CAPconnect November, 2017
Leading the CAP: Views from the Top
David A. Novis, MD FCAP
The Presidency is the highest office a Fellow can achieve in the CAP. In their campaigns, candidates itemize on their websites and in presentations to the CAP House of Delegates and state Pathology society meetings, qualifications they believe render them suited to serve in this position, and offer their opinions at to what directions they believe the CAP should pursue. But what happens at the end of their presidency? I am not aware that past presidents routinely provide their constituents post mortem reports of their services. These reflections might provide Fellows an appreciation of the assets and liabilities of the CAP, which has the second highest revenue of any medical society—second only to the American Medical Association (AMA).
To provide insights that might help Fellows frame their expectations of future presidents, and of their society’s governance system, I recently interviewed all living past CAP presidents (Table 1, see below), and asked them ten questions (Table 2, see below). I informed interviewees that I would not quote them. To be clear, it was not my intention to judge, evaluate, or validate their responses, or to provide objective views of what they did or did not accomplish during their terms of office. I was only interested in their impressions and perceptions of both the office of the Presidency and the system of governance over which they presided. All the past presidents listed in Table 1 participated in the interviews. Interviewees were given the opportunity to comment on the final draft of this manuscript before I submitted it for publication.
Below are some of my initial findings from these interviews; the remainder of my findings will be shared in part two of this blog, to be published next week. What Motivated Presidents to Seek office?
Presidents were motivated by their desire to serve the CAP, their Fellow peers, and their patients, all of whom provided meaning to their professional lives. They believed that of all the candidates who might have been willing to hold office at the time, they had the most experience and understanding of this highly complex organization, and were the best qualified to confront issues vexing the CAP. Only one President claimed to have had no designs on the office and ran only at the request of his peers.
All Presidents had served the CAP for decades—on the Board of Governors, committees, councils, House of Delegates, accreditation inspection teams—and possessed considerable knowledge of the CAP and how it works. They had developed close relationships with pathologists who had also served and/or were serving in CAP leadership roles and were thus in positions to advance their candidacies. Some Presidents planned their candidacies years in advance, others came to that decision relatively late in their careers. Regardless of the timing, for the years leading up to and during their candidacies, presidents traveled extensively, stumping at state pathology and other professional society meetings in efforts to build their networks, explain their candidacies, and expand their exposures.
How Effective were Presidents in Pursuing Their Goals?
All Presidents had specific goals they wanted to accomplish, some of which they conceived well in advance of their terms, others formulated after they were elected. Some Presidents arrived at their agendas in confines of personal vision, others in the plurality of what they believed to be general member sentiment. In an effort to understand the needs of their constituents, some Presidents traveled the country exhaustively, meticulously canvassing pathologists’ opinions, needs, and anxieties.
Most Presidents believed they were successful in achieving their goals and were able to point to evidence of those successes. For others, achievements were less tangible and open to interpretation. Some Presidents claimed that they were unable to realize their visions, at least not during their terms. Table 3 (see below) lists in no particular order, the outcomes of the goals that Presidents had in mind to achieve.
What Influenced Success? Failure?
All Presidents attributed their successes to the support they received from their peers serving on the Board of Governors, councils, committees, and in state Pathology societies. Most often, they cited their immediate predecessors as being the most supportive of their agendas. It also worked the other way. Peers whose biases ran counter to Presidential initiatives provided some Presidents considerable resistance to achieving their goals.
Almost all Presidents agreed that other than their member peers, the CAP staff was the greatest asset that the CAP provided them, and that it would have been impossible for them to achieve their goals without the assistance of this extraordinary talent.
In addition to hearing their self-reflections on successes and failures, I wanted to dig deeper into their views on the role of the CAP President, the CAP governance structure, and working with the Board of Members. Below are my findings.
How Presidents Viewed the Role of the Presidency
At one time, Presidents determined CAP strategy. During their terms as Presidents Elect, they were expected to produce strategic plans for the CAP that, pending Board approval, would determine the CAP’s course for their two-year terms as President. About a decade ago, CAP Presidents and Governors decided that resetting direction every two years was not in the best interests of the CAP and thus institutionalized strategic policy. Now, the Board of Governors, with advice from senior staff, is responsible for establishing a strategic plan, which is designed to span intervals far longer than two years. Correspondingly, Presidents currently view their role as that of Chairperson of the Board of Governors, responsible for orchestrating consensus on strategy and policy.
How Presidents Viewed the Board of Governors
Presidents unanimously commended fellow Board members for their motivation, selflessness, and knowledge. Some Presidents praised the wisdom of fellow Board members upon whom they could rely to offer challenging, sometimes iconoclastic resistance to majority notions, and in doing so prevent the Board from making ill-advised decisions.
However, several Presidents were puzzled by some Board members who at times appeared to be uncomfortable with, and thus unwilling to make difficult decisions. They feared these Governors approved decisions with which they might not have fully agreed. Presidents also cited among some Governors, provincialism that may have resulted from their limited experiences beyond their own practice settings. These Presidents felt that such provincialism may have worked to inhibit growth and innovation, and perhaps represented potential conflicts of interests in which decisions might have been biased to promote the prosperity of certain types of practices at the expense of others.
How Presidents Viewed the Governance Structure
Presidents struggled to balance the relationship between an organization that on one hand, exists to serve the needs of its members and through its members, patients; and on the other, a business that fuels the resources necessary to meet those needs. At one pole were Presidents who believed that the business focus of the CAP had migrated too far, resulting in swollen staff compensation packages and undermining the membership culture of the organization. As one President put it, “the [business focus] tail is wagging the dog.” They believed that the Board should comprise only pathologists, since pathologists bring to the governance table, experience with a wide range of professional practice environments that enable them to best understand and address the needs of their peers.
At the opposite pole were Presidents believed that in order to continue meeting the needs of its members, ensure the viability of the CAP, and perhaps ensure the existence of Pathology as a profession, CAP enterprise needed to continue growing. These Presidents held that the complexities of governing a $200 million company demanded expertise beyond that which most pathologists can be expected to possess. As one President phrased it, “we don’t know what we don’t know.” Some Presidents suggested that several pathologist Board positions be replaced with non-pathologist, independent Governors capable of providing guidance in the sorts of commercial and non-commercial activities (e.g. business, marketing, government regulation) in which the CAP is engaged. Others would preserve the current Board composition and when confronting issues with which Governors were unfamiliar, engage knowledgeable experts to counsel them.
Several Presidents believed that at times, the governance structure complicated the interaction between Fellows and CAP staff. Because CAP staff are responsible for implementing initiatives designed to both meet member needs and advance CAP enterprise, they feared that actions advancing one agenda at times depleted efforts to serve the other. One President described this tension as competition between the Board and staff for control of decision making, often manifested as staff looking to make decisions “in a hurry.” Some Presidents saw the need for a “counterbalance” to staff opinions. One President remarked on the incongruity of the staffs’ mandate to serve members who have little formal input into the evaluations of those staff.
Insights for the membership
This survey of Presidents was not meant to be a history of who did what, information that Fellows may otherwise glean from reading “From the President’s Desk” in back copies of CAP Today and archival organizational transcripts maintained by CAP staff. Rather, these interviews were meant to provide our Presidents’ insights into the CAP’s governance system; information that might help Fellows sort out their future voting decisions.
The journey for Fellows who contemplate becoming CAP Presidents is long and arduous. Presidential hopefuls need to start early, gain years of experience serving in CAP leadership roles, and must be prepared to crisscross the country building peer networks.
All Presidents targeted goals they hoped to achieve during their terms, and in general believed they were successful in accomplishing those goals (Table 3). I did not attempt to evaluate the degree of their successes. The point is, they had goals. In evaluating Presidential contenders, Fellows may want to consider not just the backgrounds and experience of the candidates, not just the opinions of what the candidates say the “CAP” should do, but rather what they as people—Presidents–plan to accomplish during their terms.
The duties of the President are described in the CAP’s Constitution and Bylaws. Fellows may also want to ask that if Presidents’ primary roles are to chair the Board of Governors, is the CAP better served by elected or appointed Board chairpersons? Fellows might conceive of two roles: an elected President serving as spokesperson for the CAP and a Board Chairperson appointed by Fellow Governors.
That the inconsistency of how Presidents regard the relationships between CAP membership and business entities, and between member and staff decision makers has been festering for decades argues for demanding that our leadership come to consensus on written policies that define these relationships. Debating this balance will necessarily require discussions about whether we should add to our Board of Governors individuals with experience and expertise that our pathologist Governors may lack, and about how to prevent our mercantile endeavors from suffocating the membership.
Table 1: Living Presidents of the College of American Pathologists
| President | Years of Terms in Office |
| Herbert Derman, MD FCAP | 1983-1985 |
| William B Zeiler, MD FCAP | 1987-1989 |
| Paul Bachner, MD FCAP | 1999-2001 |
| Paul A Raslavicus, MD FCAP | 2001-2003 |
| Mary E Kass, MD FCAP | 2003-2005 |
| Thomas M Sodeman, MD FCAP | 2005-2007 |
| Jared N Schwartz, MD FCAP | 2007-2009 |
| Stephen N Bauer, MD FCAP | 2009-2011 |
| Stanley J. Robboy, MD FCAP | 2011-2013 |
| Gene N Herbek, MD FCAP | 2013-2015 |
| Richard Friedberg, MD PhD FCAP | 2015-2017 |
Table 2: Ten Questions Presented to Presidents of the College of American Pathologists (CAP).
| 1. Why did you choose to run for the Presidency of the CAP? |
| 2. What did you hope to accomplish during your term? |
| 3. Were you successful in accomplishing what you set out to accomplish? |
| 4. If you believe that you were successful, what was the evidence of that success? |
| 5. If you believe that you were not successful, what do you believe prevented your success? |
| 6. In either case, what was the biggest obstacle you encountered in attempting to achieve your goals? |
| 7. What was the greatest asset the CAP afforded you in your attempt to achieve your goals? |
| 8. What do you think are the major assets of the Board of Governors and/or the CAP Governance system? |
| 9. What do you think are the major drawbacks of the Board of Governors and/or the CAP Governance system? |
| 10. Is the CAP governance system, i.e. the Board of Governors optimized to advance the agenda of the CAP, and if not, how would you improve it? |
Table 3: Outcomes of Goals Set by Presidents of the College of American Pathologists (CAP).
| Tangible goals Presidents believed they achieved |
| · Relocation and construction of physical plant. |
| · Changing CAP governance and organization. |
| · Overhauling the manner in which the President and Board determine CAP strategy. |
| · Formation of new councils, committees, and programs |
| · Convincing the American Medical Association to support, and federal regulatory agencies to adopt Pathology Current Procedural Terminology (CPT) codes. |
| · Re-posturing of, and increasing attendance at the annual CAP meeting. |
| · Reframing the CAP’s relationship with the American Society for Clinical Pathology |
| · Selling and incorporating into the National Library of Medicine, the CAP’s SNOMED diagnostic coding system. |
| · Strategic partnering with the Association of Pathology Chairs. |
| · Restructuring, addition and subtraction of executive staff. |
| · Expanding CAP business entities |
| Intangible goals Presidents believed they achieved |
| · Building consensus among stakeholder pathologists. |
| · Engaging peers to consider new practice strategies. |
| · Establishing or changing organizational culture. |
| · Improving patient care. |
| · Improving the training of pathologists.
· Influencing government laboratory health care regulations. |
| Goals Presidents believed they did not achieve during their terms as President
· Modification of CAP finance and budget planning. |
| · Redesign of CAP governance structure. |
| · Securing American Medical Association’s support for CAP initiatives. |
| · Integrating of state Pathology societies into the CAP advocacy system. |
| · Extending scope of CAP membership. |
COMMENTS ON BLOG
Goals? Yes – Strategy for implementation? Definitely!
November 22, 2017 06:50 PM by Karim Sirgi, MD, MBA
It is important to recognize that even when aspiring presidents come to the position with personal accomplishment goals for the organization, the ultimate goals and strategy of the College are established by the Board of Governors (BOG), presided of course by a fellow member. It is therefore as important to select the “right person” to serve on the BOG as it is to elect the “right” president.
The right dynamic between board members within the BOG, between board members and senior CAP staff, and an open, continuous and respectful communication with the membership at large are truly the real ingredients of success (or lack thereof) in an organization such as ours. Even armed with the best intentions, the president cannot succeed alone without the appropriate mix of such ingredients.
Selecting the “right” people
November 24, 2017 08:31 AM by David Novis
Thank you for your insightful comments, Karim. I believe our past presidents would agree with you that it is critical that CAP members select the “right” people to serve on the Board. My takeaway from their comments is that in choosing Board members, we should first consider some basic elements of governance that all boards consider before populating their chairs: Are governing boards better served by electing or by appointing some or all of their members? Should we consider adding to our Board, independent perhaps non-pathologist governors who possess experience and expertise in areas that the CAP requires but that our peer pathologists may lack? Difficult conversations to be sure, but conversations worth having nonetheless.
CAP board
November 24, 2017 02:58 PM by Alfred Campbell
Very well done David. I commend you for taking the initiative on this. The comments are not unlike what ex-CEO/Presidents of other organizations say after they have moved on. You have given me a lot to ponder. I thank you for that!!
More on choosing leaders…
November 24, 2017 07:36 PM by Paul Valenstein
Populating an organization’s board and its officers with the “right” people presents challenges for the CAP and for many other non-profit membership organization.
A requirement that Board members also be members of the organization itself (“Fellows” in the College vernacular) has advantages and disadvantages. On the “plus” side, this requirement ensures that the organization doesn’t drift too far from where the membership believes it ought to go — everyone on the Board is a CAP Fellow. But there are also minuses – restricting board membership to CAP Fellows reduces the diversity of perspectives on the Board. Sometimes, seasoned individuals from outside the organization and specialty can see the landscape and options more clearly than those of us immersed in practice.
A requirement that all board members and officers be elected, rather than appointed, also has advantages and disadvantages. Election of governors and officers ensures that board members generally reflect the values of the membership. But it can be difficult for Fellows to know in advance how well a candidate will function in a board setting or as an officer. Furthermore, individuals with minority perspectives or alternative career trajectories often find it difficult to be elected by the general membership. A “slotted” position for a resident helps ensure one particular minority perspective is heard, but there are other minority views that might be better developed and represented.
Finally, the CAP requirement that governors also shoulder significant council responsibilities limits board membership to individuals who can devote a great deal of time to their governance and leadership duties. This service requirement ensures candidates for the board are committed to the organization (which is good), but makes the role very difficult for mid-career pathologists and individuals outside of pathology who have comparatively less time to donate.
In my experience as a CAP board member and officer, I found the existing system for selecting board members and officers worked reasonably well. It is difficult to be sure any alternative approach would produce better results, although it might.
I can think of two variants that might be worth debating: Readers can consider the pros and cons of (1) the board appointing (or the fellowship electing) 1-2 governors who are not pathologists, and (2) creating 1-2 board positions that have fewer council and non-governance responsibilities.
Anyone want to argue for or against either of these variants?
Choosing Boards of Governors
November 26, 2017 09:06 AM by David Novis
Thanks so much for your comments, Paul as always thoughtful and perceptive.
You state with such conviction that restricting board memberships to dues paying members “ensures” that organizations will steer themselves in directions in which boards “ought” to go. That implies that boards comprising only organizational members never, or at least hardly ever chart courses that veer from their missions and visions (my definition of “ought.”). Certainly, your contention makes sense but making sense does not make it so. I wonder if there exists documentation that decisions made by boards comprising independent directors–directors bound by fiduciary responsibilities to advance the agendas of the organizations they represent—drift from organizational missions and visions more commonly than boards comprising only member directors.
Some of our colleagues might fear that they will lose control of their organization if they install several independent directors on our Board of Governors. It is easy to confuse “governance” and “control.” As you well know, governing boards exist to guide organizations in getting where they “ought” to go. Control is always in the hands of its members (or stockholders). Members have the power to dissolve and reorganize their boards when they think their boards are no longer advancing their interests.
Most presidents would agree with you that appointing rather than electing at least some fellow Governors might improve the level of competence at the Board table. They would also agree that boards with appointed “slots” are better able to fill a variety of gaps, such as those that may exist for gender, ethnicity, training level, etc. But those were not the main reasons they cited. Presidents saw that their Boards lacked critical expertise that pathologist Governors could not, nor could be expected to possess, and which they could not rely on elections to provide.
Your comment that election of governors and officers “ensures” that board members generally reflect the values of the membership assumes a cause and effect relationship. Perhaps, but I am unaware of documentation that supports such a relationship. More importantly, that notion assumes that our 18,000 members embrace one collective value. My experience as House Speaker suggests quite the opposite.
I agree with you that having Governors chair councils is an onerous responsibility. But I believe this has less to do with validating commitment than it does with educating governors in all aspects of this large complicated organization so that when moments arise, they can make intelligent decisions. As you note, the enormous amount of time this requires shuts out so many younger talented women and men who are at stages in their lives where they must exploit what little they have of it to raise families and build practices. Mitigating this inequity might require compensating Governors, a weighty debate in itself.
Finally, having served as an ex officio member of the Board of Governors, I am unable to agree or disagree with your reflection that the “system for selecting board members and officers worked “reasonably well” without knowing how you define “reasonably well” and to what outcomes or control groups you are comparing this performance.
I hope others weigh in on this provocative debate. Again, thanks for keeping it alive.