Levy, Bruce D. MD; Katz, Joel T. MD; Wolf, Marshall A. MD; Sillman, Jane S. MD; Handin, Robert I. MD; Dzau, Victor J. MD
Mentoring relationships between house officers and hospital staff physicians are an integral part of internal medicine training. Interns and residents actively seek connections to faculty members, especially during transitions in their careers.1 The emotional needs and questions regarding professional development may differ from year to year, but house officers place significant value on the availability of mentoring relationships with faculty that are confidential, informative, nurturing and, most notably, outside the evaluative relationships they share with their program directors. Successful faculty careers usually benefit from the counsel of one or more mentors.2–5 As evidenced by the frequent queries of internship applicants, the potential value of mentoring during residency and career development is a lesson learned early.
The responsibilities and stresses of internship and residency are substantial. Over the last decade, the severity and complexity of illness in hospitalized patients have increased, while length of stay has shortened. Faculty are generally less available to housestaff because of increased clinical, research, and/or administrative demands.6 In addition, residents often have personal responsibilities to significant others. The cumulative effect of these factors has a potentially serious impact on house officer morale and job satisfaction. Recent estimates indicate that more than 75% of residents suffer from burnout that affects performance, and more than 50% screen positive for depression.7,8 It is critical to identify the individual needs of interns and residents and assist them during this vulnerable period of their career, or the profession runs the risk of training a generation of dissatisfied and unhealthy physicians.
Mentors are often the individuals best suited to provide such help. Individual advocacy and attention to the career development needs of each house officer constitute the definition of effective mentoring. A mentor is distinct from a supervisor, preceptor, or role model.9 A supervisor is charged with critically watching and directing. A preceptor is focused on teaching and learning. A role model may have brief and distant exposures to a trainee, and be unaware of his or her impact on the trainee. In contrast, a mentor engages in an interactive, ongoing relationship with his or her mentee. In addition, mentors usually have mentoring relationships with only a few individuals, while a role model can affect many.9–11 An outstanding mentor is wise and resilient, exercises sound judgment, and encourages independence when his or her mentee is ready.12 The successful mentor helps mentees to identify and achieve their personal goals and supports them with emotional and practical advice. Mentors instill in mentees a sense of belonging and invest time and trust in their mentoring relationships.13 A 1998 survey of 188 internal medicine interns and residents identified several attributes of excellent attending-physician role models.14 In addition to enjoying teaching and devoting more time to education in the clinical setting, excellent attending-physician role models actively built relationships with trainees14—an activity more typical of mentors than role models.
Because the increased demands placed on both faculty and housestaff now threaten traditional mentoring relationships, the Department of Internal Medicine initiated a program at our institution in 2000 to increase the frequency and quality of housestaff mentoring and to recognize faculty contributions toward residents’ career development. At the end of the 2002–03 academic year, we asked our internal medicine housestaff to confidentially assess the program's effectiveness. In this article we present our experiences when initiating this formal mentoring program and, interwoven into the narrative, provide the housestaff's feedback on their mentoring relationships.
The time required for faculty to build relationships with trainees is largely uncompensated, undervalued by the institution, and difficult to find amidst busy schedules. Regrettably, the fundamental tenets of mentoring have been threatened by increasing demands on faculty time as well as the current criteria for academic advancement in medicine.15 Benchmarks for promotion in many academic institutions are based almost entirely on scholarship rather than citizenship. Career pressures can fuel in faculty a self-focused attitude on publishing and grant writing that leaves little room for mentoring.15 While interns and residents can be trained by supervisors, instructed by preceptors, and inspired to pursue an academic career by role models, effective mentoring is essential for facilitating successful career development in academic medicine, especially for budding clinical investigators.
To promote the mentoring activities in our Department of Medicine at the Brigham and Women's/Faulkner Hospital, our internal medicine residency program faced several challenges common to such programs in teaching hospitals. The 172 interns and residents on the medical housestaff during 1999–2000 at the Brigham and Women's/Faulkner Hospital had educational opportunities and service responsibilities at four different hospitals and 20 different ambulatory care settings. Interns, residents, and faculty often switched rotations every two weeks. The large size of our housestaff and short duration of time on rotations resulted in decreased contact with senior academic faculty. Faculty–housestaff mentoring relationships developed spontaneously for few of the housestaff, with a small number of faculty assuming a disproportionately large burden of the housestaff mentoring. Moreover, the time faculty spent mentoring was not tracked by our department and often went unrecognized, and mentoring excellence was not rewarded.
In view of these challenges, three years ago the Department of Medicine initiated a mentoring program that pairs individual housestaff and faculty. The goals of this program include
* developing an effective means to provide faculty assistance with the trainee's professional and personal development and a safe way for the trainee to express concerns and obtain guidance,
* encouraging careers in academic medicine,
* demonstrating the department's commitment to the career development of each member of the housestaff, and
* encouraging and recognizing faculty's efforts in mentoring.
This program was not meant to replace spontaneous mentoring pairs, but rather to meet the career development needs of the housestaff more broadly and create an environment that values and encourages mentoring.
Despite the more formal approach of structured mentoring programs, they can have a significant effect on the professional development of medical trainees,16 as reported in one of the very few reports of formal residency mentoring programs that exist.
The basic structure of our housestaff mentoring program strives to provide a durable, comfortable, and confidential relationship between individual faculty and house officers that is not part of the house officer's formal evaluation. The primary focus of this mentoring relationship is on career development and personal needs.
Internal medicine faculty members were asked to volunteer to participate as housestaff mentors, and over 80 faculty members agreed. Each faculty member was assigned one to three members of the housestaff as mentees. Individual relationships last as long as each mentor–mentee pair find their relationship productive. Participating faculty were asked to make a three-year commitment in order to provide the trainees with continuity during their tenure in our residency program. In addition to individual mentee assignments, mentors were also divided into groups of five or six faculty mentors with varied academic, clinical, and administrative careers to increase the diversity of faculty exposure for the house officers and facilitate social interactions. Faculty from each mentor grouping were asked to host a social event once or twice a year outside the hospital (around five faculty and ten house officers in each group). These small-group activities were also designed to enhance faculty–faculty interactions.
A good mentoring relationship requires a certain personal chemistry. Both the mentors and house officers were asked to make the relationship a high priority. Given this commitment, either the mentor or mentee could suggest a change if one or both believed that a different combination would foster a better mentoring relationship. To maximize flexibility and encourage the formation of spontaneous mentoring relationships, no reasons are necessary to effect a change. If needed, the program directors work with the house officer to find a new faculty mentor within the department. Over the last three years, 15–20% of the pairs have been changed each year, with the majority prompted by either the development of new spontaneous mentoring relationships or a change in the resident's career goals.
Much of what is discussed between a mentor and a mentee depends on what questions and concerns are raised by the mentee. When the 2002–03 medical interns and residents were surveyed, the vast majority of them highlighted the need for guidance with career decisions and planning (Table 1). Other topics requested have included assistance with personal and adjustment problems and general encouragement and support through difficult periods of training. While the house officer's professional development and personal needs are the focus of the relationship, mentoring discussions have covered a variety of issues, such as experiences on the wards, interactions with patients or other providers, the type of training opportunities the house officer should be pursuing, and the house officer's goals regarding elective rotations. Some have found the mentoring relationship useful to address such matters as work load, time management, striking an appropriate balance between professional and personal/family obligations, career expectations, and other matters where a “reality” check might be helpful.
Faculty mentors are provided with several resources to assist them in their mentoring responsibilities. Each mentor receives (1) a detailed memorandum that outlines the governing principles of the mentoring program, (2) a curriculum vitae for each mentee, (3) a resource fact sheet that outlines confidential contact information for housestaff-related matters (e.g., loan and housing information, legal assistance, and fellowship director contact information), (4) quarterly e-mails from the Medical Education Office to remind mentors to meet with mentees and to provide faculty with updated information regarding changes in the residency programs and general housestaff morale, (5) invitations to several housestaff events, and (6) a small stipend to help cover expenses incurred while meeting with their mentees.
The success of the program depends on a mutual understanding that a house officer's confidences within the mentoring relationship must be maintained. A house officer can therefore expect a faculty mentor to maintain confidences, being mindful that in certain extraordinary circumstances (e.g., instances of harassment, professional malpractice, or dangers to themselves or others), both the mentor and house officer may have an independent obligation to report to the department. Also, a faculty mentor may appropriately discuss with the residency program directors certain work or training issues, provided that their mentee has requested such direct assistance. The relationship is a “safe haven” for the house officer. No part of the mentoring relationship is considered appropriate material for any house officer evaluation. In short, all is confidential except when disclosure is legally required or when mentees request disclosure or approve it.
Time is a precious resource for both faculty and housestaff. The time commitment for faculty mentors is modest, but the impact of the faculty mentors’ attention on mentees is likely to be substantial. Without the discipline of an established meeting time, mentors and mentees often succumb to the temptation to just “find time” on an ad hoc basis. Mentoring ultimately succeeds or fails based on each participant's level of commitment.17 External enforcement mechanisms cannot produce effective mentor–mentee relationships, especially in view of the pressing demands of clinical, administrative, and research activities on faculty time. In large measure, faculty members add mentoring to their already full portfolios of professional activities.
Given the clinical and physical demands of internship and residency, it is also frequently difficult for housestaff to find time for meetings with faculty. To facilitate these meetings, housestaff can utilize the medical education office for assistance with mentor appointments. Despite an effort to confine these professional development activities to the workday, mentoring is often viewed as “extracurricular”; frequently, individual or group meetings will occur over dinner or during a weekend social activity. To enhance faculty–housestaff interaction during the care of hospitalized patients, housestaff rotations have been extended from two to four weeks whenever possible. An Internet Web site has been created that lists the principles of the mentoring program, individual faculty mentor interests and contact information, as well as a list of resources for housestaff. To improve faculty mentoring activities and help identify the qualities of mentoring that are distinct from supervising, precepting or serving as a role model, the top ten attributes of an effective mentor are listed on the mentoring Web site (Table 2).
At the end of each year, interns and residents are asked to respond to a brief confidential questionnaire to provide feedback on their mentoring experiences and make recommendations to improve the program. After institutional review board approval, our 2002–03 internal medicine housestaff were asked to complete a new questionnaire that was administered confidentially via the Internet. The overall response rate was 73.8% and was similar for interns and residents at 74.3% and 73.5%, respectively (Table 3). The most recent survey (carried out in 2003) revealed that over 90% of the housestaff thought it important that the department should assign a faculty member to serve as a personal mentor during residency. Faculty are asked to meet with each of their mentees a minimum of two times a year and to be available for urgent or emergency consultation. In practice, the number of meetings between mentees and mentors varies widely, with 58% of the pairs meeting at least twice a year and 28% meeting more than four times a year. Scheduling difficulties account for the majority of failures for the pairs to meet. Approximately half of the pairs choose to augment their interactions by communicating via e-mail, and 52% of the house officers who do this have sent messages two or more times to their mentor within the last six months. The exact format of the relationship is left up to the mentor and mentee. Of note, 50% of housestaff requested even more frequent meetings with their mentor, with many feeling responsible, in part, for the low number of meetings because of busy clinical schedules. The assigned mentors were judged by housestaff to be helpful 71% of the time and available to help 77% of the time when needed.
Housestaff are developing spontaneous mentoring relationships with another (unassigned) faculty member more frequently (true for about half the housestaff) than before the initiation of the structured mentoring program (true for fewer than a fourth). Of interest, only 17% of the housestaff requested a change, as most favor turning to this “accidental” mentor as an additional source of support. Reflective of some of the interpersonal awkwardness of assigning a mentor, only 50% of the housestaff reported that their faculty mentor got to know them as an individual. In practice, the majority report a focus on professional aspirations in the relationship. It is still too early to assess the influence of this mentoring program on the professional choices of our residency graduates because most of those involved in this new mentoring program over the last three years are still in residency or fellowship training. In addition, identifying a direct link between mentoring and career development outcomes is likely to be difficult secondary to confounding by several concomitant factors affecting training, such as the initiation of new regulations on work hours mandated by the Accreditation Council for Graduate Medical Education.
To enhance faculty participation in mentoring, the department made several changes in the faculty evaluation process. As part of their annual self-evaluation, faculty now report participation in mentoring activities and are also asked to list their personal mentors, which raises the visibility of mentoring and enables the department to identify its most effective mentors. Faculty are encouraged to report their participation in the formal housestaff mentoring program on their curriculum vitae, which contributes towards academic promotion. Coupled with the resources provided to mentors (as described earlier), acknowledgment of their mentoring activities serves to enhance faculty interest, enthusiasm, and commitment. The department also sponsors a series of grand rounds by leaders in U.S. medicine in which the speakers are asked to describe their career development as well as identify individuals who served as critical mentors. In practice, faculty enjoy mentoring because their interactions with housestaff are rewarding. Faculty volunteers have exceeded the number required for the program.
The department has also established two new mentoring awards to recognize excellence in mentoring by faculty and senior medical residents. The Faculty Mentoring Award is given in recognition of outstanding contributions to the mentoring of physicians-in-training. The Senior Resident Mentoring Award is given in recognition of outstanding contributions to the mentoring of medical students, interns, and junior residents. Nominations for these awards are solicited from medical students and internal medicine house officers. In addition to the names of potential honorees, nominators are asked to provide a paragraph explaining how the nominee has contributed to mentoring in the department. To enhance the prestige of these awards and the importance of mentoring, the recipients of these awards are announced during the medical grand rounds celebrating the annual Internal Medicine Education Day.
In summary, we have created a multifaceted program to enhance the mentoring of internal medicine interns and residents. The lack of time to devote to mentoring remains a substantial obstacle. Both faculty and physicians-in-training recognize the value of mentoring, yet finding the time for mentoring activities amidst a busy schedule teeming with clinical, administrative, and research activities challenges even those most adept at time management. From internship application onwards, housestaff are given the clear and consistent message that the department considers mentoring by faculty an important activity and that the department is committed to their individual career development. Faculty are asked to volunteer and provided with informational and financial resources to facilitate successful mentoring. Furthermore, the recognition for outstanding mentoring contributions helps build their resumes for promotion. The department has raised awareness of the value of mentoring through several activities, including establishing the structured mentoring program described here and asking each faculty member to list their mentors as part of their annual self-evaluations.
These efforts provide a mentor for each house officer in our residency and have substantially increased spontaneous mentoring by the faculty. However, the importance of having a formal mentoring program remains, since only around 50% of the housestaff currently develop successful spontaneous mentoring pairs. With increased intensity of the clinical workload, frequent and significant educational loan indebtedness, and a stressful fellowship selection process that asks interns and residents to make early career decisions before they have established clinical competency, the importance of mentoring has never been greater.
In conclusion, the paradigm of the mentor–mentee relationship, which has been a cornerstone of academic medicine, is seriously threatened by time-consuming professional activities. Both faculty and housestaff recognize the value of mentoring to successful career development, but finding time for this important activity is increasingly difficult. The initiation of a formal mentoring program in the Department of Medicine at Brigham and Women's/Faulkner Hospital has ensured that all trainees are provided with a mentor, facilitated faculty–housestaff interactions and increased recognition of faculty contributions to mentoring. A modest investment of time to the assistance of another in training carries significant personal rewards for the mentor. In the words of Albert Schweitzer, “Life becomes harder for us when we live for others, but it also becomes richer and happier.”
The authors would like to acknowledge Kay Coady, Maria DellaRocco, and Stacey Harper for administering to the details of the Brigham and Women's Hospital medical residency mentoring program and their expert assistance in the preparation of this manuscript.