes, how important a factor do you believe the AMD was in helping
you secure a job?
Very important Important Neutral Not that
important
Not important
at all
7010 0
Do you feel that participating in an AMD helped you perform your
duties as a pathologist?
Yes No NA
19 1 3
If yes, by how much? Very much Some Neutral Very little Not at all
7020 0
How well did the AMD prepare you to act as a medical director in
the following areas:
Very well Well Neutral Poorly Not at all NA
Administrative/leadership 5 0 5 0 1 1
Educational responsibilities 3 1 6 0 2 0
Delegation of tasks 2 0 6 0 3 1
Regulations and liabilities 6 0 3 0 2 1
How well did the AMD prepare you for quality assurance/quality
control activity?
Very well Well Neutral Poorly Not at all NA
8030 21
How well did the AMD prepare you for medical informatics? Very well Well Neutral Poorly Not at all NA
3050 92
How well did the AMD prepare you to act as a mentor to trainees? Very well Well Neutral Poorly Not at all NA
3050 82
How well did the AMD prepare you for a leadership role in
professional societies?
Very well Well Neutral Poorly Not at all NA
1080 72
How well did the AMD prepare you for the following: Very well Well Neutral Poorly Not at all NA
Management of and communication with staff 7 0 3 0 1 1
Communication with leadership 5 1 3 0 1 1
Involvement in departmental/institutional meetings 6 0 5 0 1 1
Communication with clients 3 1 3 1 5 4
Development of strategic goals 3 0 4 0 5 2
Project management 2 0 5 0 4 2
When applying for fellowship positions, did interviewers comment
on your participation in an AMD?
Yes No NA
13 6 4
If so, were the comments favorable? Yes No
13 0
If offered a position, did program directors or interviewers
specifically mention the AMD as a deciding factor?
Yes No NA
2164
When applying for jobs, did interviewers comment on your
participation in an AMD?
Yes No NA
14 6 3
(continued)
8Academic Pathology

With this view in mind, our training program has combined
formal, didactic training in laboratory management with optional
opportunities to function as ‘‘assistant medical directors’’ in very
specific disciplines and under the guidance/mentorship of the
faculty medical directors. Though viewed as moonlighting by
the GME office, as the experience is not part of the formal
residency curriculum, an assistant medical directorship is, nev-
ertheless, an educational as well as a service opportunity.
In order to assess the perceived value of an AMD opportu-
nity, a survey was conducted with 39 former graduates of the
University of Utah Department of Pathology residency training
program who had served in AMD’s during their training. Feed-
back was sought on both the experience itself and the perceived
impact that it had on their subsequent employment and prac-
tice. With a response rate of 59%(23 of 39), most respondents
served in AMDs during their third or fourth year of training,
with some doing so for both years. A few also served in more
than 1 AMD capacity. Eighteen (82%) of 22 respondents were
satisfied with the experience and with the achievement of the
position’s goals. Seventy-eight percent (18 of 23 respondents)
felt that the experience improved their overall management
skills. Not unlike the conclusions of other authors, management
training and experience (including the AMD) did not necessa-
rily result in perceived improvements in our resident scores on
the ASCP’s RISE or prepare them for laboratory management
questions on subsequent board examinations. The RISE for its
first 20 years of use focused on both resident self-assessment
and residency program evaluation.
23
With introduction of the
ACGME’s Outcome Project in 2000, the RISE was refocused
on residency program accomplishments. A review of the mean
increase in RISE scores by topic from the first to the last year of
residency revealed that laboratory administration scores
showed the lowest level of mean increase (49.8%) for all topics
examined (all topic range: 49.8%-114%).
In today’s competitive job market, prospective employers
may view residents and fellows who have had significant grad-
uated responsibility during their training as having more favor-
able medical knowledge and interpersonal skills than those who
have not.
6,21
This may be particularly important for those jobs
where the practicing pathologist will need demonstrated skills in
laboratory test utilization management or digital imaging, for
example. Residency training programs have for years employed
a variety of approaches to meeting these training needs in man-
agement knowledge and skills.
10,14-15,24
Techniques range from
didactic lectures, to commercially available curricula like the
LMU, to mandatory rotations in management. In 1 example of
the latter approach, the Department of Pathology of Hofstra
Northwell School of Medicine combines observational and
active participation into a 1-month rotation.
25
The authors
describe a rotation in which residents are not only exposed to
departmental leaders and managers in real-time management
situations but are required to engage in a project of strategic
value to the department and its role in the health system. In this
form of graduated responsibility, the majority of the residents
surveyed felt that the experience enabled them to compete suc-
cessfully for fellowships and their first employment.
In addition to improving their laboratory management skills,
nearly all of the respondents to our survey indicated that partic-
ipation in the University of Utah AMD program made them more
competitive for fellowships or jobs. More than two-thirds noted
that fellowship program directors and prospective employers
commented favorably on their participation in an AMD during
their training. While only2 respondents noted thatthe AMD was a
deciding factor in being offered a fellowship position, 28%(five
of 13) of respondents were told that the AMD was described as a
deciding factor in the offer of a job.Although not an overwhelm-
ing endorsement of the value of the AMD-graduated responsi-
bility opportunity by future employers, the fact that it was
considered favorably by some of them during the application
process is noteworthy and encourages support for the program.
Finally, many respondents felt that the AMD experience
improved their ability to perform their duties as fellows or
practicing pathologists. The experience was credited with help-
ing to prepare them for administrative responsibilities and lead-
ership roles, to improve their interpersonal skills and their
understanding of regulatory requirements in the laboratory, and
to perform quality assurance activities in the laboratory.
Opportunities for the design of future AMD experiences that
respondents cited included a lack of adequate preparation for
leadership roles in professional societies, a lack of focus on
mentorship of others, and a lack of preparation for the needs
of medical informatics duties.
In 2014, pathology joined other residency specialties in
phase II of the NAS inspection program of the ACGME.
13
The
NAS includes 27 pathology milestones in AP and CP residency
training. Included in these are 7 SBP milestones directly related
to patient safety management, laboratory management, and
informatics (SBP1-SBP7). Additionally, there are several
related milestones in practice-based learning improvement
(PBLI), PROF, and interpersonal communication skills (ICSs)
that share some management-related knowledge and skill sets
in error and discrepancy assessment (PBLI1), behavior
(PROF2), performance feedback (PROF4), leadership skills
(ICS1), and interdepartmental and team interactions (ICS2).
Milestone levels 1 to 3 competencies generally focus on knowl-
edge acquisition and understanding, whereas levels 4 and 5
Table 11. (continued)
If so, were the comments favorable? Yes No
13 1
If offered a position, did program directors or interviewers
specifically mention the AMD as a deciding factor?
Yes No NA
5135
Abbreviations: AMD, assistant medical director; NA, not applicable; RISE, Residency In-Service Examination.
Hanley et al 9

require skill demonstrations. Over the course of one’s resi-
dency, graduated responsibility should help to foster solid lev-
els 4 and 5 competencies.
13
As mentioned previously, a number
of the AMD positions, notably those in the automated core
laboratory, the endocrinology laboratory, and surgical pathol-
ogy, emphasize management competencies that correspond to
ACGME milestones (Table 9).
Conclusion
This article has described an innovative program that partially
addresses the need for improved pathology residency education
in laboratory management skills. The University of Utah
Assistant Medical Directorship Program at ARUP Laboratories
offers a unique experience for residents to gain skills in quality
assurance techniques, personnel management, interdepartmen-
tal communication, test management, informatics, administra-
tive experience, and laboratory utilization. The acquisition of
these skills is thought to better prepare pathologists in training
to enter the workforce by reinforcing subjects felt by the prac-
titioners in many pathology groups to be lacking. Pathology
residency programs are encouraged to incorporate some of
these methodologies into their curriculum to augment their
education in laboratory management.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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10 Academic Pathology