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Mentoring Programs in Academic Anesthesiology: A Case for PROFOUND Mentoring for Underrepresented Minority Faculty

Nafiu, Olubukola O. MD, FRCA, MS; Haydar, Bishr MD

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doi: 10.1213/ANE.0000000000004202
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Mentoring is a critical catalyst for career advancement and satisfaction in many professions and is increasingly recognized as crucial to success in academic medicine.1 Numerous studies have shown that compared to unmentored or poorly mentored faculty members, mentored faculty staff are more confident,2 express higher career satisfaction,3 and are more likely to report fruitful and productive careers.4,5 Mentoring may also help to increase workplace diversity and inclusivity given that availability of mentors is often cited as an important determinant of career choice.1,3 Improved diversity not only improves the work environment, it also increases the quality of science and academic productivity of diverse groups. Recent data indicate that gender-diverse groups tend to produce manuscripts with higher citation indexes.6

Despite these clear and consistent benefits of mentoring, the subject is infrequently addressed in the anesthesia literature.7 Indeed, most published anesthesia-specific work on mentoring have discussed the importance of mentoring8 and a general “how-to” that is in large part a “one-size-fits-all” approach.7,8 Unfortunately, although well intentioned, many of the steps outlined in these publications may not be applicable to underrepresented minority faculty. To date, we are unaware of any publications in the anesthesia literature specifically addressing the mentoring of underrepresented minority faculty in academic anesthesia.

DEFINITION OF TERMS

Although a mentor is sometimes viewed as a role model,9 mentoring goes beyond role modeling (which may be a passive process). Previously reserved for the traditional relationship (eg, between a graduate student and his/her faculty advisor, who works closely within the same field), mentoring in contemporary times may refer to a senior faculty member who works as a traditional mentor, as a connector between individuals or opportunities, as a sponsor to advance faculty into opportunities, or as a coach.10 We will discuss mentoring of underrepresented minority faculty as encompassing all 4 roles.

Mentoring requires active participation in a dynamic, dyadic relationship involving a more experienced (sometimes older) person and a less experienced (usually younger) individual. The former is the mentor; the latter is the mentee or protégé. The mentor’s role is defined by personal, committed interest in the nurturing and success (professional and personal) of the mentee,11 which requires ongoing investment of time and attention through guidance and counseling. It is important to stress that good mentoring is a form of ethical venture capitalism. The mentor is “all in” for the mentee without preconceived notions of success or failure. In some instances, the mentee is wildly successful; in others, not so much. Regardless, the mentee should have full access to all the mentor’s resources throughout the duration of the relationship.

The role of the protégé is to devise and execute plans, both short-term and long-term, that serve his or her personal and professional aspirations using the mentor’s experience and advice as a guide. Both halves of this dyad attempt to strike a balance between providing guidance versus instruction and to respect the limited time and energy of each party. As such, the relationship requires honesty both within and between the mentor and protégé, where misplaced deference or sycophantic behavior can be as limiting as ignoring counsel altogether. Members of the dyad strive to minimize the power differential and to create an atmosphere of safety and trust where authentic discussions about strengths and weaknesses can take place.11 The mentor’s investment into the protégé’s success allows for the extension of the mentor’s academic contribution through the protégé’s work. The protégé then develops into a mentor who may further perpetuate the interests and values of his/her mentor. In this way, the mentorship relationship is the antithesis of a parasitic affiliation because it should extend the life of the mentor’s academic production and influence well past the twilight of his/her career.

BENEFITS OF MENTORSHIP IN ACADEMIC MEDICINE

The crucial role of mentoring for career growth and success is near axiomatic.2,9 Although a dearth of good mentoring is not unique to underrepresented minority faculty, the effect of lack of or poor mentoring on their career trajectories can be disproportionately damaging.9 Several investigators have shown that underrepresented minority groups (including African Americans, Hispanics, Asians, American Indians, and Pacific Islanders) are often unaware of the critical need for good mentoring or, in many instances, are unable to identify mentors committed to their career advancement.9,11 Paradoxically, laudable qualities such as grit, resilience, and self-reliance that were critical for success in medical school and residency may be detrimental to the career growth and success of underrepresented minority faculty.1 After appointment in a nearly homogenous department (where they are often the token minority), junior underrepresented minority faculty generally tend to fend for themselves, often failing to understand the essential ingredients for faculty success and the realities of faculty appointments, tenure, and promotions.

Indeed, the necessity for mentoring may be even greater for underrepresented minority groups for several reasons. They are severely underrepresented in medicine in general and even more so in academic anesthesiology.12,13 Compared to Caucasian faculty, they are often promoted at a lower rate14 and typically report lower career satisfaction.15 Despite recent gains in the recruitment of women and underrepresented minority faculty into academic medicine,1,9 these faculty members are less likely to be promoted, and spend considerably longer periods in probationary ranks such as lecturer or instructor positions.11,14 They are much less likely to be promoted to full professor or hold senior faculty and administrative positions and are less likely to receive and maintain National Institutes of Health awards.15,16

Other frequently reported challenges faced by underrepresented minority groups include marginalization, overt and covert racism, and a disproportionate share of activities that, while important, do not advance careers. These include serving on time-consuming committees, sitting in for the division chief at meetings, serving as liaisons across surgical specialties, participation in community outreach programs, and advising minority students and residents.14 More often than not, underrepresented minority faculty may be unaware that these time-consuming activities are tenure-track traps that do not advance their careers. Unfortunately, even when they know, they may be afraid to turn down such “opportunities” for fear of recriminations, thus creating a vicious cycle.

Recognizing the importance and critical need for mentoring, especially for underrepresented minority faculty, some academic health systems have designed mentoring programs specifically to help minority faculty groups.16,17 The prevalence of such mentoring programs in anesthesiology programs is presently unknown. Where mentoring “programs” exist, they are often a “one-size-fits-all” concept, limiting their impact on the growth of underrepresented minority faculty and making that impact difficult to measure.7,8 Although these “cookie-cutter” mentoring programs (when available) are well intentioned, they may be ineffective in serving the needs of underrepresented minority faculty.

Here, we describe Propulsive, Receptive, On the same page, Fair, Orienting, Unselfish, Nurturing and Durable (PROFOUND) mentoring, which is a practical, easy-to-follow set of metrics for assessing the mentoring of underrepresented minority faculty in academic anesthesiology programs. However, we hope that this mentoring template could be applied to all underrepresented groups, including gender, religious, sexual, culture, and language minorities, as well as individuals with disabilities. The template could also be applied in nonacademic (private practice) settings. While not meant to be prescriptive, these contain many of the essential elements of a good mentor-mentee relationship.

CHARACTERISTICS OF THE PROFOUND APPROACH TO MENTORING UNDERREPRESENTED MINORITY FACULTY

Propulsive

Because this relationship is predicated on success, its primary purpose is to help sustain the drive toward career success and satisfaction in the protégé. Given the unique challenges of being an underrepresented minority faculty member, the mentor can serve several key roles that help sustain the protégé’s drive and progress. A mentor is often a coach, setting specific, time-limited goals, often using Specific, Measurable, Achievable, Realistic and Time-limited or newer frameworks18 that sustain and build career momentum. Effective mentors continually challenge their protégés to higher levels of achievement. For example, a protégé with fear of public speaking should be given (and should seek) multiple opportunities to speak up at local meetings, present abstracts, or give lectures at academic society meetings. Great mentors are willing to advocate for, and even firmly nudge, protégés to accept new assignments, temporary detail opportunities, and different roles. This will ensure deeper and broader personal and professional development through varied experiences within and across departments. Protégés will thus learn adaptability in a hands-on fashion. A third role is to serve as a connector.10 Mentors encourage their underrepresented minority protégés to network because progress can be often be made more rapidly through regional and cross-disciplinary interactions. Effective mentors have a wide variety of networks and contacts that their protégés do not or that protégés may not even be aware they need. This is especially important for underrepresented minority faculty because various aspects of network building within the department, institution, or national societies may be more difficult or inaccessible to them for cultural reasons. These contacts can serve as powerful motivators for protégés as they plan their career trajectory to find specific role models to follow as opposed to needing to blaze a trail de novo. Interaction with committee chairs, division chiefs, or departmental chairs may make these career achievements more tangible and therefore desirable to protégés.

Given that all the desirable features of a great mentor may not be available in a single mentor, mentees must seek and maintain >1 mentor. For example, one can have a highly productive peer-mentoring relationship, but a peer mentor is unlikely to have the social or academic capital to be a sponsor.10 Indeed, having multiple mentors is a surefire way to ensure that the mentee does not just become a clone of his/her mentor.

Receptive

Honesty, openness to feedback, and accessibility are the most essential characteristics in mentorship, although misunderstandings may be more common due to cultural differences between mentors and protégés. Mentors must have the freedom to provide frank unbiased feedback to their protégés, during which underrepresented minority protégés should seek to incorporate as much of the feedback as possible, looking past any unintended potentially discriminatory subtext. Relatedly, access is vital to successful mentor-protégé relationship. This does not have to be a completely open-door policy; mentors can be at a different institution. Regular contact and ready access to the mentor’s wealth of experience, knowledge, and contacts is essential for the protégé, especially early on. While face-to-face meetings have unique value in building this relationship, email, messaging, and telephone calls are essential as well. Frequent mentor-protégé contact is important for asking questions and keeping track of goals. Recognizing that the biggest threat to accessibility is competing work and other life commitments, both parties should seek to make these meetings high-yield encounters.

On the Same Page

Although differences in culture, background, and experience may create some distance in the dyad, creation of a shared vision and set of goals is essential. Although time and effort are limited for both protégé and mentor, the time invested in the “big-picture” perspective is well spent. An effective mentoring dyad shares a mental model of the present status of protégés and how it relates to their future, looking to the past to better understand the protégés’ innate interests and strengths. Strengths, weaknesses, opportunities, and threats (SWOT) analysis19 can be helpful, in which the protégés’ professional SWOT may identify unique challenges to underrepresented minority faculty. As protégés progress in their career, this analysis will likely transition to careful selection and pruning of administration and academic duties, in addition to the consideration of new opportunities.

Fair

This value is indispensable. Justice and equity are as essential in academic pursuits as they are in medical ethics. Within mentorship, this means that each half of the dyad works to keep the best interests of the other at heart. This necessitates free and open communication, recognition of limitations, and selection of new challenges and opportunities appropriately within the reach of the protégé. Just as with other potential conflicts of interest, mentors should disclose their mentorship when advocating for opportunities for their protégés. Diversity is valued in itself within professional societies and can lead to the identification of better solutions.9 Therefore, when advocating for protégés, it is appropriate to give weight to their underrepresented minority status in addition to their other qualifications.

Orienting

Serving as an inspiration and a roadmap is the foundation of mentorship in that it makes defined goals appear more achievable to protégés. In academic anesthesia departments, this could relate to promotion and tenure, intramural or extramural funding, the introduction of cutting-edge clinical techniques to the department, drug or device development, administrative responsibilities, or simply how to be an outstanding teacher, clinician, or role model. Providing milestones for progress, giving perspective by sharing one’s own career trajectory, and putting failures into context help break down a long and occasionally difficult road into realizable and relatively simple small steps.

Unselfish

True mentoring is an altruistic endeavor. Great mentors understand that they may never get a public acknowledgment of their efforts and that investment in a protégé may only yield modest directly tangible fruits; yet they still mentor with zeal. Given that few underrepresented minority faculty are in senior managerial or leadership positions,16 mentoring an underrepresented minority faculty member cannot (and should not) be expected to be a quid pro quo relationship. However, protégés should feel obligated to pay back the investment that others put into their career by maximizing any opportunity offered and by mentoring the next generation of faculty, whether or not they are underrepresented minority faculty.

Nurturing

Another linchpin of mentorship, having a nurturing nature can describe both the content of mentoring sessions as well as the manner in which that content is delivered. Good mentors encourage protégés to be comfortable with asking for help. They emphasize that it is perfectly normal to need professional guidance, emotional support, and feedback on proposals, manuscripts, or grants. An inspirational mentor provides a “safe space” that, with time, protégés use (or need) less often. An example of emotional support or a safe-space provision may be letting protégés know that it is okay to be upset when patients direct all inquiries to medical students or residents after they have introduced themselves as the faculty anesthesiologist or after intensive care unit nurses assumed they were from the laundry department or patient transport even though they have a badge and stethoscope in full view! The caveat here is that both members of the dyad must understand that mentoring is not therapy, and protégés should avoid treating contacts with their mentors as “sob sessions.”

Durable

Like every relationship, misunderstandings are inevitable, but a good mentor-protégé relationship must be able to withstand these conflicts. Willingness to adapt is also critical to a durable mentor-protégé relationship. Taking time to understand the cultural background of protégés is crucial because this affects their world views and relationship to authorities. On the other hand, good mentors are willing and committed participants; therefore, expecting that underrepresented minority faculty members would be willing to mentor another underrepresented minority faculty member may be totally fallacious. Because there are very few underrepresented minority faculty in leadership positions,19,20 simply pairing junior underrepresented minority faculty with senior faculty who “look like them” may not necessarily advance the career of the junior underrepresented minority faculty members. Durability can also refer to long-lasting impact of the mentor on the protégé. Mentoring allows for a part of the mentor to live on long after he/she has left the stage, whether through retirement or through the inevitable.

Mentoring or sponsoring an underrepresented minority faculty may have lifelong or even generational benefits. In academic medicine, considerable emphasis is given to the Hirsch index, a metric used to determine the productivity and academic citation of an individual or research group.21 We would encourage every successful individual in academic anesthesiology to consider another metric: the legacy index. These are the number of people whose lives we have touched or, more bluntly, the number of people who “do not look like us” that will feel compelled to show up at our funeral. Understanding that people outlive publications and/or citations is a critical maxim that great mentors seem to instinctively understand. Great mentors do not need a tombstone; they train people to be greater than themselves, and their impact may last for generations.

CONCLUDING THOUGHTS

There is an ever-present risk of alienating readers whenever issues of race, ethnicity, and diversity are being discussed, given the need for political correctness and an instinctive tendency to assume that the writer is asking for special treatment as an underrepresented minority who are just “not pulling themselves up by their bootstraps.” However, such a mindset ignores the undeniable fact that mentoring is critical for career advancement and personal growth, and underrepresented minority groups are compared to others who are less likely to have or know that they need a mentor. Indeed, of all the steps outlined in the PROFOUND approach to mentoring, access to mentoring is probably the most important. If it sounds like many of the features of great mentoring proposed here for underrepresented minority faculty are applicable to all, it is because the challenges to effective mentorship are many. Underrepresented minority groups present some particular challenges, outlined above; but we emphasize that access to good mentorship is often the greatest challenge. Seeking access to opportunities for protégés is similarly important and is the only way to change the status of underrepresented minority groups to well-represented minorities in leadership roles. Furthermore, one of the essential ways to increase the number of underrepresented minority faculty members in academic anesthesia is through effective mentoring and success of the few underrepresented minority faculty in various anesthesia departments across the nation. The benefits of diverse groups and diverse thinking are almost axiomatic, although it remains a continual challenge to fully embrace our diversity. Beyond merely counting underrepresented minority faculty, assessing for their success remains an elusive metric and is the focus of the next iteration of diversity, equity, and inclusion initiatives.

Finally, the handful of successful underrepresented minority faculty in academic anesthesia must invest the time and effort required to mentor other underrepresented minority by embracing the concept of “each one, teach one.” It is both a moral and professional responsibility for successful underrepresented minority faculty to show others the “roadmap to success.” Academic institutions and national societies must be willing to recognize and encourage such efforts. The numerous benefits of having a diverse group and the specific challenges of being underrepresented minority necessitate identification of obstacles to their success and to encourage targeted mentorship programs to help their growth and development. One such approach is through PROFOUND mentoring of underrepresented minority groups, as proposed in this viewpoint.

ACKNOWLEDGMENTS

Any successes in our academic careers are owed in large part to our mentors, who include Kevin Tremper, Olutoyin Olutoye, and Daniel Clauw (O.O.N.) and Shobha Malviya, Keith Baker, and Terri Voepel-Lewis (B.H.).

Sincere thanks to Dr Peter Davis for constructive review and feedback of this piece.

DISCLOSURES

Name: Olubukola O. Nafiu, MD, FRCA, MS.

Contribution: This author helped conceptualize the idea, review the literature, and prepare the manuscript.

Name: Bishr Haydar, MD.

Contribution: This author helped develop the idea and prepare the manuscript.

This manuscript was handled by: Edward C. Nemergut, MD.

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