Levine, Rachel B. MD, MPH; Mechaber, Hilit F. MD; Reddy, Shalini T. MD; Cayea, Danelle MD, MS; Harrison, Rebecca A. MD
Today, women make up approximately 50% of medical school classes1 and close to 30% of the physician workforce, a number that is expected to continue to increase in years to come.2 With the composition of the medical workforce changing, the career decisions, practice patterns, and approach to patient care of current female medical students will have a profound impact on the profession.3 Female physicians have experienced unique challenges in medicine, including gender discrimination, sexual harassment, salary discrepancies, underrepresentation in certain specialties, disproportionately fewer female associate and full professors at academic health centers (AHCs) and in leadership roles, and work/life balance issues, all of which may negatively affect their professional experiences.4–11 In addition, gender-related experiences, such as stereotyping and harassment, may have a significant influence on female medical students and their development as future physicians. A recent study of female clerkship students, for example, found that gender played a key role in their formative professional experiences, contributing at times to a sense of isolation and loss of self-confidence.12
Mentors serve as role models and guides for students by providing support, building skills, and creating access to professional opportunities. Exposure to rewarding mentoring experiences may help to mitigate some of the negative influences that women in medicine face. Mentors are instrumental not only in relaying knowledge to help students master explicit curricular content but also for sharing implicit knowledge about the “hidden curriculum,” including professionalism, ethics, the art of medicine, and other topics not learned in the standard medical school curriculum.13 Mentors also may provide emotional support and encouragement. Accordingly, most educators agree that some type of mentoring or advising assists students in their personal and professional development and with career planning, and many medical schools have programs that link students with faculty.14–17 However, for many students, mentoring remains a haphazard endeavor or absent entirely from their medical school experience.18 This may be particularly true for women and underrepresented minority students, two groups who may benefit most from mentoring.19 This lack of meaningful mentorship opportunities for women is commonly described in the literature as a barrier to career advancement and satisfaction for female physicians.7,20 In addition, female students may be discouraged by the challenges facing female faculty, which may affect their expectations or ambitions for their own careers.
In medicine, we have not yet identified best practices for mentoring and advising medical students in general, including the structure of mentoring relationships and the content and timing of interactions. Gender issues add complexity and the potential for additional challenges in mentoring relationships.21 For example, recommendations to support women in medicine include providing female mentors for female trainees and junior faculty. In fact, in some studies, female residents and faculty report a desire for female mentors.22–24 Yet, researchers have not established that gender-concordant mentoring pairs are beneficial, and these findings may not be generalizable to all medical students. Thus, although gender is believed to be important for mentoring, little is known about the perceived influence of gender on female medical students’ mentoring experiences. We conducted a qualitative study to gain a deeper understanding of the mentoring needs of female medical students and the role that gender plays in their mentoring experiences.
Study design and sample
We performed a qualitative study involving focus groups of female medical students at four large U.S. medical schools reflecting both regional diversity and a mix of public and private schools. The four schools included Johns Hopkins University School of Medicine, University of Miami Miller School of Medicine, University of Chicago Pritzker School of Medicine, and Oregon Health & Sciences University School of Medicine. We targeted third- and fourth-year female medical students, hypothesizing that they would have had a wider spectrum of mentoring experiences during medical school. We used a purposive sampling strategy that began with obtaining the names and e-mails of third- and fourth-year female medical students from the respective registrars offices at each medical school. We then sent out an e-mail explaining the study and inviting students to participate. We included in our study the first 12 to 16 students at each medical school who responded and who were available on the dates we scheduled the focus groups. We conducted two focus groups of 6 to 8 students at each of the four participating medical schools. The institutional review board at each participating medical school approved our study.
We developed a focus group guide using the current literature on mentoring/advising and the experiences of women in medicine.4–11,13,14,17,25 We used an iterative process to finalize the focus group guide, as all members of the study team have experience mentoring and advising medical students. We also solicited feedback on the content of the focus group guide from individual female medical students who were not involved in our study, and we made the appropriate changes according to their feedback. For our purposes, we defined a mentor as “a person with whom one meets for advice on any topic. This may be a one-time interaction or an ongoing relationship.” We used this definition as a framework for developing the focus group questions and also for analyzing the data that we collected. To ensure that this definition did not limit the focus group discussions, we did not provide participants with the definition, and we used the terms “mentor” and “advisor” interchangeably. The focus group questions first asked female students to describe their experiences with all mentors regardless of gender, and later questions asked specifically about their experiences with female and male mentors. See List 1 for the final focus group questions.
A member of our study team or a trained female facilitator conducted the focus groups between January and May 2011. Focus groups lasted 60 to 90 minutes, and we audiotaped, deidentified, and transcribed each. To ensure the anonymity of participants, we collected only limited demographic data at the start of each focus group, including age, medical school year, relationship status, children, and career specialty. We also obtained written informed consent from each participant. Finally, we provided students with a nutritious meal during the focus groups in appreciation of their participation.
A single member of the study team (R.B.L.) read all the transcripts and used a “template organizing style” to identify initial categories and create a provisional coding template. Using this method, she read the transcripts to identify meaningful segments of text that both stood on their own and were related to the purpose of the study.26 Each remaining member of the study team read two of the eight transcripts and used the same analysis method and provisional template to code categories from the transcripts. We then met as an entire study team to modify, add, and delete categories to create a final coding template. Next, we organized the categories in the coding template into themes and subthemes. Finally, a member of the study team (R.A.H.) read all the transcripts to confirm the final coding template and themes and to work with another member of the study team (R.B.L.) to choose representative quotations for presentation.
Forty-eight third- and fourth-year female medical students participated in one of our focus groups. See Table 1 for complete demographic characteristics of the participants.
We identified four major themes regarding the mentoring experiences of female medical students: (1) Optimal mentoring relationships are highly relational, (2) relational mentoring is more important than gender concordance, (3) gender-based assumptions and stereotypes affect mentoring relationships, and (4) gender-based power dynamics influence students’ thinking about mentoring. In the following paragraphs, we present in greater detail these themes and subthemes (see Table 2 for additional representative quotations).
Optimal mentoring relationships are highly relational
In successful mentoring relationships, respondents noted that mentors took the time to get to know them by asking about their career interests and their lives outside of medicine. When respondents felt that their mentors really knew and cared about them, they reported that the advice they received was more valuable. Respondents also reported that a sense of partnership, alignment of values, and a focus on the student’s best interest were important features of a successful mentoring relationship.
Being known on a personal level, trust, and personal connections. One respondent described a mentoring experience that was particularly helpful when she was seeking career advice:
You have to feel like they care about you as … a human being because if they care about you they are going to get to know you as a person and then advice is more tailored to you.
Being known on a personal level helped to create a mentoring relationship in which the respondent felt safe and was willing to share all of her concerns. In addition, trust and a sense of connectedness with a mentor were recurring features in respondents’ descriptions of positive mentoring relationships.
Reciprocity and informality in the mentoring relationship. Respondents recognized and desired reciprocity in their mentoring relationships. They wanted a chance to get to know their mentors as well. The following two quotations demonstrate that respondents felt a greater sense of affinity toward and satisfaction with a mentor who was able to share his or her own personal experiences:
Someone that is approachable and also, even makes themself a little vulnerable, like: “I actually struggled with some things too, I am not perfect and it’s okay and you are going to be fine.”
One thing I found to be great was that many times my research mentors were willing to share things about themselves, their personal background, their struggles, things that they are still trying to master as professionals. I thought that … was refreshing.
Respondents also alluded to a desire for mentoring relationships that were less hierarchical and more informal. They saw informality as a way to achieve greater personal knowledge of a mentor and increased trust and sharing in the relationship.
Relational mentoring is more important than gender concordance
Although respondents identified a distinct need for access to female mentors, many stated that when a mentor and mentee shared values, ultimately the gender of the mentor was much less important. Respondents identified a sense of connection, trust, and shared personal knowledge as more important features than gender concordance in a mentoring relationship. For example, one respondent noted:
I think the people who get to know you are the best mentors. I think I’ve had just as good, if not sometimes better, interactions with male mentors who know me really well and I think that’s more key.
Gender-based assumptions and stereotypes affect mentoring relationships Respondents reported that their mentors made gender-based assumptions and used gender stereotypes. At the same time, they also described their mentors and the behaviors they expected of their mentors using gender stereotypes.
Gender-based assumptions and stereotypes. Respondents reported that they expected female mentors to be more relational than male mentors and more likely to reach out to female students, to support them, and to offer themselves as mentors.
On the other hand, respondents also shared their beliefs that male mentors would be more direct and content-focused and less comfortable with certain discussions, such as those about work/life balance. The following quotations reveal these assumptions about gender-related mentoring behaviors:
Talking to a woman was much less procedural and much less cut and dry and more about looking into yourself and deciding what’s right for you … instead of what the paper says to do.
The females I talked to were very empathic and they usually made time especially if it was any kind of personal issue.
With the man, I talk about my career and where I am going, how to get there, what’s the best strategy.
Navigating gender-based assumptions and stereotypes. Respondents were influenced by gender-based expectations and sought out female or male mentors accordingly. For example, respondents felt that women had unique experiences in medicine, so they specifically sought out female mentors to provide their perspective. One respondent was considering a career in academic medicine and explained why she felt compelled to talk with a woman who had taken a path similar to the one she envisioned for herself:
I really wanted to talk to somebody about how it was possible, whether or not it was possible to have a pretty ambitious research career and practice clinically, and still show up at home and be present.
Respondents who were interested in traditionally male-dominated fields like surgery expressed an even greater sense of urgency about connecting with female mentors:
I’m looking into surgery…. I just want to make sure that I’m not missing anything from that perspective, and I think having someone who’s gone through that—the process of surgery training as a female—I think it would be really helpful to have that perspective.
Respondents also described a tension with regard to gender stereotypes in their mentoring relationships. They believed that, because of their gender, they were more likely to be asked certain questions compared with male students.
Many respondents felt that their gender had an impact on the advising that they received regarding their career choice. One respondent, who was interested in surgery, expressed frustration with the limitations that she believed her gender placed on her mentoring experiences:
When gender starts to drive the conversation, I can’t even tell you the number of times I’ve heard the phrase “It’s a good career choice for women” … which just drives me up the wall … phrases that would never be spoken to my male counterparts.
Respondents expressed a desire to move beyond gender stereotypes in their interactions with mentors. In mentoring conversations, respondents wanted to focus on their own personal concerns instead of issues related to their gender.
Differing standards for mentors based on gender. Respondents reported different standards for female and male mentors and remarked that they noticed when mentors strayed from their gender roles. One respondent described her interaction with a male mentor who reached out to her to discuss “women’s concerns”:
I sought [a male mentor] just for a professional reason, not to talk about work/life balance…. I was just going for advice on matching and residency programs and he … took me by surprise and asked: “Well, tell me all about your personal life. Are you single or are you married?” … so we ended up talking about the work/life balance and the unique role of, you know, having a career in academic medicine as a female and balancing your personal life. I wasn’t expecting him to have such a broad range of views, being of the opposite gender, but he did.
Gender-based power dynamics influence students’ thinking about mentoring
Respondents linked gender with power in many of their mentoring experiences. For example, respondents perceived that they had limited opportunities for sponsorship (in which their mentor was in a position of power and could provide resources or exert influence to promote them) and networking from female mentors. Respondents also reported that having a male mentor, in particular one who was in a position of power (such as a residency program director), sometimes inhibited the scope of certain discussions when they were concerned about how their professional decisions would be perceived because of their gender, particularly when they considered their personal responsibilities or desires in making decisions about their career.
One respondent highlighted the way in which men have much more exposure to informal networks and how her gender might limit her inclusion in those networks:
The guys in anesthesia have this relationship with the attendings, where they are like, “Let’s go out to a bar.” If a male attending asked a female student to go out to a bar, it would be a totally different connotation.
Respondents also mentioned a concern about discussing career decisions with mentors who may ultimately have some influence over their career. One respondent felt inhibited about sharing her motivations to rank certain residency programs specifically because she was considering the needs and desires of her partner in her decision:
I will share the truth but I fear being judged for being less competitive when it’s a male [mentor] when I choose to factor in my personal life into my professional decision making.
Our study confirmed that female medical students intentionally seek high-quality advising relationships from mentors while navigating complex arenas in their personal and professional lives. They described successful mentoring experiences using relational and values-based language. Our analysis also revealed that gender contributes to and shapes the lens through which female medical students experience mentoring. In particular, some mentors perpetuate gender-based assumptions and stereotypes, which then interact with the power dynamics present in mentoring relationships. Recent studies support our findings linking gender with trainees’ self-perception of performance, valuing of gender-stereotyped behaviors, self-confidence, sense of isolation in the profession, and external performance evaluations.12,27–30 Our findings confirmed how pervasive and influential gender remains in mentoring and in medicine and the potential impact that this interaction has on the career paths of women in medicine.
Female medical students reported valuing “relational” mentoring and described “mentee-focused” relationships in which their mentor both got to know them as a person and respected their priorities as the most successful. While recognizing the relationship component of mentoring, the prevailing culture in medicine has more often resulted in hierarchical, outcomes-focused interactions between mentees and mentors.31,32 Relational mentoring, as described by the students in our study, emphasizes connection as a core value. Suchman33 argued that a relational approach in medicine promotes greater partnership by focusing on process, exploring subjective experience, using power to benefit others, and discovering the uniqueness of the situation and individuals. Mentees who are invited to share both their personal and professional goals in a trusting and informal setting experience relational mentoring. The students in our study were more receptive to the advice that they perceived to be relational in nature, from a mentor of either gender, because they felt it reflected their unique needs. They were more likely to view recommendations from mentors that were rooted in more general knowledge as not helpful. For example, some mentors encouraged students to apply to residencies based solely on the reputation of the program, not on the students’ interests and priorities.
Recent studies on the environment at AHCs suggest that women may disproportionately experience the negative consequences of the less relational aspects of the academic medicine culture.32 For example, women view AHCs’ hierarchical and competitive structures as barriers to career advancement.34 The students in our study shared similar experiences—They recognized that mentoring relationships that deemphasized hierarchy were superior to those more hierarchical relationships. A more concerning finding, however, is that students expressed reservations about fully disclosing their decision-making processes in hierarchical situations (in conversations with potential program directors, chairs, or deans) because they feared that they would be scrutinized differently than male colleagues. The current hierarchical decision-making and leadership structures at many AHCs, then, may have a profound impact both on the career opportunities available to and the decisions of female medical students.
Addressing the current system of how students acquire mentors may help solve these problems. For example, establishing informal opportunities for mentees and mentors to connect outside of defined roles may ensure that potential mentors know students as individuals beyond the work environment. Structured mentoring programs should make every effort to separate evaluation from advising to ensure that students feel comfortable sharing their true concerns with their mentors without fear of repercussions or bias.
The question of whether gender concordance in mentoring relationships is necessary seems to be a complex one. In their systematic review of mentoring in academic medicine, Sambunjak and colleagues35 did not find a clear preference or benefit for gender-concordant mentoring for women in medicine. Although students in our study expressed a preference for relational, values-based mentoring regardless of the gender of the mentor, they also reported specific situations in which they desired a female mentor, such as hearing the unique perspective of being a woman in medicine. This desire was particularly salient for students who were pursuing careers in traditionally male-dominated specialties and for those seeking advice regarding personal issues and work/life balance. Students recognized that women offered a unique perspective regarding bearing children and managing family and work, and they felt more comfortable raising these issues with women.
Gender-based assumptions and stereotypes contributed considerably to female medical students’ mentoring experiences. For example, students expected female mentors to interact with them on a more personal level and to be better listeners, more supportive, and less directed (not acting as “fixers”) in their advice compared with male mentors. In general, students described male mentors as better suited to provide factual, data-driven, or informational advising. This type of stereotypical thinking leads to the formation and perpetuation of “gender schemas,” which contribute to our nonconscious thinking (and implicit biases) about the differences between women and men. Such gender schemas play a central role in shaping men’s and women’s professional lives.36 They affect our expectations of behaviors and our evaluations of work and performance. Implicit gender-based biases may contribute to many of the inequities faced by women in medicine. For example, women in academic medicine receive lower pay, fewer institutional resources, and less grant funding than men.6,10,37
Gender schemas contribute to the socialization and rewarding of certain behaviors and the rejection of others. For example, women are expected to be “communal” (nurturing and supportive), whereas men are expected to be “agentic” (individualistic and competitive).38 In our study, female medical students who did not receive the expected empathy or connection from female mentors made note of it. Conversely, they favorably viewed male mentors who were empathic listeners and who demonstrated interest in their personal values. This incongruity may indicate a desire for a more relational approach to mentoring in which students clearly valued a personal connection over gender concordance. On the other hand, female medical students also may hold mentors to a different set of standards based on gender stereotypes. If this is the case, efforts should be made to increase both student and faculty awareness of gender-based stereotypes and their influence on mentoring relationships. One way to accomplish this task is to establish a mutually agreed-on process between mentors and mentees for addressing gender-related issues at the start of a mentoring relationship.21
In our study, the students were keenly aware of the impact of gender on their professional careers. They experienced an uneasy tension between understanding when gender might enhance their career opportunities and when it might limit them. For example, some mentors told students that certain career paths were a good choice for women and might even increase their chances of matching in a competitive, male-dominated specialty. The students also wondered whether their gender limited the scope of the discussion around their career choice, and they viewed their gender as a potential hindrance for networking and sponsorship opportunities. For example, the students in our study reported that networking and sponsorship were mediated by the gender of both the mentor and mentee. Just as they believed that they would not be invited to participate in male-dominated networks, they also perceived female mentors as unable to provide access to key networks.
Sponsorship, as a distinct component of mentoring, represents the capacity of a mentor to “make things happen” through personal connections, knowledge of how systems work, and access to power and leadership. Sponsors are typically senior leaders with significant influence. The literature supports that a lack of sponsorship is a fundamental reason why fewer women make it to top leadership positions in the business world.39 The students in our study appeared to have made their own calculations about sponsorship and gender. They reported seeking out male mentors for access to career support because men are more often program directors, chairs, and deans and in positions to provide sponsorship. The lack of women in influential positions represents a diminished pool of potential female sponsors for medical students. Data from the Association of American Medical Colleges support students’ observations in our study that there are few women in leadership positions in medical schools despite the growing number of female trainees.40
Efforts to increase the number of women in positions of power may have a profound impact on the experiences of female medical students. However, such efforts also must target the general perception of women’s potential for successful leadership. Despite the pervasive assumption that men and women have very different leadership styles, a recent study found that female business leaders were rated higher on all aspects of leadership except one—“envisioning,” a term describing a leader’s capacity to share a compelling vision or mission for moving his or her work forward. Perception may be at the core of this finding. For example, because women may feel that they are less likely to be taken seriously as leaders, they may present their ideas in very concrete and practical terms with data to back them up, as opposed to presenting ideas as broad visionary concepts. Also, because women tend to work collaboratively, they may not receive credit for their ideas.41 The students in our study shared a concern that women in medicine were not in positions of power, primarily because of a lack of visibility. However, the perception that women are not effective leaders may have influenced this dynamic as well.
We recognize that our study has several limitations. First, our findings may not be representative of all female medical students. Although our study included participants from four large schools of medicine with a mix of public and private institutions and regional diversity, there may be unique features of our study sites that influenced our findings and limit their generalizability. Similarly, students volunteered to participate in our study and may have had specific, unique mentoring experiences (positive or negative) that inspired them to participate. Second, our study team and focus group facilitators were all women. Although this may have enhanced the students’ comfort in discussing gender-related mentoring experiences, it also may have influenced the discussions in other ways. Finally, as in all qualitative research, the experiences and biases of the study team may have influenced the findings.
The next 20 to 30 years in medicine hold the potential for profound changes in response to ongoing demographic shifts in the profession. Our findings present a glimpse of what those changes may be as they pertain to the mentoring experiences of female medical students, who desire relational, values-based mentoring that also offers opportunities for sponsorship. Gender seems to play a complex role in students’ expectations of mentors and mentoring relationships. Furthermore, many students desire to move beyond gender-based stereotypes. Our study also may serve as evidence to encourage mentors to know the needs and values of their mentees, to be aware of the influence of their “gender lens,” and to embrace their own innate strengths and style of mentoring, whether they follow gender stereotypes or not. As medical school leaders continue to incorporate in the curricula opportunities for structured mentoring between students and faculty, our study offers several key areas for these mentoring programs to address, including promoting relationship- and trust-building, encouraging less hierarchical interactions, and increasing transparency around gender-related assumptions and expectations. Future areas of research include assessing the role of gender in mentoring for male medical students and from the faculty mentor perspective.
Acknowledgments: The authors would like to extend their appreciation to Dr. Joe Carrese and Janet Bickel for their thoughtful comments on this report.
Funding/Support: This study was supported by funding from the American Medical Association’s Women Physicians’ Congress, through a grant from the Joan F. Giambalvo Memorial Fund.
Other disclosures: None.
Ethical approval: This study was approved by the institutional review boards at the Johns Hopkins University School of Medicine, University of Miami Miller School of Medicine, University of Chicago Pritzker School of Medicine, and Oregon Health & Sciences University School of Medicine.
Previous presentations: A version of this report was presented at the American Medical Association national meeting, Chicago, Illinois, June 2011.
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