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| Journal of the New Zealand Medical Association,
22-October-2004, Vol 117 No 1204
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Mentoring resident doctors
Allen Fraser
Mentorship is a relationship akin to the apprentice-master
dyad. It is a relationship characterised by an intense and global nature,
extending over a long time. It covers both professional and personal issues and
is aimed at the mentored person’s development, with the mentor having the
best interests of the mentored person at heart. Characteristically, it involves
a relationship between an older (wiser) person and a younger (developing)
person.
Traditionally, medical education has been regarded as an
apprenticeship. The trainee works with a master who helps him/her to develop
knowledge and skills. In the distant past, apprentices not only worked with
their masters, they usually also lived with them (almost as one of the family),
and they were certainly subject to the master’s discipline.
Apprenticeship training in medicine can be seen as the era
of mentoring in medicine. Subsequently, formal education has been grafted on to
the experiential part of apprenticeship, leading to increasing standardisation
and centralisation of the training process. Medical training followed the same
path, and has moved further away from the traditional apprentice model, by
focussing very intensely on the acquisition of knowledge. This extends beyond
basic training through to the completion of specialist training, with the
trainee having to pass examinations testing knowledge and skills.
While College membership or fellowship was once the result
of an election of a candidate nominated by his/her mentor after a period in an
apprentice role, our current practice is that election to fellowship occurs
because the candidate has successfully passed a set of examinations after a
period of training, with specified training experiences having been satisfied.
Indeed, the satisfaction of the training requirements is largely time-based,
although a succession of supervisors affirm that the trainee has performed to an
at least adequate standard.
It is not uncommon for informal mentoring relationships to
develop during training, as the trainee identifies a senior whose practice
he/she wishes to emulate. Such informal mentoring occurs in many settings, with
the drive to the establishment of the mentoring being sometimes from the mentor
and at other times from the student. It tends to remain within the social and
cultural niche of the student (including gender).
Issues for medical mentoringProfessionalism—Medical
professionalism is a much talked about concept, yet there is probably no
universal understanding of what is meant by the term. A commonly cited aspect of
professionalism is the subordination of one’s interests to the interests
of the patient1—at times reduced to
financial self interest.2 Sometimes the concept
of the professional appears to be subsumed into the concept of the expert
technician; therefore reducing the professional to someone with a set of skills
and knowledge for sale.
This conception of the professional leads to the desire to
have codes of ethics written for the
professional as much as by professionals themselves. It also tends to explain
the move to an increasingly rule-based code of ethics.
Being a professional is much more than being an expert
technician. It means being a person of a certain sort, someone with a particular
character. That is certainly the approach adopted by the virtue ethicists, who
identify ethical behaviour with
phronesis (practical wisdom) and with
the display of the virtues of the profession. Aristotle regarded the virtues as
the mean of a continuum between two extremes—both of which would be a
vice. So, using the example of placing the interests of the patient above
one’s own, the virtuous doctor should occupy the middle ground between
selfish disregard of the patient and self-sacrifice such that the patient (and
potential patients) can no longer be helped.
The teaching of professionalism and of ethics is much talked
about, and subject to many approaches. Didactic teaching offers the knowledge
base that is important for the
phronimos (the practically wise man) so
that it allows him to build experience upon. The true
phronimos needs to practice the virtues
and to increasingly develop them over time—it is not part of practical
wisdom that it is possible to be gained through theory alone.
Hence we return to the apprenticeship or mentorship model.
The reason for arguing for mentorship, rather than leaving this to a succession
of supervisors, is that much development of the specific virtues for excellent
and ethical behaviour is dependent on modelling, guidance, and indeed nurturing.
It is hard enough to establish a working relationship with a trainee within 6
months, let alone taking this further into the development of a mentoring
relationship.
Furthermore, it is likely that the very task- and
goal-orientated responsibilities of the clinical supervisor actually run counter
to the mentoring relationship, which is more orientated towards the young person
rather than his/her outputs. The concept is that, as the person develops through
the mentoring process, he/she will modify his/her actions to enhance their
nature and thereby produce better outcomes.
This may seem as if the supervisor should ideally act as
mentor. There is no doubt that in many supervisory relationships in medicine
there is a mentoring aspect. Many doctors reflect back on their supervisors (or
at least some of them) with fondness and gratitude. Nevertheless, the key
component of mentoring (of long duration) is negated by the 6-monthly rotations
our trainees undergo.
The nature of current practice is such that mentoring occurs
more by chance than by design, and is dependent upon the chance coinciding of
the phronimos with the eager
disciple.
Career
choice—One of the reasons many doctors give for their choice of
specialty training is the influence of an important senior practitioner in that
specialty. It can be a parent. It may be a teacher at medical school who has
inspired either personally or in the abstract. It may be a clinical teacher or
supervisor. Occasionally, such a person may also become a mentor.
Mentoring during medical school training, and more
definitively in the first postgraduate years, can assist young doctors clarify
their career choices and can also assist in attracting trainees to specific
areas of medical practice.
An area of major concern in the United States (US) is the
numbers of women and ‘minority’ groups training in a specialty. For
example, there are reports of being able to enhance the experience of training
for women and for minority groups by providing mentors who are themselves
successful women or minority members of the specialty. This is a case not only
of being a role model; if it were that simple, then the existence of the person
would be effective without there being a need for mentoring.
Mentoring adds in the opportunity to guide, to answer
questions, to challenge, and to nurture the development of the trainee. Those
aspects of the relationship cannot be hurried—time is needed to allow the
relationship to develop, in the hope that out of that will come what Aristotle
termed eudaemonia (or flourishing).
This is the achievement over the person’s life of the good after which we
all strive; the achievement of excellence.
Diminution of
stress—Being a resident doctor has always been stressful. Current
employment conditions in New Zealand aim to reduce that stress and to protect
from fatigue and the chance of error resulting from that fatigue. There has been
a recent paper expressing the concern that a new regulation in the US
prohibiting residents from working more than 80 hours in a week (and more than
24 hours continuously) may seriously interfere with the development of skills
and of professionalism.3
While that extreme view is untenable, there does seem little
doubt that there are problems faced by residents in meeting the requirements of
training, in the sense of the breadth of experience, within a practicable
timeframe. However, extending the hours of work, and decreasing the closeness of
supervision, add to the stress experienced by the resident.
A mentoring relationship can help the resident deal with
stress and also assist him/her in gaining the maximum benefit from the
experience he/she has. A report from the United Kingdom
(UK)4 showed that senior house officers (SHOs)
experience psychological distress in proportion to their confidence. Other
factors that increase stress are communication difficulties and organisational
issues. These are all amenable to benefit from a mentoring approach, and are
likely to be more helped by mentoring than by standard supervision.
A resident doctor who is feeling stressed (due either to
workload or to problems related to knowledge and/or skills) may be anxious about
confiding that to the supervisor whose report will have a significant impact on
future employment opportunities. Additionally, the supervisor-trainee
relationship is a relatively brief one, which may be perceived by the resident
doctor as not supportive enough to foster the trust needed for safe exposure of
difficulties.
A Nottingham (UK) survey5
found that 25% of SHOs reported an absence of feedback on work performance, and
25% also reported an absence of advice about career development. Over 75%
believed that careers-counselling was essential. There was also an unmet need
for counselling related to particular difficulties, with almost 50% of SHOs
saying that they wanted this as well as regular performance appraisal.
The addition of mentoring to the supervision process in
current practice, with appropriate strengthening of the supervisory requirements
on the supervisors, will begin to meet some of these needs for guidance and
support through the difficult formative years.
The mentoring relationship continues over several
attachments and stages of development, allowing the mentor to focus on
longer-term growth rather than the much shorter-term educative goals of
supervision. The main precept for the mentor is that of having the best
interests of the mentored person at heart.
Career
development—Having the support of the right person. such as a
referee or mentor, can help in career advancement. The mentor is able to
‘groom’ the protégé and assist him/her in developing
what is needed for success. Ragins and Cotton6
reported that protégés of mentors were more successful in their
careers than non-mentored individuals. Their report, which showed that
informal-mentoring relationships were more successful than formal relationships,
may be connected with a better fit being achieved in the informal,
‘voluntary on both sides’ relationships.
Informal mentoring relationships too often result in white
men being the protégés of white
men.7 As the protégés of
(generally powerful and influential) white men tend to do considerably better in
appointment to sought-after and highly-paid jobs, it is important that a
mentorship programme is organised in such a way as to spread that influence more
widely. Indeed, mentor protégés are generally better educated,
earn more at a younger age, tend to follow a career path, and report high job
satisfaction.8
Proposal for the futureResident doctors will benefit
greatly from having a mentor-protégé relationship with a senior
colleague. Such a relationship is likely to help the resident doctor deal with
the stresses experienced in training, to guide them in their career choice, and
to assist in career development. Furthermore, the mentored doctor is more likely
to achieve success in academic and clinical practice.
Frequent and informal mentoring relationships undoubtedly
occur, varying from highly successful to relatively ineffective. A programme to
develop mentorship will likely move more resident doctors towards the successful
end.
There is debate surrounding informal versus formal mentoring
programmes, rather than mentoring per
se. As already mentioned, Ragins and
Cotton6 found that protégés from
informal mentoring were more successful than were those from formal programmes.
This may reflect the choices made in informal relationships; that mentors tend
to choose someone more like themselves. This, of course, will produce a better
‘fit’, which is necessary for the best outcomes.
However, despite the seemingly positive aspects to informal
mentoring, their infrequency does mean that many young doctors who may benefit
will miss out. Regarding the low numbers of women and ethnic minorities in some
areas of medicine, informal mentorship will probably not change that. Therefore,
establishment of a formal mentorship programme in all DHBs is
advocated.
Senior doctors should be asked to volunteer as
mentors—these doctors would be asked to fill the mentor’s role of
‘teaching, coaching, supporting, counselling, and sharing information with
the protégé’.9 The doctors
who volunteer for (and accept) this mentoring role, which is a significant
addition to their current workload, are likely to benefit from training in the
role.
Having a formalised mentorship programme will more readily
permit the development of such training. It will also remove, or at least
diminish, the possibility of resistance to mentoring from the resident doctors
who may perceive mentoring as a statement that they are failing somehow. Group
mentorship may occur, provided that every individual willingly joins in the
group, and has access to individual time with the mentor as and when needed or
wanted.
Medical mentorship within the New Zealand district health
board (DHB) structure would need the backing of the chief medical advisors. Both
as a group and individually, the chief medical advisors are influential in the
development of young doctors through their responsibility for various clinical
and resource issues affecting training and career choice.
The chief medical advisors have the opportunity to be
instrumental in the development of a mentorship culture, which will enhance the
development of all younger colleagues. This should then help resolve some of the
shortages of personnel in some specialties, and may also address the gender and
ethnic mix.
Author information:
Allen Fraser, Chief Medical Officer, Waitemata District Health Board, Takapuna,
Auckland
Correspondence:
Allen Fraser, Chief Medical Officer, Waitemata District Health Board, PO Box 93
503, Takapuna, Auckland. Fax: (09) 441 8957; email: Carol.Thompson@waitematadhb.govt.nz
References:
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