Keywords
e-mentoring - Harvey Cushing - mentoring - speed mentoring - teaching - William Osler
Introduction
All of the 20th century and well into the first quarter of the 21st century, medical
teachers, albeit without any formal training in pedagogy, and their role in imparting
quality medical education continue to dominate the chatter worldwide, especially in
India. The 1.4 billion population of India is dependent on their primary and advanced
health care needs on nearly 109,170 medical graduates in modern medicine and half
as many specialists and superspecialists (47,526) that come out every year of almost
706 medical schools (
https://www.nmc.org.in/information-desk/college-and-course-search/
, accessed May 30, 2024). The quality of medical education and research, medical teachers,
and, of course, the end product—the young medical doctor—is hugely heterogeneous in
India. All aspiring doctors and specialists in India undergo a single rigorous national
entrance eligibility test (NEET) that most often tests only the lowest rung in the
cognitive domain in Bloom's taxonomy.[1] The training facilities and the exit examinations in medical schools across the
vast expanse of India remain of questionable quality. There is an urgent need to create
high-quality physicians, original content creators, researchers, and teachers to make
India self-sufficient in meeting the burgeoning health care needs of our people.
Mentoring Lessons from Historical Vignettes
Mentoring Lessons from Historical Vignettes
I share briefly how mentors, rather than mere teachers, impacted the advancements
in practice and the development of subspecialization in medicine in the early decades
of modern medicine.
William Osler, who cofounded the Johns Hopkins Hospital and School of Medicine in
Baltimore, Maryland (United States), is the father of modern bedside medicine. He
had a profound and lasting impact on medical education. “Osler's wisdom is as relevant
now as in his era.”[2] His textbook The Principles and Practice of Medicine, first published in 1892, was the most widely read book for the next 40 years.[2] He mentored several physicians, among the most famous of which was Harvey Cushing
(the first neurosurgeon to operate on brain tumors).[3] Avid book collectors shared a common interest in neurological disorders, and Osler
often referred his patients to Cushing. Harvey Cushing was also mentored and befriended
by one of the founders of the Mayo Clinic, William James Mayo. They exchanged nearly
100 letters of correspondence discussing complex and exciting case presentations.[3] Mayo helped him found the Society of Neurological Surgeons. A protégé of Cushing,
Van Wagenen, a second-generation neurosurgeon, continued the legacy of Cushing's high
standards in neurosurgery.[4] Decades later, Cushing's neuroanatomical studies highly impacted Rhoton Jr, who,
while working at the Mayo Clinic, carried forward the legacy of Cushing and became
the father of microsurgical neuroanatomy.[3]
Tinsley Harrison was an Oslerphile physician whose father had worked with Osler for
a while, which influenced his entry into the Johns Hopkins Hospital.[5] Harrison believed that Osler was a perfect physician and followed his principles
all his life. Hardly a physician today has not read Harrison's Principles of Internal Medicine.
Dr. John E. Molder, a well-known scientist in radiation biology at the Medical College
of Wisconsin, studied extensively the effect of ionizing and nonionizing radiation
on normal tissues and mentored the next generation of radiation biologists. He expanded
the field by recruiting new scientists, providing critiques and hands-on laboratory
training, and organizing didactic programs and seminars. His mentees went on to significantly
impact the field, as evidenced by their contributions to publications, conference
presentations, and obtaining funding.[6]
Osler invested heavily in his students, who gathered every Saturday evening at his
house for “conversations and suppers.”[7] During these informal evening sessions, Osler often taught the history of medicine,
which whetted his students' appetites to “learn more,” a trait far more helpful to
them later than learning only bits of factual knowledge.[8]
In the olden days, bright residents and fellows, as well as their mentors, believed
marriage was a hindrance to academic careers. Percival Bailey, who first classified
gliomas, was a protegee of Harvey Cushing. The latter was so invested in Bailey's
life, then his student, that he even traveled to meet Bailey's future Armenian in-laws
to block his marriage by most effusively praising Bailey. It had precisely the opposite
effect.[9]
Important lessons learned from some of these historical vignettes include teachers'
recognition of talent, providing opportunities, righteousness, mutual respect, shared
interests, guidance, and sustained interest in their students' lives and professional
progress.[4]
How Do We Become Medical Teachers in India?
How Do We Become Medical Teachers in India?
Many become teachers opportunistically, lured by a steady income and life. Opportunistic
teachers abound in our medical schools. The traits of teachers who ultimately evolve
into mentors are rooted in the reasons that prompt them to become teachers in the
first place: be it for altruistic reasons, a passion for teaching, a desire to be
surrounded by curious young minds, or to ignite their minds to ask questions that
have no answers.
Do Medical Teachers Seek Appreciation from Their Students?
Do Medical Teachers Seek Appreciation from Their Students?
It is common knowledge that students seek appreciation from their teachers. Is it
true the other way around? Teachers need to know what students think about them. Generally,
the students are highly perceptive. They can quickly tell whether they learned a lot
or learned very little. They can quickly tell the difference between a good and a
poor teacher when prompted. They also point out the signs of weak teachers who tend
to dominate, control, and instill fear.[10] I suggest a simple test—do your students look forward to attending your class?
The Teacher Redefined
I shall quote John Quincy Adams, the sixth President of the United States, who once
defined leaders thus: “If your actions inspire others to dream more, learn more, and
become more, you are a leader.” With due apologies to John Quincy, my definition of
a teacher is the following: “If your actions inspire others (students) to dream more,
learn more, and become more, you are a teacher.” An ideal teacher aims to inspire
students to carry his ideals, techniques, and legacy forward. According to the bible,
“God created Adam and Eve in his own image (Genesis 1:26, 27), that is, holy and righteous”
(
https://wels.net/about-wels/what-we-believe/this-we-believe/creation/
, accessed June 20, 2024). An ideal teacher creates students in her own holy and righteous
image.
Parents and Teachers as Mentors
Parents and Teachers as Mentors
Mentoring starts at home. Children imitate their parents and siblings. Being a parent
is a highly responsible business. “Being a good parental mentor requires much selflessness
and nurturing.”[11] During the most impressionable age, the medical undergrads and the postgrads stay
in close contact with their teachers for several years. Besides learning, students
imperceptibly imbibe their teachers' gestures, body language, communication skills,
and value systems. These values stay with the students forever. My carry-home message
is, “Just like parents, you as a teacher are like a stage performer. There cannot
be any unguarded moments. There are no retakes for parents or the teachers.”
Is There a Role for Teachers in Today's World
Is There a Role for Teachers in Today's World
Until September 4, 1998, when Larry Page and Sergey Brin launched Google (
https://en.wikipedia.org/wiki/Google
), there was a significant disparity in accessing information, mainly limited by the
lack of resources. Teachers were the proverbial “fountains of knowledge” from whom
the information and knowledge flowed to students. Teachers sat on a high pedestal
with students, often at their mercy, whether they had learned much or little. If you
knew a specific question and an answer was available, Google would find it within
a fraction of a second. Google made access to information a level playing field. Students
with internet access had access to as much information as their teachers. Information
is simply a way of organizing the facts in an understandable format. The prime examples
of information are books, newspapers, magazines, scientific journals, and conference
proceedings. Smartphones and notebooks in the classrooms emboldened the students to
question the teachers if they were wrong. Teachers bemoaned that students do not come
to their classes. Teachers, who were simply suppliers of information, became redundant.
William Osler once said, “It is much simpler to buy books than to read them, and easier
to read them than to absorb their contents” (
https://wellcomecollection.org/works/xaza2yys
). It becomes knowledge only when the information is internalized, absorbed, and understood.
However, more critical for physicians is to apply knowledge in the proper context.
A contextual application of knowledge makes them wise. Mere possession of information,
which students have in plenty, does not make them knowledgeable or wise. Information
in medical sciences is growing exponentially. The role of teachers lies in making
the students knowledgeable and wise.
The Changing Role of Medical Teachers
The Changing Role of Medical Teachers
Traditionally, teachers have been assigned the function of providing information,
facilitating learning, designing courses and curricula, and doing facultative and
summative assessments of learning. They are expected to be role models in all these
functions.[12] Teachers, when asked, rated teaching in the clinic or laboratory and role modeling
as their highest-ranking activity.[12] Medical teachers become wise with experience and facilitate the student's ability
to sieve the grain from the chaff. In complex situations, they teach how to solve
problems and resolve conflicts. The clinical and surgical skills, the keystones of
medical sciences, cannot be learned from textbooks.
Moreover, they help the students find unanswered research questions and become knowledge
creators. While the trust between doctors and patients is well known, the trust between
a medical teacher and the student in whose care patients are often left is critical
for the patient's welfare. The institutions must create an enabling environment for
the most effective teaching–learning activity.[13]
Transitioning from a Teacher to a Mentor
Transitioning from a Teacher to a Mentor
The word “Mentor” was first used in Homer's epic poem in the 12th century BC, Odyssey, which describes the story of the apocryphal long drawn-out Trojan War. When Odysseus,
the king of Ithaca (a Greek island), left for the war, the goddess of wisdom, Athena,
appeared as a friend named Mentor to teach and guide Telemachus, his son. Barondess
quotes Duffy to summarize Mentor's role: “Mentor was the transition figure in Telemachus'
life during the journey from youth to manhood.”[14] However, a more modern interpretation of “Mentor” comes from a book authored by
a 17th-century bishop, Francois Fenelon, who wrote on the adventures of Telemachus.[15] According to Dr. Ferreres, “Athena represents the good counsel, the wisdom and righteousness.”[15] To “teach and guide” is the essence of being a mentor.
While the role of teachers is more formal, mostly confined to classroom teaching to
the students of the same institution, the role of a mentor is more fluid and informal
and can cut across institutions and distances. Paula Marantz Cohen once summed up
the subtle differences between teachers and mentors. She says, “A teacher has greater
knowledge than a student; a mentor has greater perspective. In this sense, a mentor
is more like an editor—or the best kind of editor.”[16] The term “mentee” was possibly first used for students in 1916 by the University
of Michigan's School of Engineering and decades later by a report in the Journal of the American Institute of Architects (
https://www.cjr.org/language_corner/mentee_fresh.php
, accessed on June 16, 2024). The Merriam-Webster dictionary used the term “Mentee”
in 1965 to define the student being mentored. It is a synonym of “Protégé,” which
is defined as “one who is protected or trained or whose career is furthered by a person
of experience, prominence, or influence” (
https://www.merriam-webster.com/dictionary/mentee#word-history
, accessed on June 16, 2024).
A universally accepted definition of mentoring is “The process whereby an experienced,
highly regarded, empathic person (the mentor) guides another individual (the mentee)
in the development and re-examination of their own ideas, learning, and personal and
professional development.”[17] The relationship between the mentor and the mentee is lifelong. It may be informal
based on mutual interests shared between the mentor and the mentee.[18] Unfortunately, formal mentoring is often discontinued upon completing the formal
course.[18]
There is, however, a need for institutional mechanisms to promote formal mentoring.
Mentors should always be available to their “mentees” and guide them in academic and
research activities and making future career and life choices. As Rohrich put it,
“The mentors I remember best have become lifelong friends. They have been there for
me ‘rain or shine.’”[11] Mentoring increases faculty vitality and a sense of belonging to the institute.[19] Successful mentoring requires a “chemistry” or trust between the mentor and the
mentee. Looking out for mentors may require a lot of effort and persistence. The house
staff, research fellows, and junior faculty members at Harvard defined monitoring
the research progress, not abusing power, advice on career plans, helping research,
improving communication skills, and providing professional networking as the most
significant qualities of their mentors.[20]
Who Benefits the Most from Mentoring
Who Benefits the Most from Mentoring
In a systematic review of resident physicians, the prevalence of depression or depressive
symptoms was 28.8% (range: 20.9–43.2%).[21] Medical residents feel that not only are they overworked but also their work is
undervalued by their attending physicians, resulting in a loss of self-worth and unhealthy
interrelationships among the residents.[17] A mentor–mentee approach promotes collegiality, personal well-being, an egalitarian
approach to patients, and confidence in problem-solving and consulting skills.[17] Moreover, there is objective evidence that the mentor–mentee relationship works
to the advantage of both in an academic environment. Together, they publish more papers,
get more grants, get quicker academic promotions, and have greater career satisfaction.[22]
The mentored junior faculty are more academically successful and likely to stay in
the institution than their nonmentored colleagues.[23] While the primary goal of structured mentoring of students is to increase their
professional competencies, it is often short-lived and lasts till the course is completed.[24] In one such program in the department of pediatrics, 81% of the surveyed house staff
believed the mentorship program helped them provide feedback, emotional support, and
practical advice. It was crucial for completing their residency.[25] Mentoring ought to be self-perpetuating. In a study of senior faculty members of
the University of Wisconsin, 90% had mentors, 75% of whom mentored their students.
Most believed that having a mentor early in their career led to career and personal
development advancements and prepared them to deal with stress later in life.[26]
How to Link the Mentors and Mentees
How to Link the Mentors and Mentees
Strikingly, only 8% of the “protégés” admitted to having a mentor.[26] However, in an extensive survey of the faculty of 26 academic health centers, irrespective
of gender, seniority in an academic position, or minority status, only 30% admitted
being positively mentored. In contrast, 43% believed they were inadequately mentored.[19] There is a lack of good-quality data on the benefits of mentoring programs. In a
systematic review, less than 50% of the students and less than 20% of the faculty
in some specialties admitted to having a mentor.[27] The teaching faculty is saddled with increasing patient care workload, research
demands, and administrative tasks. There is a clear gap in understanding the mentoring
phenomenon between the faculty and the residents. Linking the mentors and mentees
remains a significant challenge. There is an obvious need to introduce formal mentoring
programs in academic institutions to increase dialog and awareness among faculty and
students and promote mentor–mentee relationships. A systematic review identified at
least seven models of formal mentoring techniques, including person-to-person (dyad
model), peer, facilitated peer, functional, speed, group, and distance mentoring,
of which dyad mentoring was the most commonly followed.[18] Mentor–mentee programs are most successful when the mentees are encouraged to choose
their mentors and develop facultative alliances with them.[28] One of the exit surveys of mentees found “speed mentoring” as the most effective
strategy to achieve this linkage by providing them with brief biographies of the potential
mentors and arranging a 15-minute brief meeting between the potential mentors and
mentees, a strategy on the lines of “speed dating.”[29]
The major limitation of running mentoring programs is the need for more institutional
support. Providing grants to protect mentors' time, especially for underrepresented
minorities, has been successful.[30] Mentoring can be built into continuing medical education programs with multilevel
outcomes measured from time to time.[31] The lack of suitable mentors can be compensated through peer groups and facilitated
mentoring, whereby more mentees can be helped.[18]
Life without Mentors
Several euphemisms used to differentiate teaching, role modeling, coaching, tutoring,
and supervision are a continuum and integral components of mentoring.[32]
[33] The growth of an academic without mentors is slow, organic, and full of hits and
misses. Typical mentors play four distinct roles—the traditional mentor, the coach,
the sponsor, and the connector.[34] With a mentor, it is easier to know the rules of academic medicine and how to deal
with the frequent roadblocks. Ninety-eight percent of the interviewed academic medicine
faculty members suggested that lack of mentorship significantly hindered career development.[35] It is already too late when you overcome the hurdles.[35]
Locating the Right Mentor
Locating the Right Mentor
Locating the right mentor is critical in furthering the academic career of the mentees.
The mentor should help achieve the mentee's personal goals as a researcher, teacher,
or practicing physician. While an ideal mentor should be a role model and a highly
accomplished person in the field, his or her presence should not be intimidating.
Mentees need to be comfortable communicating with him or her. Moreover, he or she
should be available, generous, and willing to mentor you. Contact his or her previous
mentees to learn about their experiences and career paths. However, the most critical
factor in fostering a successful mentor–mentee relationship is mutual trust. A mentor
failing to keep the promise of sharing an article with the mentee or the mentee failing
to complete a simple task before the next meeting may be signs of a relationship heading
for failure. Therefore, it is essential to establish and maintain mutual trust in
the mentor–mentee relationship.[36]
Qualities of a teacher that make him or her an ideal mentor: Great mentors share several
personal attributes, including effective communication, motivation, sharing, and nonjudgment.[37]
-
Mentors are accomplished: As stated earlier, mentors are seniors in age, have spent decades in their profession,
are already accomplished in their field, and are well known and respected in their
peer group. They will happily provide research ideas to their mentees, help write
grants, and guide them in bringing the research to fruition with a suitable publication.
They will offer their mentee the first or even the corresponding authorship and often
take the last position on the list of authors.[37] Straus and Sackett remarked: “Career disasters occur when mentors compete with their
mentees.”[37] A mentor who is not ready to accept the first authorship of their mentee in a major
journal that as a mentor they helped to get through is not ready to be a mentor.[37]
-
Communication: Verbal and nonverbal communication between the physician and the patient is the keystone
of interpersonal relationships and empathy,[38] which the students and mentees imbibe. Communication failure, rather than the lack
of technical skills, is at the root of over 70% of severe adverse health outcomes.[39] It is universally agreed that good listeners make for great teachers, leaders, and
mentors.[37] A teacher who does not encourage questions from either the students or the patients
is far from being an ideal mentor.
-
Comprehension: The teachers who quickly grasp and paraphrase the issue under discussion make for
great mentors.
-
Mentors share freely: Unlike poor teachers, mentors do not keep new knowledge and resources to themselves
but freely share these without reservations. It is often said that knowledge dies
with the person who holds it confined to the self but multiplies manifold when it
is shared. The biblical fable that Jesus could feed 5,000 people from five loaves
and two fishes, yet the basket remained full, is an apt analogy for sharing knowledge,
wisdom, and insight with others.[40] Surrounded by sharp young minds, mentors learn more from their mentees than vice
versa.[33]
-
Mentors do not like the “status quo”: They are on an eternal quest for the better, bigger, and higher. They keep the bar
moving up. Mentors do not believe that they have all the answers. True mentors are
critical and skeptical of their observations and remain open to criticism and acceptance
if they ever made a mistake in the past. They believe someone (their mentee, who else!)
will find a better solution. Researching with a mentor who says “I do not know; let
us find out” can be great fun. William Oh, a legendary neonatologist known for his
groundbreaking research and mentoring the next generations of neonatologists, recalled
the words of his mentor John Lind at the Karolinska Institute in Stockholm: “Johnny
was always thinking and would ask, ‘Why?’ He would say that if you have three whys,
and you do not have an answer, that's a project worth doing. I told my fellows that
as well.”[41]
-
Mentors have sharp observation skills: Observations are the keystone of all sciences. True mentors are good observers and
know when a new observation departs from what is already known and what questions
to ask to further the knowledge in the field.[42] They teach how to frame the unasked questions and use valid, reliable, and verifiable
tools to carry out their research.
-
Mentors walk the talk: No matter what the temptation, true mentors react to the dictates of their conscience.
Their values are constant and do not change with situations. They cherish punctuality,
honesty, integrity, equity, and discipline. They often maintain a calm temperament
even in a grave provocation.
Challenges of Gender Disparities in Mentoring Roles
Challenges of Gender Disparities in Mentoring Roles
More women now join the residency programs. However, women face gender discrimination
at several levels. Women physicians have less research output, have a lesser package,
are less likely to be promoted, and have less job satisfaction.[43]
[44] Work–life balance issues are incredibly challenging for women physician-researchers.[45] Women physicians need more help locating mentors than male colleagues.[27] It is generally believed that women prefer women mentors.[46] A nationwide survey among young women physicians indicated unavailability or access
to senior women mentors. When available, they often needed more personal guidance
to maintain a life–work balance.[47] However, when available, mentors had a more significant impact on the careers of
women mentees than men.[47] Cross-gender mentoring can be successful in personal and professional growth, provided
distinct boundaries are adhered to.[35] When senior mentors are not available to women, the peer group can be a valuable
alternative source of support.[47] It is as accurate now as it was three decades earlier that most physicians (53%
women) believed that women still faced gender-based issues in India that prevented
their entry into leadership roles in medicine.[48] It is no different in super-specialties. Twenty percent or less of positions of
chairpersons, speakers, paper presenters, or orations in the Indian Rheumatology Association
were given to women, depriving them of career development, networking opportunities,
and peer group visibility and recognition.[49]
Changing Dynamics of Mentor–Mentee Relationships
Changing Dynamics of Mentor–Mentee Relationships
Admittedly, mentors play a crucial role in shaping the professional careers of mentees.
The fast-evolving and complex needs of mentees may not allow for a single long-term
relationship, but rather multiple short-term mentor–mentee relationships driven by
the needs of mentees rather than the mentors. A network of mentor–mentees across disciplines
and institutions can be created in a workshop model to meet this demand.[50] During the annual meetings of the professional bodies, a concept of speed mentoring
was introduced recently to connect novice and mid-career mentees with leaders in the
profession, which may eventually lead to long-term relationships.[50]
Mentor Training Programs
A free interactive group discussion among all the stakeholders is the key to developing
a successful formal or informal mentorship program to promote clinician-researchers.[51] Having realized that promoting translational research requires strong mentors, the
University of California, San Francisco, developed an exhaustive curriculum consisting
of 10 case-based seminars for formal training of future research mentors. Nearly 90%
of the trainee mentors were extremely satisfied and confident in achieving the program's
goals.[52] Other universities have also successfully implemented faculty development programs
to enhance connectivity with the students and faculty colleagues to teach core professional
values.[53]
[54]
[55]
A 6-week preceptorship program under the guidance of a physician-scientist faculty
member was successfully initiated by the University of Wisconsin medical scientist
training program with the Institute for Clinical and Translational Research of the
same university to provide hands-on clinical experience and integrate it with research.
Five years later, the students who had gone through the course were found to be highly
confident in carrying out translational research and the nuances of clinical research.[56] There is a strong need to clearly define and align the goals, milestones, and expectations
for mentors and mentees before entering into formal relationships to prevent later
disappointments.[57]
E-Mentoring
In the resource-limited regions of the world, e-mentoring, a web-based distance learning
resource rather than the more conventional face-to-face mentoring, is potentially
an alternative model.[58]
[59] It reduces costs and provides adaptable and timely support.[60]
[61] It allows for privacy and honest discussions, facilitates knowledge and collaborative
learning, and provides networking opportunities. Furthermore, e-mentoring supports
mentees whenever needed, without being restricted by time or geographical limitations.[62]
Evaluation of Mentoring Programs
Evaluation of Mentoring Programs
Several parameters can measure the success of an informal mentoring program, including
the number of publications, awards and honors, research grants, professional leadership
roles, and mentoring and advisory roles played by the mentees.[23]
However, formal evaluation by the mentees of their mentors in real time is a significant
challenge. Mentees and students are usually hesitant to opine freely because of fear
of retribution by their mentors.[63] Several instruments have been designed to evaluate the performance of both the mentors
and the mentees. These are, in general, based on the frequency of communication, availability,
satisfaction levels in the meetings, and the ability of the mentees to meet the training
or research goals. A mentor–mentee relationship in the long term has ever-evolving
goals. The major challenge in evaluating mentorship programs is the need for high-quality,
experimental (interventional), and prospective data on the impact of informal or formal
mentor–mentee programs on career choices and professional growth.[27]
Nonaligned expectations of mentors/mentees, poorly trained mentors, unethical behavior
resulting primarily from inadequate institutional oversight, lack of training, and
objectivity in evaluating such programs need urgent attention.[64] While innumerable tools have been used in the past that remain unvalidated, there
is a need to develop a consensual holistic tool based on discussions between all stakeholders.[65] Overcoming the barriers identified in the evaluation process also remains a significant
challenge.
Conclusion
The need for mentorship skills in medical teachers is a significant challenge in India.
Mentorship–mentee programs are needed to create future-ready physicians for health
care needs and innovative research. The availability of search engines like Google
has made the role of teachers redundant as mere information providers. Teachers need
to get regular feedback from their students as a first step. In the changing paradigm,
teachers must create an enabling environment, resolve conflicts in information, teach
the students problem-solving skills, and apply knowledge in the proper context. Mentorship
begins at home with parents and continues through teachers in formal education courses.
Students may need multiple mentors in specific fields in an ever-evolving dynamic
world, ensuring a robust support system. Although formal mentorship programs are difficult
to evaluate objectively, they have led to increased vitality and output in the academic
environment.
