The Book at a Glance

Five parts that follow one career across four countries. Each place taught a different lesson about leading a laboratory. The arc is deliberate: you meet the work first, then the people, then the worst day, then the gold standard, and finally the place where all of it comes together — the small hospital lab, where you are the whole system.

Part One — The Philippines: Where the Bench Teaches You

1. The Dignity of the Bench

Where I started, how I fell into this profession by accident, and why I still think the bench is the most honest place in medicine.

2. Leading With Not Enough

Resourcefulness as a first leadership skill. Running good labs without good equipment, and what that teaches you that money can hide.

3. Teaching the Next Bench

My years as a university professor in the College of Medical Technology and Nursing — where I first learned that real leadership means growing the skill in someone else, not just having it yourself. Competence is the price of admission, not the job.

Part Two — Saudi Arabia: Leading People Who Aren't Like You

4. Ten Nations, One Bench

Leading a team that does not share your language, your training, or your assumptions — and why that made me a better leader. The first of two Saudi stints.

5. Quality at Volume

High throughput, high stakes, and what it taught me about systems that hold up when you are tired.

6. Far From Home, Twice

The loneliness of the expatriate tech, leading people who are all a little homesick at once — and what it meant to go back a second time, after six years home, and see the same place with older eyes.

Part Three — Nebraska: The Year I Got Fired

7. Twenty Years In, and “You Don’t Know the Job”

My first US job. No real onboarding, an unfamiliar system, and a manager who decided the problem was me. Told straight.

8. Onboarding Is a Leadership Act

Pulling the lesson out of the wound. What a rushed start does to even a veteran, and why “they didn’t know the job” is usually a leadership failure wearing an employee’s name.

Part Four — Johns Hopkins: What Excellence Actually Looks Like

9. A Short Time in a Great Place

I left my small Arizona lab for a short, formative stint at Hopkins. What it feels like to work, even briefly, somewhere that decided quality is non-negotiable — and why what I saw there sent me back home, not away.

10. What the Big Place Cannot Do

The limits of scale. Why size buys you systems but costs you speed — and what that means for where you work now.

11. What a Small Lab Should Steal

The handful of Hopkins habits that fit in a small lab, and the ones that do not. Take the standard, leave the bureaucracy.

Part Five — Arizona: When You Are the System

12. Nobody Is Coming

The heart of the book, and the lab I chose to come back to. The loneliness, and the freedom, of being the one in charge of a small hospital lab.

13. Everything but the Title

Carrying a lead’s whole load — calibration, failed QC, peer group, CLIA prep, the entire regulatory weight — without the badge or the pay. The unfairness of it, and the mastery it forges.

14. Retention Starts at the Bench

Why people really leave, and the daily friction a leader can actually fix. Onboarding, schedules, workload, fairness, growth.

15. Spotting Burnout Before It Breaks People

Reading the early signs in yourself and your staff, and acting before the good ones walk out the door.

16. The Manager People Don’t Leave

Becoming the leader Nebraska wasn’t. What carries across every country and every loop, and the kind of lab worth staying in — worth coming back to.

INTRODUCTION

The Letter I Wish Someone Had Handed Me

Why a bench tech wrote a leadership book, and who it is for.

I did not set out to become anybody’s idea of a leader. I set out to be a good medical technologist, which to me meant getting the right result, getting it on time, and not making the patient or the physician pay for my mistakes. That was the whole ambition. For a long time it was enough.

Then the years stacked up. Three decades of them, and the path was not the straight line westward that it looks like in hindsight. The Philippines, where I trained, learned that you can run a good laboratory without good equipment if you are resourceful and honest, and where I also spent years as a university professor in a College of Medical Technology and Nursing, teaching the people who would take the next bench. Saudi Arabia, where I worked alongside technologists from a dozen nations — first for six years, then again for three after a long stretch back home, because careers loop in ways the neat story never admits. The United States, where I landed first in Nebraska and got the worst professional surprise of my life. Then Arizona, a small hospital where I spent five good years. Then a short, formative stint at Johns Hopkins, where I saw what a laboratory looks like when an institution decides that excellence is simply not up for debate. And then — this is the part I want you to notice — I went back to the same small Arizona hospital, on purpose, and I have been there six years since. I had seen one of the finest laboratories in the country, and I chose the small lab anyway. That choice is, in a sense, the whole argument of this book.

Somewhere in there, without quite noticing it happen, I became the person other techs came to. The new hire who did not understand the LIS. The night-shift tech who was drowning and too proud to say so. The supervisor two departments over who could not figure out why his good people kept quitting. I did not have a title that explained why they came to me. They came because I had been at the bench long enough to have made most of the mistakes already, and because I was willing to say plainly what I had learned from them.

This book is the long version of those hallway conversations.

Who this is for

You asked me, when you opened this book, who I was writing it for, and the honest answer is three kinds of people at once.

It is for the new lead or supervisor — the tech who was the best on the bench and got promoted into a job nobody trained them for, which is almost everyone in lab leadership. You did not get a management degree. You got a good reputation and a new set of headaches. This book is for you most of all.

It is for the veteran technologist who has been at the bench twenty or thirty years and is tired of watching the same preventable problems repeat. You may not want a title. You may just want the place to run better, and to understand why it doesn’t. There is a lot here for you, because most of what wears down a lab is not exotic. It is ordinary, and it is fixable.

And it is for the hospital administrator who is not a lab person and quietly knows it. You see the turnover numbers and the overtime line and the vacancy that will not fill, and you want to understand what is actually happening down in that windowless department that you only hear about when something breaks. I will try to translate. The lab is not a black box. It is a group of people doing exacting work under conditions that are usually harder than you think.

Most leadership books are written for people who lead from an office. This one is written for people who lead from behind an analyzer with their sleeves pushed up.

Why the small lab, specifically

There are good books about running large reference laboratories and academic medical centers. This is not one of them, on purpose. The small hospital lab is a different animal, and almost nobody writes for it honestly.

In a big lab, leadership is largely about tending systems. You have layers of people, dedicated quality and safety staff, a budget with real lines in it, and the luxury of specialization. In a small hospital lab, you are the supervisor and the troubleshooter and the QC reviewer and, often enough, the only tech on the bench at two in the morning. The systems are not separate from you. You are the system. That changes everything about how leadership works, and most of the standard advice quietly assumes a world you do not live in.

So I am going to take a few clear positions in this book, and I would rather warn you now than have you discover them by surprise. I think technical skill is the price of admission, not the job. I think onboarding is one of the most important leadership acts there is, and that we treat it like a clerical chore. I think most people who quit are leaving a manager, not a laboratory. I think the LIS will never save you from a bad culture. And I think the smallness of the small lab, which everyone treats as a limitation, is actually the closest thing to real freedom that exists anywhere in healthcare, if you have the nerve to use it.

You will not agree with all of it, and you should not. I am one tech with one set of scars. But I have earned these opinions the slow way, and I will show you the work behind each one.

A word about getting fired

I want to tell you early that this book has a low point in it, because I think you should trust a leadership book more when the author admits to having been on the receiving end of bad leadership.

My first job in the United States ended with a manager telling me, a technologist with twenty years of experience, that I did not know my job. I will tell that story in full when we get to Nebraska, and I will try to tell it without flinching and without settling scores. For now I will only say this: it was the most useful failure of my career, because it taught me precisely what not to do to a human being who walks into your laboratory wanting to do good work. Almost everything I believe about leading a lab well, I believe partly because I once saw it done badly to me.

So this is not a book written from the mountaintop. It is written by someone who got knocked flat early in the US, got back up, and spent the next stretch of his career figuring out how to be the opposite of the leader who knocked him down.

I will also tell you, since you and I are going to spend a book together and I would rather you hear it from me plainly, that some years ago I was diagnosed with young-onset Parkinson’s disease. I mention it here, once, near the beginning, and then I mostly let it sit quietly under the rest — which is how I carry it in life. It did not end my career. I am still at the bench. If anything, it sharpened my conviction about everything in these pages, because when you know that your time and energy are not unlimited, you stop wasting them on the wrong things, and leading people well is very much one of the right ones.

If you are at the bench right now, tired, doing the work of three people, wondering whether anyone above you understands what your shift is actually like — this book is me, leaning over, telling you what I wish someone had told me. Let’s begin where I began.

CHAPTER ONE

The Dignity of the Bench

Where I started, and what the work is really for.

Before any of the leadership, before the four countries and the titles and the things that went wrong, there was just the bench. There always is. Every laboratory leader I respect started as a pair of hands and a microscope and a long stretch of learning how not to be wrong. If you forget that, you cannot lead a lab. You can occupy a chair in one, but you cannot lead it.

So I want to start the book here, at the beginning, with the work itself — because the whole argument I am going to make about leadership rests on a particular feeling about what the work is for. If you do not share that feeling, or at least understand it, the rest will sound like management technique. And this is not really a book about management technique.

What we actually do

A patient never sees us. That is the first strange fact of our profession. The physician orders a test, the nurse draws the blood, and somewhere out of sight a result appears that can change everything about how that patient is treated — whether they are sent home or admitted, whether they get the transfusion, whether the antibiotic is the right one. Most patients go their whole lives without learning that a medical technologist exists. They are alive, in some cases, because one paid attention.

I have never minded the invisibility. I came to like it, actually. There is a clean honesty to work that nobody applauds. You cannot coast on charm at the bench. The control is either in range or it is not. The result is either right or it is not. The crossmatch is compatible or it is not, and no amount of likeability will change the answer. In a world full of jobs where appearance can substitute for substance, the laboratory is gloriously immune. The instrument does not care whether you are having a good day.

I should tell you, before I say one more word about the dignity of this work, that I did not choose it. Not really. When I was in high school I had no idea what a medical technologist even was. I could not have told you the difference between one and a nurse, or what happened to your blood after somebody drew it. The profession was simply not on my map.

What I had was a scholarship. I was a full scholar, which in practical terms meant I could take almost any course I wanted, and that kind of freedom is wasted on a teenager who does not yet know what anything is. So I did what a lot of us did. I asked my mother. She told me to go to college and take Bachelor of Science in Medical Technology, and so I did. That was the whole of my grand calling. My mother said this course, and I had a scholarship that would cover it, and I was young enough to trust that the adults pointing me somewhere knew where they were pointing.

I am not embarrassed by that, although I used to be. For a long time I thought a person was supposed to have a story about a calling — a sick relative, a childhood microscope, a moment of clarity. I had none of that. I had a mother with good instincts and a scholarship I did not want to waste. The love of the work came later, slowly, the way it does for most honest people in most honest jobs. You do the thing competently before you do it with feeling. The feeling is earned at the bench, not brought to it.

And that, it turns out, is its own small lesson about leading people, which is why I am starting the book with it instead of hiding it. Most of the techs you will ever lead did not arrive with a burning calling either. They arrived because of a parent, a scholarship, a practical choice, a door that happened to be open. If you wait around for staff who showed up pre-loaded with passion, you will lead a very empty laboratory. The leader’s job is not to find people who already love the work. It is to run a lab good enough that they come to love it the way I did — by being trusted with something that matters and slowly realizing it matters.

I learned that lesson twice, in fact, because for a stretch of my Philippine years I stood on the other side of it entirely. I taught. I was a university professor in a College of Medical Technology and Nursing, in front of rooms full of young people who were exactly where I had been once — most of them sent there by a parent or a practical calculation, very few of them on fire about clinical chemistry. Teaching them is where I first understood that leadership and instruction are nearly the same act. You cannot simply be good at the work yourself. You have to grow it in someone who did not ask for it yet. I will come back to those teaching years more than once, because they shaped how I lead more than any title ever did. For now, just hold the thought: I came to this work by accident, grew to love it at the bench, and then spent years trying to hand that same slow-earned love to students who started exactly as blank as I had.

That feeling I described earlier — that the work is real, that it has consequences, that it cannot be faked — is the foundation everything else in this book is built on. I did not bring it with me. I built it, shift by shift, until one day I noticed it was there. A leader who has lost it becomes a paperwork manager. A leader who keeps it can ask people to do hard things, because they know the leader believes the hard things matter.

Why I call it dignity

I use that word, dignity, on purpose, and I want to be careful about what I mean by it, because it is easy to turn into a greeting card.

I do not mean that the work is always pleasant. A great deal of it is repetitive, and some of it is unpleasant in ways the public would rather not picture. I do not mean that we are unsung heroes, a phrase I have come to dislike, because it asks for a medal instead of a fair schedule. By dignity I mean something plainer and harder: the work has worth that does not depend on anyone noticing it. The night-shift tech who catches a mislabeled specimen at three in the morning, alone, with no one to praise the catch, has done something genuinely important. The importance is real whether or not it is seen.

Dignity is worth that does not depend on being noticed. The lab runs on it. So does good leadership.

Here is why this matters for leadership, which is, after all, what you came here for. A laboratory runs almost entirely on work that nobody sees. The careful repeat. The second look at a smear. The phone call to verify an order that did not look right. None of it shows up in a metric that an administrator reviews. All of it is the difference between a safe lab and a dangerous one. And the only thing that reliably produces that unseen work, shift after shift, year after year, is people who believe it has worth even when no one is watching.

You cannot buy that belief with a pizza party. You cannot mandate it in a policy. You can only protect it, model it, and refuse to insult it. A leader who treats the bench as unskilled labor to be squeezed will, sooner or later, get exactly the lab they have implied they expect: one where people do only what is seen and measured, and quietly stop doing the unseen work that was holding everything together. I have watched it happen. It does not announce itself. The numbers look fine right up until the day they don’t.

The first leadership lesson, before I knew it was one

I did not think about any of this as leadership when I was young. I thought I was just learning to be a good tech. But the habits I built at the bench in those first years turned out to be the entire root system of how I would later lead, and I want to name them, because you are building yours right now whether you mean to or not.

The first was never hiding a mistake. The bench teaches this fast, because a buried error in a laboratory does not stay buried. It travels downstream into a patient. I learned early that the tech who says “I think I made an error, let me recheck” is worth ten who never admit to one, and I have hired and promoted on that principle ever since.

The second was respect for the specimen. Behind every tube is a person who was stuck with a needle, who is waiting, who is probably frightened. The tech who remembers that handles the work differently than the tech who sees a rack of barcodes. Leadership is partly the job of keeping that human fact alive in a room that processes hundreds of samples a day and could so easily forget.

The third was the discipline of the boring. Most of safety is boring. Running the controls, documenting the temperature, doing the maintenance that probably was not needed today. The bench taught me that the boring tasks are boring precisely because they are usually working, and that the day you skip one to save time is the day it would have caught something. A leader’s job is to make the boring feel important, because it is.

These are not advanced ideas. A first-year tech can understand all three. But I have met laboratory leaders two and three levels up who lost hold of them somewhere on the way to the office, and their labs felt it. The dignity of the bench is not nostalgia. It is the operating principle that everything else in this book depends on. Lose it, and the best management techniques in the world will not save you. Keep it, and you can lead through almost anything — which, as the next chapters show, I had to.

We start with too little. That is where the Philippines comes in, and it is the next thing the bench taught me: how to lead when you do not have what you need.

CHAPTER TWO

Leading With Not Enough

Resourcefulness as the first leadership skill.

Every laboratory I trained in early on had the same condition, and it was not a temporary one. There was never quite enough. Not enough reagent, not enough working instruments, not enough hands on a busy day, not enough budget to fix the thing that everyone knew needed fixing. We worked anyway, and we worked well, and the lesson buried in that is one of the most valuable I ever learned: scarcity is a teacher, if you let it be.

I want to be careful, because there is an ugly version of this idea floating around healthcare. Administrators sometimes romanticize doing more with less, as though chronic understaffing were a character-building exercise rather than a slow injury to people. That is not what I am saying, and I will say so plainly more than once in this book. Being under-resourced is not noble. It is hard, and it has real costs, and pretending otherwise is one of the small management lies that eventually shows up in turnover.

But here is the more complicated truth that sits right next to that one. Learning to lead under scarcity made me better than I would have been if I had started with plenty. It taught me things that abundance can actually hide. And since most of you reading this work in laboratories that will never be fully resourced, I would rather hand you what scarcity taught me than pretend you are going to get the staffing you deserve.

What money can hide

When a laboratory has plenty — new analyzers, full staffing, a generous supply budget — it can paper over a surprising number of leadership failures. A poorly designed workflow does not hurt as much when you have enough people to absorb the waste. A weak training program is survivable when you can simply hire experienced techs. Bad communication costs less when there is enough slack in the system to recover from the confusion. Money buys margin, and margin forgives mistakes.

Take the money away and every one of those weaknesses becomes visible immediately. A clumsy workflow with no spare hands means someone stays late every single night. A weak training program with no budget to hire experience means errors. Poor communication with no slack means a missed critical. Scarcity is a harsh auditor. It finds every soft spot in how a lab is run, because there is no cushion to hide them in.

Abundance forgives bad systems. Scarcity exposes them. That is why a leader trained under scarcity often sees more clearly than one who never had to.

This is why I do not entirely envy the leaders who came up in well-funded laboratories. Many of them are excellent. But some of them have never had their systems truly tested, and they mistake the cushion of their budget for the quality of their leadership. Take away the margin and you find out fast which is which. I had my margin taken away as a starting condition, so I learned to design things that worked without it. That skill turned out to travel everywhere I went, including, eventually, to a small hospital in Arizona where the margin was just as thin in its own way.

Let me tell you what blood chemistry meant when I started, because the word means something completely different now, and the difference is the whole point.

There was no analyzer you fed a tube into and walked away from. You built every result with your own hands. You pipetted the sample and the reagents yourself — in the early days by mouth, which I know sounds alarming now and was simply how it was done, and later with manual pipettes that you squeezed and watched and trusted your own steadiness with. You set up your tubes, you put them in the incubator, you waited out the reaction by the clock on the wall, and then you read the absorbance one tube at a time. A spectrophotometer for some tests, a colorimeter for others, depending on what you were running. The instrument did not hand you an answer. It handed you a number for the optical density, and the answer was still yours to find.

And finding it meant the standard curve. You ran your standards, you read each one, and you plotted the points by hand on graph paper, and you drew the line, and you read your unknown off against that line you had drawn yourself. If your curve was sloppy, your result was wrong, and there was no software to hide it from you. You looked at the curve and you knew, in your own hand, whether the run was good. Nobody had to tell you. You could see it.

I am not telling you this to sound like an old man describing how we walked uphill both ways. I am telling you because of what that manual work did to your understanding, and because of what its disappearance quietly costs a laboratory today. When you build a result with your hands from the sample all the way to the plotted line, you know what a result is made of. You develop a feel for it. You can sense when a value is wrong before anything formally flags it, because you have watched ten thousand reactions develop and this one looked off — the color was not right, the curve did not sit where it usually sits, something in the rhythm of the run was wrong. That feel is real, and it saved patients, and it is very hard to teach.

When you build a result with your hands, you know what it is made of. The analyzer gave us speed and quietly took away some of that feel. A good leader notices the trade.

Here is the leadership lesson, and it is not the one you might expect. I am not nostalgic for mouth pipetting, and I would not give back a single one of the analyzers that replaced all that careful, slow, manual labor. The automation is better. It is faster, safer for the tech, more precise, and it lets a small lab do volumes we could never have dreamed of by hand. I am glad it is gone. But I watched something leave with it, and a leader has to be honest about that. The push-button generation of techs — and I mean no insult, they are excellent, they handle a complexity we never faced — often never had the chance to develop the gut feel that the manual era forced into us. They get a number from a machine they were trained to trust, and trusting the machine is mostly correct, right up until the day the machine is confidently wrong and nobody at the bench has the instinct to doubt it.

So part of leading a modern laboratory, especially a small one where there is no second layer to catch a bad result, is deliberately keeping that judgment alive in people who were never made to earn it the hard way. You teach them to look at the result and ask whether it makes sense, not just whether the instrument flagged it. You make them check the patient’s history, eyeball the trend, question a value that does not fit the clinical picture. You are, in effect, trying to hand them by instruction the thing my generation got by necessity. That is harder than it sounds, and most labs do not even try, because the numbers look fine — right up until the day they don’t.

The skills scarcity actually builds

When I look back at what those early years gave me, it was not just grit, which is the word people reach for and which I find a little lazy. It was a specific set of leadership skills that I have used in every laboratory since. Let me name them, because they are learnable on purpose, not only by accident of circumstance.

Triage as a habit of mind. You learn what is actually essential. When you cannot do everything, you are forced to find out what truly matters versus what is merely habit. Scarcity strips a process down to its load-bearing parts. A leader who has done that stripping knows their operation in a way that someone with endless resources never had to.

Workflow design under pressure. With few resources, the difference between a smart sequence and a foolish one is the difference between finishing and drowning. You learn to think hard about order, batching, and timing, because you have no surplus to waste on a sloppy plan.

Genuine teamwork, not the poster kind. When you cannot fix a problem with money, you have to fix it with people — their cooperation, their flexibility, their willingness to cover for one another. Scarcity forces you to become good at the human side, because the technical shortcuts are not available.

Cross-training as survival. A short-staffed lab cannot afford a tech who only knows one bench. You learn to build versatility into your people, which later turns out to be one of the strongest tools you have for resilience and for keeping the work humane.

Notice that every one of those is portable. None of them depends on staying poor. When I later worked in well-resourced places, I did not throw these skills away. I used the resources better than colleagues who had never learned to think this way, because I knew which spending actually mattered and which was just buying forgiveness for a system nobody had bothered to design. Scarcity, paradoxically, makes you better at abundance.

The line you must not cross

Now the hard part, and the place where I want to plant a flag, because resourcefulness has a dark twin and I have seen good leaders confuse the two.

Resourcefulness means doing good work despite missing resources. It never means compromising the quality of a result to hide that the resources are missing. The first is leadership. The second is a slow betrayal of the patient, and it usually starts so small that it does not feel like a decision at all. You skip a control to save a reagent. You stretch a calibration past where you should. You let a corner round itself off because you are tired and short-handed and it has been fine so far. Each step is tiny. The destination is a dangerous laboratory that still believes it is a careful one.

Resourcefulness is doing good work without enough. The moment it becomes hiding that you don’t have enough by quietly lowering the standard, it has turned into something else, and patients pay for the difference.

So here is the rule I carried out of those early years and never broke. You can flex almost anything to cope with scarcity except the integrity of the result. You can change the schedule, the sequence, the staffing pattern, the workflow, the hours. You cannot change the truth of what you report, and you cannot let the pressure of not-enough push you into pretending. When the scarcity gets so severe that the only way to keep up is to cut into quality, the leadership job is no longer to cope quietly. It is to say so, loudly, to the people who control the resources — to make the shortage their problem instead of absorbing it invisibly until something breaks.

That last sentence is, in a way, the entire bridge from the Philippines to the rest of my career. For years I absorbed shortages quietly, because I was good at it, and being good at it felt like the job. It took getting to the United States, and getting fired in Nebraska, to understand that absorbing every problem in silence is not strength. Sometimes it is just a leader doing the institution’s failure for free. But that is getting far ahead of the story. Before I ever left home, there was one more thing the Philippines taught me, and it turned out to be the most important leadership lesson of all — because for a stretch of those years, I was not at the bench. I was at the front of a classroom, trying to put everything I knew into people who did not have it yet.

CHAPTER THREE

Teaching the Next Bench

Where I learned that real leadership means growing the skill in someone else.

For a stretch of my years in the Philippines, I was a university professor in a College of Medical Technology and Nursing. I want to tell you about that time, because it changed how I think about leadership more than any job at any bench ever did, and because almost nobody connects teaching to leading a laboratory. They should. They are the same act wearing two different uniforms.

When you are a good tech, the work lives in your own two hands. You get the result, you catch the error, you make the call. The skill is yours, and there is a quiet pride in that which I will never apologize for. But the day you stand in front of a room of students, that pride becomes useless. It does not matter anymore how good you are. What matters is whether you can put what you know into a person who does not have it yet — and most of them, frankly, did not even want it yet. They were there because of a parent or a practical calculation, exactly as I had been. The fire was not lit in them. My job was to light it, or at least to lay the wood so carefully that it would catch later, on its own, at some bench I would never see.

Being good at the work is not leadership. Growing the skill in someone who does not have it yet — that is leadership. Teaching is where I finally understood the difference.

Strict, but warm

If you asked my old students what kind of teacher I was, I think they would tell you the same two words, and they would say them with a smile: strict, but warm. I have come to believe that combination is the whole secret, not just of teaching but of leading anyone at anything that matters.

Strict mattered because the work is unforgiving. In the laboratory, a result is right or it is wrong, and a wrong one can hurt a patient who will never know your name. I refused to pretend otherwise to spare a student’s feelings. I held them to the real standard, the one the bench would hold them to later, because lowering it in the classroom would only have been a lie that someone else paid for down the line. A teacher who is easy is not being kind. They are just postponing the moment the student discovers they were not actually prepared, and arranging for that discovery to happen somewhere more dangerous than a classroom.

But strict by itself produces fear, and fear is a terrible teacher. People who are afraid hide what they do not understand, and in our profession, hiding what you do not understand is exactly the habit that kills patients. So the warmth was not decoration. It was structural. The students had to know, all the way down, that I was strict because I wanted them to be good, not because I wanted them to feel small. They had to trust that when they admitted they did not understand something, I would teach it again, not shame them for it. Strict tells people the standard is real. Warm tells them you are on their side in reaching it. Take away either one and the whole thing collapses — and I would say the exact same about leading a laboratory today.

The microscope, again and again

The thing I taught over and over, the thing I could probably still teach in my sleep, was the microscope. Cells, smears, parasites. There is no shortcut to it and there never will be. You cannot lecture someone into seeing what is on a slide. They have to sit at the scope, hour after hour, and slowly train their own eye until the difference between one cell and another, between an artifact and an actual organism, finally becomes obvious to them — obvious in a way it simply was not the day before.

I watched that moment happen in hundreds of young people, and it never stopped moving me. A student would struggle for weeks, seeing nothing, frustrated, certain they were not cut out for it. I would sit with them at the scope and point, and point again, and describe what I was seeing until I was tired of my own voice. And then one day — you could not predict the day — something clicked behind their eyes, and they saw it. Really saw it. After that they could not un-see it. The parasite that had been invisible to them for a month was suddenly just obviously there, and they would look up at me almost angry, as if to say, how did I not see that the whole time?

Let me tell you about two kinds of students I had, because between them they taught me almost everything I believe about patience.

There was one who was, to put it plainly, hardheaded. Stubborn. The kind of student who argues, who resists, who makes you wonder some days why you bother. I will not pretend I always had the patience of a saint with him, because I did not — there were afternoons he tested every bit of the strict in strict-but-warm. But I held the standard with him and I did not give up on him, and here is the thing I want you to sit with: he works in the laboratory now. The hardheaded one. He made it. He is doing the work. Every time I am tempted to give up on a difficult trainee, I think about him, because if I had written him off on one of those frustrating afternoons, I would have been wrong about a person who turned out to be perfectly capable of the very thing I was about to decide he could not do.

And then there are the others, at the far end of the same lesson. I have former students who own their own laboratories now. They started exactly where everyone starts — not seeing what was on the slide, not sure they belonged, sent there by a parent or a practical calculation like the rest of us — and they went on to build and run laboratories of their own. When I sat with them at the microscope all those years ago, I had no way of knowing which ones they would become. The struggling beginner and the future laboratory owner looked exactly the same on the difficult days. They were the same, in fact. The only difference was time, and whether someone held the standard and stayed patient long enough for the time to do its work.

The stubborn one who barely made it and the student who now owns a lab looked identical on the hard days. You cannot tell them apart in the moment. So you do not give up on either.

That is the whole secret of teaching, and of leading, compressed into one observation. You cannot tell, in the moment of someone’s struggle, what they will become. The frustrating trainee in front of you may be a future owner of laboratories, or a steady reliable tech who anchors a bench for thirty years, or yes, occasionally, someone who really is in the wrong profession — but you do not get to know which on the hard day, and acting as if you do is how good leaders throw away good people. So you hold the standard for all of them and you stay patient with all of them, and you let time sort out who becomes what. I have been proven right about that more times than I can count, by students who became friends, who still visit, who still write from across the world to tell me what they are doing now. Every one of them was once a person I could not yet read.

That breakthrough, that click, is the most addictive thing I have ever experienced in this profession, and it is the reason teaching ruined me a little for ever being satisfied with my own competence again. Getting a result right myself felt good. Watching the eye open in someone else felt like something larger — like I had not just done the work, I had planted it, and it would go on being done in places and in patients I would never know about. A good tech produces correct results for as long as they stand at the bench. A good teacher produces correct results for a generation, through hands that are not their own. Once you have felt that difference, you cannot lead any other way.

The lesson that was waiting for Nebraska

Here is what I did not know at the time, and what I want you to carry into the next part of this book.

Teaching is onboarding. They are the same thing. When you bring a new tech into a laboratory and teach them your systems, your instruments, your particular way of catching errors, you are doing exactly what I did at that scope — putting knowledge into a person who does not have it yet, patiently, at the real standard, without humiliating them for what they do not know on the first day. The strict-but-warm formula is not just for classrooms. It is precisely how you should receive a human being who walks into your lab wanting to do good work. Hold the real standard. Be unmistakably on their side in reaching it. Teach the hard thing again when they do not get it the first time, because of course they do not get it the first time. Nobody does. I have never met the student who saw the parasite on day one.

I spent years learning to do this well. I got good at it. I came to believe it was close to the most important thing a person in our profession could do for another person. Which is exactly why what happened to me in my first American job cut the way it did. I walked into Nebraska as a man who had spent years teaching others how to be brought along properly — patiently, at the standard, with warmth — and I was met by the precise opposite. No teaching. No patience. No standard explained, no system shown, no warmth. Just a new place, an unfamiliar way of doing everything, and a manager who skipped straight past the part where you teach a person and went directly to deciding the person was the problem.

I knew, in my bones, that it did not have to be that way. I had proof in my own past, hundreds of former students scattered across the world by then, many of them friends to this day — they still visit, they still write, some of them now working in countries I will never see and still reaching out to ask my advice. Every one of them was evidence that a person can be brought along well, that the awkward beginner can become the steady professional if someone strict and warm takes the time. I had done it over and over. And then someone looked at me, twenty years in, and could not be bothered to do it even once.

That is the story I have been circling since the first page, and it is time to tell it straight. But I needed you to see the classroom first. I needed you to know that when I say onboarding is a leadership act, I am not repeating something I read. I am telling you something I taught, for years, to people who became my friends — and then watched a manager throw away as if it were nothing. Let me take you to Nebraska.

PART TWO

Saudi Arabia

Leading people who aren’t like you. Two stints, ten nationalities, and the standard that became our common language.

CHAPTER FOUR

Ten Nations, One Bench

Leading people who do not share your language, your training, or your assumptions.

When I left the Philippines for Saudi Arabia the first time, I thought I was going for the salary, like most of us were. What I actually got was the hardest and best leadership education of my life, and I did not sign up for it on purpose. It came with the job.

The hospital was private, and busy, and the bench around me looked like a small United Nations. Filipinos like me. Indians. Pakistanis. Arab colleagues. People trained in systems I had never seen, who had learned the work in different schools, in different languages, with different ideas about how a laboratory should be run and how people should speak to one another while running it. And I was not just one tech among them. I was a senior, a lead, which meant the job was not only to do my own work well but to make all of those different people function as one laboratory. Nobody trained me for that either. You were simply expected to figure it out, usually on a night when it was already too busy to think.

The trap of leading people unlike you

There are two easy ways to lead a team of people who are nothing like you, and both of them are wrong. I tried both before I found the third.

The first wrong way is to pretend the differences do not exist. You tell yourself everyone is the same, we are all professionals, culture does not matter at the bench. It sounds generous. It is actually lazy, because it means you never bother to understand how the person in front of you was trained, what they consider respectful, what a nod means to them, whether their silence is agreement or whether it is the polite disagreement of someone who was raised never to contradict a senior out loud. I missed real problems early on because I read silence as agreement when it was nothing of the kind. The differences do not disappear because you decided to ignore them. They just go underground, where you cannot manage them.

The second wrong way is the opposite — to demand that everyone do it your way, the way you learned at home, because your way is obviously correct. This is the instinct of a lot of new leads, and I had it too. But when you lead four nationalities, insisting on your single way means three-quarters of your bench is now working against their own training and instincts, resentful, slower, and quietly convinced you are a fool who thinks the Philippine way is the only way. You can force it for a while. You cannot sustain it, and you certainly cannot build trust on it.

You cannot lead people unlike you by erasing the differences, and you cannot lead them by steamrolling the differences. You lead them by finding the one thing everyone already agrees on.

The standard as a common language

The third way, the one that actually worked, took me a while to find, and it is simple to say and hard to do. You find the one thing every single person on that bench already believes in, regardless of where they came from, and you make that the common language. In a laboratory, that thing is always the same. The patient’s result has to be right.

It did not matter whether a tech was from Manila or Karachi or Cairo. Every good one of them believed, all the way down, that a wrong result that hurt a patient was the worst thing that could happen in that building. That shared belief was bigger than any cultural difference between us, and once I learned to lead from it, everything got easier. I stopped trying to make everyone Filipino. I stopped pretending we were all identical. Instead I pointed, constantly, at the thing we already shared. Not “do it my way.” Not “your way is wrong.” But “what does the patient need from us here, and what is the way — any of our ways — that gets that right?”

That question has no nationality. A Pakistani tech and a Filipino tech could disagree about a hundred things and still stand shoulder to shoulder over that one question, because they both already cared about the answer more than they cared about being right. The standard became the language we all spoke when our actual languages did not match. I have used that lesson in every diverse team I have led since, including here in the United States, where the bench is just as mixed in its own way. You do not unify people by flattening them. You unify them around the thing they already came in caring about.

I should be honest about something here, because it shaped how I led that bench. The mix of cultures surprised me at first — I had not worked alongside that many nationalities before, and there was a lot I did not know about how each of them saw the world and the work. But I coped with it more easily than I had any right to expect, for a simple reason: I get along with people. I always have. I am the kind of person who can sit down with almost anyone, from anywhere, and find the human being underneath the accent and the customs and be comfortable with them quickly. That was not a skill I worked for. It was just how I am made, and in Saudi Arabia it turned out to be the most useful trait I owned.

So I will not tell you a dramatic story of conflict and hard-won harmony, because that was not my experience. My experience was that the differences that intimidate a lot of people simply did not frighten me. A tech from Pakistan, a tech from India, an Arab colleague, my fellow Filipinos — I enjoyed all of them. I was curious about them. I asked about their families and their food and their training and their countries, and that ordinary human curiosity did most of the work of leading them before I ever had to manage anything. People will follow someone who is genuinely glad to know them. I was, and they could tell, and it mattered more than any technique.

I will not pretend to you that I remember every name and every face from those years, because I do not, and a book that invented them would be a lesser book than one that tells you the truth. What I remember is the texture of it: the easy way a bench of Filipinos, Indians, Pakistanis, and Arabs could become, over enough shared shifts, something close to a family that happened to come from everywhere. We learned each other’s foods and holidays and small habits. We covered for one another. We argued and forgave the way people do when they are stuck together far from home and have decided, mostly without saying it, to make the best of each other. That ordinary, daily getting-along across every line that supposedly divides people is, I think, one of the quietly beautiful things about our profession, and I got to live inside it for years.

I want to be honest that I did not always get this right, especially the first time around. There were techs I misjudged, conflicts I handled clumsily because I read them through my own assumptions instead of theirs. Leading across cultures is a skill you get less bad at, not one you master. But the core of it held: when I led from the shared standard instead of from my own habits, the bench came together. When I forgot, and led from “the way we do it back home,” it came apart. The lesson cost me some pride to learn, and pride is usually the tuition for the lessons worth keeping.

CHAPTER FIVE

Quality at Volume

What high throughput taught me about systems that hold up when you are exhausted.

The other thing Saudi gave me was volume. Real volume, the kind that does not let up, in a busy private hospital where the specimens kept coming whether or not you were ready for them. After the Philippines, where the constraint was always too few resources, this was a different kind of pressure entirely. Here we had the equipment. What we did not have was time, or slack, or any margin to be slow. The work simply did not stop.

And volume teaches a lesson that scarcity cannot, because volume tests something different. Scarcity asks whether you can do good work with too little. Volume asks whether your systems hold up when everyone is tired, when the queue is long, when there is no time to think your way carefully through each step. It is a brutal, honest auditor of how a laboratory is actually built, because at high volume there is nowhere for a weak system to hide. A process that works fine when you are rested and unhurried will fail at three in the morning in the middle of a flood of specimens, and it will fail in exactly the place you never reinforced because it never broke before.

Scarcity tests whether you can work with too little. Volume tests whether your systems survive your own exhaustion. Both are real. The second one nearly killed me before it taught me.

Tired is the real test condition

Here is the thing most quality systems are designed for that they should not be. They are designed for a rested, careful tech who has time. That tech barely needs the system. The system exists for the other tech — the same person, eleven hours into a shift, running on too little sleep, with a backlog of specimens and a phone that will not stop ringing. That is the real operating condition of a busy laboratory, and a system that only works for the rested version of your staff is not a system. It is a wish.

Volume taught me to design for the tired tech, including when the tired tech was me. That meant building processes that were hard to do wrong even when you were not fully paying attention. Labeling that caught its own errors. Workflows where the safe path was also the fast path, so that being rushed did not push you toward the dangerous shortcut. Checks that did not depend on someone having the energy to remember them, because at hour eleven nobody has that energy, and a safety step that relies on an exhausted person’s memory is a safety step that is already gone. I learned to ask of every procedure: does this still protect the patient when the person doing it is running on empty? If the answer was no, the procedure was decoration, and at volume, decoration kills.

I will not single out one shift, because the truth is that the volume was not one terrible night you could point to afterward and tell stories about. It was relentless and ordinary, day after day, which is its own kind of hard — the steady flood that never quite becomes a crisis you can rally against and never quite lets up either. That is the volume that tests a laboratory: not the dramatic surge, but the permanent pace that asks you to be careful at hour eleven exactly as you were at hour one, when every cell in your body has stopped cooperating. You learn, in that environment, that good intentions are worthless and only good systems survive. The tired version of you cannot be relied upon to remember anything; it can only be relied upon to follow the path that has been built to be hard to do wrong. That is what high volume taught me to build, because I watched what happened on the days we had not built it.

This is also where I learned, in my body and not just in my head, that protecting your people from burnout is not softness. It is quality control. A laboratory running flat out on exhausted staff is not a high-performing lab. It is a lab that has not had its serious error yet. The volume that looked like productivity from the outside was, on the inside, slowly grinding down the very people the quality depended on. I did not have the words for it then — burnout was not something we talked about, you simply endured — but I was watching it happen to good techs around me, and to myself, and filing away a lesson I would not fully understand until decades later in Arizona. We will come back to it, because it turns out to be one of the most important things a small-lab leader has to watch for. For now, just hold this: when a leader pushes volume without protecting the people producing it, the numbers look wonderful right up until they don’t.

CHAPTER SIX

Far From Home, Twice

The loneliness of the expatriate tech — and what it meant to go back a second time.

I have written about the bench and the team and the volume, the professional things, because this is a professional book. But I would be lying to you about Saudi if I left out the part that was actually the hardest, and it had nothing to do with any laboratory. It was all of it at once, stacked on top of each other, every day. Being far from my family. The sheer volume of the work. The constant effort of leading across cultures and languages. The heat, the rules, the simple daily weight of living somewhere that was not home and never quite became home. No single one of those would have broken anyone. All of them together, for years, is the real condition of the expatriate worker, and it is heavier than people who have never done it understand.

I tell you this in a leadership book on purpose, because if you lead a laboratory anywhere in the world today, some of your best people are carrying exactly this weight, and most leaders never see it. The Filipino tech, the Indian tech, the nurse from wherever — they are very good at their jobs and very good at not showing you what it costs them to be so far from everyone they love. I know, because I was that tech, and I got very good at not showing it too.

The homesickness nobody mentions at work

There is a particular loneliness to being the dependable foreign professional. You are competent, you are valued, you are maybe even a lead like I was. And you go back to quiet quarters at the end of the shift and you are a very long way from your family, in a place where you are always, on some level, a guest. You send money home. You miss the birthdays, the funerals, the ordinary Tuesday evenings that turn out to be the things you actually miss most. You hold it together because holding it together is the job and because the people back home are depending on the holding-together. And almost none of that ever shows up at the bench, where you are simply the reliable senior tech who always seems fine.

Some of your best people are homesick in a way they will never show you. The fact that they hide it well is not evidence that it is light. It is evidence of how strong they are.

I am not going to reach for one dramatic moment of homesickness, because that is not how it actually worked. The distance was not a single sharp grief. It was a low, constant hum underneath everything — the ordinary evenings that were ordinary for everyone back home and quietly missing me from them, the milestones I learned about after they had already happened, the slow accumulation of being elsewhere for the parts of life that do not announce themselves as important until you have missed enough of them. You do not break down over it. You just carry it, the way you carry the weight of the work, and you get so practiced at carrying it that the people around you would never guess it was there. That is the part I want a leader to understand: the steadiest, most uncomplaining person on your bench may be the one carrying the most, and carrying it well is not evidence that it is light.

What this taught me about leadership is something I did not learn until I was on the other side of it, leading people who were carrying what I had carried. It taught me to assume there is a private weight I cannot see. Not to pry, not to force anyone to talk about home, but simply to lead with the quiet awareness that the steady, never-complains, always-covers tech may be holding more than anyone around them knows. That awareness changes how you treat people. It makes you more patient with a rough day. It makes you protect the schedule a little harder so someone can make a video call home at a decent hour. It costs you almost nothing and it tells your people that you see them as human beings and not just as pairs of hands. The leaders I remember with gratitude from those years are the ones who saw the weight. The ones I do not remember fondly are the ones who only ever saw the output.

Going back, with older eyes

I did Saudi twice. Six years the first time, then a long stretch of six years back home in the Philippines, and then I went back again for three more. I want to end this part of the book on that returning, because going back to a hard place with older eyes taught me something I could not have learned the first time.

The first time, I was younger, hungrier, leading mostly on instinct and energy, getting a lot of it wrong without quite realizing it. The second time, I was a different person. I had been home, I had lived a whole chapter of life in between, and I came back understanding what I had only survived before. I saw the homesickness in the younger techs because I had finally felt the full weight of my own. I led across the cultures more wisely because I had stopped assuming my way was the obvious one. I protected my people better because I knew, now, exactly what was being asked of them. The work was the same. I was not.

That is worth saying to anyone earlier in their career who feels like they are just enduring a hard posting. You may be getting more than a paycheck out of it, even when it does not feel like it. You may be quietly assembling the understanding that will make you wise later, in some other laboratory, leading some other tired tech who is carrying a weight you will recognize because you carried it first. The hard years are not wasted years. I went back to Saudi a second time and found that the place had not changed at all, and that I had changed completely, and that the changing was the entire point.

And then I left for the United States, carrying all of it — the bench, the classroom, the diverse team, the volume, the distance — certain, after a career like that, that I knew how to walk into a laboratory and do good work. Nebraska was waiting to tell me otherwise.

PART THREE

Nebraska

The year I got fired. Twenty years in, failed by the people sent to teach me — and what it taught me never to do to anyone else.

CHAPTER SEVEN

Twenty Years In, and “You Don’t Know the Job”

My first job in America, and the worst professional surprise of my life.

I have been putting this chapter off for the whole book, circling it, promising you I would get to it. Here it is. My first job in the United States ended with me being let go, and the reason I was given, in effect, was that I did not know my job. I was a medical technologist with twenty years of experience. I had run benches in the Philippines, taught the profession at a university, led a multinational laboratory team through two stints in Saudi Arabia. And in my first American laboratory, I was told I did not know the work.

I want to tell this plainly, without naming anyone and without turning it into a courtroom where I get to be the wronged hero. People who tell these stories to settle scores always sound smaller than they mean to. I am not interested in that. I am interested in what actually happened, because what actually happened is one of the most useful things I know about leadership, and I learned it the hard way so that maybe you will not have to.

The setup

I came in, as everyone does, on training. Orientation. The period where a new person learns how this particular laboratory does things — its systems, its instruments, its quirks, the local way of doing what is fundamentally the same work everywhere. That period is normal and necessary, and I expected it. What I did not expect was who would be doing the teaching.

My mentors — the people assigned to train me and, it turned out, to judge me — were technicians. I am a technologist. I do not say that to look down on anyone, because I have worked beside excellent technicians my whole career and a good one is worth more than a lazy technologist any day. But there is a difference in training and scope between the two roles, it is a real difference, and in this case the people evaluating whether a twenty-year technologist knew his job were working from a narrower base than the person they were judging. And, by my honest read of it, they were not especially strong at the work even by their own measure.

The people sent to judge whether I knew the work knew less of it than I did. That is not a complaint about their rank. It is a fact about who was holding the pen.

What it was really about

Here is the part that took me a little while to understand, because at first I did what most conscientious people do when they are told they are failing. I assumed it was me. I doubted myself. I went home at night and turned it over, wondering what I was missing, how a person could do this work well for two decades and suddenly be bad at it the moment he crossed a border.

But the answer, when it came into focus, was not about my competence at all. It was about money. I strongly sensed — and the longer I was there the clearer it became — that the people training me believed I was being paid more than they were, and that this was intolerable to them. Why should the new man, the foreigner, the one who needs us to show him our system, be making more than we do? You could feel it under everything. The corrections that were a little too eager. The small tests that felt designed to be failed. The notes taken on things that would never have been noted for someone they liked. It was not an evaluation. It was a verdict, reached first and justified afterward, and the justification was dressed up as a judgment about my skill because resentment cannot be written down on a form but incompetence can.

I had spent years in front of classrooms learning to tell the difference between a student who cannot do something and a student who has decided not to like someone. I knew what I was looking at. I just could not stop it, because I was the new person, on training, with no standing and no one above me who knew me well enough to take my side.

I will not manufacture a single dramatic confrontation for you, because that is not how it felt, and this book has run on the truth this far. How it felt was smaller and more grinding than any one scene. It was being corrected, again and again, on things I knew cold — fundamentals I had been performing competently since before some of the people correcting me had entered the field. That is a particular humiliation, being nitpicked on the basics by someone who knows less than you do, and being unable to say so, because you are the new one on training and they hold the pen. Each correction was small. None of them, on its own, was worth protesting. But stacked up, day after day, they built a record — a paper case that a twenty-year technologist did not know his job, assembled out of things that twenty-year technologist could have done in his sleep. I could feel the file being built. I could feel the conclusion that had been reached before the evidence, and the evidence being gathered afterward to fit it. And I could not stop any of it, because you cannot argue your way out of a verdict that was never really about the thing it claims to be about.

The manager who never looked

I have thought hardest, over the years, not about the technicians who wanted me gone. Their motive was ugly but at least it was human and understandable. Resentment about money is as old as money. No, the person I have thought hardest about is the manager — the one who actually had the authority, the one who signed off on letting a twenty-year technologist go.

Because that manager had a choice that the resentful technicians did not. The manager could have looked. Could have spent one hour actually watching me work. Could have asked why the only people reporting that I was incompetent were people with a reason to want me gone and less experience than the man they were grading. Could have wondered, even idly, how someone hired on the strength of two decades of experience had become useless in a matter of weeks. Any of those small acts of curiosity would have changed everything. None of them happened. The manager took the mentors’ word, did no real checking of his own, and made their verdict official.

The technicians wanted me gone. The manager simply did not bother to find out whether they were right. I have never decided which one I hold more responsible.

That is the whole failure, and I want you to sit with how ordinary it is. No villain twirling a mustache. Just a manager who outsourced his judgment to the wrong people and never audited it — who treated the most consequential call you can make about a human being, ending their job, as a piece of paperwork to be signed on someone else’s say-so. It cost me that job. It cost the laboratory a technologist with twenty years of experience that it apparently needed badly enough to hire in the first place. And nobody above ever knew the trade they had made, because the numbers on the form looked fine. They always do.

I will tell you honestly where I have landed with this, because I promised you honesty and this is the part that is hardest to be honest about. I have learned from it. Everything in the rest of this book grew out of it. But it still stings. Decades later, a successful career later, it still has a small sharp edge when I touch it. I am suspicious of anyone who tells you that time turns every wound into a tidy lesson with no scar. Some of them stay tender. This one did. What I have managed to do is put the tenderness to work — to let the sting remind me, every time I am responsible for a new person, of exactly what it feels like to be on the other end of a leader who did not bother to look. That is the most I have made of it. It turned out to be a great deal.

CHAPTER EIGHT

Onboarding Is a Leadership Act

Pulling the lesson out of the wound.

If Nebraska had only been a personal injury, it would not deserve two chapters in a book about leadership. Bad things happen to people at work; that alone is not instructive. What makes it worth your time is that everything that went wrong in my firing was a leadership failure with a name, and every one of those failures is common, preventable, and probably happening in some laboratory near you right now. Let me pull the lessons out one at a time, because these are load-bearing for everything that comes after.

Onboarding is not clerical. It is leadership.

We treat onboarding like paperwork. A checklist, a stack of competencies to sign, a few weeks of someone shadowing someone else until the boxes are ticked. We hand it to whoever is available, we do not think hard about who, and we consider it a low-status chore rather than what it actually is: the single most important leadership act in the life of a new employee. How you receive a person determines who they become in your laboratory. It sets whether they will speak up or hide, whether they will trust you with a mistake or bury it, whether they will stay.

In my case, the onboarding was handed to people who were both unqualified to do it and motivated to see it fail. Think about how casual that decision must have been on someone’s part — just assign the new guy to whoever is on that bench, never considering that the people you have made responsible for a newcomer’s success have a reason to want his failure. That is not a small administrative oversight. That is a leader not understanding that handing someone the power to make or break a new hire is itself one of the most important decisions they make. Who you choose to onboard a person is a statement about what you value. Choose carelessly and you will lose good people and never understand why.

How you receive a person decides who they become in your lab. Hand that power to the wrong people and you will lose good staff and blame the staff.

“They don’t know the job” is where inquiry should begin, not end

The sentence that ended my job — he does not know the work — is one of the most dangerous sentences in any laboratory, and not because it is always false. Sometimes it is true. It is dangerous because of what it does to the person who hears it. It closes the case. It feels like a conclusion, when it should be the opening of an investigation.

A real leader, hearing that a new person is not performing, treats it as a symptom with many possible causes, only one of which is the employee. Maybe they were never actually taught the thing they are failing at. Maybe they were taught it badly. Maybe the person teaching them is the problem. Maybe there is a personality conflict, or a resentment, coloring the report. Maybe the new person is struggling with something outside work entirely. Maybe — and this is the one that requires real humility — the system itself is bad, and this newcomer is simply the first person honest enough or new enough to stumble on its flaws. “They don’t know the job” answers none of these. It just picks the laziest explanation, the one that requires the leader to do nothing and change nothing, and that is exactly why it is so popular.

I tell every newer leader I mentor: when you hear that someone is failing, the very next words out of your mouth should be a question, not a judgment. Why? Show me. Let me see for myself. Who taught them, and how? Curiosity is the cheapest and most powerful tool a leader has, and the failure to use it is what turned a resentment among technicians into the end of my job. One hour of genuine curiosity from the manager would have saved the whole thing.

A leader who outsources judgment is not leading

This is the deepest lesson, and the one I have built my own leadership around in direct opposition to what was done to me. The manager who let me go did not, as far as I could tell, have any real opinion about my work, because he had never actually observed it. He had borrowed his opinion from the people training me, and he had not checked their work any more than he had checked mine.

Borrowed judgment is the quiet killer of fairness in a laboratory. It is so easy to do. You are busy. You have people you trust, or at least people who are conveniently present, and they tell you things, and you act on what they tell you because going and looking yourself is slow and you have forty other things to do. I understand the temptation completely. But the moment you make a serious decision about a human being — a bad evaluation, a denied promotion, a firing — based entirely on someone else’s account that you never verified, you have stopped leading and started rubber-stamping. And the people whose accounts you are rubber-stamping may have motives you cannot see from your office.

Borrowed judgment is the quiet killer of fairness. The day you end someone’s job on a report you never checked, you are not leading. You are signing.

So I made myself a rule, and it is one of the few I have never broken in the years since. I do not make a consequential judgment about a person from a secondhand account alone. I go and look. I watch the person work. I form my own view, and then I weigh it against what others tell me, and where they conflict I trust my own eyes first and dig into why the accounts differ. It costs time. It is worth every minute, because the alternative is becoming the manager who ended my career without ever once watching me do the work I had done well for twenty years.

What the wound became

I said at the end of the last chapter that the firing still stings, and that I have put the sting to work. This is what I meant. Every principle in the rest of this book — the way I onboard people, the way I refuse the lazy verdict, the way I insist on seeing for myself, the way I watch for the resentments and politics that can poison a team, the way I treat the reception of a new person as sacred — every bit of it is the photographic negative of what was done to me in Nebraska. I am, as a leader, deliberately the opposite of the people who decided I did not know my job.

I would not wish that experience on anyone, and I am not going to insult you with the tidy lie that I am grateful for it. I am not grateful for it. But I have refused to let it be only a wound. I turned it into the clearest possible picture of the leader I did not want to be, and then I spent the rest of my career walking in the other direction. When I finally got my own laboratory to look after, in a small hospital in Arizona, I knew exactly what kind of place I was going to build, because I had felt, in my own gut, precisely what happens when a leader does the opposite.

But before Arizona, something unexpected happened. I went — briefly, improbably — to one of the finest laboratories in the country, and I saw what excellence looks like when an institution takes it seriously. After a place that decided I was the problem, I walked into a place that had decided, top to bottom, that quality was not optional. The contrast nearly knocked me over. That is the next part of the story.

PART FOUR

Johns Hopkins

What excellence actually looks like. A short stint in a great place — and why it sent me home, not away.

CHAPTER NINE

A Short Time in a Great Place

What it feels like to work somewhere that decided quality is not optional.

After Nebraska, I needed to remember that I was good at this. I do not mind telling you that. A firing like the one I described does something to your confidence even when you know, rationally, that it was not about your competence. The doubt gets in anyway. It sits there. And what pulled it out of me was not a pep talk or time passing. It was walking into Johns Hopkins.

It was not a long stint. I want to be honest about that, because I am not going to inflate a short chapter of my life into something it was not, and this whole book has been about telling the truth even when a bigger story would sound better. But some experiences do not need length to matter. A short time in a truly excellent laboratory taught me more about what a high standard actually looks like, in practice, than years in ordinary places had. Sometimes you only need to see the real thing once to recalibrate forever.

What excellence felt like from the inside

Here is what struck me first, and it was not the equipment, though the equipment was extraordinary. It was that excellence was simply assumed. It was the water everyone swam in. Nobody was making a special effort to be careful; careful was just the baseline, the floor, the way things were done by everyone without anyone having to be reminded. In a lot of laboratories, doing it right is something you have to push for, argue for, stay late for. At a place like this, doing it right was not the exception that required a hero. It was the ordinary expectation that the whole institution quietly enforced on everyone, all the time, without drama.

That is the thing most people misunderstand about excellence. They think it is about extraordinary individuals doing extraordinary things. Sometimes it is. But sustained institutional excellence is something else — it is a culture so strong that the high standard is the path of least resistance. The systems, the expectations, the people around you all push gently in the same direction, so that meeting the standard does not take heroism. It just takes showing up and doing what everyone around you is already doing. The heroism has been engineered out of it, on purpose, because an institution that needs heroes to be safe is one bad day away from disaster.

In an excellent lab, doing it right is not the heroic exception. It is the path of least resistance. The whole culture is built so the high standard is the easy one to follow.

What stays with me is not one scene but an atmosphere, and atmospheres are hard to photograph, so let me try to describe it. It was the quiet of competence everywhere around me — the sense that everyone on the bench simply knew what they were doing and did it to a standard that nobody had to announce because it was assumed. There was no scrambling, no heroics, no one person holding it together by force of will. The excellence was distributed, baked into how the place ran, so steady that it became almost invisible until you compared it, as I could not help comparing it, to where I had just come from. After Nebraska, walking into a room where high standards were simply the air everyone breathed was like stepping from a storm into a still house. I did not need anyone there to tell me I was capable. The room itself told me, every day, by letting me be one of them.

Why it healed Nebraska

Working there, even briefly, did something quiet and important for me. It reminded me that the verdict in Nebraska had been wrong. Here I was, in one of the most demanding laboratory environments in the country, and I could do the work. I belonged. The hands that some technicians in Nebraska had decided did not know their job were perfectly capable of meeting the standard at Johns Hopkins. I did not need anyone to tell me that. I could feel it, in the work itself, every day. The doubt that Nebraska had planted simply could not survive the evidence.

I tell you this because if you have ever been made to feel small in a job — and most people who have worked long enough have — you should know that the cure is rarely an argument. It is competence, exercised somewhere that recognizes it. You do not talk yourself back into confidence. You work your way back into it, in a place that lets you. Hopkins was that place for me, and I will always be grateful to it for arriving in my life exactly when it did, right after the lowest professional moment I had ever had.

And then, having been reminded of what excellence looks like, I made a choice that surprised the people around me, and that is the heart of the next two chapters. I did not try to stay in the world of the great institution. I went back to a small hospital laboratory in Arizona. On purpose. Knowing exactly what I was leaving. Let me tell you why — because the reason is the entire argument of this book.

CHAPTER TEN

What the Big Place Cannot Do

The limits of scale, and why size buys you systems but costs you speed.

I want to be careful in this chapter not to do the thing that small-lab people sometimes do, which is to comfort ourselves by running down the big institutions. That is sour grapes, and it is beneath the truth. Johns Hopkins is great at things my small hospital lab will never match, and pretending otherwise would insult your intelligence. So let me first say plainly what the big place does that the small place cannot, and only then tell you what it cannot do — because the second list is the reason I went home.

A large, excellent institution gives you depth that is genuinely impossible at small scale. Specialists for everything. Layers of people so that no single absence breaks the operation. Dedicated quality staff whose entire job is to watch the things a small-lab leader watches in the cracks of a hundred other duties. Resources for the rare and the complex. A bench deep enough that someone always knows the answer. When the case is unusual, when the problem is hard, when the volume of expertise matters, the big place wins, and it is not close. I would never tell a patient with a genuinely rare and complex problem that they are better off in my small lab. They are not.

The cost of all those layers

But every one of those strengths has a shadow, and the shadow is the same word each time: layers. The depth that makes a big institution powerful is built out of layers — of people, of approval, of process — and layers are slow. They have to be. You cannot run an enormous organization on everyone's individual judgment; you need procedure, sign-off, committee, consensus. That is not a flaw in big institutions. It is the necessary price of their size. But it is a real price, and you feel it the moment you want to change anything.

At Hopkins, a good idea has to travel. It goes through people, through review, through the proper channels, and it arrives — if it arrives — changed, slowed, sanded down by the journey. That is appropriate for an institution where a careless change could affect enormous numbers of patients. The caution is earned. But it means the big place turns slowly, like a great ship, and a tech on the bench with a better way of doing something may wait years to see it adopted, or never see it at all. The very systems that guarantee the high standard also guarantee that the standard changes slowly.

Size buys you systems and depth. It costs you speed. The layers that make a great institution safe are the same layers that make it slow to change.

I felt this even in my short time there. I would notice something — a small thing, a way a process could be a little better — and I would understand, almost immediately, that there was nothing I personally could do about it. It was not my place. It was not anyone's individual place. The thing would have to move through a system designed, correctly, so that no one person could change it on a whim. In a great institution, that is wisdom. But for someone like me, someone who had spent a career being the person who fixes the thing he notices, it was a particular kind of frustration. I could see the machinery of excellence, and I could also see that I was a very small part inside it, with my hands tied in exactly the way the institution needed everyone's hands tied.

Knowing which kind of leader you are

This is where I learned something about myself that I think every laboratory professional should figure out about their own nature, because it determines where you will be happy. There are leaders who thrive inside great systems — who find deep satisfaction in tending a piece of a magnificent machine, in upholding a standard they did not have to invent, in the security and depth that scale provides. These are not lesser people. The world needs them badly, and the best institutions are full of them. If that is you, a great institution is where you belong, and you should go and be excellent there with my full blessing.

But that is not me, and Hopkins is where I found that out for certain. I am the other kind. I need to be able to see a problem and fix it, myself, soon. I need the distance between noticing something is wrong and making it right to be short. I would rather have less depth and more agency, fewer resources and more reach. A magnificent machine that I could only polish a small corner of was never going to satisfy me, no matter how much I admired it. And the strange gift of working somewhere genuinely excellent was that it showed me, clearly, that the small lab was not my consolation prize. It was my actual preference. I just had not understood that until I had seen the alternative up close and felt myself wanting to go home.

CHAPTER ELEVEN

What a Small Lab Should Steal

Take the standard. Leave the bureaucracy.

So I went home to Arizona carrying something valuable: a clear, firsthand picture of what excellence looks like, and an equally clear understanding of which parts of it I could actually use in a small hospital laboratory and which parts I had to leave behind. That sorting — what to steal from the great institution and what to refuse — is one of the most useful things a small-lab leader can do, and most never get the chance, because most never work in a great institution to begin with. I did, briefly, and I want to hand you what I took from it so you do not have to go yourself.

Steal the standard, not the structure

The single most important thing I brought home was this: the high standard at Hopkins did not come from the layers, the committees, or the resources. Those things protected and enforced the standard, but they were not the standard itself. The standard was, at bottom, a shared belief that the work mattered and that good enough was not good enough. And a belief is portable. A belief does not require a budget. I could not bring home the dedicated quality department or the depth of specialists. But I could absolutely bring home the conviction that doing it right is simply the way we do it here, the floor and not the ceiling, the assumption rather than the achievement. That conviction costs nothing and it is the actual engine of excellence. Everything else is just machinery to protect it.

The standard at a great institution is not the committees and the budget. It is a shared belief that good enough is not good enough — and a belief is free. You can take it anywhere.

In a small lab you cannot build the machinery, but here is the thing nobody tells you: in a small lab you may not need most of it, because you do not have the distance that the machinery exists to bridge. The committees and sign-offs at a big institution exist largely to carry the standard across the gap between the person at the top who holds it and the person at the bench who must live it. In a small lab there is no gap. You are both people. The standard does not have to travel through layers to reach the bench, because you are standing on the bench. So you can hold the standard directly, by example, in person, every shift — which is something the big institution, for all its power, actually cannot do.

Leave the slowness behind

What I deliberately did not bring home was the bureaucracy — not because bureaucracy is stupid, but because in a small lab it is unnecessary and even harmful. The layers of approval that are wisdom at Hopkins would be a self-inflicted wound in a small hospital lab. The whole advantage of being small is speed: the ability to notice something on Monday and fix it by Friday, with no committee in between. To import the big institution's slowness into a small lab would be to throw away your one great advantage while gaining none of the depth that made the slowness worth it. That is the worst of both worlds, and I have seen small labs do it — drowning themselves in process they copied from somewhere bigger, becoming slow without becoming deep.

So the rule I came home with is simple to state and hard to practice: steal the standard, leave the structure. Take the conviction that good work is non-negotiable. Refuse the layers that a big place needs and a small place does not. Be the institution that holds the standard directly, in person, at speed, because you can — and that is not a weaker version of Hopkins. For a small hospital, it is actually a better fit, because it pairs a great institution's standard with a small lab's reflexes.

The choice that explains the book

I told you that I went back to the small Arizona lab on purpose, and that the reason is the whole argument of this book. Here it is, finally, plainly. I had seen excellence at scale. I admired it. And I understood, having seen it, that I did not want to spend my career as a small part of a great machine. I wanted to hold the standard myself, directly, in a place small enough that my hands actually reached everything — where noticing a problem and fixing it were the same motion, where the distance between a leader's conviction and the bench's reality was zero because the leader was on the bench.

That is what a small hospital lab offers that Hopkins, for all its greatness, never could. Not lower standards — the same standard, held more directly. Not less excellence — excellence with shorter wires. I chose it knowing exactly what I was giving up, because I finally understood what I was getting. And what I was getting was the chance to be the leader Nebraska had failed to be, in a place small enough that I could be that leader for every single person who walked in. That place was waiting for me in Arizona. I had worked there before. This time I came back understanding, at last, exactly what I was for.

Which brings us, after a long road through four countries and one hard fall, to the heart of everything I have been trying to tell you. Nobody is coming. And in the small Arizona hospital where I have spent the last six years, I finally learned to be glad of it.

PART FIVE

Arizona

When you are the system. The small hospital lab I chose, returned to, and learned to be glad of — carrying everything the road taught me.

CHAPTER TWELVE

Nobody Is Coming

The loneliness, and the freedom, of being the one in charge.

In a big lab, when something goes wrong at two in the morning, you call someone. A senior tech. A supervisor. The pathologist on the floor. There is always a next layer, a person whose job is to be the one you escalate to.

In a small hospital lab, you are the next layer. There is nobody behind you. On nights, the entire laboratory is sometimes one person, and that person is the bench, the troubleshooting, the QC review, and the critical call all at once. If you are standing there waiting for backup to walk through the door, I have bad news. You are going to wait a long time.

I do not say that to depress you. I say it because a lot of good lab people stay quietly miserable for years, and most of the time it is because they never really accepted this one fact. They run the small lab as if they are owed a bigger one. They wait for the second night tech that the budget is never going to approve. They wait for administration to finally understand. They treat every hard judgment call as something they need cover for, and then they resent it when the cover never shows up. The waiting becomes the whole career.

Nobody is coming. I know how that sounds. But once you actually take it in, the job gets lighter, not heavier — because you stop waiting and start deciding.

By the time I came back to my small Arizona hospital for good, I had earned this lesson from every possible direction. I had improvised through scarcity in the Philippines. I had led a bench of many nations in Saudi Arabia. I had been failed, badly, by a place that should have brought me along and did not. I had stood inside one of the great laboratories of the country and understood that it was not where I belonged. And I had been handed a diagnosis that made the limits of my own time and energy suddenly, permanently visible. All of it pointed at the same truth, and the small Arizona lab is where I finally lived inside it: nobody is coming, and that is not a tragedy. It is the beginning of freedom.

The freedom on the other side of the loneliness

When you stop waiting to be rescued, you also stop asking permission for things that were always yours to decide. You can fix the broken QC procedure tomorrow morning, because you are the one who runs QC. You can decide that this lab does not release a critical without a documented read-back, and it becomes true the moment you decide it, because there is no committee sitting between your decision and the actual practice. The smallness that feels like a limitation is, looked at the right way, the shortest distance between a good idea and a changed reality that exists anywhere in healthcare.

This is the thing I tried to show you all the way back in the Hopkins chapters. The big institution moves good ideas through layers, and they arrive years later, sanded down. In my small Arizona lab, I can have a better idea on Monday and be living inside it by Friday. I gave up depth to get that reach, and knowing what I know now, after seeing both, I would make the same trade every time. Especially now. When your own clock has become something you can hear ticking, the ability to fix what you see, now, today, without waiting for anyone’s permission, stops being a professional preference and becomes something closer to a gift.

Let me give you the truest picture I have of what “nobody is coming” actually feels like, because it is not usually dramatic in the way people imagine. It is not a heroic save. Often it is the opposite — it is standing there, unable to do the one thing everyone needs you to do, with no one to call and no way to make it better.

Here is the one that stays with me. An emergency comes in. The floor needs results now, the kind of now where minutes matter. I go to the analyzer — and it has chosen that exact moment to begin its automated maintenance cycle. Once that cycle starts, you cannot interrupt it. There is no override, no skip, no amount of experience or seniority or desperation that makes it go faster. The machine is simply unavailable until it decides it is finished, and you can only stand there and watch it run.

And the phone starts. The nurses are calling, and calling again, because of course they are — they have a patient who needs those results and they do not know and should not have to care that my analyzer is in the middle of a cycle I cannot stop. Where are the results. We need them now. Is it ready yet. And I have nothing to give them. Nothing. I cannot do anything but wait for a machine, hold my composure on the phone, and absorb a pressure that has nowhere to go because there is no one behind me to escalate to and no button that makes the wait shorter.

Nobody is coming, the machine will not be hurried, and the phone will not stop ringing. Sometimes leadership in a small lab is simply holding the line through a thing you cannot fix.

That is the part no one tells you about leading a small laboratory alone. The hardest moments are not the ones where you spring into action and save the day. They are the ones where there is no action to take, where the only thing within your control is how you carry yourself through the helplessness — whether you stay calm on that phone, whether you keep the floor informed instead of going silent, whether you manage the people waiting on you with honesty rather than panic. The analyzer will finish when it finishes. What I can control is that the nurse on the other end of the line trusts that I am on it, that I am not hiding, that the moment it is ready they will be the first to know. That composure, in the face of a thing you genuinely cannot fix, with no one coming to help you carry it — that is the job. Not the heroics. The holding.

So this is the deal the small hospital lab offers you, and once you see it clearly, I think it is a good one. You will be underbudgeted and undermanned. You will cover roles that three separate people cover somewhere else. Nobody is coming to save you on the bad nights. And in exchange, you actually get to lead — not manage upward, not wait for sign-off, but lead, in the oldest sense of the word: to go first, and to own where you go. I took that trade more than thirty years into a career, came back to the same small lab I had left, and I have spent the last six years certain it was the right one. Nobody is coming. Good. Let us get to work.

CHAPTER THIRTEEN

Everything but the Title

On carrying a lead’s whole load without the badge or the pay that should come with it.

There is a particular situation I have lived for a long stretch of my career, and I have come to believe it is one of the most common and least talked-about realities in small laboratories everywhere. It is being the lead in everything except the title and the paycheck. On paper you are a staff technologist like any other. In practice you are the one who gets handed nearly everything — the troubleshooting, the regulatory work, the problems nobody else wants to touch — because you are the one who knows how, and knowing how, in a small lab, quietly becomes a sentence to do it all.

I want to write this chapter honestly, including the parts that are not noble, because if you are living this you are tired of books that only show you the inspiring side of leadership. The inspiring side is real and I have written plenty of it. But there is also just the load. The daily, grinding, often-thankless load of being the person the laboratory actually runs on while someone else holds the title that says so.

A day in the real job

Let me walk you through what the work actually is, because the public, and frankly a lot of hospital administrators, have no idea. They think the laboratory is a place where you put a tube in a machine and a number comes out. They do not see the scaffolding underneath that number, and the person holding that scaffolding up is very often the unofficial lead, doing it on top of a full bench.

Before you run a single patient sample, the instrument has to actually be trustworthy, and making it trustworthy is its own full job. There is calibration, and then there is calibration verification to prove the calibration holds across the reportable range. There is quality control, every shift, and the moments — they will come — when the QC fails, and now you cannot run patients at all until you have figured out why. Is it the control? The reagent? The instrument? The calibration? You are now a detective, on the clock, with the bench backing up behind you and the floor waiting, working a problem that has to be solved before the real work can even begin. And nobody upstairs sees any of this. They see only that results were a little slow today.

Then there is the peer group — the proficiency testing and the comparison of your results against other laboratories running the same methods. When your peer group comparison comes back wrong, when your numbers drift from where they should sit, that is not a quiet footnote. That triggers investigation and corrective action, real documented work to find the cause and prove you have fixed it, because a lab that cannot match its peers is a lab producing results you cannot fully trust. And all of that lands on the person who knows how to run it down, which is, once again, you.

Before a single patient result goes out, someone has calibrated, verified, controlled, troubleshot, and documented — and in a small lab that someone is usually the person without the title, doing it on top of a full bench.

And then, hanging over all of it, the inspection. CLIA. The preparation that consumes you for weeks — the records pulled into order, the procedures confirmed current, the competencies documented, the corrective actions closed out, the thousand small compliance details that have to be exactly right because the laboratory’s very ability to operate depends on passing. Who pulls that together in a small lab? Not usually the person whose title says they should. Usually the person who actually knows where everything is and how it all works, which is the unofficial lead, absorbing the inspection stress on top of the daily stress, for the same pay as the tech beside them who goes home at the whistle.

The unfairness, said plainly

I am not going to pretend this is fine, because it is not, and you deserve to hear someone say so. There is a real injustice in being given a lead’s entire responsibility without a lead’s title, recognition, or pay. It is one of the quiet, ordinary unfairnesses of our profession, and it grinds people down precisely because it is invisible. The work does not show. The number comes out fine, so everyone assumes it was easy, so the person carrying the load gets neither help nor credit, just more load, because they have proven they can take it. If that sounds familiar, it is the same machine I described in the burnout chapter — the dependable one gets buried because they are dependable. This is what it looks like dressed in regulatory paperwork.

So if you are the unofficial lead, doing everything for the title of nothing, I want to validate it before I say anything else: you are right that it is unfair, you are not imagining the weight, and you are allowed to be tired of carrying what should be shared and should be paid. Naming it honestly is not weakness or complaint. It is the first step to either getting it changed or deciding, clear-eyed, what you are going to do about it.

And the part nobody warns you about: it makes you

Here is the other half of the truth, and I hold it alongside the unfairness without letting it cancel the unfairness out. Carrying all of that — the calibrations, the failed QC you ran to ground, the peer group you corrected, the inspection you survived — made me. There is no faster way to become genuinely, deeply competent than to be the person everything lands on. The tech who only runs their bench and goes home knows their bench. The unofficial lead who troubleshoots the whole laboratory knows the whole laboratory, in their hands and their gut, in a way no title could confer and no class could teach. The load that was unfair was also, without my consent, the finest education I ever received.

I am not telling you that to excuse the system, because the system should pay and title the people it leans on, full stop. I am telling you because it is true, and because it may be the thing that gets you through. When you are buried under a regulatory load that is not officially your job, you are also, quietly, becoming the person this laboratory cannot function without — and that is not nothing. It is leverage, eventually, if you choose to use it. It is mastery, regardless. And it is the reason that when a title finally did come, or when I finally ran my own small lab the way I wanted, I was ready in a way that someone handed the role cleanly never could have been. I had already done every part of the job. I just had not been called it yet.

So carry it if you are carrying it — but carry it with your eyes open. Know that it is unfair, and say so, and push for the recognition you are owed. And know, at the same time, that the weight is forging something in you that the people who avoided it will never have. That is not a consolation prize. In a profession where competence is the only thing that cannot be faked, it may be the whole game.

CHAPTER FOURTEEN

Retention Starts at the Bench

Why people really leave, and the daily friction a leader can actually fix.

Let me say the thing that every administrator looking at a turnover report needs to hear and almost never does. People do not usually leave laboratories. They leave managers. They leave the daily, grinding, fixable friction that a leader either attends to or ignores. And by the time someone is sitting across from you giving notice, the decision was made a long time ago, in a hundred small moments you probably did not notice, most of which you could have done something about.

I learned this from both ends. I learned it from being the technologist that Nebraska threw away over resentment and neglect. And I learned it from three decades of watching good techs walk out of laboratories that never understood why, while the leaders left behind blamed the new generation, or the pay, or the schedule, or anything at all except the one thing actually within their control: how it felt to work there, day to day, under them.

People rarely leave laboratories. They leave managers. The bad fit, the unfair schedule, the silence where appreciation should be — those are leadership choices, and they are where retention is won or lost.

It starts the first day, because everything starts the first day

If you have read this far you already know how much I believe in onboarding, because you read what happened to me when it was done wrong. So I will not repeat the whole argument. I will only say that retention begins before the new hire has finished their first shift, in the simple matter of whether they were received by someone competent who wanted them to succeed, or handed to whoever was free and left to sink. The first week teaches a new tech whether this is a place that will invest in them or use them up. They are deciding about you while you think they are just learning the analyzers. Almost everything you will later call a retention problem was actually an onboarding problem wearing a disguise.

The friction you can actually fix

Most of what drives good people out is not dramatic. It is friction — the small, daily, grinding kind — and friction is exactly what a present leader can reduce. Let me be concrete, because vague talk about culture helps no one.

The schedule is a moral document. Nothing burns through goodwill faster than a schedule that treats people as interchangeable parts. Who gets stuck with every bad shift, every holiday, every short-notice change? If it is always the same people, they are already drafting their resignation in their heads. Fairness here is not a nicety. It is retention.

Workload is the slow leak. A laboratory chronically run on too few people does not look like a crisis from the outside, because the work still gets done. It gets done because your best people are quietly absorbing the gap, and they will do it right up until the day they cannot, and then they will leave, and you will be even shorter than before. Protect your people from the permanent overload, or it will solve itself by losing them.

Appreciation is not a luxury. The unglamorous, unseen, careful work that the whole lab depends on — the catch, the repeat, the second look — needs to be noticed by someone, or people stop doing the part nobody sees. You do not need a budget for this. You need to pay attention and say so out loud. Recognition is the cheapest retention tool there is, and the most neglected.

Growth, or the exit. People stay where they can become more than they are. A tech who sees no path — no new skill, no growth, no future different from today — is a tech already looking elsewhere, even a good and loyal one. You may not control titles or pay scales in a small lab, but you almost always control whether someone is learning. Teach them. It is the thing I know best, and it keeps people more than money does.

I have watched it happen more times than I would like. A person comes into the laboratory, capable enough, and then the pressure of the work — the volume, the pace, the weight of knowing a result matters — simply becomes more than they can carry, and one day they are gone. They leave the workplace because they cannot handle the pressure. I do not say that with contempt, because the pressure is real and it is not for everyone. I say it because of what a leader is supposed to do about it, and usually does not.

Here is the part that is on us, not on them. Some of that pressure is the irreducible nature of the work, and no leader can make a clinical laboratory low-stakes. But a great deal of it is friction we pile on top of the real pressure — the bad scheduling, the chronic short-staffing, the lack of any real support in the first hard months, the silence where encouragement should be. We take a job that is inherently demanding and we make it needlessly punishing, and then when someone breaks under the combined weight, we tell ourselves they just could not handle the work. That is the comfortable lie again, the same family as “they don’t know the job.” It lets the leader off the hook for the part that was actually theirs to fix.

When I see someone starting to crack under the pressure, I have learned to ask which pressure it is. The real kind, the kind that comes with caring for patients, I can only help them build the resilience to carry — by training them well, by standing with them, by making sure they are never alone in it the way I was made to feel alone. The other kind, the friction we manufacture, I can actually remove, and removing it is not coddling. It is the difference between losing a good person and keeping one. People can withstand a great deal of genuine pressure if they are not also drowning in the pressure we invented and could have spared them.

None of this is complicated, and that is exactly the point. Retention is not a mystery to be solved with a consultant or a survey. It is a hundred ordinary decisions about whether the people who work for you are treated as resources to be spent or as human beings to be looked after. In a small lab you cannot hide from those decisions, because you make every one of them yourself, in person, in plain view of the people they affect. That is the burden. It is also, once more, the freedom: there is no committee to blame and no policy to hide behind. The culture of your lab is, quite simply, you. And the people will stay, or not, largely on the strength of that.

CHAPTER FIFTEEN

Spotting Burnout Before It Breaks People

Reading the early signs — in your staff, and in yourself.

I told you back in the Saudi chapters that I watched volume grind down good people, including me, long before any of us had the word burnout to describe it. We just called it the job and endured it. I want to come back to that now, with everything the years have taught me since, because spotting burnout early is one of the most important things a small-lab leader does, and almost nobody is trained to do it.

Here is the trap. Burnout does not look like a crisis in its early stages. It looks like dependability. The tech who is burning out is very often your best one — the reliable one, the one who covers, who never says no, who absorbs every shortage so the patients never feel it. From the outside, that looks like excellence, and a careless leader will keep leaning on it, will even reward it with more, right up until the person breaks or quits. The early signs of burnout and the signs of a model employee are nearly the same signs. That is what makes it so dangerous, and why you have to look harder than the surface.

Burnout, early on, does not look like a problem. It looks like your most dependable person. By the time it looks like a crisis, you have usually already lost them.

What to actually watch for

The shift is usually subtle, and it shows up as change more than as any fixed symptom. The tech who used to catch everything starts to make small, uncharacteristic errors, because exhaustion erodes attention before it erodes anything visible. The person who used to care visibly goes quiet and flat — not complaining anymore, which a careless leader mistakes for things improving, when in fact the complaining stopped because the hoping stopped. Withdrawal. A shortening fuse, or its opposite, an unsettling detachment. The good cheer that used to be real becoming a thing that is performed. You learn to read these in people, but only if you are close enough to have a baseline, and in a small lab you are close enough. That closeness is your early warning system. Use it.

And you have to watch for it in yourself, which is harder, because the same trait that makes you a dedicated leader — the willingness to absorb, to cover, to carry — is exactly the trait that drives you into the ground without your noticing. I have learned this with particular seriousness in recent years, for reasons I have already told you about. When you carry a diagnosis like mine, you cannot afford the lie that your reserves are bottomless, because they are demonstrably not. In a strange way, that has made me a better leader on this specific point. I monitor my own limits honestly now, because I have to, and having to do it for myself taught me to watch for it in everyone around me. The leader who pretends to be tireless gives everyone else permission to destroy themselves trying to match an illusion.

I will give you the example I know best, because it is my own. I was the good one. The dependable one. The tech who could be counted on to absorb whatever the lab needed absorbed, who covered, who carried, who made it look manageable because I was good at making it look manageable. And I burned out. I am the cautionary tale in my own chapter, and I have earned the right to tell it as a warning.

Because here is the mechanism, and once you see it you cannot unsee it. Leaders tend to punish the hero and reward the villain. The dependable person — the hero — gets handed more and more, precisely because they can take it, because they never say no, because loading them is the path of least resistance. And the person who does the bare minimum — the one who deflects, who is conveniently unavailable, who lets things slide — gets left alone, gets the easier load, because leaning on them is more trouble than it is worth. So the hero is rewarded for excellence with exhaustion, and the villain is rewarded for doing little with peace. It is exactly backwards, and most laboratories run this way without anyone deciding to. It is just what happens when a leader distributes work by who is easiest to load instead of who it is fair to load.

Leaders tend to punish the hero and reward the villain — piling work on the dependable one because they can take it, and leaving the slacker in peace. I was the hero. That is how I burned out.

So the warning is for both sides of that equation, and I have stood on both. If you are the hero reading this: your willingness to absorb everything is not the unlimited virtue you think it is. It is the exact trait that will be used, without malice, to grind you down, and the lab will not stop on its own because from the outside your suffering looks like dependability. You have to protect yourself, because for a long time no one else will. And if you are the leader: look hard at how work actually flows in your lab, not how you imagine it does. Find out who is carrying the disproportionate load and ask yourself honestly whether you are loading them because it is right or merely because it is easy. The hero will not tell you they are drowning. They will keep swimming until they cannot, and then they will leave, and you will have rewarded your best person with burnout and your worst with a comfortable career. I lived the hero’s end of that. I do not run a lab that way now, because I know exactly where it leads.

Protecting people is quality control

I want to end this chapter by saying plainly something I only hinted at in Saudi. Protecting your people from burnout is not softness, and it is not a human-resources nicety bolted onto the real work. It is quality control. A laboratory run on exhausted staff is not a high-performing laboratory. It is a laboratory that has not had its serious error yet. Every safeguard you have — every check, every repeat, every careful second look — ultimately runs on the attention of tired human beings, and attention is precisely the thing that burnout destroys first. When you let your best people grind themselves down, you are not just being unkind. You are quietly dismantling the safety of the entire operation, one exhausted shift at a time. The numbers will look fine. They always look fine. Right up until the day they don’t.

So watch your people. Watch yourself. In a small lab there is no one else assigned to do it, which means if you do not, no one will. Nobody is coming to notice that your best tech is running on empty. That, too, is your job now.

CHAPTER SIXTEEN

The Manager People Don’t Leave

Becoming the leader Nebraska wasn’t — and the kind of lab worth coming back to.

We have come a long way together, across four countries and thirty years, and it is time to gather it all into one place. This last chapter is about the kind of leader worth working for — the manager people do not leave — and I am going to build the picture out of everything the road taught me, because every piece of it came from somewhere real.

I know exactly what the opposite looks like. I met him in Nebraska. The manager people leave is the one who outsources his judgment and never checks it, who reaches for the lazy verdict instead of the patient question, who treats the people under him as interchangeable and the reception of a new person as a chore beneath his attention. I do not have to imagine that manager. He fired me. And in a strange way I owe him the clearest gift in this book, because he showed me, in one stroke, precisely the leader I was never going to be.

What the road taught, gathered up

Everything I believe about leading a laboratory came from a specific place along this journey, and I can name them for you now like a map of where I have been.

From the Philippines: That the work has worth whether or not anyone sees it, and that a leader who loses that conviction becomes a paperwork manager. I learned it at the bench, where I came to love a profession I had stumbled into by accident.

From the classroom and the manual bench: That you can do good work without enough, that scarcity exposes every weak system, and that the only thing you must never flex is the truth of a result. And that teaching someone is the same act as leading them: hold the standard, stay patient, and never decide on the hard day what a struggling person will become.

From Saudi Arabia: That you lead people unlike you not by erasing the differences or steamrolling them, but by standing on the one thing everyone already shares — and that some of your best people carry a private weight they will never show you.

From Nebraska: That onboarding is a leadership act, that “they don’t know the job” is where inquiry should begin and not end, and that a leader who decides a person’s fate from a report he never verified is not leading but signing.

From Johns Hopkins: That excellence is a culture strong enough to make the high standard the easy path — and that you can carry that standard into a small lab without the bureaucracy, holding it directly, in person, at speed.

From Arizona: That nobody is coming, and that this is freedom; that retention is won in a hundred ordinary daily decisions; that protecting people from burnout is quality control; and that the culture of a small lab is, quite simply, the leader, standing in plain view.

The manager people don’t leave is not the one with the best budget or the newest analyzers. It is the one who looks — at the work, at the new person, at the tired tech — and acts on what he sees.

The lab worth staying in

So what is the laboratory worth staying in, worth coming back to, worth giving your working life to? It is not the one with the most resources, or I would have stayed at Hopkins. It is not the one with the easiest work, because no good lab has easy work. It is the one led by someone who sees you — who received you well on your first day, who holds a real standard and helps you reach it, who notices the unseen work, who fixes the friction instead of blaming you for feeling it, who watches for the day you are running on empty, and who never, ever decides who you are from someone else’s say-so without looking for himself.

That is the lab I came back to Arizona to build, in my own small corner of healthcare, with my own hands, for the years I have. It is not a famous lab. It will never be written up in a journal. But the people in it are seen, and the work in it is honest, and on the bad nights when nobody is coming, the person who is there knows that they were brought along by someone who wanted them to be good. That is the whole of what I was trying to make. I think it is enough. I think it might be the most that any of us can make, and more than most ever do.

Still here

I will end where the truth of my own life is. I came to this profession by accident, sent into it by a mother and a scholarship before I knew what it was. I grew to love it at the bench, taught it to people who became my friends, carried it across the world and back, and was nearly talked out of believing in myself by one bad place at one bad time. I saw greatness and chose smallness on purpose. And somewhere in there I was handed a diagnosis that told me, in no uncertain terms, that my time at this work is not unlimited.

None of it stopped me. I am still here, in a small Arizona hospital laboratory, doing the work I love and leading the people I am lucky enough to lead, for as many years as I am given. Young-onset Parkinson’s did not end my career, and a manager in Nebraska did not end it either, and the long odds of a kid from the Philippines who did not even know what a medical technologist was — those did not end it. I chose this, every step, more deliberately the further I went. And I will keep choosing it, on my own terms, at my own bench, for as long as I am standing at it.

Nobody is coming. I learned, at last, to be glad of it — because it meant the showing up was mine to do, and the showing up was always the whole of the job.

If you are at the bench tonight, in a small lab, doing the work of three people, wondering whether anyone understands — someone does. I have stood where you are standing, on more nights and in more countries than I can count. Nobody is coming to make it easier. But you can be the one who makes it matter, for the patients whose names you will never know and for the people working beside you who will remember, for the rest of their careers, that you saw them. That is leadership in the small hospital laboratory. It is the realest thing I know. Now go and do it, because nobody else is going to — and because, once you understand that, you finally get to.

— · —

for every tech alone at the bench when nobody is coming