Key Points
- Peter H Gilligan, Ph.D., D(ABMM) emeritus and F(AAM), shares lessons that 35 years of experience taught him about leading a clinical microbiology lab.
- Health care represents approximately 18% of the U.S. economy.
- Hospital laboratories are one of the few areas of hospitals that generate revenue.
- Cultivating good working relationships with many individuals from around the hospital can facilitate key insights about how the microbiology lab can best support patient and hospital needs.
- Recognizing and addressing medical errors quickly is critical.
- Educating the public about medical microbiology issues is key to building trust and mitigating misinformation, and it can be rewarding.
I wish I knew then what I know now.
When I completed my CPEP medical and public health microbiology fellowship at the University of North Carolina, I was confident that I was prepared to direct a clinical microbiology laboratory. In reality, I was naïve, inexperienced and unprepared in many ways, despite having excellent clinical training. However, over the ensuing 4 decades, I developed what psychologists call crystallized intelligence-the ability to apply experience gained over time to solve problems.
It was through learning how to navigate what I did not know-that health care is a highly regulated business; how to create an inclusive working environment; the importance of networking and teamwork; developing clinical expertise to serve unique clinical needs; the importance of recognizing and addressing medical errors; and educating the public about medical microbiology issues-that I became an effective medical microbiologist.
Health Care is a Highly Regulated Business
Health care represents approximately 18% of the U.S. economy. Only a few areas in a hospital generate revenue, and laboratories are 1 of them. As a result, laboratories are under constant scrutiny, externally and internally.
Externally, laboratories must have Clinical Laboratory Amendments (CLIA) certificates, which require that the laboratory meet specific standards in employee certification and competency and maintain specific testing and quality control protocols that meet defined standards. Without a CLIA certificate, laboratories are not reimbursed for their services. As a fellow, I had only a vague idea about these things because the laboratory supervisors oversaw business activities, while I focused on learning the science of clinical microbiology.
My first job after fellowship was as the Director of the Microbiology Laboratory at St. Christopher's Hospital for Children in Philadelphia. When I arrived, the supervisor told me she would be leaving for graduate school in a few weeks, and there would be a laboratory inspection soon thereafter. Its successful completion was central to maintaining the laboratory's CLIA certificate. She showed me the procedure manual and quality control records before she left.
Looking back, I realize that the first thing I should have done was review and sign all the laboratory standard operating protocols, but, at the time, I was trying to get my footing in a hospital with highly complex clinical needs, and I had no experience.
It wasn't long before the lab was up for inspection. The inspector was clearly disturbed by the state of the procedure manual (I had never written a laboratory procedure, despite developing tests during my fellowship) and the limited documentation of quality control. She sat me down and lectured me firmly, but kindly, that things needed to be different next time. They were for the next 37 years. Lesson learned.
St. Christopher's had significant financial constraints during my time there. The laboratory had a budget, but the hospital was almost months behind in paying for laboratory supplies and frequently concerned about meeting payroll. To try to alleviate that stress, I set up a reference test for Clostridioides difficile toxin, a newly recognized pathogen at the time. Our client list quickly grew to include most of the teaching and community hospitals in the city and suburbs of Philadelphia. This took some of the financial pressure off the laboratory-including helping us to meet payroll in times when we might not have.
Creating a Laboratory Culture
One of the most important aspects of leading a clinical microbiology laboratory is creating a positive working environment. Clinical microbiology is a highly dynamic science characterized by the constant recognition of new pathogens and development of new technologies. Additionally, the work has a direct impact on patients and their families. To deal with some of these unique pressures as my career progressed, I developed specific core principles that were informed by listening to laboratory members during daily interactions, as well as interacting with a wide variety of hospital staff. These principles were essential to creating an inclusive, positive and welcoming laboratory work environment. Here are some examples of those core principles:
- All laboratory professionals are valued and respected as health care professionals with special, essential knowledge.
- All laboratory professionals are well trained, and training is continuous.
- All laboratory professionals understand that education is a core function.
- All laboratory professionals have a safe work environment.
- All laboratory professionals participate in laboratory innovation.
- All laboratory professionals are accessible and held accountable.
- All laboratory professionals know that they are heard when they have concerns.
- All laboratory professionals are celebrated for contributing to a positive laboratory culture.
Networking and Teamwork
Health care is an exceedingly complex and high-stakes endeavor. To be successful, a laboratory director needs to know their customers and how to serve them. Our actual "customers" are the patients and their families, but between the patients and the clinical microbiology laboratory are health care providers who translate our "product," (information gleaned from laboratory test results), into specific action.
Experience taught me that working closely and effectively with those care providers was critical to everyone's success. And the adult and pediatric infectious disease teams were the major consumers and translators of our products. When planning for the next fiscal year, we consulted our infectious disease colleagues (and other services) for feedback on proposed changes, which often included innovations leading to modifications in our services.
I also cultivated good working relationships with many individuals from around the hospital that I could call on to get insights into how our services impacted various areas of the hospital. They are too numerous to list, but important connections included, the chief medical officer; department chairs of surgery, pediatrics and medicine; nurses in employee health (needlestick injuries, PPD testing, pathogen exposures and influenza vaccination); infection control practitioners; physician's assistants in the HIV clinic; chief emergency department (ED) clinician; vice president for nursing and clinical operations (which included laboratories); hospital lawyers and many others.
I made it a point to round with one of the chief medical officers whenever he was on clinical service, so he could show me, in broad strokes, how the microbiology laboratory might better serve hospital needs. One of those experiences rounding helped me understand why having rapid flu testing available with a 1 hour turn around helped patient throughput when ED resources were overwhelmed.
Developing Expertise for Specific Clinical Needs
My initial experience at St. Christophers prompted me to develop expertise in specific diagnostic areas to better serve unique patient populations, such as cystic fibrosis (CF) lung infections and infants with botulism. When I moved to the UNC Hospitals Clinical Microbiology-Immunology Laboratories, that expertise expanded to include detection of a wide variety of emerging pathogens, agents of bioterrorism, infections in burn and CF lung transplant patients, ophthalmologic infections, delusional parasitosis and Munchausen syndrome by proxy.
One of the best examples of developing this expertise was in 2003 when our fellow, Melissa Miller, Ph.D., D(ABMM), FAAM, working with a former fellow, Rick Hodinka, Ph.D., developed a test for severe acute respiratory syndrome (SARS) CoV-1 virus after a case was diagnosed by the Centers for Disease Control and Prevention (CDC) at UNC Hospital. Although that test never left the freezer from that experience, Miller developed nationally recognized expertise for devising laboratory developed tests (LDT) for viral agents, most significantly SARS CoV-2.
Medicolegal Aspects of the Clinical Microbiology Laboratory
One of the most important responsibilities I had as a laboratory director was recognizing and responding to medical errors. All institutions are required by accrediting agencies to have risk management systems that are essential to patient safety and improving quality of care. The "early-warning" system for risk management at our institution was "the incident report," which documented an event that might delay diagnosis, impact care or cause harm to the patient, and initiated an investigation. Examples of such incidents included the delay in transporting or loss of a critical specimen or mis-identification of an organism.
As part of this process, during our department of hospital laboratories monthly management meeting, I often presented a "morbidity and mortality report," where I might discuss specific errors impacting patient care or describe "near misses," which were events that had potential to, but did not cause harm to, the patient.
A key aspect of the report was to get colleagues' input on how to improve processes to prevent patient harm in the future. My philosophy of addressing medical errors was simple, "Own your mistakes, and then take action to prevent them in the future." You can't change the past, only improve in the future.
Media Relations
At a time when the expertise of scientists is often drowned out by reams of scientific misinformation, the public's health is best served by a scientific community providing scientific facts to media in all its myriad forms.
My initial press conference in the early 1990s to explain an outbreak of flesh-eating bacteria (Streptococcus pyogenes necrotizing fasciitis) was interesting and, in some ways, empowering.
Today, especially with the advent of the 24-hour news cycle and the wide array of social media platforms from which people get information, it is important that medical microbiologists participate in public dialogue. A key component in this engagement is to begin all interactions with the specific information that you want to communicate, even if it is not the question you are asked.
For example, if someone might ask me about measles, I would begin by saying, "Measles is a dangerous disease that is easily and rapidly spread from person-to-person. It can be prevented by vaccination." ASM provides guidance on how to provide easily understood information for the public on infectious disease threats using a variety of social media. Engage your social communities using ASM resources.
Building Your Career in Medical and Public Health Microbiology
When I began my career as a medical microbiology laboratory director, I lacked essential knowledge of how to lead a laboratory because my training had only scratched the surface of the complexities of that endeavor. Over the ensuing 4 decades, I was often humbled by my lack of knowledge. However, I recognized that a willingness to admit my shortcomings, and address them by constantly learning, allowed me to be a more effective leader. I share these lessons not as absolutes, but as a guide to the types of challenges that may be encountered in a medical and public health microbiology career.
