Mentorship in General Internal Medicine: Investment in Our Future
MARILYN M. SCHAPIRA, MD, MPH, ADINA KALET, MD, MPH, MARK D. SCHWARTZ, MD, MARTHA S. GERRITY, MD, MPH THE SURVIVALAND GROWTHof general internal m e d i c i n e (GIM) as a viable academic field d e p e n d not only on its traditional role of clinical care and education but on its research contributions as well. An important building b l o c k for this growth is to train general m e d i c i n e trainees and junior faculty in research. It is w i d e l y believed that an effective m e n t o r i n g relationship is a critical aspect of research training. In Designing Clinical Research, Hulley states that the "single most important decision for an investigator w h o is not yet e x p e r i e n c e d is his choice of a senior scientist to serve as his mentor. ''1 As current or recent fellows in GIM, w e have a personal interest and c o n c e r n with respect to the issue o f mentorship. Supervision and guidance are critical if w e are to use o u r valuable years of fellowship wisely. However, because GIM is a relatively y o u n g field, there may be a shortage of a p p r o p r i a t e mentors for the number of fellows and junior faculty currently training in GIM. Petersdorf notes that w h i l e there is growth in fellowship programs, "supervision and guidance are lacking. ''2 In this article w e present a historical background to the c o n c e p t of mentoring, discuss the importance of m e n t o r s h i p in general m e d i c i n e divisions, and address issues in m e n t o r i n g research. Finally, w e propose solutions to the mentoring shortage.
THE HISTORY OF MENTORING Mentoring dates b a c k to classical times. The w o r d m e n t o r has its origin in H o m e r ' s saga, the Odyssey. 3 In the Odyssey, the goddess of wisdom, Athena, appears in the form of Mentor, an old and wise friend of Odysseus. Mentor gives advice and counsel to Odysseus' son Telemachus in his journey to find his father. In this saga w e see Mentor demonstrating s o m e of the basic traits that to this day are associated with the c o n c e p t of a mentor: age, wisdom, friendship, nurturing, and guidance. In m o d e m times the topic of m e n t o r i n g has b e e n o f great interest to d e v e l o p m e n t a l psychologists and soci-
Received from the Division of General Internal Medicine, Duke University Medical Center, Durham, NC (MMS), the Division of Primary Care Internal Medicine, New York University Medical Center, New York, NY (AK, MDS), and the Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina, Chapel Hill, NC (MSG). Address correspondence and reprint requests to Dr. Schapira: General Medicine Department, 11 l-B, VA Medical Center, Milwaukee, W-l[53295.
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ologists. Daniel Levinson, in his b o o k The Seasons o f a Man's Life, describes the m e n t o r i n g relationship as " o n e of the most c o m p l e x and d e v e l o p m e n t a l l y important a man can have in early adulthood. ''4 Levinson's description of m e n t o r i n g was influential because he defined the relationship not in terms o f formal roles such as a teacher or a boss, b u t in terms of its character and the functions it served. The responsibilities Levinson felt a m e n t o r should fulfill included teaching, sponsoring, guidance, socialization into a profession, and providing counsel and moral support. The most important function was felt to be the realization o f the dream. Thus, the m e n t o r was also to provide an inspirational figure to the y o u n g adult. Levinson further describes h o w the mentoring relationship changes over time. Using the analogy of a love relationship, he notes the often difficult separation that occurs as each party o f the relationship matures and establishes himself or herself personally and professionally. The first profession to take a strong interest in mentoring was business. Mentoring b e c a m e a w i d e l y discussed topic in the business field with the publication of an article, " M u c h ado about m e n t o r s " , in the Harvard Business Review in 1979. 5 Investigators found that executives w h o have had mentors earn m o r e m o n e y at a y o u n g e r age, are better educated, are m o r e likely to follow their initial career paths, and enjoy greater career satisfaction than do those w h o report not having had mentors. Their conclusion was consistent w i t h those o f other studies, w h i c h r e p o r t e d that strong mentoring relationships are associated w i t h a variety of positive career outcomes. 6, 7 The interest of the medical profession in mentoring initially focused on the m e n t o r ' s role for medical students as they struggled to take on the identity of physicians. Thus, it e m p h a s i z e d the role-modeling functions of the mentor. Recently, there has b e e n increasing interest in m e n t o r i n g in medicine as it applies to faculty career d e v e l o p m e n t . 8, 9
THE FUNCTIONS OF THE MENTORING RELATIONSHIP Mentoring involves a multifaceted relationship bet w e e n a junior professional and a senior professional that has the p r i m a r y goal of nurturing the prot6g~'s professional d e v e l o p m e n t . The m e n t o r has several functions: teaching, professional and personal guid-
JOURNALOFGENERALINTERNALMEDICINE,Volume 7 (March/April), 1992
ance, sponsorship, role-modeling, and socialization into a profession. The teaching role of the m e n t o r involves such activities as feedback on research ideas, one-on-one didactic sessions in a content area, and advice on important reading and coursework. In the guidance role the mentor, drawing on a greater wealth of experience, provides advice on personal and professional decisions facing the protege. For example, the m e n t o r may advise the prot6g~ to attend a c o n f e r e n c e that offers important networking opportunities or advise the prot~g~ to join a specific c o m m i t t e e that w o u l d provide visibility in the medical center. In the sponsorship role the m e n t o r acts on behalf of the prot~g~ in a w a y that further p r o m o t e s the prot~g6's career. For example, the m e n t o r m a y invite the prot~g6 to participate in a w o r k s h o p at a national meeting, thereby providing an o p p o r t u n i t y for professional d e v e l o p m e n t and networking. The role-modeling function of a m e n t o r involves providing an e x a m p l e of a professional or personal life that the prot6g~ may wish to emulate. Role-modeling differs from mentoring in that it is not an interactive process but one in w h i c h the prot~g~ learns from observation. Finally, the m e n t o r may aid in the function of socialization into the profession. By conveying a p p r o p r i a t e social protocols and inviting the prot~g~ to divisional social functions, the m e n t o r can encourage a sense of belonging and value within the professional setting. In the mentoring relationship the prot~g~ also provides beneficial functions to the mentor. The prot~g~ is e x p e c t e d to c o m m i t time and energy to the relationship. The prot~g~ may contribute significantly to the research agenda of the m e n t o r either directly or by providing a stimulating source of interaction that may r e n e w the m e n t o r ' s o w n spirit of inquiry. The process of helping a younger person d e v e l o p his or her career may also provide a personal sense of satisfaction to one w h o is at a mid-career level.
IMPORTANCE OF MENTORING TO GIM A m e n t o r can be invaluable in helping one to deal successfully with major issues of career d e v e l o p m e n t in GIM. Issues that have b e e n identified as important to academic m e d i c i n e generally include the following: 1) defining career goals, 2) a p p r o p r i a t e job selection and negotiation of support, 3) time management, 4) understanding r e q u i r e m e n t s for p r o m o t i o n , and 5) choosing a research focus and maintaining productivity, lo Because of the m u l t i p l e roles general internists are exp e c t e d to fulfill, the i m p o r t a n c e of these issues are often magnified in GIM. A m e n t o r can h e l p to guide a prot6g~ through the c o m p l e x task of job negotiation. Given the high teaching and clinical demands on GIM departments, one must be careful to negotiate an a p p r o p r i a t e a m o u n t of p r o t e c t e d research time if d e v e l o p i n g a research career
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is the goal. O t h e r important resources to negotiate are a p p r o p r i a t e facilities for clinical, educational, and research work, such as office space, s u p p o r t staff, and c o m p u t e r access. Finally, the prot~g~ should negotiate a salary that is appropriate for his or her degree of training and the contributions he or she is e x p e c t e d to make to the division. A m e n t o r can coach the prot~g~ through this process, locate appropriate job opportunities, and directly p r o m o t e the prot~g~ as a job candidate. The p r o m o t i o n and tenure process is a second aspect of career d e v e l o p m e n t in w h i c h the guidance of a m e n t o r can be helpful. Requirements for p r o m o t i o n differ a m o n g programs and a m o n g different tracks within a program. Faculty in GIM should understand h o w their clinical and educational contributions, as well as research, will contribute towards p r o m o t i o n . A m e n t o r can assist in this process b y advising the prot6g~ on career decisions that may have a significant impact on successful p r o m o t i o n . A division or d e p a r t m e n t a l chairman can h e l p to provide this function by meeting on a regular basis with faculty and providing feedback on their performances. Time m a n a g e m e n t skills are critical for academic general internists b o t h in training and in junior faculty positions. One must set goals and priorities if the years of training or p r o t e c t e d research time are to be used productively. For example, if d e v e l o p i n g a research agenda is a goal of fellowship, one must limit other time c o m m i t m e n t s such as additional clinical and teaching responsibilities. If education and clinical w o r k are the desired goal, one needs to avoid pressure to define success on the basis of research accomplishments. An effective m e n t o r can h e l p to negotiate these potential conflicts and serve as a role-model in balancing the m a n y time demands of an academic career. Defining a research agenda in GIM can be difficult. The s p e c t r u m of research applicable to GIM is very broad, including medical education, health service research, decision analysis, clinical research, and medical ethics. The clinical areas w e study are also broad, spanning not only the field of internal m e d i c i n e but the practice of other medical specialties as well. It is necessary to define a clinical a n d / o r m e t h o d o l o g i c area of expertise from a m o n g these choices as one develops a research agenda. A m e n t o r can assist in this process b y providing f e e d b a c k on research ideas and guiding o n e towards a feasible and important area of study.
DIFFICULTIES OF FINDING MENTORS IN GIM As important as m e n t o r i n g is, the GIM trainee in search of a m e n t o r encounters n u m e r o u s difficulties. First, GIM is a y o u n g field w i t h relatively f e w senior faculty, w h o are most likely to have the time and the expertise n e e d e d to train fellows in research. The value of senior faculty as mentors is s u p p o r t e d b y research in physicians and m e n t o r i n g ) 1 Second, GIM research
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Schapira eta/., MENTORSHIP IN GENERAL iNTERNAL MEDICINE Context
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FIGURE 1. A suggestedframework for the study of mentorship. Adaptedwith permissionfrom: Hunt DM, MichaelC. Mentorship:a career training and developmenttool. Acad ManageRev. 1983:8:475-85.
covers a diverse range of topics as discussed above. Faculty expertise in these areas may be outside the division of GIM or even outside the d e p a r t m e n t of medicine. As GIM divisions increase the sizes o f their senior faculties they will be better positioned to provide mentors with expertise in these interdisciplinary fields. Finally, GIM training programs a p p e a r to follow a different m o d e l of m e n t o r i n g than do traditional subspecialties such as cardiology and p u l m o n a r y medicine. In traditional training programs fellows or junior faculty are likely to join a lab and take on a project associated w i t h ongoing research. It is o u r e x p e r i e n c e that in GIM, one is often e x p e c t e d to d e v e l o p original research ideas and projects. This model, w h i l e encouraging i n d e p e n d e n t thought, m a y make it m o r e difficult to initiate mentoring relationships early in the course of training.
RESEARCH IN MENTORING Although m u c h research in m e n t o r i n g has b e e n done over the past decade, it has faced substantial methodologic p r o b l e m s that limit the usefulness of this b o d y of work. A major and persistent p r o b l e m has b e e n the operational definition of a mentor. Failure to use a con-
sistent definition of a m e n t o r has led to confusion about inclusion and exclusion criteria for studies of mentoring, making it difficult to c o m p a r e studies or to draw general inferences from the findings. An operational definition of a m e n t o r i n g relationship, p u t forth to advance research, has recently b e e n published'2: "a dynamic, reciprocal relationship in a w o r k e n v i r o n m e n t b e t w e e n an advanced career i n c u m b e n t ( m e n t o r ) and a b e g i n n e r (protege) aimed at p r o m o t i n g the career dev e l o p m e n t of b o t h . " This definition incorporates several important c o n c e p t s o f the mentoring relationship: it changes over time (dynamic), it works to the advantage o f both m e n t o r and prot~g~ (reciprocal), it takes place within a w o r k environment, and it involves a senior person and a junior person. A second issue in research in mentoring has b e e n the absence of a theoretical f r a m e w o r k to guide research. A c o n c e p t u a l f r a m e w o r k for the study of mentorship has been p r o p o s e d b y Hunt and Michael. 13 This f r a m e w o r k include the following domains: organizational context in w h i c h the relationship develops, characteristics of the m e n t o r and the protege, stages of the m e n t o r s h i p process, and o u t c o m e s of the relationship. Hunt's f r a m e w o r k c o u l d be e x p a n d e d to include the functions p r o v i d e d by the mentor. The e x p a n d e d m o d e l is d e p i c t e d in Figure 1. Several important questions remain to be answered w i t h respect to the m e n t o r i n g process. H o w prevalent are mentoring relationships? H o w do they develop? What makes the relationship successful? What are the positive and negative o u t c o m e s for the prot~g~ and the mentor? By using a c o n c e p t u a l f r a m e w o r k to define research questions, w e can a p p r o a c h the t o p i c of mentoring in a systematic and c o m p r e h e n s i v e way.
POSSIBLE SOLUTIONS TO THE MENTORING SHORTAGE The traditional m o d e l of m e n t o r i n g involves a very time-consuming and e m o t i o n a l l y intensive relationship b e t w e e n the m e n t o r and the protege. In today's w o r k environment, as in GIM departments, such a relationship m a y not be possible due to a limited p o o l of a p p r o p r i a t e mentors. Because of such constraints it is necessary to e x p l o r e other solutions. At the Medical College of Wisconsin, Milwaukee, a p r o g r a m of " a c a d e m i c friends" was initiated as an alternative to traditional m e n t o r i n g relationships. In this program each m e m b e r of the division of GIM was paired with another m e m b e r as an a c a d e m i c friend. Assignments w e r e made on the basis of p r e f e r e n c e of faculty m e m b e r s w h o listed their top three choices for an academic friend. The faculty m e m b e r s paired m e t on a regular basis to discuss issues relevant to career develo p m e n t . This p r o g r a m addressed the issue of the mentoring shortage by providing a m e c h a n i s m for all faculty m e m b e r s to benefit f r o m some aspects o f a
JOURNALOFGENERALINTERNALMEDICINE°Volume 7 (March/April), 1992
m e n t o r i n g r e l a t i o n s h i p . Specifically, t h e p r o g r a m w a s d e s i g n e d to fulfill t h e s o c i a l s u p p o r t r o l e o f t h e m e n t o r . H o w e v e r , g i v e n t h a t an a c a d e m i c f r i e n d w a s just as l i k e l y to b e o n e ' s j u n i o r o r p e e r p r o f e s s i o n a l l y as a s e n i o r c o l l e a g u e , t h e p r o g r a m w a s less l i k e l y t o p r o v i d e the teaching, guidance, or sponsorship functions of a traditional mentor. A n o t h e r a p p r o a c h to t h e m e n t o r i n g s h o r t a g e is for t h e d i v i s i o n s o f GIM to g i v e a h i g h e r p r i o r i t y to m e n t o r i n g in t h e d e s i g n o f t h e i r f e l l o w s h i p a n d f a c u l t y d e v e l opment programs. A division should envision an approp r i a t e m e n t o r for e a c h f e l l o w s h i p p o s i t i o n t h e y offer. Ideally, this relationship should be discussed during the recruitment process. Faculty development prog r a m s c o u l d b e e s t a b l i s h e d w i t h i n t h e d i v i s i o n to t e a c h a n d e n c o u r a g e s e n i o r f a c u l t y to t a k e o n this r o l e . O n a national level, division chiefs and senior members of t h e S o c i e t y o f G e n e r a l I n t e r n a l M e d i c i n e m a y w a n t to consider forming a group that would encourage and t e a c h t h e s k i l l s r e l e v e n t to t h e m e n t o r i n g p r o c e s s . What can be done by a fellow or junior faculty m e m b e r w i t h i n t h e e x i s t i n g s t r u c t u r e o f GIM d i v i s i o n s to f a c i l i t a t e f i n d i n g a m e n t o r ? O n e a p p r o a c h is to imm e r s e o n e s e l f in t h e " i n t e l l e c t u a l n e t w o r k " o f t h e ins t i t u t i o n in t h e a c a d e m i c a r e a o f i n t e r e s t . It is e s s e n t i a l to s e e k o u t t h o s e f a c u l t y w h o h a v e s i m i l a r i n t e r e s t s a n d to b e c o m e f a m i l i a r w i t h t h e r e s e a r c h o r c l i n i c a l netw o r k t h a t m a y b e f u n c t i o n i n g in t h a t area. This i n t e l l e c t u a l n e t w o r k is a p o t e n t i a l l y r i c h r e s o u r c e f r o m w h i c h a m e n t o r i n g r e l a t i o n s h i p m a y arise. F i n d i n g a m e n t o r o u t s i d e o f GIM d i v i s i o n s is a p o t e n t i a l s o l u t i o n to t h e m e n t o r i n g s h o r t a g e . This o p t i o n w i d e n s t h e p o o l o f a v a i l a b l e m e n t o r s . It also a l l o w s f e l l o w s to s e e k o u t e x p e r t s in a g i v e n m e t h o d o l o g i c o r c l i n i c a l area. T h e s e m e n t o r s a r e l i k e l y to p r o v i d e s t r o n g t e a c h i n g f u n c t i o n s w i t h i n t h e i r areas o f e x p e r t i s e . H o w ever, t h e y a r e less l i k e l y to act as r o l e m o d e l s f o r acad e m i c g e n e r a l i n t e r n i s t s o r to p r o v i d e s p o n s o r s h i p w i t h i n t h e GIM d i v i s i o n . M e n t o r s m a y a l s o b e s o u g h t o u t s i d e o f o n e ' s instit u t i o n . S u c h c o n t a c t s c a n b e m a d e at f a c u l t y d e v e l o p m e n t c o u r s e s , w h i c h a l l o w s o n e to d e v e l o p p r o f e s s i o n a l r e l a t i o n s h i p s w i t h n a t i o n a l l y k n o w n e x p e r t s in a s p e c i f i c r e s e a r c h o r c l i n i c a l field. D e v e l o p i n g a n d m a i n t a i n i n g s u c h r e l a t i o n s h i p s m a y b e b e n e f i c i a l in terms of networking and collaborative opportunities. Finally, it m a y b e i m p o r t a n t f o r a GIM t r a i n e e to u s e
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several mentors, with each of them performing some of the important mentoring functions. One mentor may be i m p o r t a n t for e d i t i n g p a p e r s , a n o t h e r f o r d e v e l o p i n g r e s e a r c h ideas, a n d a t h i r d for e m o t i o n a l a n d s o c i a l s u p p o r t in t h e d i v i s i o n . This f l e x i b i l i t y w i l l e n a b l e t h e t r a i n e e to e s t a b l i s h a s u p p o r t i v e a n d e d u c a t i o n a l envir o n m e n t e v e n if t h e " i d e a l , " w e l l - r o u n d e d m e n t o r is not available.
CONCLUSION A c a d e m i c d e v e l o p m e n t in GIM is a c h a l l e n g i n g a n d difficult p r o c e s s . M e n t o r i n g m a y b e an e s s e n t i a l i n g r e d i e n t to t h a t p r o c e s s . It is i m p o r t a n t to s t r u c t u r e p r o g r a m s s u c h t h a t t h e s e r e l a t i o n s h i p s c a n d e v e l o p eff e c t i v e l y . I n d o i n g so, GIM d i v i s i o n s m u s t d e a l w i t h problems raised by having young faculty with diverse r e s e a r c h i n t e r e s t s . By s u p p o r t i n g g o o d m e n t o r i n g relat i o n s h i p s , GIM d i v i s i o n s m a y h e l p t h e i r r e s e a r c h a n d t r a i n i n g p r o g r a m s t o flourish.
The authors thank Dr. John Feussner, Dr. Wendy Levinson, Dr. Mark Linzer, and Dr. Thomas Inui for the contributions they made in the development of the manuscript.
REFERENCES 1. Hulley SB, Cummings SR. Designing clinical research. Baltimore: Williams and Willdns, 1988. 2. Petersdorf RG. General internal medicine: fad or future? J Gen Intern Med. 1989;4:527-32. 3. Homer. The Odyssey. New York: Simon and Shuster, 1969. 4. Levinson DJ. The seasons of a man's life. New York: Ballantine Books, 1978. 5. Roche GR. Much ado about mentors. Harvard Bus Rev. 1979;1:14-31. 6. Riley S, Wrench D. Mentoring among women lawyers.J Appl Soc Psychol. 1985; 15:375-86. 7. Zuckerman H. Nobel laureates in science: patterns of productivity, collaboration, and authorship. Am Sociol Rev. 1967; 37:391-403. 8. Strange KC, Hekelman FP. Mentoring needs and family medicine faculty. Fam Med. 1990;22:183-5. 9. Rogers JC, Holloway RL, Miller SM. Academic mentoring and family medicine's research productivity. Fam Med. 1990; 22:186-9. 10. ApplegateWB. Career development in academic medicine.AmJ Med. 1990;88:263-7. 11. Ochberg RL, Barton GM, West AN. Women physicians and their mentors. J Am Med Wom Assoc. 1989;44:123-6. 12. Healy CC, Welchert AJ. Mentoring relations: a definition to advance research and practice. Educ Res. 1990; 19:17-21. 13. Hunt DM, Michael C. Mentorship: a career training and development tool. Acad Manage Rev. 1983;8:475-85.
MARILYN M. SCHAPIRA, MD, MPH, ADINA KALET, MD, MPH, MARK D. SCHWARTZ, MD, MARTHA S. GERRITY, MD, MPH THE SURVIVALAND GROWTHof general internal m e d i c i n e (GIM) as a viable academic field d e p e n d not only on its traditional role of clinical care and education but on its research contributions as well. An important building b l o c k for this growth is to train general m e d i c i n e trainees and junior faculty in research. It is w i d e l y believed that an effective m e n t o r i n g relationship is a critical aspect of research training. In Designing Clinical Research, Hulley states that the "single most important decision for an investigator w h o is not yet e x p e r i e n c e d is his choice of a senior scientist to serve as his mentor. ''1 As current or recent fellows in GIM, w e have a personal interest and c o n c e r n with respect to the issue o f mentorship. Supervision and guidance are critical if w e are to use o u r valuable years of fellowship wisely. However, because GIM is a relatively y o u n g field, there may be a shortage of a p p r o p r i a t e mentors for the number of fellows and junior faculty currently training in GIM. Petersdorf notes that w h i l e there is growth in fellowship programs, "supervision and guidance are lacking. ''2 In this article w e present a historical background to the c o n c e p t of mentoring, discuss the importance of m e n t o r s h i p in general m e d i c i n e divisions, and address issues in m e n t o r i n g research. Finally, w e propose solutions to the mentoring shortage.
THE HISTORY OF MENTORING Mentoring dates b a c k to classical times. The w o r d m e n t o r has its origin in H o m e r ' s saga, the Odyssey. 3 In the Odyssey, the goddess of wisdom, Athena, appears in the form of Mentor, an old and wise friend of Odysseus. Mentor gives advice and counsel to Odysseus' son Telemachus in his journey to find his father. In this saga w e see Mentor demonstrating s o m e of the basic traits that to this day are associated with the c o n c e p t of a mentor: age, wisdom, friendship, nurturing, and guidance. In m o d e m times the topic of m e n t o r i n g has b e e n o f great interest to d e v e l o p m e n t a l psychologists and soci-
Received from the Division of General Internal Medicine, Duke University Medical Center, Durham, NC (MMS), the Division of Primary Care Internal Medicine, New York University Medical Center, New York, NY (AK, MDS), and the Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina, Chapel Hill, NC (MSG). Address correspondence and reprint requests to Dr. Schapira: General Medicine Department, 11 l-B, VA Medical Center, Milwaukee, W-l[53295.
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ologists. Daniel Levinson, in his b o o k The Seasons o f a Man's Life, describes the m e n t o r i n g relationship as " o n e of the most c o m p l e x and d e v e l o p m e n t a l l y important a man can have in early adulthood. ''4 Levinson's description of m e n t o r i n g was influential because he defined the relationship not in terms o f formal roles such as a teacher or a boss, b u t in terms of its character and the functions it served. The responsibilities Levinson felt a m e n t o r should fulfill included teaching, sponsoring, guidance, socialization into a profession, and providing counsel and moral support. The most important function was felt to be the realization o f the dream. Thus, the m e n t o r was also to provide an inspirational figure to the y o u n g adult. Levinson further describes h o w the mentoring relationship changes over time. Using the analogy of a love relationship, he notes the often difficult separation that occurs as each party o f the relationship matures and establishes himself or herself personally and professionally. The first profession to take a strong interest in mentoring was business. Mentoring b e c a m e a w i d e l y discussed topic in the business field with the publication of an article, " M u c h ado about m e n t o r s " , in the Harvard Business Review in 1979. 5 Investigators found that executives w h o have had mentors earn m o r e m o n e y at a y o u n g e r age, are better educated, are m o r e likely to follow their initial career paths, and enjoy greater career satisfaction than do those w h o report not having had mentors. Their conclusion was consistent w i t h those o f other studies, w h i c h r e p o r t e d that strong mentoring relationships are associated w i t h a variety of positive career outcomes. 6, 7 The interest of the medical profession in mentoring initially focused on the m e n t o r ' s role for medical students as they struggled to take on the identity of physicians. Thus, it e m p h a s i z e d the role-modeling functions of the mentor. Recently, there has b e e n increasing interest in m e n t o r i n g in medicine as it applies to faculty career d e v e l o p m e n t . 8, 9
THE FUNCTIONS OF THE MENTORING RELATIONSHIP Mentoring involves a multifaceted relationship bet w e e n a junior professional and a senior professional that has the p r i m a r y goal of nurturing the prot6g~'s professional d e v e l o p m e n t . The m e n t o r has several functions: teaching, professional and personal guid-
JOURNALOFGENERALINTERNALMEDICINE,Volume 7 (March/April), 1992
ance, sponsorship, role-modeling, and socialization into a profession. The teaching role of the m e n t o r involves such activities as feedback on research ideas, one-on-one didactic sessions in a content area, and advice on important reading and coursework. In the guidance role the mentor, drawing on a greater wealth of experience, provides advice on personal and professional decisions facing the protege. For example, the m e n t o r may advise the prot6g~ to attend a c o n f e r e n c e that offers important networking opportunities or advise the prot~g~ to join a specific c o m m i t t e e that w o u l d provide visibility in the medical center. In the sponsorship role the m e n t o r acts on behalf of the prot~g~ in a w a y that further p r o m o t e s the prot~g6's career. For example, the m e n t o r m a y invite the prot~g6 to participate in a w o r k s h o p at a national meeting, thereby providing an o p p o r t u n i t y for professional d e v e l o p m e n t and networking. The role-modeling function of a m e n t o r involves providing an e x a m p l e of a professional or personal life that the prot6g~ may wish to emulate. Role-modeling differs from mentoring in that it is not an interactive process but one in w h i c h the prot~g~ learns from observation. Finally, the m e n t o r may aid in the function of socialization into the profession. By conveying a p p r o p r i a t e social protocols and inviting the prot~g~ to divisional social functions, the m e n t o r can encourage a sense of belonging and value within the professional setting. In the mentoring relationship the prot~g~ also provides beneficial functions to the mentor. The prot~g~ is e x p e c t e d to c o m m i t time and energy to the relationship. The prot~g~ may contribute significantly to the research agenda of the m e n t o r either directly or by providing a stimulating source of interaction that may r e n e w the m e n t o r ' s o w n spirit of inquiry. The process of helping a younger person d e v e l o p his or her career may also provide a personal sense of satisfaction to one w h o is at a mid-career level.
IMPORTANCE OF MENTORING TO GIM A m e n t o r can be invaluable in helping one to deal successfully with major issues of career d e v e l o p m e n t in GIM. Issues that have b e e n identified as important to academic m e d i c i n e generally include the following: 1) defining career goals, 2) a p p r o p r i a t e job selection and negotiation of support, 3) time management, 4) understanding r e q u i r e m e n t s for p r o m o t i o n , and 5) choosing a research focus and maintaining productivity, lo Because of the m u l t i p l e roles general internists are exp e c t e d to fulfill, the i m p o r t a n c e of these issues are often magnified in GIM. A m e n t o r can h e l p to guide a prot6g~ through the c o m p l e x task of job negotiation. Given the high teaching and clinical demands on GIM departments, one must be careful to negotiate an a p p r o p r i a t e a m o u n t of p r o t e c t e d research time if d e v e l o p i n g a research career
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is the goal. O t h e r important resources to negotiate are a p p r o p r i a t e facilities for clinical, educational, and research work, such as office space, s u p p o r t staff, and c o m p u t e r access. Finally, the prot~g~ should negotiate a salary that is appropriate for his or her degree of training and the contributions he or she is e x p e c t e d to make to the division. A m e n t o r can coach the prot~g~ through this process, locate appropriate job opportunities, and directly p r o m o t e the prot~g~ as a job candidate. The p r o m o t i o n and tenure process is a second aspect of career d e v e l o p m e n t in w h i c h the guidance of a m e n t o r can be helpful. Requirements for p r o m o t i o n differ a m o n g programs and a m o n g different tracks within a program. Faculty in GIM should understand h o w their clinical and educational contributions, as well as research, will contribute towards p r o m o t i o n . A m e n t o r can assist in this process b y advising the prot6g~ on career decisions that may have a significant impact on successful p r o m o t i o n . A division or d e p a r t m e n t a l chairman can h e l p to provide this function by meeting on a regular basis with faculty and providing feedback on their performances. Time m a n a g e m e n t skills are critical for academic general internists b o t h in training and in junior faculty positions. One must set goals and priorities if the years of training or p r o t e c t e d research time are to be used productively. For example, if d e v e l o p i n g a research agenda is a goal of fellowship, one must limit other time c o m m i t m e n t s such as additional clinical and teaching responsibilities. If education and clinical w o r k are the desired goal, one needs to avoid pressure to define success on the basis of research accomplishments. An effective m e n t o r can h e l p to negotiate these potential conflicts and serve as a role-model in balancing the m a n y time demands of an academic career. Defining a research agenda in GIM can be difficult. The s p e c t r u m of research applicable to GIM is very broad, including medical education, health service research, decision analysis, clinical research, and medical ethics. The clinical areas w e study are also broad, spanning not only the field of internal m e d i c i n e but the practice of other medical specialties as well. It is necessary to define a clinical a n d / o r m e t h o d o l o g i c area of expertise from a m o n g these choices as one develops a research agenda. A m e n t o r can assist in this process b y providing f e e d b a c k on research ideas and guiding o n e towards a feasible and important area of study.
DIFFICULTIES OF FINDING MENTORS IN GIM As important as m e n t o r i n g is, the GIM trainee in search of a m e n t o r encounters n u m e r o u s difficulties. First, GIM is a y o u n g field w i t h relatively f e w senior faculty, w h o are most likely to have the time and the expertise n e e d e d to train fellows in research. The value of senior faculty as mentors is s u p p o r t e d b y research in physicians and m e n t o r i n g ) 1 Second, GIM research
~.50
Schapira eta/., MENTORSHIP IN GENERAL iNTERNAL MEDICINE Context
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FIGURE 1. A suggestedframework for the study of mentorship. Adaptedwith permissionfrom: Hunt DM, MichaelC. Mentorship:a career training and developmenttool. Acad ManageRev. 1983:8:475-85.
covers a diverse range of topics as discussed above. Faculty expertise in these areas may be outside the division of GIM or even outside the d e p a r t m e n t of medicine. As GIM divisions increase the sizes o f their senior faculties they will be better positioned to provide mentors with expertise in these interdisciplinary fields. Finally, GIM training programs a p p e a r to follow a different m o d e l of m e n t o r i n g than do traditional subspecialties such as cardiology and p u l m o n a r y medicine. In traditional training programs fellows or junior faculty are likely to join a lab and take on a project associated w i t h ongoing research. It is o u r e x p e r i e n c e that in GIM, one is often e x p e c t e d to d e v e l o p original research ideas and projects. This model, w h i l e encouraging i n d e p e n d e n t thought, m a y make it m o r e difficult to initiate mentoring relationships early in the course of training.
RESEARCH IN MENTORING Although m u c h research in m e n t o r i n g has b e e n done over the past decade, it has faced substantial methodologic p r o b l e m s that limit the usefulness of this b o d y of work. A major and persistent p r o b l e m has b e e n the operational definition of a mentor. Failure to use a con-
sistent definition of a m e n t o r has led to confusion about inclusion and exclusion criteria for studies of mentoring, making it difficult to c o m p a r e studies or to draw general inferences from the findings. An operational definition of a m e n t o r i n g relationship, p u t forth to advance research, has recently b e e n published'2: "a dynamic, reciprocal relationship in a w o r k e n v i r o n m e n t b e t w e e n an advanced career i n c u m b e n t ( m e n t o r ) and a b e g i n n e r (protege) aimed at p r o m o t i n g the career dev e l o p m e n t of b o t h . " This definition incorporates several important c o n c e p t s o f the mentoring relationship: it changes over time (dynamic), it works to the advantage o f both m e n t o r and prot~g~ (reciprocal), it takes place within a w o r k environment, and it involves a senior person and a junior person. A second issue in research in mentoring has b e e n the absence of a theoretical f r a m e w o r k to guide research. A c o n c e p t u a l f r a m e w o r k for the study of mentorship has been p r o p o s e d b y Hunt and Michael. 13 This f r a m e w o r k include the following domains: organizational context in w h i c h the relationship develops, characteristics of the m e n t o r and the protege, stages of the m e n t o r s h i p process, and o u t c o m e s of the relationship. Hunt's f r a m e w o r k c o u l d be e x p a n d e d to include the functions p r o v i d e d by the mentor. The e x p a n d e d m o d e l is d e p i c t e d in Figure 1. Several important questions remain to be answered w i t h respect to the m e n t o r i n g process. H o w prevalent are mentoring relationships? H o w do they develop? What makes the relationship successful? What are the positive and negative o u t c o m e s for the prot~g~ and the mentor? By using a c o n c e p t u a l f r a m e w o r k to define research questions, w e can a p p r o a c h the t o p i c of mentoring in a systematic and c o m p r e h e n s i v e way.
POSSIBLE SOLUTIONS TO THE MENTORING SHORTAGE The traditional m o d e l of m e n t o r i n g involves a very time-consuming and e m o t i o n a l l y intensive relationship b e t w e e n the m e n t o r and the protege. In today's w o r k environment, as in GIM departments, such a relationship m a y not be possible due to a limited p o o l of a p p r o p r i a t e mentors. Because of such constraints it is necessary to e x p l o r e other solutions. At the Medical College of Wisconsin, Milwaukee, a p r o g r a m of " a c a d e m i c friends" was initiated as an alternative to traditional m e n t o r i n g relationships. In this program each m e m b e r of the division of GIM was paired with another m e m b e r as an a c a d e m i c friend. Assignments w e r e made on the basis of p r e f e r e n c e of faculty m e m b e r s w h o listed their top three choices for an academic friend. The faculty m e m b e r s paired m e t on a regular basis to discuss issues relevant to career develo p m e n t . This p r o g r a m addressed the issue of the mentoring shortage by providing a m e c h a n i s m for all faculty m e m b e r s to benefit f r o m some aspects o f a
JOURNALOFGENERALINTERNALMEDICINE°Volume 7 (March/April), 1992
m e n t o r i n g r e l a t i o n s h i p . Specifically, t h e p r o g r a m w a s d e s i g n e d to fulfill t h e s o c i a l s u p p o r t r o l e o f t h e m e n t o r . H o w e v e r , g i v e n t h a t an a c a d e m i c f r i e n d w a s just as l i k e l y to b e o n e ' s j u n i o r o r p e e r p r o f e s s i o n a l l y as a s e n i o r c o l l e a g u e , t h e p r o g r a m w a s less l i k e l y t o p r o v i d e the teaching, guidance, or sponsorship functions of a traditional mentor. A n o t h e r a p p r o a c h to t h e m e n t o r i n g s h o r t a g e is for t h e d i v i s i o n s o f GIM to g i v e a h i g h e r p r i o r i t y to m e n t o r i n g in t h e d e s i g n o f t h e i r f e l l o w s h i p a n d f a c u l t y d e v e l opment programs. A division should envision an approp r i a t e m e n t o r for e a c h f e l l o w s h i p p o s i t i o n t h e y offer. Ideally, this relationship should be discussed during the recruitment process. Faculty development prog r a m s c o u l d b e e s t a b l i s h e d w i t h i n t h e d i v i s i o n to t e a c h a n d e n c o u r a g e s e n i o r f a c u l t y to t a k e o n this r o l e . O n a national level, division chiefs and senior members of t h e S o c i e t y o f G e n e r a l I n t e r n a l M e d i c i n e m a y w a n t to consider forming a group that would encourage and t e a c h t h e s k i l l s r e l e v e n t to t h e m e n t o r i n g p r o c e s s . What can be done by a fellow or junior faculty m e m b e r w i t h i n t h e e x i s t i n g s t r u c t u r e o f GIM d i v i s i o n s to f a c i l i t a t e f i n d i n g a m e n t o r ? O n e a p p r o a c h is to imm e r s e o n e s e l f in t h e " i n t e l l e c t u a l n e t w o r k " o f t h e ins t i t u t i o n in t h e a c a d e m i c a r e a o f i n t e r e s t . It is e s s e n t i a l to s e e k o u t t h o s e f a c u l t y w h o h a v e s i m i l a r i n t e r e s t s a n d to b e c o m e f a m i l i a r w i t h t h e r e s e a r c h o r c l i n i c a l netw o r k t h a t m a y b e f u n c t i o n i n g in t h a t area. This i n t e l l e c t u a l n e t w o r k is a p o t e n t i a l l y r i c h r e s o u r c e f r o m w h i c h a m e n t o r i n g r e l a t i o n s h i p m a y arise. F i n d i n g a m e n t o r o u t s i d e o f GIM d i v i s i o n s is a p o t e n t i a l s o l u t i o n to t h e m e n t o r i n g s h o r t a g e . This o p t i o n w i d e n s t h e p o o l o f a v a i l a b l e m e n t o r s . It also a l l o w s f e l l o w s to s e e k o u t e x p e r t s in a g i v e n m e t h o d o l o g i c o r c l i n i c a l area. T h e s e m e n t o r s a r e l i k e l y to p r o v i d e s t r o n g t e a c h i n g f u n c t i o n s w i t h i n t h e i r areas o f e x p e r t i s e . H o w ever, t h e y a r e less l i k e l y to act as r o l e m o d e l s f o r acad e m i c g e n e r a l i n t e r n i s t s o r to p r o v i d e s p o n s o r s h i p w i t h i n t h e GIM d i v i s i o n . M e n t o r s m a y a l s o b e s o u g h t o u t s i d e o f o n e ' s instit u t i o n . S u c h c o n t a c t s c a n b e m a d e at f a c u l t y d e v e l o p m e n t c o u r s e s , w h i c h a l l o w s o n e to d e v e l o p p r o f e s s i o n a l r e l a t i o n s h i p s w i t h n a t i o n a l l y k n o w n e x p e r t s in a s p e c i f i c r e s e a r c h o r c l i n i c a l field. D e v e l o p i n g a n d m a i n t a i n i n g s u c h r e l a t i o n s h i p s m a y b e b e n e f i c i a l in terms of networking and collaborative opportunities. Finally, it m a y b e i m p o r t a n t f o r a GIM t r a i n e e to u s e
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several mentors, with each of them performing some of the important mentoring functions. One mentor may be i m p o r t a n t for e d i t i n g p a p e r s , a n o t h e r f o r d e v e l o p i n g r e s e a r c h ideas, a n d a t h i r d for e m o t i o n a l a n d s o c i a l s u p p o r t in t h e d i v i s i o n . This f l e x i b i l i t y w i l l e n a b l e t h e t r a i n e e to e s t a b l i s h a s u p p o r t i v e a n d e d u c a t i o n a l envir o n m e n t e v e n if t h e " i d e a l , " w e l l - r o u n d e d m e n t o r is not available.
CONCLUSION A c a d e m i c d e v e l o p m e n t in GIM is a c h a l l e n g i n g a n d difficult p r o c e s s . M e n t o r i n g m a y b e an e s s e n t i a l i n g r e d i e n t to t h a t p r o c e s s . It is i m p o r t a n t to s t r u c t u r e p r o g r a m s s u c h t h a t t h e s e r e l a t i o n s h i p s c a n d e v e l o p eff e c t i v e l y . I n d o i n g so, GIM d i v i s i o n s m u s t d e a l w i t h problems raised by having young faculty with diverse r e s e a r c h i n t e r e s t s . By s u p p o r t i n g g o o d m e n t o r i n g relat i o n s h i p s , GIM d i v i s i o n s m a y h e l p t h e i r r e s e a r c h a n d t r a i n i n g p r o g r a m s t o flourish.
The authors thank Dr. John Feussner, Dr. Wendy Levinson, Dr. Mark Linzer, and Dr. Thomas Inui for the contributions they made in the development of the manuscript.
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