REVIEW ARTICLE ANZJSurg.com
Mentoring in surgical training Prem Rashid,* Maruthi Narra† and Henry Woo‡ *Department of Urology, Port Macquarie Base Hospital, Rural Clinical School, The University of New South Wales, Sydney, New South Wales, Australia †Department of Surgery, Albury Wodonga Health, Albury, New South Wales, Australia and ‡Department of Urology, Sydney Adventist Hospital Clinical School, The University of Sydney, Sydney, New South Wales, Australia
Key words mentor, mentoring, surgical mentor, surgical supervision. Correspondence Associate Professor Prem Rashid, Urology Centre, 3 Highfields Circuit, Port Macquarie, NSW 2444, Australia. Email: [email protected] P. Rashid PhD, FRACS (Urol.); M. Narra MBBS; H. Woo FRACS (Urol.). Accepted for publication 23 December 2014. doi: 10.1111/ans.13004
Abstract Surgical mentors have helped trainees develop fulfilling and academically productive careers, while supervisors are formally assigned to impart skills and oversee training. This paper reviews the comparative roles of the supervisor and mentor and how they overlap, while exploring the impact of the ‘unknown’ mentor. While the supervisor’s role in directing the student is formally recognized, the mentee will personally select a mentor who successfully models the career and life balance to which the mentee aspires. The unknown mentor is known only to the mentee. The mentee’s commitment to communicating with both mentor and supervisor is crucial to success. Better processes can be used to guide the mentor relationship. Confusion between the two roles – mentor and supervisor – is due to their complementary nature as well as an overlap in roles. Both remain essential to the growth and development of the surgical trainee. The unknown mentor could give detached advice and guidance to the student, while acting as a positive role model.
Introduction It is erroneously believed that the character Mentor (from Homer’s Odyssey), a trusted friend of Odysseus, was responsible for protecting his house and educating his son, Telemachus, while he fought in the Trojan War.1 It was, in fact, Pallas Athene (the goddess of wisdom) who fulfilled that role.2 It would appear that Dionysus (the god of illusion) continues to cast his influence upon the term to this day.3 Mentors have been an integral part of surgical training since the 19th century when the American surgeon William S. Halsted incorporated mentors into his Socratic surgical teaching methods, using an apprenticeship model.4 His greatest contribution was the creation of a formal system to train surgeons at Johns Hopkins.5 Halsted’s mentoring model was intended to ‘produce not only surgeons, but surgeons of the highest type, men who will stimulate the first youths of our country to study surgery and to devote their energies and their lives to raising the standard of surgical science’.6 One of Halstead’s own mentees, Harvey Cushing, founded neurosurgery, demonstrating the value of mentorship in developing ability and innovation.4 He was however a hard taskmaster who played favourites and could be cruelly sarcastic. Fortunately, despite his personal style, his system of training was a major contribution to surgical education.7 The surgical training environment continues to rely upon the apprenticeship model but there is an increasing need to supplement © 2015 Royal Australasian College of Surgeons
teaching the skills required.8 Developing structure of mentoring within a training system may be fruitful and could continue throughout a surgeon’s career into senior roles.9 Mentoring can be defined in a number of ways. A mentor is usually a ‘wise and trusted’ counsellor, or a person who is experienced enough to be of assistance to a junior.1,10 Mentoring is the pairing of those with experience and knowledge (mentor) with those who lack it (mentee).10 It is also a term that carries high ‘rhetorical strength’ – being a mentor to a younger colleague.3 Surgical supervision is more on the management of performance by oversight and direction.10 In that sense, supervising has ‘teaching’ as a key component.11 In surgery, there are elements to supervision that are different from mentoring. Equally, there are similarities, teaching being broadly one of those similarities. When dealing with the unique complexities and pressures of the surgical environment, a trainee could find that several people are able to provide overlapping support as mentor and supervisor, in order to impart skills, offer tailored career guidance and advice about dealing with specific professional challenges of surgery. This narrative review outlines the roles of the mentor against the background of the formal supervision of trainees. It explores the impact of the ‘unknown’ mentor, specifically in relation to surgical training. ANZ J Surg 85 (2015) 225–229
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The terms ‘trainee’ and ‘mentee’ will be used interchangeably, the former more when it relates to supervision and the latter when it relates mentoring.
Conceptual ideation of mentoring and supervising It is not always clear, in the literature, whether the terms mentor or mentoring also encompass the supervisor role.3 There is significant overlap between the two.12 Many of the articles published in this area are commentary and editorial in nature.8,13,14 Mentors should be able to share skills, knowledge and background to provide mentees with a perspective of the issues to help them resolve some of the challenges they face. Mentoring is also about motivation and empowerment, to allow the mentee to face their challenges, by offering ways to address different situations.15 Achieving balance in the support provided is important, so the experience of professional growth is a positive one. Motivated mentees usually have a structured plan, will ask pertinent questions, actively listen, complete tasks and ask for feedback.16,17 They should also be accepting advice (within reason, or constructively and passionately argue the point), be committed to success and take the initiative.18 In reality, the process is often far less formal.19,20 Supervising relates more specifically to demonstrating and training in practical skills, techniques and knowledge, as well as non-technical aspects including communication, compassion, professionalism, teamwork and ethics.21 While the supervisor’s role is on-site and is formally recognized in the trainee’s workplace, the mentor’s role is more of an informal relationship, offering guidance and advice rather than direct supervision. The link with a mentor is sometimes initiated because of common interests and being similar in some ways.22 It is however estimated that less than half of supervising senior doctors exhibit professional qualities that junior doctors want to emulate.23
Mentoring during surgical training Supervising is recognized as an essential component of surgical training, enabling senior colleagues to teach trainees how to develop clinical skill and communication strategies.24 Formal mentoring may assist in supporting trainees through their programme.25 An experienced mentor can also help the mentee make effective decisions and choices about their long-term career path.19,26 Another role mentors can help with is providing perspective on work/life balance.19 Rather than providing direct advice, skilled mentors could help by asking provocative questions to engage critical assessment and thinking to help mentees find their own answers to the questions they pose.27 Surgeons have different needs from their mentors at different times throughout their career. Trainees and junior surgeons need guidance in order to handle their year-to-year appointments, develop management styles and prepare for advancement. Senior surgeons need guidance to adjust communication strategies, handle conflict resolution, deal with complex clinical situations and adapt to changes in their level of responsibility.19 Sambunjak and Marusic divided the concept of mentoring into three areas.3 They include: • Structural – This is typical of the senior mentor and junior mentee model, with the concepts described above. He considers
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institutional proximity a key and thus excludes distance support, including e-mentoring or virtual mentoring. While the latter two are new and perhaps unclassified, distance mentoring can and does work in the informal setting, which has also been shown to be more effective for some. Surgeons have favoured the concept of the less formal unknown mentor. This is someone who is only known to the mentee and the arrangement is selfdriven by the mentee. In this example, virtual or distance mentoring may not be an impediment as the mentor plays the role of ‘informal’ advisor on a range of issues. • Interactional – Where the interaction is more of an educational, professional and personal developmental process. While a mentor can serve as a ‘role model’, the latter term does not encompass the higher level of commitment of a mentor, or the specific task-driven implications of being a direct supervisor. Here, he argues that supervision comes close to mentoring, but supervision has a more direct structured role, with formal assessment of work practice often included in supervision, but not in mentoring. Both roles require growth and development as outcomes. The interactions with the mentor can be less structured when compared to the supervisor. • Temporal – Mentoring tends to have a longer-term connotation. Supervision is usually pre-defined to a task/project or time period. As time progresses, the nature of both roles may change. They may cease to play a role and new mentors and/or supervisors become involved, but usually, the mentor continues to evolve in their role and the supervisor’s role is completed when the task/project or time period ends. The supervisor, though, may evolve into a mentor for the next phase.
Is structure of roles relevant? There are political pressures to ensure that purposeful and efficient surgical training is delivered.28 This highlights the need for the skills and resources to be able to produce effective supervision for higher education.29 All higher education institutions need to meet the demands of not just ensuring high quality training but also preparing their graduates, with integrated skills for employment.11 Mentors can be assigned formally, and within a known and planned structure, the system can work.30,31 Formal assignment, however, can have its pitfalls.18,32–34 This can relate to a lack of choice for the mentee selecting who would work best with them. It can also be problematic if the mentor is not seen to be supportive, or impartial, within the structure of the organization. Equally, the ‘selfdentification’ informal model has its merits in allowing for a fluid relationship to evolve.18,32,33 The downside here is that the mentee may not have canvassed widely enough to select the best mentor for them. In addition, the mentor may not have the skills to help the mentee develop to the best of their abilities. There does not appear to be a clear process by which trainees select mentors.20 It may be useful for each person to consider what they want from a mentor.6 Each system has pros and cons, but training programmes should have some guiding system of mentorship in place.20 The surgical trainee needs a range of role models and mentors not only to demonstrate the practical work of a surgeon, including surgical, organizational and communication skills, but also to help them © 2015 Royal Australasian College of Surgeons
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make appropriate career choices and strike a healthy balance between their professional and personal life.20 Trainees identify ‘teachers’ and ‘role models’ as two separate types of trainer, with teachers or supervisors conveying practical skills, while the role model or mentor demonstrates overarching global skills and worklife balance.13,35 Trainees also often look to those who are a just few years senior to them for year-to-year personal mentoring.25 As mentioned, trainees could also benefit from more than one mentor to cover their interest in the various aspects of training. However, a good research mentor is not necessarily the right person to offer guidance on clinical issues, while the surgeon who is fully committed to career to the exclusion of family, or social life, cannot give effective advice on work–life balance.6
Benefits of mentoring Mentoring is recognized across professions as an important aspect of fast-tracking development.36–38 Mentoring is a skill like any other that can be taught and developed upon. Recognizing the responsibility of the role, the limitations and the pitfalls can be worthwhile.39 Mentorship differs from direct supervision in its broader ‘off-site’ functions. It often has a longer time frame in career development with a personal aspect to it.40 It is the longer-term connectedness that separates it from direct time-specific, term supervision. Professional boundaries, however, need to be respected. Inappropriate personal relationships can personally and professionally damage both individuals.32,41,42 To enable higher education institutions to accomplish their objectives, providing structure to the roles of supervisor and mentor, in addition to training and education for these roles, is vital rather than relying purely upon experience to date.31
Specific roles Supervisors and mentors have a multitude of roles. Some roles are more specific to supervision:11,22,43 • Co-author • Critic • Examiner • Expert • Facilitator • Manager • Teacher Both supervisors and mentors share some of these roles:11,22,43 • Adviser • Coach • Colleague • Counsellor • Friend • Guide • Networker • Referee • Supporter Being a mentor (providing advice and support on skill and career development43) is a recognized role of a supervisor, although not all supervisors would be mentors. © 2015 Royal Australasian College of Surgeons
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Special circumstances (gender and cross-cultural) There is some evidence that women and men have differing professional development priorities that are unrelated to child rearing.44 Women feature less in leadership roles, are promoted less and still command lower annual incomes.45 Gender and cultural issues may be under-reported but are not thought to be a significant barrier.32 Mentors should be aware of their own biases in these matters. Equally, there lies the potential for gender and cross-cultural exposure to foster mutual understanding and growth.46 It has been purported that men have greater benefit from mentoring than women, although the reasons for this are unclear.47–49 It is considered that some mentors and supervisors view professional women with small children as less professionally motivated.50 While same-gender role models are believed to be more effective in giving guidance on work–life balance, women also have lesser numbers of successful peers, or seniors, who can provide the ‘social capital’that men often have more of.51 ‘Social capital’ can be defined as the availability of senior peers of a similar background within a network that can be accessed by a mentee. It can be argued that abundant ‘social capital’ is a good indicator of potential success.52 Male mentors may not be able to judge the estimations of how a female views her potential and anticipates career trajectory.53 For example, the ‘fastest’ way may not always be the most appropriate.50 In addition, a different manner of progress can also be misinterpreted. Successful men can and are often expected to be assertive and decisive. Women who exhibit those traits may not appear to be nurturing and could be judged harshly.50 Overall, women experience greater challenges in procuring effective mentorship and it does remain a key factor in career progression.24,54,55 Well-organized programmes do appear to help, and the changes brought about by mentoring of women can be sustained.56 Clear boundaries need to be in place as sexual harassment has been reported.32,33,41,42 Mentoring of minority cultures can present unique challenges, too. This is more so when it affects cross-cultural women, particularly as pairing of mentors is not usually possible.33 Being aware of potential cross-cultural issues is the first important step in avoiding problems. This is a situation where distance mentoring could be employed. Having more than one mentor can be helpful but may also bring about some confusion with differing opinions.18,33,57 Good communication and being perceptive to the possibility of misinterpretation, or misunderstanding, remains the key.18
The unknown mentor In a surgical context, the unknown mentor advises the trainee outside the workplace, while the supervisor oversees the trainee on a daily basis, during the direct interaction with patients. While the supervisor has a direct personal interest in the trainee’s day-to-day progress, the mentor is more detached and is therefore in a position to give advice that is more considered and more tailored to the trainee’s individual concerns and challenges, whether it relates to handling patient interaction or choosing a career path. Asupervisor is allocated because of the nature of term placements, but trainees often select their mentor.20 The mentor may be unknown to the supervisor. The supervisor may have more to directly gain (or lose) in
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their working relationship with the trainee but the mentor, being indirectly involved, has a buffer. Nevertheless, both benefit by the success of the trainee, although for the supervisor, it is more tangible, and repeated success (or failures) could have consequences for the supervisor.30 Both supervisors and mentors need to review their roles periodically. Supervisors have a more structured review with outcomes that are documented. Both also play a role in networking and fostering growth of the student/mentee. Mentors have a less structured arrangement and, in that sense, also less formal responsibility. Mentors may benefit from career support, protected time to facilitate mentoring, interpersonal support and training for their role.1,20,37 Mentors also benefit in knowing that they are ‘giving back’, can take pride in developing the next generation, help grow the peer group and, in the process, build a network of collaborators.58 In addition, they may enjoy academic recognition and, when involved, may become aware of gender and cross-cultural issues.1,16,38,39 In the greater scheme, mentors make a positive impact on the mentee with regard to career progression, research endeavours and clinical acumen.12,14 They also provide for broader vision building and goal setting in the longer term.22,57,59
The mentee/trainee Central to the whole issue is the trainee who is working towards completion of surgical training, being undertaken within a specific time frame and longer-term career goals. They are endeavouring to establish an appropriate career path and looking to the mentor for a supportive framework possibly with a structured plan.20 While the unknown mentor may not have all the skills the mentee needs, they unquestionably sparked an interest in the eyes of the mentee who saw fit to approach them and continue the relationship.22 Mentoring for the mentee enhances what the supervisor can offer. There can be greater facilitation of socialization and networking as well as collaborative relationships. There can also be an opportunity for a greater level of appreciation of career path development and involvement in academic activities.40 In addition, where relevant, awareness of the gender and cross-cultural issues may emerge. Finally, the mentor helps drive motivation and provides peer support when needed.1,16,60 The mentor should identify the mentee’s potential strengths and failings, and offer career advice tailored to the mentee’s abilities and talents.26
Conclusion Surgeons need to respond to the unique pressures and challenges they face every day. The advice and support of a mentor is helpful.31 The surgical trainee requires multifaceted role models who can act as a supervisor, demonstrating both surgical techniques and daily clinical skill, as well as a mentor, who can guide them on a personally satisfying career path and a suitable work–life balance within the unique parameters of surgical demands. The roles of supervisor and mentor are both vital to the success of a trainee. One person can play both roles and there would be examples of that working successfully. A better system would be one where the mentor supplements what the supervisor may not be able to provide. There may be more than one mentor fulfilling different aspects of the multifaceted role.Apositive fruitful experience will open up career opportunities and begin a process where the successful trainee becomes
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the supervisor and/or mentor and the cycle repeats.56 Each role is complex and each role can be learnt so that the process continues to improve with each experience. A structure by higher education institutions to foster mentoring by providing educational upskilling is an unmet need.20 The underlying values of confidentiality, trust, respect, honesty and clear open communication are common to both direct supervision and mentorship.18,61 Supervision is more about the direct hands on day-to-day project management but in the process teaches the student about becoming independent. Supervisors may become mentors during, or after, the specific project is completed. The unknown mentor does not have a formal role in the mentee’s professional life but takes a more independent ‘global’ approach in the background; guiding, nurturing and helping the mentee evolve. They can also play a vital role in ‘ironing out’ complex interpersonal issues that may develop between a supervisor and the student. In addition, they, directly or indirectly, can play a part in the personal development of the mentee. The unknown mentor, appointed by the trainee, has a longerterm role as they assist the mentee, when asked, about a wider range of issues. In some circumstances, they can be a role model for what the ideal represents (in the eyes of the mentee). In most situations, they are the ‘sounding board’ the mentee feels meets their needs. The challenges of time constraints and matching cross-cultural mentor partnerships can be circumvented through modern communication technology, enabling a mentee to communicate with a compatible mentor regardless of distance, at a mutually acceptable time. While Dionysus continues to create some confusion, it would appear that the main reason for that is the overlapping aspect of both roles, with each ideally complementing the other.12 There remains a significant merit in the role of the many unknown mentors who guide the next generation of surgeons to academic and professional success.
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Mentoring in surgical training Prem Rashid,* Maruthi Narra† and Henry Woo‡ *Department of Urology, Port Macquarie Base Hospital, Rural Clinical School, The University of New South Wales, Sydney, New South Wales, Australia †Department of Surgery, Albury Wodonga Health, Albury, New South Wales, Australia and ‡Department of Urology, Sydney Adventist Hospital Clinical School, The University of Sydney, Sydney, New South Wales, Australia
Key words mentor, mentoring, surgical mentor, surgical supervision. Correspondence Associate Professor Prem Rashid, Urology Centre, 3 Highfields Circuit, Port Macquarie, NSW 2444, Australia. Email: [email protected] P. Rashid PhD, FRACS (Urol.); M. Narra MBBS; H. Woo FRACS (Urol.). Accepted for publication 23 December 2014. doi: 10.1111/ans.13004
Abstract Surgical mentors have helped trainees develop fulfilling and academically productive careers, while supervisors are formally assigned to impart skills and oversee training. This paper reviews the comparative roles of the supervisor and mentor and how they overlap, while exploring the impact of the ‘unknown’ mentor. While the supervisor’s role in directing the student is formally recognized, the mentee will personally select a mentor who successfully models the career and life balance to which the mentee aspires. The unknown mentor is known only to the mentee. The mentee’s commitment to communicating with both mentor and supervisor is crucial to success. Better processes can be used to guide the mentor relationship. Confusion between the two roles – mentor and supervisor – is due to their complementary nature as well as an overlap in roles. Both remain essential to the growth and development of the surgical trainee. The unknown mentor could give detached advice and guidance to the student, while acting as a positive role model.
Introduction It is erroneously believed that the character Mentor (from Homer’s Odyssey), a trusted friend of Odysseus, was responsible for protecting his house and educating his son, Telemachus, while he fought in the Trojan War.1 It was, in fact, Pallas Athene (the goddess of wisdom) who fulfilled that role.2 It would appear that Dionysus (the god of illusion) continues to cast his influence upon the term to this day.3 Mentors have been an integral part of surgical training since the 19th century when the American surgeon William S. Halsted incorporated mentors into his Socratic surgical teaching methods, using an apprenticeship model.4 His greatest contribution was the creation of a formal system to train surgeons at Johns Hopkins.5 Halsted’s mentoring model was intended to ‘produce not only surgeons, but surgeons of the highest type, men who will stimulate the first youths of our country to study surgery and to devote their energies and their lives to raising the standard of surgical science’.6 One of Halstead’s own mentees, Harvey Cushing, founded neurosurgery, demonstrating the value of mentorship in developing ability and innovation.4 He was however a hard taskmaster who played favourites and could be cruelly sarcastic. Fortunately, despite his personal style, his system of training was a major contribution to surgical education.7 The surgical training environment continues to rely upon the apprenticeship model but there is an increasing need to supplement © 2015 Royal Australasian College of Surgeons
teaching the skills required.8 Developing structure of mentoring within a training system may be fruitful and could continue throughout a surgeon’s career into senior roles.9 Mentoring can be defined in a number of ways. A mentor is usually a ‘wise and trusted’ counsellor, or a person who is experienced enough to be of assistance to a junior.1,10 Mentoring is the pairing of those with experience and knowledge (mentor) with those who lack it (mentee).10 It is also a term that carries high ‘rhetorical strength’ – being a mentor to a younger colleague.3 Surgical supervision is more on the management of performance by oversight and direction.10 In that sense, supervising has ‘teaching’ as a key component.11 In surgery, there are elements to supervision that are different from mentoring. Equally, there are similarities, teaching being broadly one of those similarities. When dealing with the unique complexities and pressures of the surgical environment, a trainee could find that several people are able to provide overlapping support as mentor and supervisor, in order to impart skills, offer tailored career guidance and advice about dealing with specific professional challenges of surgery. This narrative review outlines the roles of the mentor against the background of the formal supervision of trainees. It explores the impact of the ‘unknown’ mentor, specifically in relation to surgical training. ANZ J Surg 85 (2015) 225–229
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The terms ‘trainee’ and ‘mentee’ will be used interchangeably, the former more when it relates to supervision and the latter when it relates mentoring.
Conceptual ideation of mentoring and supervising It is not always clear, in the literature, whether the terms mentor or mentoring also encompass the supervisor role.3 There is significant overlap between the two.12 Many of the articles published in this area are commentary and editorial in nature.8,13,14 Mentors should be able to share skills, knowledge and background to provide mentees with a perspective of the issues to help them resolve some of the challenges they face. Mentoring is also about motivation and empowerment, to allow the mentee to face their challenges, by offering ways to address different situations.15 Achieving balance in the support provided is important, so the experience of professional growth is a positive one. Motivated mentees usually have a structured plan, will ask pertinent questions, actively listen, complete tasks and ask for feedback.16,17 They should also be accepting advice (within reason, or constructively and passionately argue the point), be committed to success and take the initiative.18 In reality, the process is often far less formal.19,20 Supervising relates more specifically to demonstrating and training in practical skills, techniques and knowledge, as well as non-technical aspects including communication, compassion, professionalism, teamwork and ethics.21 While the supervisor’s role is on-site and is formally recognized in the trainee’s workplace, the mentor’s role is more of an informal relationship, offering guidance and advice rather than direct supervision. The link with a mentor is sometimes initiated because of common interests and being similar in some ways.22 It is however estimated that less than half of supervising senior doctors exhibit professional qualities that junior doctors want to emulate.23
Mentoring during surgical training Supervising is recognized as an essential component of surgical training, enabling senior colleagues to teach trainees how to develop clinical skill and communication strategies.24 Formal mentoring may assist in supporting trainees through their programme.25 An experienced mentor can also help the mentee make effective decisions and choices about their long-term career path.19,26 Another role mentors can help with is providing perspective on work/life balance.19 Rather than providing direct advice, skilled mentors could help by asking provocative questions to engage critical assessment and thinking to help mentees find their own answers to the questions they pose.27 Surgeons have different needs from their mentors at different times throughout their career. Trainees and junior surgeons need guidance in order to handle their year-to-year appointments, develop management styles and prepare for advancement. Senior surgeons need guidance to adjust communication strategies, handle conflict resolution, deal with complex clinical situations and adapt to changes in their level of responsibility.19 Sambunjak and Marusic divided the concept of mentoring into three areas.3 They include: • Structural – This is typical of the senior mentor and junior mentee model, with the concepts described above. He considers
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institutional proximity a key and thus excludes distance support, including e-mentoring or virtual mentoring. While the latter two are new and perhaps unclassified, distance mentoring can and does work in the informal setting, which has also been shown to be more effective for some. Surgeons have favoured the concept of the less formal unknown mentor. This is someone who is only known to the mentee and the arrangement is selfdriven by the mentee. In this example, virtual or distance mentoring may not be an impediment as the mentor plays the role of ‘informal’ advisor on a range of issues. • Interactional – Where the interaction is more of an educational, professional and personal developmental process. While a mentor can serve as a ‘role model’, the latter term does not encompass the higher level of commitment of a mentor, or the specific task-driven implications of being a direct supervisor. Here, he argues that supervision comes close to mentoring, but supervision has a more direct structured role, with formal assessment of work practice often included in supervision, but not in mentoring. Both roles require growth and development as outcomes. The interactions with the mentor can be less structured when compared to the supervisor. • Temporal – Mentoring tends to have a longer-term connotation. Supervision is usually pre-defined to a task/project or time period. As time progresses, the nature of both roles may change. They may cease to play a role and new mentors and/or supervisors become involved, but usually, the mentor continues to evolve in their role and the supervisor’s role is completed when the task/project or time period ends. The supervisor, though, may evolve into a mentor for the next phase.
Is structure of roles relevant? There are political pressures to ensure that purposeful and efficient surgical training is delivered.28 This highlights the need for the skills and resources to be able to produce effective supervision for higher education.29 All higher education institutions need to meet the demands of not just ensuring high quality training but also preparing their graduates, with integrated skills for employment.11 Mentors can be assigned formally, and within a known and planned structure, the system can work.30,31 Formal assignment, however, can have its pitfalls.18,32–34 This can relate to a lack of choice for the mentee selecting who would work best with them. It can also be problematic if the mentor is not seen to be supportive, or impartial, within the structure of the organization. Equally, the ‘selfdentification’ informal model has its merits in allowing for a fluid relationship to evolve.18,32,33 The downside here is that the mentee may not have canvassed widely enough to select the best mentor for them. In addition, the mentor may not have the skills to help the mentee develop to the best of their abilities. There does not appear to be a clear process by which trainees select mentors.20 It may be useful for each person to consider what they want from a mentor.6 Each system has pros and cons, but training programmes should have some guiding system of mentorship in place.20 The surgical trainee needs a range of role models and mentors not only to demonstrate the practical work of a surgeon, including surgical, organizational and communication skills, but also to help them © 2015 Royal Australasian College of Surgeons
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make appropriate career choices and strike a healthy balance between their professional and personal life.20 Trainees identify ‘teachers’ and ‘role models’ as two separate types of trainer, with teachers or supervisors conveying practical skills, while the role model or mentor demonstrates overarching global skills and worklife balance.13,35 Trainees also often look to those who are a just few years senior to them for year-to-year personal mentoring.25 As mentioned, trainees could also benefit from more than one mentor to cover their interest in the various aspects of training. However, a good research mentor is not necessarily the right person to offer guidance on clinical issues, while the surgeon who is fully committed to career to the exclusion of family, or social life, cannot give effective advice on work–life balance.6
Benefits of mentoring Mentoring is recognized across professions as an important aspect of fast-tracking development.36–38 Mentoring is a skill like any other that can be taught and developed upon. Recognizing the responsibility of the role, the limitations and the pitfalls can be worthwhile.39 Mentorship differs from direct supervision in its broader ‘off-site’ functions. It often has a longer time frame in career development with a personal aspect to it.40 It is the longer-term connectedness that separates it from direct time-specific, term supervision. Professional boundaries, however, need to be respected. Inappropriate personal relationships can personally and professionally damage both individuals.32,41,42 To enable higher education institutions to accomplish their objectives, providing structure to the roles of supervisor and mentor, in addition to training and education for these roles, is vital rather than relying purely upon experience to date.31
Specific roles Supervisors and mentors have a multitude of roles. Some roles are more specific to supervision:11,22,43 • Co-author • Critic • Examiner • Expert • Facilitator • Manager • Teacher Both supervisors and mentors share some of these roles:11,22,43 • Adviser • Coach • Colleague • Counsellor • Friend • Guide • Networker • Referee • Supporter Being a mentor (providing advice and support on skill and career development43) is a recognized role of a supervisor, although not all supervisors would be mentors. © 2015 Royal Australasian College of Surgeons
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Special circumstances (gender and cross-cultural) There is some evidence that women and men have differing professional development priorities that are unrelated to child rearing.44 Women feature less in leadership roles, are promoted less and still command lower annual incomes.45 Gender and cultural issues may be under-reported but are not thought to be a significant barrier.32 Mentors should be aware of their own biases in these matters. Equally, there lies the potential for gender and cross-cultural exposure to foster mutual understanding and growth.46 It has been purported that men have greater benefit from mentoring than women, although the reasons for this are unclear.47–49 It is considered that some mentors and supervisors view professional women with small children as less professionally motivated.50 While same-gender role models are believed to be more effective in giving guidance on work–life balance, women also have lesser numbers of successful peers, or seniors, who can provide the ‘social capital’that men often have more of.51 ‘Social capital’ can be defined as the availability of senior peers of a similar background within a network that can be accessed by a mentee. It can be argued that abundant ‘social capital’ is a good indicator of potential success.52 Male mentors may not be able to judge the estimations of how a female views her potential and anticipates career trajectory.53 For example, the ‘fastest’ way may not always be the most appropriate.50 In addition, a different manner of progress can also be misinterpreted. Successful men can and are often expected to be assertive and decisive. Women who exhibit those traits may not appear to be nurturing and could be judged harshly.50 Overall, women experience greater challenges in procuring effective mentorship and it does remain a key factor in career progression.24,54,55 Well-organized programmes do appear to help, and the changes brought about by mentoring of women can be sustained.56 Clear boundaries need to be in place as sexual harassment has been reported.32,33,41,42 Mentoring of minority cultures can present unique challenges, too. This is more so when it affects cross-cultural women, particularly as pairing of mentors is not usually possible.33 Being aware of potential cross-cultural issues is the first important step in avoiding problems. This is a situation where distance mentoring could be employed. Having more than one mentor can be helpful but may also bring about some confusion with differing opinions.18,33,57 Good communication and being perceptive to the possibility of misinterpretation, or misunderstanding, remains the key.18
The unknown mentor In a surgical context, the unknown mentor advises the trainee outside the workplace, while the supervisor oversees the trainee on a daily basis, during the direct interaction with patients. While the supervisor has a direct personal interest in the trainee’s day-to-day progress, the mentor is more detached and is therefore in a position to give advice that is more considered and more tailored to the trainee’s individual concerns and challenges, whether it relates to handling patient interaction or choosing a career path. Asupervisor is allocated because of the nature of term placements, but trainees often select their mentor.20 The mentor may be unknown to the supervisor. The supervisor may have more to directly gain (or lose) in
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their working relationship with the trainee but the mentor, being indirectly involved, has a buffer. Nevertheless, both benefit by the success of the trainee, although for the supervisor, it is more tangible, and repeated success (or failures) could have consequences for the supervisor.30 Both supervisors and mentors need to review their roles periodically. Supervisors have a more structured review with outcomes that are documented. Both also play a role in networking and fostering growth of the student/mentee. Mentors have a less structured arrangement and, in that sense, also less formal responsibility. Mentors may benefit from career support, protected time to facilitate mentoring, interpersonal support and training for their role.1,20,37 Mentors also benefit in knowing that they are ‘giving back’, can take pride in developing the next generation, help grow the peer group and, in the process, build a network of collaborators.58 In addition, they may enjoy academic recognition and, when involved, may become aware of gender and cross-cultural issues.1,16,38,39 In the greater scheme, mentors make a positive impact on the mentee with regard to career progression, research endeavours and clinical acumen.12,14 They also provide for broader vision building and goal setting in the longer term.22,57,59
The mentee/trainee Central to the whole issue is the trainee who is working towards completion of surgical training, being undertaken within a specific time frame and longer-term career goals. They are endeavouring to establish an appropriate career path and looking to the mentor for a supportive framework possibly with a structured plan.20 While the unknown mentor may not have all the skills the mentee needs, they unquestionably sparked an interest in the eyes of the mentee who saw fit to approach them and continue the relationship.22 Mentoring for the mentee enhances what the supervisor can offer. There can be greater facilitation of socialization and networking as well as collaborative relationships. There can also be an opportunity for a greater level of appreciation of career path development and involvement in academic activities.40 In addition, where relevant, awareness of the gender and cross-cultural issues may emerge. Finally, the mentor helps drive motivation and provides peer support when needed.1,16,60 The mentor should identify the mentee’s potential strengths and failings, and offer career advice tailored to the mentee’s abilities and talents.26
Conclusion Surgeons need to respond to the unique pressures and challenges they face every day. The advice and support of a mentor is helpful.31 The surgical trainee requires multifaceted role models who can act as a supervisor, demonstrating both surgical techniques and daily clinical skill, as well as a mentor, who can guide them on a personally satisfying career path and a suitable work–life balance within the unique parameters of surgical demands. The roles of supervisor and mentor are both vital to the success of a trainee. One person can play both roles and there would be examples of that working successfully. A better system would be one where the mentor supplements what the supervisor may not be able to provide. There may be more than one mentor fulfilling different aspects of the multifaceted role.Apositive fruitful experience will open up career opportunities and begin a process where the successful trainee becomes
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the supervisor and/or mentor and the cycle repeats.56 Each role is complex and each role can be learnt so that the process continues to improve with each experience. A structure by higher education institutions to foster mentoring by providing educational upskilling is an unmet need.20 The underlying values of confidentiality, trust, respect, honesty and clear open communication are common to both direct supervision and mentorship.18,61 Supervision is more about the direct hands on day-to-day project management but in the process teaches the student about becoming independent. Supervisors may become mentors during, or after, the specific project is completed. The unknown mentor does not have a formal role in the mentee’s professional life but takes a more independent ‘global’ approach in the background; guiding, nurturing and helping the mentee evolve. They can also play a vital role in ‘ironing out’ complex interpersonal issues that may develop between a supervisor and the student. In addition, they, directly or indirectly, can play a part in the personal development of the mentee. The unknown mentor, appointed by the trainee, has a longerterm role as they assist the mentee, when asked, about a wider range of issues. In some circumstances, they can be a role model for what the ideal represents (in the eyes of the mentee). In most situations, they are the ‘sounding board’ the mentee feels meets their needs. The challenges of time constraints and matching cross-cultural mentor partnerships can be circumvented through modern communication technology, enabling a mentee to communicate with a compatible mentor regardless of distance, at a mutually acceptable time. While Dionysus continues to create some confusion, it would appear that the main reason for that is the overlapping aspect of both roles, with each ideally complementing the other.12 There remains a significant merit in the role of the many unknown mentors who guide the next generation of surgeons to academic and professional success.
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