Surgical Mentoring Building Tomorrow's

Surgical Mentoring



John Rombeau  •  Amy Goldberg Catherine Loveland-Jones

Surgical Mentoring Building Tomorrow’s Leaders

John Rombeau Department of Surgery Temple University Hospital 3401 N. Broad St. Philadelphia Pennsylvania 19140 USA [email protected]

Catherine Loveland-Jones Department of Surgery Temple University Hospital 3401 N. Broad St. Philadelphia Pennsylvania 19140 USA

Amy Goldberg Department of Surgery Temple University Hospital 3401 N. Broad St. Philadelphia Pennsylvania 19140 USA

ISBN 978-1-4419-7190-6 e-ISBN 978-1-4419-7191-3 DOI 10.1007/978-1-4419-7191-3 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2010935290 © Springer Science+Business Media, LLC 2010 All rights reserved. This work may not be translated or copied in whole or in part ­without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar ­methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

This book is dedicated to our mentors who have immeasurably influenced our careers and continue to improve the care of our patients. Clyde F. Barker Clarence J. Berne Thomas V. Berne Robert F. Buckman Daniel T. Dempsey Victor W. Fazio Charles F. Frey Alden H. Harken Jonathan R. Jones Christine F. Loveland Jonathan E. Rhoads Wallace P. Ritchie Robert J. Smith Rupert B. Turnbull, Jr. Douglas W. Wilmore



Preface

The relationship between a senior surgeon (mentor) and his or her protégé (mentee) is like no other; thus, mentors are acknowledged more in surgery than perhaps any other medical discipline. One of the reasons surgical mentors are so highly respected is that we want to emulate them. This is exemplified by most successful surgeons having had at least an association with other successful surgeons. Although one can argue the associative versus causative nature of this relationship, it is irrefutable that something “happens” between these individuals which makes each a better surgeon. Why a book on surgical mentoring? First and foremost is to articulate the importance of a mentor to the education and growth of a young surgeon. A second goal is to provide state of the art, hands-on and didactic information on the current status and new directions in this field. Every attempt has been made to integrate day-to-day mentoring practices with evidence-based information. Surgical training in the twenty-first century is undergoing many changes which clearly alter the available time and opportunity to mentor. These changes mandate new approaches to mentoring. For example, most of today’s mentees will benefit from multiple mentors in a variety of areas including personal life, technical skills, research, clinical aptitudes and administrative duties. Additionally, exciting advances in the surgical simulation laboratory and information technology expand the ability of the mentee to learn more safely and expeditiously when compared to previous eras. Finally, we strongly believe there is a need to integrate the “old” with the “new.” Distinguishing qualities of

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humanism, altruism and empathy of surgical mentors of the past are just as relevant today as when the senior mentor was a mentee. We are concerned these qualities are regrettably becoming lost in today’s frenetic world of surgery. By design, the collaborative efforts of the authors provide varied mentoring experiences. Catherine Loveland-Jones, a senior surgical resident and research fellow, is in the clinical and educational “trenches” in addition to being an active participant in new approaches to mentoring, surgical education and information technology. Amy Goldberg, Surgical Residency Program Director, Temple University, has dedicated her entire career to surgical education and she is intimately (and sometimes painfully) aware of the highs and lows of surgical residents and the unlimited help the mentor can provide to them. Having mentored surgical trainees for 35 years, senior surgeon John Rombeau has had the good fortune to have been mentored by several clinical and research giants whose ghosts continue to haunt him. This book is an expression of his gratitude. Our book is organized to clearly communicate several objectives: succinctly define the topic and relevant issues affecting the mentoring process; describe why, when and how surgical mentoring should be performed; suggest ways to mentor specific groups of mentees; and, finally, speculate on future directions. Chapters are organized to present both hands-on approaches and evidence-based reports in support of these approaches. An appendix of websites with particular relevance to each chapter is included. Most of the references have been obtained from North American studies with the recognition that different issues exist internationally. Despite this continental approach, a representative review of international studies reveals striking similarities in the issues of surgical mentoring throughout the world. Our book is specific to surgical mentoring. It is not intended to be an exhaustive review on mentoring; there are several texts solely devoted to this topic. One of the most difficult aspects of this book has been to differentiate between mentoring and teaching. As noted in the text, all mentors are teachers; however, very few teachers become mentors. This is due in part to the extensive personal commitment of the mentor to guide both the personal and professional growth of the mentee. Nevertheless, we acknowledge the vast overlap between these two areas. This book is written for the continuum of surgeons, as mentoring is a career-long process. Our hope is to “plant the seed” for the medical

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student rotating on surgery as to both the joy of mentoring and the importance of seeking a mentor(s) early and often in one’s career. The surgical resident and fellow will learn the value of having an accessible and committed mentor and the importance of being a mentor to junior trainees. The tremendous benefits to the young surgical attending of having a wise and seasoned mentor are endless, particularly in navigating the many obstacles along the journey for career success. Senior attending surgeons will appreciate that mentoring is indeed a two-way street as they both mentor to and learn from their mentees. Additionally, we hope the immense influences of these attending surgeons (both positive and negative) will be better understood. We are convinced that mentoring makes a significant difference in the surgical world and epitomizes our heritage. Enjoy the journey! John Rombeau Amy Goldberg Catherine Loveland-Jones



Foreword

This book is important for all present and future surgeons because every surgeon needs mentors, and sooner or later most surgeons should become mentors. These trusted, experienced, committed (usually older) advisors and counselors are essential to the professional development, success, and job satisfaction of the young surgeon. And providing mentorship to (usually younger) colleagues is one of the most important and gratifying parts of a surgical career. Drs. Rombeau, Goldberg, and Loveland-Jones have written this book on surgical mentoring to fill an obvious need. It is up-to-date, comprehensive, readable, and evidence-based. If one searches “mentor” on the Amazon.com website, there are over 10,000 hits. If one searches “mentor and surgery,” there are only 4 hits, and all these books have a different focus from the current volume which provides invaluable information for surgeons at all levels of their careers. It is well referenced and a variety of useful websites is included. We are proud of the fact that the authors are members of the Department of Surgery at Temple University where there has been a long and very strong emphasis on surgical education for students and residents. Dr. Jonathan Rhoads, an important mentor of Dr. Rombeau, and Dr. Wallace Ritchie, an important mentor of Dr. Goldberg, were also invaluable mentors to me in my surgical career. Surgery is a small world with many satisfying rewards behind each of the many doors. Good mentorship provides the right keys for the right doors for the young surgeon. Both the mentor and mentee should read this

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book to better understand the who, what, when, where, and how of surgical mentorship in the modern era. What you learn will likely make a difference in your career. Daniel T. Dempsey, MD George and Louise Peters Professor and Chairman of Surgery Temple University

Acknowledgments

This book would not have come to fruition without the help of Maureen Rombeau. Her innumerable suggestions, editing skills, tenacity and indefatigability helped transform an idea into its present form. Most importantly, her love, support and teamwork throughout the past 40 years have made the senior author’s journey all the more productive and enjoyable! The authors gratefully acknowledge the encouragement, insightful reviews, suggestions and comments of the following individuals who have enriched the quality of this book: Keith Apelgren, Dick Bell, Tom Berne, Jeff Carpenter, John Clarke, Carol Cohen, Pamela Craig, Karen Deveney, Charles Frey, Argenis Herrera, Colleen Gaughan, Sloane Guy, Alden Harken, Samantha Hendren, Karen Horvath, Jeremy Korteweg, Aditi Madabhushi, James McClurken, Marc Mitchell, Jon Morris, Donna Muldoon, Patricia Numann, Ronan O’Connell, Emily Carter Paulson, Hiram Polk, Kathy Reilly, Bob Rhodes, Rolando Rolandelli, Robert Roses, Ajit Sachdeva, Jack Sariego, Smit Singla, Chip Souba, Omaida Velazquez, Malcolm Wheeler, Alliric Willis and Heidi Yeh. We are indebted to our Chairman Dan Dempsey – master mentor, teacher and role model, who continues to show us that mentoring is indeed a top-down process.

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Table of Contents

1 What is Mentoring and Who is a Mentor?.......................

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2 Why Surgical Mentoring is Important and Evidence That it Makes a Difference.........................

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3 What are the Qualities of an Outstanding Surgical Mentor?.................................................................

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4 How and Where Should Surgical Mentoring Be Performed?.....................................................................

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5 Mentoring Women Surgeons..............................................

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6 Mentoring International Medical Graduates...................

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7 How to Develop Faculty Mentors....................................... 113 8 How to Choose a Mentor.................................................... 133 9 Future Directions................................................................. 145 Appendix: Websites of Interest (Organized by Chapter)........ 165 Index............................................................................................ 167

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Chapter 1

What is Mentoring and Who is a Mentor?

“We must acknowledge that the most important, indeed the only thing we have to offer our students is ourselves. Everything else they can read in a book.” [or find on the Web] Daniel Tosteson, M.D. Dean, Harvard Medical School 1979

Key Concepts • Mentoring is the provision of personal and professional guidance usually to a younger individual. • A mentor is an experienced advisor and trusted friend who is committed to the personal and professional successes of the mentee. • Changing demographics in surgery mandate the need for multiple mentors for each mentee. • Future changes in mentoring will incorporate ongoing advances in information technology. Surgery has a long and proud heritage of mentoring. Perhaps more than any other group of physicians, surgeons are imbued with appreciation, respect, and a sense of awe for the seminal contributions by the “giants” in their field. This appreciation is exemplified by most major surgical texts containing a chapter on surgical history, replete with old portraits, photographs, and in some instances, monographs of famous surgeons. These venerated individuals have both directly and indirectly served as mentors to perpetuate our specialty and provide the foundation for surgical leaders of the twenty-first century. Many of today’s acknowledged surgical mentors trace their educational lineage to more than a century. In contrast to their more famous counterparts, the majority of today’s surgical mentors do not receive national or

J. Rombeau et al., Surgical Mentoring: Building Tomorrow’s Leaders, DOI 10.1007/978-1-4419-7191-3_1, © Springer Science+Business Media, LLC 2010

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international notoriety; however, they play important roles in the perpetuation of quality surgery and the training of tomorrow’s leaders. This chapter defines mentoring, tells who a mentor is and explains what mentoring encompasses. The distinctions, often subtle, among mentors, teachers and role models are discussed. The etymology of the term “mentor” as well as historic examples of the evolution of mentoring are presented. Historic changes in surgical mentoring are discussed as well as a brief commentary on the changing mentoring environment for surgeons of the twenty-first century. (This topic is discussed extensively in Chap. 9.)

Mentoring and Mentor – Definitions The term “mentoring” originates from the Greek language and literally translates as “enduring” [1]. Mentoring is defined as a process whereby an experienced, highly regarded, empathetic person (the mentor) guides another usually younger individual (the mentee) in the development and re-examination of their own ideas, learning, and personal or professional development [1]. It is essentially the provision of both personal and professional guidance, usually to a younger individual. Frey opines that the mentoring process “is about inspiring interest and excitement in others” [2]. In surgery, this interaction may vary greatly from communicating a “love of surgery” to medical students, to discussing ways to improve ABSITE scores with residents, to providing advice to junior colleagues as to which surgical society to join. For purposes of this discussion, a mentor is defined as an experienced and trusted advisor committed to the personal and professional successes of the mentee. This definition is both pragmatic and subjective. Understanding the three descriptors – experience, trust and commitment – is fundamental to appreciate and comprehend the complete concept of mentoring. Experience is indeed an important pre-requisite for being a mentor. For example, it is our belief that for a surgeon to be an outstanding clinical mentor, he/she must be a good operating surgeon. The surgical mentor has more experience than the mentee (student, resident, junior faculty) as to the particular aspect of surgery or type of operation being mentored. Experienced surgical mentors are well founded in the

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scientific basis and clinical rationale for their decisions as to when to operate, when not to operate, what to take out and what to leave in. They also have proven expertise in perioperative care. In some instances, experience includes performing hundreds of specific operations, whereas the operative experience may be very limited while caring for patients with rare or unusual conditions, yet still be a valuable asset to the mentee. Trust and commitment are inherent in mentoring and are perhaps the quintessential qualities which distinguish the mentor from the teacher (see section  Differences Among Mentors, Teachers, and Role Models). Most importantly, trust encompasses a personal relationship and commitment of the mentor to the mentee with the ultimate goal to develop the mentee into a successful professional. The trusting relationship is often more intuitive than explicit and is most effective when it is voluntary and not mandated. This is significantly different than most teacher–student interactions. Barondess describes the mentoring process as “Implicit processes, conversely, are not consciously or deliberately displayed. They involve the exemplar role of the mentor: intellectual style, professional priorities, deliberateness, truth telling, and the flavor of interpersonal relationships. Elements of scholarliness, thoroughness and loyalty, as well as styles of interactions with patients, peers and juniors are also powerfully displayed in implicit fashion” [3]. Implicit processes also include the important set of qualities noted by McDermott as the Samaritan functions of the physician – support, empathy and identification with the suffering of the patient [4]. These qualities are deeply imbued in respected surgical mentors. As an effective advisor, the mentor assesses the aptitudes and abilities of the mentee particularly as to the appropriateness of projected goals. This does not mean that the mentor directly “spoonfeeds” or tells the mentee what to do. Most experienced mentors recognize that the most cogent advice is often communicated by defining problems or clarifying issues to guide the mentee to arrive independently at the solution. This process stimulates both active listening and critical reasoning in the mentee. By teaching the trainee to listen, think and question, the mentor helps to transform information into maturity and wisdom. Clearly, the transference of knowledge is integral to effective mentoring. According to Souba, “Challenging the mentee forces him to step out of his comfort zone (where there is predictability and minimal risk but limited potential

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for new growth) into the zone of discomfort (where there is conflict and greater uncertainty, but potential for growth and new learning)” [5]. A major function of the mentor is to communicate the importance of acquiring the “whole package” along the journey to become an accomplished surgeon. This “package” includes not only clinical expertise but knowledge of relevant research, good communication skills, and integrating empathy and humanism into the complete management of the patient (see Chap. 3). As eloquently expressed by Barondess, this unique relationship is a “multifaceted and complex relationship between senior and junior professionals which, when successful, serves to fortify and extend within the younger person characteristics and qualities integral to professional development” [3]. Mentoring is truly a partnership between the mentor and mentee. Is it no longer acceptable for the mentor to control the relationship through the use of intimidation, power and subservience [6]. Mentoring is a career long process for many; however, there is generally a time limit to most mentor-mentee relationships. As the mentee matures, gains self-confidence and feels empowered he/she naturally becomes less dependent upon the mentor. A great mentor genuinely wants his/ her mentee to do better than the mentor has done and takes to heart the old proverb “If the accomplishments of the student do not exceed those of the teacher, the teacher has failed.”

Differences Among Mentors, Teachers, and Role Models Mentors are both teachers and role models; however, only a few teachers and role models are mentors. Perhaps the most important differentiating quality among mentors, teachers and role models is the personal commitment of the mentor to the mentee; thus, mentors are engaged in not only the transference of information but in the personal and professional successes and growth of the mentee. Additionally, the mentoring process is characterized by frequent oneon-one informal interactions instead of being limited to a formal classroom setting. In some instances this interaction may evolve from an advisor or teacher into a mentor. Most importantly, surgical mentors do not just question the student as to didactic knowledge; they want

Defining the Mentee

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the mentee to understand why problems occur and the rationale for their treatments. Teaching the mentee to question dogma and to approach surgical problems in an organized and objective manner are major goals of the mentor. Although most mentors are role models to the mentee, most role models are not mentors. The major difference between the two is the extent and duration of interaction. In some instances role models may have very limited contact or even no contact with the student or mentee. For example, Michael Jordan is unquestionably a role model for many aspiring basketball players but he is not a mentor to them. In surgery, many influences of the role model are passive and often conveyed through publications, verbal presentations or professional awards. The mentor’s quest and qualities are summarized by Barondess: “Mentoring, to be effective, requires of the mentor empathy, maturity, self-confidence, resourcefulness, and willingness to commit time and energy to another. The mentor must be able to offer guidance for a new and evolving professional life, to stimulate and challenge, to encourage self-realization, to foster growth, and to help make more comprehensible the landscape in which the protégé stands” [3].

Defining the Mentee The mentee is the individual taught and guided by the mentor. Although the mentee is always a student, whether formally or informally, young or old, only a few students are truly mentees. Historically, the mentee was occasionally known as a protégé (favorite, dependent), a term derived from the French verb protéger – to protect. To a certain extent today’s mentor still “protects” the mentee; however, the mentee’s ultimate autonomy and personal identity are implicit in the relationship. Mentees are often inspired to “give back” as the result of the mentoring process. Souba proposes that the best way to become a mentor is to be mentored. He states, “At the core of being a mentor is a basic understanding of people – what motivates them and what gives their life meaning and fulfillment. Our mentors help us appreciate the value of sharing the potential they helped cultivate in us. In so doing they inspire us to want to reciprocate” [7].

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History and Evolution of Mentoring Literature The concept of mentoring is thought to have originated from Gilgamesh, a Sumerian king, who lived about 2600 BC. Gilgamesh’s life was replete with many adventures, battles and legends [8]. He was described as two thirds god and one third human (perhaps a little less god-like than promulgated by many surgeons!) Despite his purported deification, Gilgamesh was arrogant, vain and ruthless. During his wanderlust, he serendipitously met Enkidu, a mentor who, through many fights, disagreements and interactions, changed Gilgamesh’s errant behavior by channeling him into benevolence and being a responsible leader. This epic legend underscores the mentoring impact of Enkidu, a friend and advisor, to ultimately provide guidance and influence leadership for the betterment of mankind. The word “mentor” is first mentioned in Homer’s Odyssey [9]. Mentor, a wise and trusted friend of Odysseus (Ulysses), King of Ithaca, remained in Ithaca to educate and take care of Telemachus, Odysseus’ infant son, and his wife Penelope, while Odysseus left for 20 years to fight the Trojans (Fig. 1.1). Mentor’s dedicated commitment to the education and well being of Telemachus provided the initial inspiration for the use of the term mentor. Mentor was not only responsible for educating Telemachus, most importantly, and apropos to the concept of mentoring, he was charged with teaching personal values and integrity with the ultimate goal of communicating wisdom. The importance of mentoring in this epic is further emphasized by Athena, the goddess of wisdom. As Mentor aged, Athena disguised herself and assumed the form of Mentor and continued the mentoring process. Due to the prolonged absence of Odysseus, Mentor and Telemachus set out to find the Ithacan King. At the completion of his journey, Telemachus had truly matured and was able to function as a wise and trusted adult. Thus, Mentor, and Athena disguised as Mentor, were key individuals in the education and transformation of Telemachus. This story is perhaps the most important historic example of the qualities of a mentor as an experienced, committed, trusted friend and advisor and an important influence on the education of a younger person.

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Fig. 1.1  Telemachus conferring with mentor (public domain)

Additional historic examples of mentors and their respective mentees are evident in the early Greek literature with examples including Socrates (see Chap. 4, section Socratic Method) and Plato, Plato and Aristotle, and Aristotle and Alexander the Great. Major historic examples of mentorship are also noted in religions and include the Greek pederasty, the Hindu and Buddhist guru-disciple relationship, the Rabbinical and Christian systems of Elders and the medieval guild system of apprenticeship. Dante’s Divine Comedy is often acknowledged as a classic example of the metaphorical journey of mentoring. This epic highlighted the role of a guide in the journey of life. The ideal guide was the Roman poet, Virgil, who directed Dante through the treacherous pathways of Hell and Purgatory to be followed by Beatrice, Dante’s ideal woman, who directed him through Heaven.

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Nineteenth Century Early Surgical Mentoring (Preceptorships) Although not a true mentor–mentee relationship because of frequently selfish motives of the preceptor, a facsimile of surgical mentoring was provided by older, experienced preceptors during this period. Preceptorships varied from minimal, peripheral exposure between experienced and younger individuals to a more intense, closer interaction. In some instances preceptorship was harsh and physically demanding servitude of the preceptee. This relationship was an apprenticeship and the duration and quality of training varied immensely; in many instances there was not a well defined end point for completion of the preceptorship. The preceptee was often viewed by the senior surgical mentor (preceptor) as being “not quite ready” thus affording the preceptor prolonged and increasingly experienced assistance at a very low salary. Theodor Billroth (1829–1894) was perhaps the greatest surgical mentor of the nineteenth century (Fig.  1.2). His renowned surgical

Fig. 1.2  Theodor Billroth (1829–1894) (public domain)

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expertise attracted apprentices from throughout the world. A close friend of Johan Brahms, Billroth became known as an accomplished musicologist as well as the father of “modern” abdominal surgery. He mentored a prodigious number of surgeons in his Viennese clinic including Carl Langebush, who became Professor of Surgery at the University of Vienna and Theodore Kocher, a brilliant Swiss surgeon who founded thyroid surgery and was awarded the Nobel Prize for Medicine and Physiology in 1909. Billroth’s influence is evident today through his tutelage of the Polish surgeon Jan MikuliczRadecki (1850–1905) who discovered inflammation of the lacrimal and salivary glands (Mikulicz disease), the Heineke-Mikulicz pyloroplasty and gauze packing of open surgical wounds (Mikulicz pack [also known as a laparotomy pack] currently used by many surgeons). American surgery was directly influenced by another Billroth pupil, John B. Murphy (1857–1916), who became Professor of Surgery at Northwestern University School of Medicine. Doctor Murphy devised the Murphy “button” to join the intestine without the need for extensive sutures. This concept was ultimately incorporated into gastrointestinal stapling devices. Finally, the eminence of the Billroth Clinic and the enormous successes of its trainees served as a prototype for the Halstedian program at Johns Hopkins University. Mentoring by preceptorship continued well into the twentieth century and was a frequent mode of “refresher” training for surgeons returning home following military service in World War II and the Korean War. The University of Pennsylvania built the Graduate Hospital in Philadelphia to train and re-train returning physician veterans.

Halstedian Training The beginning of formal, structured surgical training and mentoring in the United States is credited to William Stewart Halsted (1852– 1922) at Johns Hopkins Medical School in the late 1800s and early 1900s (Fig. 1.3). One of Halsted’s seminal contributions to surgical mentoring was the emphasis upon scientific evidence for clinical decisions. This approach included integrating anatomic and physiologic principles and even the results of animal experimentation into decisions affecting patient care. Apropos to mentoring, Halsted strove to train outstanding surgical teachers and scientists and not

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Fig. 1.3  William Stewart Halsted (1852–1922) (public domain)

just technically competent surgeons. A classic example of Halsted’s effectiveness as a mentor was his tutelage of Harvey Cushing. Halsted stimulated Cushing to integrate surgical science into clinical care and encouraged him to go into neurosurgery. Halsted also introduced Cushing to William Osler, the most important physicianmentor of his time. Cushing and Osler shared a lifelong mentoring relationship. Many principles of Halstedian training have remained in surgery into the present. This is particularly true in research-oriented departments of surgery where the provision of surgical training and clinical care is strongly influenced by evidence-based research.

Twentieth Century Influence of Television Television became immensely popular in the 1950s and included many medical programs which portrayed the complex interactions between physician/surgeon role models and mentors. Marcus Welby epitomized the caring physician who routinely placed the

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patient first when making clinical decisions. Ben Casey revealed the intensity and clinical challenges of a young neurosurgeon who struggled with the complexities, rigors and responsibilities of caring for patients with potentially fatal conditions. Dr. Kildare personified the insecurities, triumphs and disappointments in the daily life of an intern in training. The popular theme of medical/surgical training continues today in programs such as Grey’s Anatomy and ER. These shows reflect contemporary changes and demands in surgical/medical training such as limited training hours and teambased care.

Twenty-first Century: A Changing Paradigm for Surgical Mentoring Many recent events of the twenty-first century have both directly and indirectly led to significant changes in surgical training and mentoring (Table 1.1). The demographics of surgical trainees are changing in a dramatic fashion reflective of an increasingly diverse population in the United States. The previous preponderance of white males has been replaced by varied ethnicities and gender equality. Most contemporary training programs include nearly equal numbers of men and women [10]. Current surgical demographics mandate changes in Table 1.1  Changes in surgery – twentieth and twenty-first centuries Twentieth century Twenty-first century Surgical Primarily white Gender equality demographics males Varied ethnicity Clinical schedules Every other night call 80 h work week Financial debts of Significant, but payable Significant, payable only resident over prolonged period Patient responsibility Autonomous Team based Operative decisions Unquestioned Insurance companies-major influence Transparency, liability Minimal accountability Public information Primary task Patient care Business/clients/customers; entrepreneurs Mentors Solitary Multiple, more fragmented

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mentoring to accommodate the needs of pregnancy, parenting, and shared marital responsibilities heretofore performed solely by women (see Chap. 5). Currently many surgeons have working spouses which in turn leads to less time for leisure and family activities. Shared marital responsibility for household and childcare tasks is becoming the norm. Increasing numbers of surgical trainees are international medical graduates. These individuals are frequently unfamiliar with many nuances and customs of American medicine and training programs. The cultural backgrounds and differences in medical school training of these individuals must be addressed to provide effective mentoring (see Chap. 6). The time available for surgical mentoring has significantly diminished. Surgical training in the twentieth century was arduous. Every other night call schedules often resulted in residents spending up to 120 h a week in the hospital (hence the term “resident”). Despite many hardships created by these rigorous schedules, there were positive sequelae. The extensive hours in the hospital provided numerous opportunities for mutual interactions between an experienced mentor and a young mentee-resident. These associations were strengthened by increased operative experience for the mentee. Additionally, this milieu provided more opportunities for intraoperative teaching and establishment of a close rapport between the mentor and mentee. The current 80 h work week in the United States has reduced operative experience for the trainee, decreased time for perioperative care and increased demands for the acquisition of surgical knowledge in an increasingly limited teaching environment. Decreased time in the hospital also reduces the surgical trainee’s clinical experience and interaction with seasoned mentors. Furthermore, senior surgical mentors are confronted with increasing pressures to generate more revenue, thus reducing their time for mentoring. Consequently, many younger surgeons are first confronted with certain diagnostic and therapeutic problems after completion of their training and well into clinical practice. These changes necessitate new strategies in mentoring such as having multiple mentors (see Chap. 9), and mentoring after the mentee is in clinical practice. Today’s surgical trainee has unprecedented financial debt due to increasing costs of medical training. These debts are compounded by relatively fixed incomes, increased costs of living, and the inordinately

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long duration of surgical training when compared to other medical specialties. Whereas previous eras were characterized by single mentor– mentee relationships, the need for multiple mentors is rapidly becoming dominant in today’s world of limited time for teaching. Multiple mentors include individuals with special expertise (e.g., research, clinical care, administrative, etc.) who, due to time constraints, limit their interaction with the mentee to well-defined areas. This approach is the antithesis of the classic, one-on-one mentor–mentee dyad relationship. Moreover, it intensifies the difficulties of maintaining a personal and close commitment between the mentor and mentee. It is therefore anticipated that future mentoring will be provided by many individual mentors for each mentee. As mentioned, this paradigm continues to be driven by decreased training hours of the mentee and increased demands enforced upon the mentor to generate more clinical revenue. The concept of multiple mentors is discussed in greater detail in Chap. 9. Regrettably, surgery is changing rapidly from a revered profession, primarily dedicated to helping patients, to a multibillion dollar business. In many instances the clinical relevance of diagnostic tests and treatments is ultimately determined by insurance companies rather than by physicians and surgeons. The term “patient” has been replaced by “customer” or “client” in many medical environments. These “new rules” are here to stay and must be incorporated into today’s mentoring process. The surgical mentee must therefore be taught to be an astute and informed business person to survive in today’s new world of medical economics; thus the importance of the business mentor (see Chap. 4). Despite these problems there are exciting aspects of today’s new surgical mentoring (see Chap. 9). Surgical simulators have greatly enhanced the learning of laparoscopic techniques and endoscopy. Within seconds, the computer and wireless aids provide access to unlimited amounts of clinical and research information both at the bedside and in the operating room. Teleconferencing and telementoring provide the opportunity to transmit a single operating room into hospitals and classrooms throughout the world. Initially restricted to selected broadband wave length transmission, telesurgery is now transmissible via the Internet [11]. Today’s younger surgeons are group learners and are comfortable providing care within this context.

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Summary and Conclusions Mentoring is the provision of personal and professional guidance usually to a younger person. A mentor is an experienced and trusted advisor who is committed to the personal and professional successes of the mentee. The personal relationship with the student or mentee differentiates the mentor from the teacher or role model. Examples and qualities of mentors are depicted throughout history from the Homeric legends to contemporary television programs. The twenty-first century has changed the traditional paradigm for surgical mentoring and provides exciting new opportunities.

References 1. Taherian K, Shekarchian M (2008) Mentoring for doctors. Do its benefits outweigh its disadvantages? Med Teach 30:e95–e99 2. Fernandez-Zapico ME (2008) Mentoring is about inspiring interest and excitement in others. An interview with Charles Frey. Pancreatology 8:415–419 3. Barondess JA (1997) On mentoring. J R Soc Med 90:347–349 4. McDermott W (1978) Medicine: the public good and one’s own. Perspect Biol Med 21:167–187 5. Souba WW (1999) Reinventing the academic medical center. J Surg Res 81:113–122 6. Souba WW (1999) Mentoring young academic surgeons, our most precious asset. J Surg Res 82:113–120 7. Souba WW (2000) The essence of mentoring in academic surgery. J Surg Oncol 75:75–79 8. Epic of Gilgamesh (2009) http://www.studylit.com/summaries/gilgamesh. htm. Accessed 17 Feb 2009 9. Homer (1979) The Odyssey. Simon & Shuster, New York 10. AAMC (2010) Women in U.S. academic medicine: statistics and benchmarking report 2008–2009. http://www.aamc.org/members/gwims/statistics/stats09/ wimstatisticsreport2009.pdf. Accessed 28 March 2010 11. Sterbis JR, Hanly EJ, Herman BC et al (2008) Transcontinental telesurgical nephrectomy using the da Vinci robot in a porcine model. Urology 71:971–973

Chapter 2

Why Surgical Mentoring is Important and Evidence That it Makes a Difference

I have learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel. Maya Angelou

Key Concepts • Most successful surgeons have had accomplished surgical mentors. • Mentoring provides evidence-based personal and career benefits to the mentee. • Immense personal satisfaction and a prolonged opportunity to help others are the principal benefits to the surgical mentor. Most surgeons continue to seek challenges regardless of the stage of their careers. Whether preparing younger surgeons for private practice or an academic career, mentoring is one such challenge. This is particularly true for senior surgeons working in teaching hospitals and academic institutions. Both the mentee and the mentor benefit from the mentoring process. The mentee receives personal and ­professional benefits to his/her career which are documented in ­evidence-based studies. Mentoring provides an enormous sense of satisfaction to the mentor as well. The patient is the ultimate and most important ­beneficiary. This chapter presents an example of an ­exemplary surgeon who mentored other surgeons, reviews the ­rationale for the mentoring process as determined by its benefits to mentees, mentors and patients and provides evidence for this rationale.

J. Rombeau et al., Surgical Mentoring: Building Tomorrow’s Leaders, DOI 10.1007/978-1-4419-7191-3_2, © Springer Science+Business Media, LLC 2010

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Jonathan E. Rhoads – A Successful Surgical Mentor It is meaningful to examine the careers of successful surgical mentors and their protégés as their lives and accomplishments provide inspiration for medical students and surgical residents to find mentors. A few of the many revered, successful surgical mentors from the latter half of the twentieth century include Professors Austen, Coller, Dunphy, Longmire, Moore, Sabiston, Spencer, and Wangensteen. One of us (JLR) was fortunate to have spent a considerable amount of time with an equally successful surgical “giant,” Jonathan Evans Rhoads (Fig. 2.1). Dr. Rhoads spent his entire professional career at the University of Pennsylvania where he was Professor and Chairman of the Department of Surgery 1959–1972, and Provost of the University of Pennsylvania 1956–1959. He is perhaps best remembered for his research in intravenous feeding. His persistence in this field, combined with the able and creative assistance of his many surgical mentees, particularly Stanley Dudrick and Douglas Wilmore, led to the discovery of total parenteral nutrition (TPN). Currently used in every major hospital worldwide, TPN has saved thousands of lives.

Fig. 2.1  Jonathan E. Rhoads, M.D. 1907–2002 (Credit Yousuf Karsh, 1984)

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Table  2.1  Surgical chairmen trained by Jonathan E. Rhoads, Chairman of Surgery, University of Pennsylvania 1959–1972 Clyde F. Barker University of Pennsylvania P. William Curreri University of South Alabama Stanley J. Dudrick University of Texas Houston Robert W. Crichlow Dartmouth University James O. Finnegan Medical College of Pennsylvania C. Everett Koop Children’s Hospital Philadelphia, U.S. Surgeon General Leonard D. Miller University of Pennsylvania F. Carter Nance St. Barnabas Medical Center, Livingston, NJ Charles C. Wolferth, Jr. Hahnemann University

Dr. Rhoads’ many career accomplishments have been chronicled elsewhere [1–3]; however, he is an outstanding example of how a single mentor/role model/surgeon can affect the creation of other successful surgical mentors. A list of his mentees who became surgical chairmen is shown in Table 2.1. The number of additional successful surgeons who trained under Dr. Rhoads’ mentees is exponential and their influences on today’s younger surgeons continue to be significant. On a personal note, Dr. Rhoads’ “ghost” continues to haunt me (JLR) as rarely a day goes by without my invoking his presence. At times when I’m confronted with a difficult clinical decision or even a seemingly mundane action is required, I find myself asking “What would Dr. Rhoads do?” Recently, following an especially challenging operative day interspersed with varied administrative tasks, I finished my last case about 9:30 p.m. exhausted and barely able to change out of my scrubs. All I could think about was heading straight home, skipping dinner and going immediately to bed! Then I hesitated, remembering there was one inpatient whom I had not seen earlier in the day. She was an elderly lady, several days postop, in a distant part of the hospital, whom the chief resident had previously told me was doing well and I could definitely see her the next morning. The nagging question arose – “What would Dr. Rhoads do?” The answer was obvious – Dr. Rhoads would see the patient. By now it was after 10 p.m. Suffused with fatigue I reluctantly trudged to her room where I was surprised to see four family members who had waited several hours to see me. A rapid chart review followed by a brief physical exam (both unnecessary) confirmed the prior feedback that the patient was doing well and was ready for discharge in the morning. Her family (and she) was effusive in their gratitude for my seeing

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their mother at such a late hour and mentioned it was definitely worth the wait. Once again Dr. Rhoads’ enduring mentoring influence had been felt. Never underestimate the far-reaching guidance of a good mentor!

Importance of Mentor­ing to the Mentee Most successful surgeons have had at least an association with an older, more experienced, successful surgeon. While one can argue whether this is an associative versus causative phenomenon, it is indisputable that something “happens” in this relationship which, in turn, influences the career success of the younger surgeon. This hierarchical experience permeates all levels of surgeons from the medical student rotating on a surgical service to the accomplished professor. There is a strong precedent for mentoring at the highest level of academic excellence as exemplified by more than 50% of US Nobel laureates having served under other Nobel laureates in the capacity of student, postdoctoral fellow or junior collaborator [4]. Mentoring benefits the surgical apprentice in many ways. Firstly, “doors of opportunity” are opened as the result of the acknowledged prestige, stature, peer recognition and accomplishments of the mentor. When referring to a young surgeon who has recently completed training, how often do we hear the compliment “He trained under the famous surgeon Professor X?” Whether or not completely justified, comments and associations such as these frequently provide an aura of instant credibility to the mentee. While one can dispute the ­appropriateness of this evaluation, associations with influential mentors ­continue to be vital in the twenty-first century to advance careers of young surgeons.

Evidence-Based Benefits to the Mentee Mentoring in Academic Medicine Many investigators have tested the hypothesis that mentoring actually benefits the mentee. A recent review by Sambunjak and colleagues of the importance of mentoring in academic medicine

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examined the actual prevalence of mentorship and its relation to career development [5]. Although this study did not address surgical training per se, many of the findings encompass all medical specialties. Based upon predetermined criteria, 42 reports describing 39 studies were selected for analysis from 3,640 citations and 142 full text articles. In a subset analysis of 24 US medical schools, faculty members with acknowledged mentors had significantly higher career satisfaction scores than those without mentors (p < 0.03). In another subset analysis of Canadian OB/Gyn fellows, those with mentors were more likely to be promoted (CI 1.36–3.99) following completion of their training. This is a particularly relevant finding especially in today’s competitive medical environment. Additionally, there was a significant association between having a mentor and being the principal investigator on a research grant (OR 2.1–3.1). Despite these benefits to the mentee, fewer than 50% of medical students and, in some disciplines, less than 20% of faculty members had an acknowledged mentor. Furthermore, the investigators perceived that women had more difficulty finding mentors than their colleagues who were men (see Chap. 5). The authors concluded that mentors provide an important influence on the personal development, career guidance and choice, and overall productivity of the mentee. An important paradox in Sambunjak’s report is the high percentage of junior faculty members who did not have an influential mentor despite proven benefits of the mentoring process [5]. Is this the fault of departmental Chairs and academic training programs or the lack of initiative of the potential mentees? It would seem all sides are, in part, culpable. As one matriculates through medical education, there is clearly less structure and more responsibility placed upon the junior physician to become a self-directed learner. It is imperative that senior mentors support and guide the mentee through this transition to selfreliance. Additionally, the proven benefits of this guidance should be brought to the attention of departmental Chairs who may then provide the resources to support this process (see Chap. 7). Due to the reduced hours for clinical training in the USA, alternative teaching techniques such as simulation laboratories are now present in most surgical teaching programs. This topic is discussed extensively in Chap. 9. Simulation laboratories are outstanding examples of evidence-based support for surgical mentoring and will be briefly mentioned in this section. Simulation programs provide opportunities for objective measurements of mentoring and are particularly effective

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in teaching surgical techniques. Questions arise as to the optimal methods to teach surgical skills and whether there is evidenced-based support to confirm these teaching methods. Murphy and colleagues conducted a randomized trial to determine the benefits of mentoring surgical trainers on a specific cognitive method to insert an internal venous jugular catheter in mannequins at the John Radcliffe Hospital, Oxford, UK [6]. Ten experienced surgeons were randomized to use either a 4-step cognitive instructional method or their own independent method to instruct medical students. When compared to independent techniques, students receiving the cognitive instruction had significantly better performance scores (Fig. 2.2). The investigators concluded that instructing the trainer in a cognitive training method results in a significant improvement in training outcomes. As the result of the public outcry concerning “practicing on patients,” it is now mandatory that improved methods of teaching and mentoring be implemented in simulated settings. While trainers are not always mentors, the acquisition of surgical skills is particularly relevant in these settings. Although results of the aforementioned study show significant advantages to “training the trainer,” the challenging aspects of inserting a central catheter are not addressed in more difficult settings such as patients with either emphysema or previous thoracic surgery. Moreover, one can argue whether the statistically significant time saved in catheter insertion with the mentored approach is truly a clinically relevant difference. Despite these concerns, simulation labs are important settings for mentoring.

Performance score

17.5 17 16.5 16 15.5 15

Standard training

Trained training

Fig. 2.2  Performance scores of medical students with mentored training versus standard training (Reprinted from [6]. With permission from Elsevier)

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Regardless of the setting, it is imperative for the mentor to continue to emphasize the importance of thinking about the whole patient and not just focusing on the technique being taught. Investigators have questioned the relevance of having a faculty mentor present in a surgical skills laboratory. Jensen et al. evaluated the impact of expert instruction in laboratory based surgical skills training [7]. Forty-five junior residents were randomly assigned to learn basic surgical skills (skin closure and bowel anastomosis) in either a self-directed or faculty-directed setting. When compared to self-directed learning, Objective Structural Assessment of Technical Skill, time to completion, and skin aesthetic rating were not significantly improved in the faculty-directed group, although isolated improvement in anastomotic leak pressure was observed. Although residents perceived facultydirected training to be superior, this perception was not supported by objective analyses of performance. The investigators concluded there was minimal objective evidence in the simulation lab that facultydirected training improved transfer of certain learned skills to more complex tasks. While these findings differ from the Murphy report, clinical tasks were not the same in each study. The teaching of many surgical skills can most likely be performed well by a senior level resident, whereas others are better taught by an experienced mentor.

Mentoring and Research Success in research is one of the most consistent examples of the benefits of mentoring. Steiner and colleagues examined the influence of mentors on the research development of 215 Primary Care Fellows who were recipients of National Research Service Awards between 1988 and 1997 [8]. The purpose of the study was to investigate the quality and quantity of their mentorship experience. Twenty-seven percent had no influential mentor and 73% identified an influential mentor. When compared to their unmentored colleagues, individuals with influential mentors spent more time conducting research ( p = 0.007), published more papers ( p = 0.003), were more frequent principal investigators on grants ( p = 0.008) and provided more research mentorship to others (73% vs. 36% without influential mentors p = 0.008). This study is particularly relevant because it is increasingly more difficult to obtain research funding. Moreover, it is almost impossible to succeed in research without recognition by one’s peers

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as exemplified by serving as a principal investigator on a grant funded by a prestigious organization such as the National Institutes of Health. The major influence of mentoring on the research career of the junior investigator continues to be acknowledged as noted in this study.

Medical Students Rotating on Surgical Services As detailed in other sections of this book, patients are becoming increasingly more adamant about not being “practiced upon” during their operations. Additionally, increased student involvement may unnecessarily prolong the operation, which in turn, has both clinical and financial implications. Nonetheless, placing a few sutures or staples in the skin often has an enormously positive influence on the medical student, at no proven detriment to the patient, and it may “plant the seed” for a surgical career. The role of the attending surgeon is vital in these situations. If the major segment of the operation has proceeded uneventfully and if the patient has no major co-morbidities, the student can be more engaged as discussed. Attracting more medical students into careers in surgery is a major goal of residency program directors and surgical chairs. Berman and colleagues sought to identify the aspects of surgical clerkships that influenced a medical student’s decision to select a surgical career [9]. Students who sutured ( p = 0.001), or operated the laparoscopic camera ( p = 0.01) felt more involved in the operating room and viewed residents and attendings as positive role models. These students were four to seven fold more apt to enter surgery (95% CI 1.1–466.8) when ­compared to their less involved colleagues. The investigators concluded that students who participate actively in the operating room and those exposed to positive role models are more likely to be ­interested in pursuing a career in surgery. This study provides strong support for meaningful engagement of students in the operating room. Despite the acknowledged benefits of getting the student “involved” in the operation as noted in this report and others [9, 10], the question is whether this tradition (as remembered and appreciated by many of us) is appropriate in the twenty-first century? At the University of Wisconsin, O’Herrin and co-authors reviewed and analyzed the completed operative logs of 146 third year medical students with respect to the residencies in which they matched. In spite of finding no significant

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differences between the total number of operative cases observed for students matching into general surgery, surgical subspecialty or nonsurgical residencies, students who matched into categorical general surgical programs saw significantly more abdominal and general surgical operations than those matching into either surgical subspecialty or nonsurgical residencies [10]. These studies underscore the importance of acknowledging the medical students as part of the surgical team and allowing them to actively participate in general surgery operations.

Specialty Selection of Surgical Residents Mentors frequently provide an important influence on the specialty and job/career selection of the surgical resident. In some instances this influence occurs merely by serving as an example, whereas in other situations, the mentor has a more proactive role in career decisions of the mentee. Mentoring by example often includes subliminal communication by the mentor through behavior, attitudes and an expression of job satisfaction and personal fulfillment. Every experienced surgeon has learned there is no utopian job. As a result of age and experience, the surgical mentor is generally well qualified to elucidate both the favorable and unfavorable aspects of various job and fellowship opportunities and to help guide the younger surgeon to an independent decision. This guidance is not solely based upon the resident’s interests but also incorporates the younger surgeon’s aptitudes and abilities. The reasons for choosing a surgical specialty for a resident in training were investigated by Ko and colleagues [11]. Three hundred and fifty-two surveys from senior surgeons of regional and national societies were reviewed. The most common reasons for choosing a specialty were role models or mentors (56%), research interests (51%) and available patient population (23%). Stages of training at which the respondents became most interested in a specialty or an area of surgical expertise were at the junior resident level. This study confirms the significant influence of attending surgeons on career choices of surgical trainees during early periods of residency training. These results have implications for the types (i.e., general surgery, plastics, surgical oncology, etc.) and length and frequency of rotations on various surgical services for interns and junior surgical residents. Furthermore, as many training programs are moving to “early

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branching” with less exposure to general surgery, the need for faculty mentoring is projected to be even more relevant in the future especially during the first 2 years of training in general surgery. Thankur and co-investigators studied the impact of various influences, including mentor guidance, on the career selection of 86 graduates of UCLA’s surgical residency between 1975 and 1989 [12]. Not surprisingly, the most important influence was the resident’s interest in a specific area. Two-thirds of the respondents chose the same career as their mentors, attributing this to the mentor’s skill, achievements, and fellowship recommendations within their own specialty. The investigators concluded that mentor guidance was an important criterion in selecting career specialties. More recently, the impact of mentoring on career choices by surgical residents was investigated. McCord and colleagues sent a 32 item web survey to 99 graduates of the University of Wisconsin surgical residency who matriculated between 1985 and 2007 [13]. An important focus of this study was to determine the effect of mentoring on career decision-making in graduates who acknowledged an influential mentor when compared to their colleagues who did not identify such a mentor. The response rate was 84%. Sixty-one (75%) indicated an influential mentor was either important or very important in ultimately selecting their specialty field. The mentored residents identified clinical expertise (77%), being a role model (72%), and practicing professional integrity (70%) as the most important mentor characteristics which influenced their career decisions. In the mentored group the majority of respondents [72% (43/60)] were in the same field as their mentor ( p = <0.0001) as shown in Fig. 2.3. It was concluded that mentored surgical residency graduates were likely to enter the same specialty and practice type as their mentors. Additionally, the earlier in training the mentor was identified, the more likely the trainee selected the same specialty as the mentor. Similar findings have been noted by others [14]. The results of these reports and others are consistent with observations of most senior attending surgeons and those responsible for residency training programs. Although the Wisconsin study was only conducted in one training program, the findings can probably be extrapolated to other surgical residencies. An important caveat is these results will only occur in a training program which has quality mentors and where mentoring is given a high priority by the surgical chair. As mentioned, these findings are not surprising to senior surgeons. When reflecting on their own careers, many senior surgeons are chagrined as to the paucity of objective criteria

Importance of Mentoring to the Mentor

Number in Each Field

14 12 10

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Graduates Mentors

8 6 4 2

Tr au m a/ C Bu ar rn di ot ho ra ci C c ol o G re en ct al er al Su rg er y M IS Va sc ul ar Pe ds Pl as tic s Su rg O nc Tr an sp la nt En do cr in e

0

Fig.  2.3  Comparison of specialty selection of graduates and their mentors (Reprinted from [3]. With permission from Elsevier)

in support of their decisions to become a surgeon. More often than not, the decision was strongly influenced by an enthusiastic and knowledgeable individual (e.g., mentor) who took a special interest in a young trainee, thus resulting in a major, life-altering career.

Importance of Mentoring to the Mentor Most individuals who have assumed the title of senior surgeon readily acknowledge the importance and continued impact of mentors in their own careers and personal lives. Moreover, many senior ­surgeons feel an obligation to perpetuate this rich surgical legacy and to repay “debts.” This concept is eloquently expressed by Daloz who states, “What we model for our students is not our knowledge, but our curiosity, the journey, not the destination. As teachers, we recognize that we are channels through which information flows, configuring itself into certain patterns they may name ‘knowledge.’ However, the tradition we keep is not the knowledge itself but the capacity to generate it” [15]. Consequently, it behooves interested and experienced surgeons, whenever possible, to mentor their younger colleagues. The enriching experience of mentoring leads to enormous rewards for the mentor, the most significant of which are subjective. There is indeed a purposeful feeling which arises from sharing information and experience. Surgeons with major teaching responsibilities often live

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vicariously through the achievements of their trainees and find their accomplishments provide enormous personal joy and gratification. What greater contribution can a surgeon make to his/her younger counterpart than to “plant the seed” as to the importance of pursuing excellence, stimulating curiosity, asking the right questions, and mandating dedicated scholarship and ethical decision making in surgery? Furthermore, as the mentee matriculates and becomes a recognized authority in his/ her field, especially in another institution, professional networks expand accordingly and the mentor may find his/her own career and stature indirectly enhanced by the mentee’s success(es). The mentor also receives objective benefits from the two-way process of mentoring. The assistance from a mentee/protégé in perioperative and intraoperative care and being “challenged” by his/her innovative and therapeutic suggestions help keep the mentor “sharp.” Exposure to the mentee’s high energy, inquisitiveness and increased familiarity with new technologies collectively keep the mentor well informed, current and involved in surgical advances. These interactions may enhance the “persona” of the mentor and in turn bring exciting new perspectives to clinical care. Additionally, mentors with increasing clinical or administrative responsibilities and major research commitments realize the importance of a junior research mentee. These younger individuals are frequently the key determinants in the overall success of a laboratory or a specific research project. Perhaps the mentor’s ultimate reward is the realization that he/she provides positive impact on younger surgeons and their patients even after the mentor’s retirement and subsequent death.

Importance of Mentoring to the Patient and Surgical Care in General The most significant benefit of surgical mentoring is to the patient, thus collectively improving surgical care in our society. It is estimated that the learning of key clinical patterns may encompass the first two-thirds of a surgeon’s career [16]. This long learning process emphasizes the importance of mentoring early in the training of the mentee especially since more surgeons are retiring in their mid-50s. It stands to reason that if senior surgeons become involved in mentoring and convinced of its value, their careers will be extended,

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increased mentoring of younger trainees will ensue and more patients will be the ultimate beneficiaries. As most senior surgeons have learned, the process of transferring knowledge and perpetuating wisdom primarily accrues through clinical experience. Hence, it is intuitive that if the professional longevity of the surgeon is prolonged, general improvements in healthcare will accrue. As surgeons age and become clinically less active, increased time may be available for mentoring. Furthermore, this setting is a perfect opportunity for experienced surgeons to continue to make a difference even though they may not be directly caring for patients. Additional opportunities to mentor result from somewhat lessened pressures to generate departmental revenue, and decreased stresses engendered by competing for patients in a fixed clinical population. The mentoring process creates a “winwin” situation wherein the early and continual transfer of surgical knowledge benefits the mentee, patient and surgical care in general.

Summary and Conclusions Most successful surgeons have been mentored by accomplished surgeons. Mentoring provides numerous objective and subjective benefits to enhance the professional career and personal successes of the mentee. These benefits are confirmed in evidence-based studies and include guiding selection of surgical careers, enhancing research productivity, facilitating acquisition of fellowships, and obtaining jobs in private practice or academic institutions. Most of the benefits to the mentor are subjective such as enormous personal satisfaction, feeling of accomplishment, and a sense of purposefulness by helping patients long after one’s retirement. The results of surgical mentoring collectively improve patient care and enhance healthcare throughout our society.

References 1. Rombeau JL, Muldoon D (1997) Jonathan E. Rhoads M.D.: Quaker sense and sensibility in the world of surgery. Hanley Belfus, Inc., Philadelphia 2. Barker CF, Daly JM (1989) Jonathan E. Rhoads: eightieth birthday symposium. J.B. Lippincott, Philadelphia

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3. Barker CF (2002) Jonathan Rhoads, MD (1907–2002). Ann Surg 235:740–744 4. Zuckerman H (1977) Scientific Elite: Nobel laureates in the United States. The Free Press, New York 5. Sambunjak D, Straus SE, Marušić A (2006) Mentoring in academic medicine: a systematic review. JAMA 296:1103–1115 6. Murphy MA, Neequaye S, Kreckler S et al (2008) Should we train the trainers? Results of a randomized trial. J Am Coll Surg 207:185–190 7. Jensen AR, Wright AS, Levy AE et al (2009) Acquiring basic surgical skills: is a faculty mentor really needed? Am J Surg 197:82–88 8. Steiner JF, Curtis P, Lanphear BP et al (2004) Assessing the role of influential mentors in the research development of primary care fellows. Acad Med 79:865–872 9. Berman L, Rosenthal MS, Curry LA et al (2008) Attracting surgical clerks to surgical careers: role models, mentoring, and engagement in the operating room. J Am Coll Surg 207:793–800 10. O’Herrin JK, Lewis BJ, Rikkers LF et al (2003) Medical student operative experience correlates with a match to a categorical surgical program. Am J Surg 186:125–128 11. Ko CY, Whang EE, Karamanoukian R et al (1998) What is the best method of surgical training? Arch Surg 133:900–905 12. Thankur A, Fedorka P, Ko C et al (2001) Impact of mentor guidance in surgical career selection. J Pediatr Surg 36:1802–1804 13. McCord JH, McDonald R, Sippel RS et al (2009) Surgical career choices: the vital impact of mentoring. J Surg Res 155:136–141 14. Lukish J, Cruess D (2005) Personal satisfaction and mentorship are critical factors for todays’ resident surgeons to seek surgical training. Am Surg 71:971–976 15. Daloz LA (1986) Effective teaching and mentoring: realizing the transformational power of adult learning experiences. Jossey-Bass Inc., San Francisco 16. Pellegrini VD (2006) Mentoring during residency education: a unique challenge for the surgeon? Clin Orthop 449:143–148

Chapter 3

What are the Qualities of an Outstanding Surgical Mentor?

It’s not enough to espouse high standards. To live up to them – and help others do the same requires an ethical cast of mind that lets you practice your principles consistently. Howard Garner

Key Concepts • Mentoring qualities are both innate and learned. • Character, integrity and professionalism are inherent in outstanding surgical mentors. • Humanism complements cognitive proficiency and technical expertise. • Creative strategies are needed to integrate surgical mentoring into today’s challenging medical environment. • Students and residents perceive a mentor differently. • Surgical residents must be trained to become mentors. Outstanding surgical mentors are both born and made. Clearly, many such individuals have “genetic gifts” such as limitless energy resulting in enhanced productivity, innate creativity to devise new operations, effortless communication skills, and an insatiable desire to seek and share knowledge. The majority of surgical mentors, without these innate gifts, must acquire their skills through experience, observation, and most importantly, substantial interaction with a wise and seasoned mentor. Those of us who have accepted the challenge of being mentors recognize that acquiring these requisite skills is a career-long process. This theme is articulated by Rich Holt, an experienced surgical mentor who states, “In my opinion, it is important for those of us who have taken on the responsibility for training new practitioners in our subspecialty to realize J. Rombeau et al., Surgical Mentoring: Building Tomorrow’s Leaders, DOI 10.1007/978-1-4419-7191-3_3, © Springer Science+Business Media, LLC 2010

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that this training not only includes the clinical aspects of the field, but also the professionalism and character traits that make a physician a ‘healer of people.’ While none of us can be shining examples of all of the characteristics, we can strive to demonstrate them as best we can through word and deed and through an awareness of our responsibilities [1].” This chapter reviews qualities present in most outstanding mentors. Every effort is made to discuss these attributes within a surgical context and to provide examples for their importance in training young surgeons. Mentoring qualities based upon the perspectives of students and residents are also presented.

Qualities in Outstanding Surgical Mentors Opinions on the requisite qualities of a mentor are varied and sufficient enough to fill a textbook. In most instances we prioritize these qualities based upon our surgical training and clinical experiences. Nevertheless, and of particular relevance to surgeons, certain requisite qualities are omnipresent among outstanding mentors. For purpose of this discussion these qualities are arbitrarily divided into personal attributes, knowledge proficiency, technical expertise and teaching skills (Table 3.1).

Personal Attributes Character/Integrity/Professionalism While the personal attributes discussed in this section are not necessarily listed in order of perceived importance, it is hard to argue against ranking character, integrity, and professionalism near the top. Table  3.1  Qualities of outstanding surgical mentors

Personal attributes · Character/integrity/professionalism · Humanism · Curiosity Availability/accessibility Knowledge proficiency Technical expertise Teaching skills

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Character is defined as the mental and moral qualities distinctive to an individual, and integrity is the quality of being honest and having strong moral principles [2]. These qualities are indeed present in most outstanding mentors regardless of profession and are both innate and learned. Strength of character is frequently displayed from an early age during childhood and presumably has a genetic component. This important trait is also learned through interactions with family, teachers, role models and other exemplary individuals. As noted by Holt [1] and eloquently expressed by Simpson: “If you have integrity, nothing else matters. If you do not have integrity, then nothing else matters [3].” Character and integrity permeate the very being of most physician mentors. They are particularly called forth in surgeons when having to notify patients and their families as to technical problems in the operating room, and in discussing iatrogenic complications in front of one’s colleagues and mentees in morbidity and mortality conferences. In an attempt to deny culpability, surgeons occasionally provide alternative explanations such as citing the patient’s disease as the major cause of an untoward, iatrogenic event. These explanations may occur in lieu of acknowledging technical errors, mistakes in judgment or postoperative complications. Although co-morbidities and severity of illness definitely contribute to adverse postoperative outcomes, the surgeon’s explanations should always be honest and transparent. Our character and integrity are often tested to the limit in these situations. Another example of “character tests” is the need to disclose industrial support and to list potential conflicts of interest when giving talks, writing scientific manuscripts and using operative prostheses for which the surgeon has a vested interest. These disclosures should be communicated preoperatively to the patient and included at the beginning of verbal and written communications. It is incumbent upon the mentor to emphasize the importance of these issues to the mentee. Ethical conduct is interwoven within character, integrity and professionalism. Edward “Ted” Copeland III, former President of the American College of Surgeons, emphasized this interdependency during his 2006 ACS Presidential Address entitled “The role of a mentor in creating a surgical way of life.” Dr. Copeland states, “In short, the mentor establishes for the protégé the professional ethics that dictate practice patterns long after the protégé leaves the direct guidance of the mentor. The principles established by the mentor stay with the protégé and often can, and probably should, create a bit of anxiety if such principles are not followed [4].”

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Professionalism describes the cognitive, moral and collegial attributes of professionals [5]. It is a quality present in outstanding mentors. The significance of professionalism in surgery is emphasized in an insightful review by Souba and Steinberg [6]. They recount its historic evolution and the elements of a profession which epitomize the true meaning of being a physician and surgeon. Pursuit of excellence, altruism, and self-regulation are yet a few of the principles embodied in these elements which are both explicit and implicit in outstanding mentors [6]. In 1999 the Accreditation Council on Graduate Medical Education (ACGME) developed the Outcome Project, resulting in the need for residents to demonstrate competency in six general areas: Patient Care, Medical Knowledge, Professionalism, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, and SystemsBased Practice. The first two competencies, Patient Care and Medical Knowledge, have been the foundation of surgical training since Halsted. Professionalism was described by the ACGME “as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.” Interpersonal and Communication Skills were defined as “effective information exchange and teaming with patients, their families, and other health professionals [7].” Most surgical residencies have simulation ­centers and skills laboratories to mentor and assist with the training of residents in all six competencies (see Chap. 9). Additionally, these facilities have significantly improved the teaching of these competences especially within today’s confines of duty hour regulations; however, they probably have a lesser impact upon mentees when compared to direct interaction with an experienced surgical mentor. Prior to the ACGME Outcome Project, residents were not overtly taught these skills. It was presumed professionalism would be learned by observation and did not require the same amount of time or formal structure as needed to teach a resident to insert a central venous catheter or perform a colon resection. To correct this deficiency, the ACGME Outcome Project acknowledged the importance of teaching professionalism and communication skills concurrently with teaching an operation, resuscitating a trauma patient and caring for a patient in the intensive care unit. Surgeons have a professional responsibility to treat each patient equally regardless of social, financial and ethnic characteristics. When this does not occur, there must be consequences for unprofessional behavior.

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We must regulate ourselves and understand that the behavior of each ­member of the profession affects the whole and any abuse of patient or public trust diminishes us all. Additionally, surgeons must be committed to quality improvement and the maintenance of competence (see section Knowledge Proficiency) in a field that changes so rapidly. The role of professionalism in surgery is an important priority of the American College of Surgeons (ACS) which created a Task Force to address this issue. The ACS Code of Professional Conduct (Table 3.2) was the result of deliberations that emphasized four components of professionalism [5]: (1) A competent surgeon is more than a competent technician. (2) Whereas ethical practice and professionalism are closely related, professionalism also incorporates surgeons’ relationships with patients and society. (3) Unprofessional behavior must have consequences. (4) Professional organizations are responsible for fostering professionalism in their membership. Increasing emphasis upon entrepreneurialism in surgery is a potential threat to usurp intrinsic values such as professionalism. Interestingly, this is not a new problem in medicine. In 1951 Talcott Parsons opined, “The ideology of the profession lays great emphasis on the obligation of the physician to put the ‘welfare of the patient’ above his personal interests, and regards ‘commercialism’ as the most serious and insidious evil with which it has to contend [8].” Additionally, Pellegrino and Thomasma identify entrepreneurialism as one of the perils to healthcare as medicine is increasingly viewed as a commodity rather than a calling. They state, “When economics and entrepreneurialism drive the professions, they admit only selfinterest and the working of the market place as the motives for professional activity. In a free-market economy, effacement of self-interest, or any conduct shaped primarily by the idea of altruism or virtue, is simply inconsistent with survival [9].” In 1998 Henry Buchwald, Professor of Surgery and Biomedical Engineering, University of Minnesota stated, “Several years ago, I coined the term ‘administocracy’ to epitomize top-down control of money, resources, and opportunities by all these forces that restrict the autonomy of the clinician and academic [10].” In 2009 he lamented, “Unfortunately, administocracy has or is gaining control of our medical schools, our teaching and community hospitals, our income, and our ability to provide health care. We are being reduced to ‘vendors’ of health care; this status is not a firm base for the autonomy necessary for self-determination in our profession [11].”

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Table  3.2  American College of Surgeons Code of Professional Conduct (Reprinted from http://www.facs.org/memberservices/codeofconduct.html. With permission from American College of Surgeons) As Fellows of the American College of Surgeons, we treasure the trust that our patients have placed in us, because trust is integral to the practice of surgery. During the continuum of pre-, intra-, and postoperative care, we accept responsibilities to · Serve as effective advocates for our patients’ needs; · Disclose therapeutic options, including their risks and benefits; · Disclose and resolve any conflict of interest that might influence the decisions of care; · Be sensitive and respectful of patients, understanding their vulnerability during the perioperative period; · Fully disclose adverse events and medical errors; · Acknowledge patients’ psychological, social, cultural, and spiritual needs; · Encompass within our surgical care the special needs of terminally ill patients; · Acknowledge and support the needs of patients’ families; and · Respect the knowledge, dignity, and perspective of other healthcare professionals. Our profession is also accountable to our communities and to society. In return for their trust, as Fellows of the American College of Surgeons, we accept responsibilities to · Provide the highest quality of surgical care; · Abide by the values of honesty, confidentiality, and altruism; · Participate in lifelong learning; · Maintain competence throughout our surgical careers; · Participate in self-regulation by setting, maintaining, and enforcing practice standards; · Improve care by evaluating its processes and outcomes; · Inform the public on subjects within our expertise; · Advocate strategies to improve individual and public health by communicating with government, healthcare organizations, and industry; · Work with society to establish a just, effective, and efficient distribution of healthcare resources; · Provide necessary surgical care without regard to gender, race, disability, religion, social status, or ability to pay; and · Participate in educational programs addressing professionalism.

Administrative pressures to increase revenue generation are becoming increasingly more prevalent in surgery. For example, today’s junior attending surgeon is continually “encouraged” to generate more relative value units, analogous to billable hours for young attorneys in large firms. When confronted with spending a couple of hours on

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voluntary teaching rounds or working on a grant, versus performing another elective cholecystectomy or herniorrhaphy, the young surgeon really does not have a viable option. Nevertheless, there must be a consensus between commitments to both the academic and business demands of surgery. Surgical ideology and principles are meaningless if they are not applied. As noted by Stern, “Medical practice cannot be insulated from an otherwise commercial world, and financial solvency is a necessity. Rather than condemn all forms of commercial interest, we encourage our students to engage in the development of regulating policies and systems that benefit patients and are concordant with our values. Advocacy at the local, national and international levels is critical to such engagement [12].” Despite this ongoing dilemma, the welfare of the patient should be preeminent in the decision making.

Humanism Humanism is omnipresent among outstanding surgical mentors and is particularly manifest in the mentor’s personal commitment to the professional success of the mentee. Often couched within the cliché the “art of medicine,” humanism is characterized by compassion, empathy and concern for the emotional well being of the patient as well as the physical illness. Many humanistic issues, such as responding to family questions and phone calls, are perceived by some surgeons as trite, unimportant, and tasks solely to be relegated to a secretary, nurse practitioner or junior resident. The wise surgical mentor recognizes which responses are appropriately conveyed to a patient by a surrogate and when communication is optimally provided by the responsible, attending surgeon. When in doubt, a good rule is to err on the side of direct communication by the responsible attending surgeon. Humanistic surgeons take time to learn about the non-medical aspects of the patient, such as family and employment. These inquiries help to create rapport at the outset of the patient encounter, “soften” communication barriers and relieve fears. This is especially relevant if unfavorable and perhaps life threatening clinical information is to be discussed. As noted by Malcolm Wheeler, the renowned endocrine surgeon, “A few moments before talking with patients or

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their relatives, surgeons should try to put themselves into the position of those being spoken to or being given bad news” (M. Wheeler, personal communication). Despite the importance of humanistic qualities (often requiring considerable time when interacting with patients) for all physicians, surgeons are faced with the additional demands of intra- and perioperative care which in turn reduce available time for these expressions with the patient. Despite these increased demands, sagacious surgical mentors have learned that humanistic qualities complement cognitive and technical attributes and benefit the “whole patient” in a synergistic manner. The surgical mentor, imbued in humanism, not only helps the patient but influences the mentee in a positive manner. To make this relationship work, the mentor must be committed to the mentoring process. Observing the attending surgeon’s ability to effectively console postoperative patients who are suffering is as important an influence on a mentee as discussions of wound care, laboratory tests and x-rays. This inclusive approach creates a favorable impression for medical students as well as young surgical trainees. Moreover, these impressions may have more lasting influences on surgical trainees than observing the technical aspects of an operation. Humanism among surgeons is frequently needed in discussions with patients and their families in outpatient clinics and inpatient rounds (see Chap. 4). This is an outstanding opportunity for surgeons to mentor by example. During these interactions, students and housestaff readily perceive the differences between surgeons who carefully listen to their patients, willingly answer questions from family members, and continue to care for the “whole patient” when compared to colleagues who do not take sufficient time for these important interactions. In spite of the acknowledged importance of this quality, it is our view that the perpetuation of humanism among surgeons is in jeopardy. Regrettably, it is disappearing from today’s surgeons due to the maze of administrative commitments, endless paperwork, decreasing departmental resources, transition to incentive/bonus practice plans, decreasing payer reimbursement and expanding malpractice premiums (Table 3.3). In short, in today’s frenetic world of surgery it is difficult to find sufficient time to both generate more revenue and listen thoughtfully to patients. Souba and Steinberg express their concern about the progressive demise of humanism, compassion and empathy in surgery [6]. They note how rapid advances in biomedical research may be inadvertently

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Table 3.3  Barriers to humanism in surgery · Insufficient clinical time · Increased administrative commitments · Decreasing Departmental resources for protected time · Transition to incentive/bonus practice plans · Decreasing payer reimbursement · Increasing malpractice premiums

reducing humanism in surgical care. “Given the high position of science and technology in our societal hierarchy, we may be headed for a form of medicine that includes little caring but becomes exclusively focused on the mechanisms of the treatment, so that we deal with sick patients much as we would a flat tire or a leaky faucet. In such a form of medicine, healing becomes little more than a technical exercise and any talk of morality that is unsubstantiated by hard facts is considered mere opinion and therefore carries little weight. We must remind ourselves that a true professional places service to the patient above self-interest and above reward [6].”

Curiosity Curiosity, a quality inherent in most outstanding mentors, includes knowing when and how to ask the right questions and not being hesitant to challenge surgical tradition and dogma. Questioning established mores and traditions has been a major raison d’être for teachers, researchers and mentors since time immemorial. The importance of curiosity in mentors is further explained by surgeon Gary Dunnington, “Effective mentors are skilled in questioning. Studies of ward and bedside teaching have shown that medical faculty ask predominately low level questions that call for only recall of factual material. The skilled questioner [mentor] focuses on higher levels of thinking and poses questions that call for comparison, analysis and reasoning [13].” Surgeons who have had at least a modicum of exposure to basic research will acknowledge that an important “separator” between good and outstanding researchers is the ability to ask the right questions. These questions are not necessarily complex nor in need of elaborate phraseology or expensive solutions; however, they are hypothesis-driven, innovative, insightful, and (in surgery) usually

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address an unsolved surgical problem. John Ciardi suggests that “a good question is never answered. It is not a bolt to be tightened into place, but a seed to be planted and to bear more seed toward the hope of greening the landscape of ideas [14].”

Availability/Accessibility Availability has traditionally been deemed the “top A” of the three key A’s to success in clinical practice – Availability, Affability and Ability. Being available as a mentor is not always synonymous with accessible and approachable. To maintain a reputation of accessibility the mentor must reliably be present for mentoring sessions. Repeated cancellations will undo all previously established credibility. Many successful mentors have an “open door” policy thus encouraging visits from mentees. This policy should be made known to students, surgical residents and junior faculty. It should be well defined as to time and day of the week. Sessions should be limited (perhaps to 45 min) to insure focused discussions and permit the availability of the mentor for additional mentees. The sessions can be either scheduled or impromptu (see Chap. 4, section Intentional and Unintentional Mentoring). Scheduled sessions permit the mentor to prepare and reflect on the mentee and to review previous sessions prior to the meeting. Impromptu sessions provide an opportunity for the mentee to either review new clinical problems or discuss emergent/urgent personal or professional issues. Obviously, impromptu sessions must not be overly utilized or used inappropriately. Both personal and professional problems arise in all training programs and the veteran mentor recognizes that accessibility strengthens the personal commitment of the mentor to the mentee.

Knowledge Proficiency To gain the respect and allegiance of medical students who might become surgeons, surgical residents – often overwhelmed with both didactic and technical learning, and junior faculty in need of experienced guidance, the surgical mentor must be both knowledgeable

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and technically adept. The acquisition of sufficient knowledge for surgical mentoring is a career-long journey for which there is no final destination. The successful completion of examinations, such as those devised by the American Board of Surgery and comparable surgical organizations, is essential to professional recognition. In addition to board certification, re-certification and maintenance certification, it is important to stay current on advances in surgical knowledge and clinical care. While not always correlated with clinical competence, these certifications are today’s “gold standard” measurements of surgical knowledge in the United States. Recently, one of us (JLR) was queried by a junior surgical resident as to what percentage of the cognitive and technical care that he provided today was identical to that administered on the last day of specialty fellowship more than 30 years previously. Upon reflecting on this probing question, the response was approximately 10–15%. This estimated percentage undoubtedly varies among individual surgeons, surgical specialties and relevant clinical advances. Regrettably, there are some senior surgeons who practice today exactly the same way they did at the completion of their training. This outmoded approach does the patient a disservice by failing to incorporate the many ongoing, evidence-based and innovative advances in surgery. Moreover, the mentee fails to receive vital information concerning the “state of the art” advances in surgery. Maintaining competency in one’s specialty is aided by attendance at regional and national meetings and reading peer reviewed periodicals.

Technical Expertise Technical expertise is necessary in every surgical mentor; however, its presence does not always correlate with the ability to teach operative skills in an effective manner. The ability to operate safely and efficiently is a requisite goal for all surgical trainees, thus the need for technically proficient mentors. Surgery is a technical discipline; therefore, the acquisition of effective operative skills is a “rite of passage” in most surgical training programs. Competent mentors of surgical technique are astute at assessing the mentee’s level of expertise early in the course of an operation. This quick assessment helps to insure an effective operative experience for the mentee while not unduly

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prolonging the operation and still optimizing postoperative outcome. If the expectations for performance skills differ between mentor and mentee, this should be discussed one-on-one in a constructive manner in a private setting (see Chap. 4). Technical expertise among surgical trainees is more difficult to objectively assess than knowledge proficiency. Assessment of technical skills is frequently subjective and often based on hearsay (“he/she knows how to cut”) or random, and sometimes limited observations by more experienced surgeons. When technical aspects of operations are discussed among surgeons, it is easy to discern the surgeon whose comments are based more on reading than actually performing the operation. An indirect measure of a surgeon’s technical expertise is a review of complications and postoperative mortality; however, caution must be exercised when evaluating this information due to confounding influences of co-morbidities, documented risk factors and differences in the degree of difficulty among operations. Furthermore, a surgeon may be technically proficient, while occasionally exercising poor intraoperative judgment, thus adversely affecting postoperative outcome. New methods of objectively assessing technical expertise in the simulation laboratory are currently being investigated and appear promising (see Chap. 9).

Teaching Skills Most accomplished surgical mentors have effective communication skills learned through experience, observation, trial and error, and most importantly an intense desire to become a better teacher. The discussions of challenging patients, difficult operative decisions and technical tour de forces are outstanding ways to communicate information to surgical trainees. In some instances this process is nurturing and in other situations the mentee must arrive at independent decisions. Upon reflecting on a difficult evaluation by her mentor, surgical resident Angela Mouhlas opined, “In hindsight, it’s the constructive criticism and avenue of communication that is the foundation for a mentormentee relationship [15].” Similar to preparing a talk, an effective communicator understands the importance of the background knowledge, informational needs, and educational goals of the intended audience (mentees) when

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conducting mentoring sessions. Particular emphasis is placed upon the mentee’s pre-existing knowledge and the requisite information to be communicated within the allotted time. Experienced surgical teachers are able to communicate complex information in a comprehensible manner. Oftentimes the content and levels of communication vary greatly based upon the learner’s familiarity with the subject matter. Just because the senior surgical teacher has extensive experience in an area does not ensure that he/she is able to communicate information in an intelligible manner. There is no substitute for content preparation and practicing communication skills.

Qualities of a Mentor as Perceived by Students, Interns and Residents The basic relationship of mentoring is an interaction between a teacher and student; therefore, it is relevant to consider qualities in a mentor as perceived by students, interns and residents. Presumably there is agreement among educators, students and residents for many such qualities; however, certain attributes in mentors are characteristically valued more highly by younger mentees, perhaps influenced, in part, by age and generational issues. The difference in perceptions of attending physicians, when evaluated by students and residents, was investigated by Elzubier and Rizk [16]. They devised a 45 item self-administered questionnaire to a sample (n = 96), response rate 80%) consisting of three groups (1) students in years 3–6 of the medical curriculum (n = 66); (2) interns (n = 17) and (3) residents (n = 13). The questionnaire grouped qualities of a mentor into five general categories: personality, clinical, research, teaching skills and community service. The collective results revealed that personality, teaching, and clinical skills were ranked as the top three factors and community service and research skills as the least important attributes by 79 (82%) respondents. The personal qualities cited as the most essential were positive, respectful attitudes toward patients and their families, staff and colleagues; honesty; politeness; enthusiasm; competence and knowledge. Interestingly, females rated nine personal characteristics significantly higher than males ( p < 0.05). Interns and residents valued teaching enthusiasm and competence significantly more than students ( p = 0.01). Similar to

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studies discussed in Chap. 2, role models had a strong influence on the specialty choice of 53 (55%) of respondents. The study concluded that knowing the characteristics of excellent role models and mentors should help in their recruitment by medical educators. Cochran and colleagues from the Department of Surgery, University of Utah, surveyed third year medical students rotating on surgery to identify their characterization of the qualities of the best attending and resident surgical mentors [17]. Comments were systematically evaluated using content and analysis. The survey response rate was 95% with 98 of a possible 103 students responding. Characteristics of clinical teachers were based on four roles as noted by Ullian consisting of teacher, person, physician and supervisor [18]. The distribution results among these roles are shown in Table 3.4. Students most frequently described the “teacher” role for attending surgeons. For the surgical resident-mentor, students most frequently described the “person” role. The authors concluded that this difference may be due to the way medical students interact with residents and the importance of surgical residents’ role in mentoring medical students. What can be learned from this study? Greater characterization of attending surgeons as “teachers” and less as “persons” presumably reflects age disparity and less time spent with students compared to residents. The greater characterization of residents as “persons” may in part be due to the student actively participating as a member of the clinical team directed by the resident. Perhaps the most important message of this study is the major mentoring role of the surgical resident. To attract more students into surgery it behooves training programs to build upon these perceptions and to train surgical residents to become mentors. Due to decreasing availability of attending surgeons, it is anticipated that surgical residents will play an increasingly greater role in mentoring medical students (see Chap. 7).

Table  3.4  Role distribution of student comments permission from Elsevier) No. (%) No. (%) Mentor type physician supervisor Attending mentors 37 (14.7) 31 (12.4) (comments = 251) Resident mentors 54 (18.6) 27 (9.3) (comments = 291)

(Reprinted from [17]. With No. (%) teacher 101 (40.2)

No. (%) person   69 (27.5)

  77 (26.5)

127 (43.6)

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Studies such as these must be interpreted within the context of the location and department or institution being investigated. For example, in those departments with either a strong research identity or extensive involvement in community service, these areas would undoubtedly be acknowledged more highly by respondents. Cultural, language, and in some instances random exposure to certain clinical experiences may also strongly influence study findings.

Summary and Conclusions Innate and learned mentoring qualities in surgeons are honed with increasing experience. Character, integrity and professionalism are omnipresent among outstanding surgical mentors. Humanistic qualities complement cognitive proficiency and technical expertise. Creative strategies are needed to preserve mentoring in today’s entrepreneurial surgical environment. Students differ in their perceptions of mentoring qualities in attending surgeons and surgical residents. To meet increasing demands, surgical residents must be trained to become mentors.

References 1. Holt R (2008) Idealized mentoring and role modeling in facial plastic and reconstructive surgery training. Arch Facial Plas Surg 10:421–426 2. Concise Oxford American Dictionary (2006) Oxford University Press, New York 3. Quotes and Poems.com (2008) http://www.quotesandpoems.com/quotes/ showquotes/author/alan-k.simpson/125057. Accessed 5 Sept 2008 4. Copeland EM III (2006) Presidential Address: the role of a mentor in creating a surgical way of life. Bull Am Coll Surg 91:8–13 5. Gruen RI, Ayra J, Cosgrove EM et al (2003) Professionalism in surgery. J Am Coll Surg 197:605–608 6. Souba WW, Steinberg SM (2008) 1. Professionalism in surgery. ACS surgery: principles and practice. Elements of contemporary practice. WebMD, New York, pp 1–4 7. ACGME (2000) Outcome project: enhancing residency education through outcomes assessment. Accreditation Council for Graduate Medical Education, Chicago. http://www.acgme.org/Outcomes. Accessed 27 July 2009 8. Parsons T (1951) The social system. Free Press, Glencoe, p 435

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9. Pellegrino ED, Thomasma DC (1997) Helping and healing. Georgetown University Press, Washington 10. Buchwald H (1998) CSA presidential address: a clash of cultures: personal autonomy versus corporate bondage. Surgery 124:595–603 11. Buchwald H (2009) The problem of self-determination of professionalism and ethics. Bull ACS 94(4):8–13 12. Stern DT, Papadakis M (2007) Reply to letters to the editor. N Engl J Med 356:640 13. Dunnington GL (1996) The art of mentoring. Am J Surg 171:604–607 14. Ciardi J (1972) Manner of speaking. Rutgers University Press, New Brunswick 15. Mouhlas A (2009) Growing under a watchful eye. Bull ACS 94(4):30 16. Elzubier MA, Rizk DEE (2001) Identifying characteristics that students, interns and residents look for in their role models. Med Educ 35:272–277 17. Cochran A, Paukert JL, Scales EM et al (2004) How medical students define surgical mentors. Am J Surg 187:698–701 18. Ullian JA, Bland CJ, Simpson DE (1994) An alternative approach to defining the role of the clinical teacher. Acad Med 69:832–838

Chapter 4

How and Where Should Surgical Mentoring Be Performed?

When asked by a reporter why he played so hard every game, Joe DiMaggio’s response was, “There is always some kid who may be seeing me for the first or last time, I owe him my best.” Joe DiMaggio

Key Concepts • Mentoring medical students, residents, fellows and junior faculty is integral to their and the mentors’ professional development. • A series of probing questions (Socratic Method) is a vital component of mentoring and an effective stimulus for critical thinking. • The content and method of mentoring should be individualized to the clinical background, aptitudes and academic level of the mentee. • A thoughtfully written evaluation and direct verbal feedback are vital to the personal and professional growth of the mentee. • The operating room is a unique and effective site for surgical mentoring when utilized appropriately. • The mentee is invariably and disproportionately influenced by negative mentoring. • Surgeons must incorporate creative mentoring strategies into enlarging clinical practices. Mentoring medical students, surgical residents, fellows and young faculty is integral to their professional development and is the foundation for the perpetuation of surgery. Although this premise is intuitively sound, the means by which effective mentoring is performed is frequently challenging to both the mentor and mentee, nevertheless, mentoring is also one of the most gratifying, rewarding and fun aspects of surgery.

J. Rombeau et al., Surgical Mentoring: Building Tomorrow’s Leaders, DOI 10.1007/978-1-4419-7191-3_4, © Springer Science+Business Media, LLC 2010

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This chapter discusses how and where medical students, residents and young faculty should be mentored. Mentoring by example and the Socratic Method are reviewed as important components of how to mentor. The need to “tailor” mentoring techniques and content to the professional level of the mentee is underscored. Particular emphasis is placed upon mentoring in the operating room but it is acknowledged that mentoring occurs in the cafeteria and the parking lot. Finally, obstacles to becoming a good surgical mentor and negative mentoring are discussed. Suggestions to overcome these barriers are presented.

How Should Surgical Mentoring Be Performed? General Principles Mentoring by Example Students, residents, fellows, junior faculty and senior faculty colleagues are constantly observing. These people wouldn’t have gotten to where they are with blinders on. Moreover, thoughtful investigators have repeatedly inquired as to the reasons students and residents select a discipline within medicine. Over and over again, the pivotal determinant(s) were not the science of the discipline, material rewards, or lifestyle – it was usually because the student found someone (or a mosaic of “someones”) that they wanted to be like. That’s first class mentoring. “Doing” is vastly more influential than “talking.” Mentoring by example is often the most effective form of mentoring. Exemplary mentoring includes daily expressions of the qualities most admired in surgical mentors (see Chap. 3) which are not just expressed in a teaching conference. The attending surgeon’s behavior relative to interactions with the scrub technician, circulating nurse and anesthesiologist are constantly on display. Again, students and residents watch. Mentoring by example is often “tested” in the “heat of the battle.” How the mentor handles a difficult case or situation will be noted and emulated if performed in a professional and effective manner. Conversely, rude, arrogant and unprofessional behavior by the attending surgeon sends a powerful message. Although “negative mentoring” is a formidably

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powerful tool, none of us want to include this in the “teaching awards” section of our CV’s! “Reverse mentoring” (mentee mentoring the mentor) is always present and highly valued by the perceptive surgeon – we all can learn from the wise and compassionate behavior of the uniquely mature student/resident and fellow. We waste opportunity if we believe that mentoring is a one-way street.

Socratic Method Imbued in most accomplished surgical mentors, the Socratic Method is as relevant today as in the fourth century B.C. The Greek philosopher Socrates is credited as the paragon for teaching by questioning preconceived views. He sought not to just obtain direct answers but to conduct a dialogue with a series of probing questions until the student (mentee) independently deduced the answer [1]. The Socratic Method engages the mentee as exemplified by Socrates’ statement “To find yourself, think for yourself.” It is applicable to mentoring in the operating room, on clinical rounds, in teaching conferences or in the parking lot. Both the mentor and mentee must be cognitively engaged. To learn, you must “turn on” your brain. Nothing is duller than a recitation of memorized facts. For example, when an attending is presented with a detailed patient history or an array of test results, it is reasonable to ask the presenter “What does this mean to you?” to be followed by “Why did you give this response?” and “What’s the next course of action?” A risk of the Socratic Method is that the instructor may push the student too far and publicly humiliate the mentee by continued “peppering” of questions in the absence of a correct response. To avoid this embarrassment, wise mentors know when to “back off”; but an alternative strategy is to ask a question to three or four students/residents simultaneously, then no one gets embarrassed. A good mentor will usually be able to reconstruct almost any answer to make it “correct” then refine the inquiry with additional questions. Robert Oh [2] emphasizes that the proper use of the Socratic Method in medicine hones critical thinking skills, identifies the learner’s level of understanding and encourages self-directed learning. It is impossible to teach the mentee every conceivable clinical scenario, but this approach can provide the foundation, principles and processes to consider the issue at hand.

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Rohrich and Johns [3] support the use of the Socratic Method in teaching plastic surgery fellows in all clinical encounters, including teaching conferences, within the operating room and on patient rounds. They point out that both the fellow and attending surgeons benefit from this form of mentoring. The fellow develops reasoning and deductive thinking which results in safe, sound, surgical judgment and a better understanding of the relevancy of the topic of discussion. The mentor is stimulated to reexamine his/her knowledge and think and act clearly by developing rationale for the topic to be discussed. Teaching thus exposes the limits of the teacher’s (mentor’s) knowledge.

Intentional Mentoring Intentional mentoring is planned, structured, and occurs at a specific time and place. It may occur one-on-one or with a group of mentees. The mentor and mentee(s) usually have a specific agenda such as a research project, written or oral presentation or a discussion of future career plans. As the result of its prearrangement, the mentor and mentee are aware of the content to be discussed and goals for the mentoring session. Intentional mentoring usually occurs in an office or small conference setting. It may evolve from previous sessions of unintentional mentoring. The real risk here is that the mentor begins to think that he/she is only in the “spotlight” during formal mentoring sessions.

Unintentional Mentoring – Mentoring Moments The most effective mentoring is almost always unintentional. It occurs spontaneously without a predetermined agenda, location or number of mentees. This approach is used most effectively by veteran mentors who understand and appreciate the effectiveness of “mentor moments” – but don’t let your guard down – every moment is a “mentoring moment.” As Shakespeare wrote in As You Like It, “The whole world’s a stage…” and extending Shakespeare: “good education is good theater.” If they are not engaged they are not learning. As such, mentor moments can occur spontaneously in a conference, on rounds, in the operating room or just walking through the hospital.

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Unintentional interactions with a medical student or resident must be used efficiently and not squandered. This approach is especially relevant in today’s clinical environment of duty hour restrictions. Depending upon the content, mentoring moments are also known as “teachable moments.”

Mentoring by Faculty Mentoring Junior Faculty Although the majority of time devoted to mentoring by most attending surgeons is dedicated to teaching surgical residents, junior faculty also benefit from interactions with seasoned mentors. As emphasized in Chap. 1, most successful surgeons have had at least a close association with a senior surgeon (the person they want to be like) who has done well and is doing what he/she wants to do. Moreover, this interaction may be essential to the career advancement of the junior surgeon (see Chap. 7). Mentoring junior faculty is often more lasting for the senior surgeon than interactions with surgical residents and medical students. Residents and students rapidly matriculate through rotations and assume other areas of interest. In contrast, faculty relationships are more permanent and encompass social interactions as well as professional obligations. Additionally, these difficulties may in part be due to administrative decisions such as arbitrary assignation of mentors by the Chairman. For example, when a junior faculty surgeon is assigned to a senior surgical mentor, significant disagreements may be present as to the mentee’s career goals and ways by which these goals should be achieved. Therefore, this is not a good “match.” Furthermore, the mentor may not appreciate these expectations within the context of the junior faculty’s lifestyle, family values, and quality of life. These disagreements are usually prevented or ameliorated by permitting the mentee to personally choose his/her mentor with agreement of the Chairman. The mentor must then accept this additional (and rewarding) responsibility. Assigning mentor/mentee relationships is administratively foolish. Although typically done with laudable intent, this presumes that the assignor understands both the mentor and mentee better than they do.

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Topics in mentoring of junior faculty include care of patients, research projects and issues relating to career goals. Mentors should not impose their clinical views on junior faculty unless input is requested. Most senior surgeons have learned that there are many approaches to successfully solve clinical problems. Knowing the senior surgeon is available and receptive to discuss clinical issues is reassuring to junior faculty. The mature junior surgeon realizes that input from the more experienced senior surgeon will frequently improve the final outcome of the patient and may prevent complications. Time management is vital to the success of junior faculty. The mentor can provide invaluable help as to the amount of time to allocate for patient care, teaching, research and administration. Inherent in time management is learning when to say “no.” New junior faculty are inundated with requests and invitations to join medical school and hospital committees, give talks and write grants. Needless to say, it is impossible to fulfill all of these requests with quality participation. In fact, the young attending usually ends up performing many tasks poorly. One approach is to thank the inviting committee chair but politely decline the invitation due to too many new commitments. These regrets can be followed by the response “Ask me next year.” Experience has shown that approximately 50% of these requests will not occur “next year,” however, if they do, it is incumbent upon the junior faculty to accept! It is remarkable to ponder the immense amount of formal education required for physicians to reach their goals. Interestingly, it is rare for any of us to ever take a course in time management. A major mentoring role of the academic senior surgeon is to provide career advice to junior faculty based upon the senior mentor’s institutional, regional, national and international interactions. Every surgeon cannot be the best in the world in his/her field; however, the senior mentor raises the level for potential achievements and expectations for the mentee. If these seemingly unrealistic initial goals are established within the context of the mentee’s aptitudes and abilities, the final level of achievement will, in most instances, greatly exceed initial expectations. Mentoring junior faculty as to the socio-political nuances within one’s institution is an important function of the senior surgeon. Here again it is crucial that the mentor and mentee’s “styles” match. A political hurdle for one individual might well be an opportunity for another. In every institution there are both unrealistic and achievable goals.

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Unrealistic goals include trying to usurp the identity of a well established clinician or researcher in the same area of expertise at the same institution. In some instances the established individual may be successful based more on political posturing than merit. In many instances the established surgeon generates significant revenue for the hospital or parent institution. Regardless of the reason, it is usually “political suicide” for a junior surgeon to joust with the dinosaurs! As the result of increased longevity in the institution and established associations with various “power brokers,” the advice from the more perceptive senior mentor is invaluable in these circumstances. In every instance it is better to “prevent fires” than to try to extinguish them. By virtue of their experience, reputation, and, in some instances academic rank, most senior surgical faculty belong to prestigious societies and distinguished organizations. These positions provide outstanding opportunities to sponsor junior faculty for membership. If the young faculty surgeon is not fully qualified for senior membership, there are junior member categories in many societies. The colleagues and associations accrued through these memberships are invaluable to the career success of the junior faculty and often lead to lifelong friendships. Most senior faculty are experts in a specific field and many have published extensively in their area of expertise. As the result of these accomplishments, senior faculty are often invited to write reviews and book chapters in their specialty areas. This is another opportunity to mentor junior faculty by including them as co-authors. Not only does the junior faculty gain more knowledge in a specific area, inclusion as a co-author with an acknowledged expert is an honor. Assisting in the organization, writing and re-writing of a manuscript is essential preparation for ensuing independent publications by the junior faculty.

Mentoring Residents The highest academic responsibility of the faculty mentor is to teach the surgical resident to become a safe and proficient clinical surgeon; however, becoming a competent surgeon is not restricted to activities in the operating room. Indeed, we love surgery partly because we ­garner recognition and sometimes undue credit outside the O.R. It is not surprising that surgical residents are an eclectic group with differing

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cognitive levels, technical skills and varied interests. Seasoned surgical mentors have learned to adapt their approaches to mentoring. This adaptation is not a compromise but more of a consensus with the mentee to determine the most effective way of communicating technical and didactic information. Inherent to this teaching approach is the mutual understanding of the requisite knowledge and technical skills needed to be communicated to ensure safety, competence and continued matriculation of the resident-mentee. A foolproof method of cementing the mentor/mentee relationship is for the mentor to point out attributes that he/she (the mentor) has learned from the mentee (“reverse mentoring”). Show them that this is a “two-way” street. The content of mentoring sessions varies as to the level of the resident. For example, in the first year a mentor focuses on such topics as preparing for the ABSITE, caring for specific patient problems and assisting with operations. Additional content includes participating on clinical teams, giving oral presentations and navigating the nuances of the residency. For young trainees with research aspirations, it is not too early to inquire about potential investigative mentors and to find out about sources of funding. As the resident matriculates, performance evaluations and their potential improvements are discussed. Administrative and business expertise is increasingly important in today’s entrepreneurial surgical environment. Most surgical residencies teach didactic information, technical skills and research principles in an intelligible and clinically relevant manner. However, there is minimal time devoted to learning administrative and business aspects of surgery. Almost all surgical education in university hospitals is conducted by faculty who are not only less knowledgeable of the business aspects of surgery, but sometimes actively disdain it. Generally, surgical faculty begin their academic careers immediately after completing a residency or fellowship and have limited interaction with the private sector. In an increasing number of sectors of our society surgery has become a business. The term “patient” is replaced with the monikers “client” or “customer.” New surgical graduates enter today’s aggressive, entrepreneurial medical environment of private or academic practice with little knowledge of coding, billing and third party payers. Today’s properly trained surgery residents must be taught the “survival” principles of the current environment and ways by which administrative efficiency and rudimentary business expertise can be acquired. Pertinent topics for administrative and business mentoring

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Table 4.1  Administrative and business topics for mentoring surgical residents and junior faculty • • • • • • • • • •

Establishing and maintaining relationships with referring physicians Proper coding of operations and clinical diagnoses Interacting in group practices Assessing office overhead and maintaining competency of the support staff Voluntary participation in hospital committees Internet marketing and the Professional Web Page Identifying a “niche” to fill a surgical void in the community Appropriate billing practices and interactions with third party payers Investing in the practice to grow the future (partners, employees, associates) Interacting in a multi-specialty group practice

are shown in Table  4.1. Jack Sariego, Professor of Surgery at Temple University, and formerly a private practitioner, routinely includes this information in mentoring surgical residents. The clinical attending surgeon in private practice who is also affiliated with the residency training program is an excellent person to teach this information. These individuals are familiar with coding, setting up offices, and they understand both the objective and subjective nuances of group practices, salaries and other key financial issues. The departmental business manager is an additional teaching resource for these topics. Many of these individuals gladly welcome the opportunity to be involved in resident teaching. Providing tutelage of basic administrative and business skills is relevant to junior faculty as well. To help establish a personal relationship and create more effective communication, the faculty mentor should learn about the non-surgical life of the resident-mentee. While some of today’s lifestyle challenges are not unique to the current generation of surgical residents, new issues do exist. Today’s surgical residents are confronted with enormous debts with seemingly unending repayment, long duration of residency training, and increased sharing of spousal responsibilities. The current reduction in hours for clinical learning has created new stresses due to the need to assimilate expanding amounts of didactic information and gain sufficient operative experience to become a technically proficient surgeon. Good non-surgical topics for discussion with the new mentee include hobbies, travel, music, art and sports. When the mentor is familiar with these aspects of the resident’s non-surgical life, the relationship is more conducive to communication and learning.

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As mentioned in Chap. 1, this relationship and personal commitment differentiates the mentor from the teacher and role model. As the relationship matures, the personal commitment is enhanced by inviting the resident to surgical dinner meetings and, when appropriate, asking the mentee and his/her family to the attending’s home for dinner or Sunday brunch. The mentor must be aware of inappropriate topics and issues when establishing meaningful, non-surgical interactions with the mentee. Subjects such as marital problems and pregnancy should be avoided unless raised by the mentee. If these topics arise, a gratifying statement of “trust” ensues with an even greater responsibility and opportunity for non-judgmental assistance. Topics to be strictly avoided are jokes of poor taste and subjects with sexual innuendo. Similar to all interpersonal interactions with the mentee, and regardless of gender, discretion is mandatory.

Mentoring Students In the 2001 general surgery National Residency Matching Program (NRMP) 68 categorical positions were not filled in 40 general surgery residency program matches [4]. This triggered much introspection and questioning by the surgical community as to why medical students failed to choose a career in surgery. Following extensive discussions among surgical leaders and educators, the consensus emerged that surgeons needed to be better mentors to attract medical students into surgery. Fortunately, surgical training programs are responding to this recommendation. Recommendations are available to guide medical students and residents as to both academic and private practice [5]. The priority of teaching medical students is emphasized by surgeon Gary Dunnington as he recounts his experience in a faculty meeting with the Dean concerning a budget crisis [6]. When asked who is the most important consumer in the medical school, the Dean promptly replied, “Our number one consumer is the medical student.” This response is indeed correct especially when reflecting on medical schools’ composite mission of patient care, research and teaching. Patients are given state of the art clinical care in many non-university, highly accredited community hospitals.

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Cutting-edge research is conducted daily by research institutes and pharmacologic companies as acknowledged by their scientists having won Nobel Prizes. However, only medical schools are primarily responsible for teaching medical students. Thus, by virtue of being a faculty member, it is incumbent upon academic surgeons to provide the highest quality of mentoring to medical students. What should be included in these mentoring sessions? Most medical students do not become surgeons. Principles of surgical patient care and reasons to consult surgeons are relevant topics for medical students. These principles are generally well received because they may apply to the care of non-surgical patients as well. To provide a better example of the “surgical experience” additional emphasis should be placed upon those qualities unique to surgeons and surgical care, such as caring for the acutely ill, performing lifesaving operations and actually curing (not just controlling) disease. Further appropriate topics include discussions of preoperative evaluations, assessment of operative risks and delivery of appropriate postoperative care. These topics are best communicated within the context of the actual care of the patient assigned to the student, rather than as an abstract topic for discussion. Most attending surgeons are continually intrigued and challenged by the most difficult aspects of intraoperative and perioperative care. However, these topics are inappropriate for the neophyte medical student with only a few short weeks on a surgical rotation. Mentoring sessions should be interactive and the student should be identified as a responsible caregiver and integral member of the clinical team and not just a repository of information or a “messenger.” Step one is to learn the student’s name. He/she will be gratified and pleasantly surprised. Students will also realize that they are being held to a higher standard because you know and care who they are. Faculty mentors must encourage questions and be available and accessible for either formal or informal visits (see Chap. 3, section Availability/Accessibility). Direct availability to students is preferable to traditional hierarchical approaches of having to interact via an intermediary. The consequences of direct personal interactions with medical students may be profound. There is no greater reward for a surgical mentor than when a student decides to become a surgeon and the decision, in part, is due to interaction with the senior surgeon.

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Mentoring by Surgical Residents Most surgical residents receive the majority of their training from their co-residents and not from the attending faculty. This should not be a surprise because residents spend considerably more time together than they do with attending surgeons. Nearness in age and proximity of the training between junior and senior residents fosters close communication. The intense camaraderie as an active member of the multiresident surgical team creates a sense of loyalty, friendship and commitment which lasts long after the completion of residency training. It is therefore imperative that surgical residents become good mentors (see Chap. 7, section Delegate Selective Student Mentoring to Appropriately Trained Surgical Residents/Fellows). We believe that good mentors learn their skills early in their careers. Thus the opportunity for residents to mentor residents and medical students plants the seed for this growth process. Similar to any teaching experience, the ability to organize and communicate information in an intelligible manner improves the fund of knowledge of the mentor as well as the mentee. Moreover, repetition of information enhances retention. The frenetic schedules of most surgical services create challenges for conducting structured resident-resident teaching. An effective approach is for the chief resident to assign a junior resident a topic related to an in-patient problem or scheduled operation. When such assignments are made, it is incumbent upon the chief resident to follow-up on the process and query the junior resident on the patient and the information to be discussed. Junior residents can conduct similar teaching sessions with interns if time permits. On most surgical rotations, especially early in the academic year, interns are frequently overwhelmed with innumerable new tasks; therefore, teaching assignments must be made judiciously. During their surgical clerkship, medical students interact considerably more with residents than attending surgeons. Due to increasing pressures on attending surgeons to see more patients and generate more revenue, departments are delegating more medical student teaching to surgical residents. In contrast to interns, medical students rotating on surgical services have considerably more time for teaching sessions. The mentoring of medical students is an excellent opportunity for junior residents

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to learn good teaching skills and improve their surgical knowledge. When a mentoring topic is selected, the resident-mentor is forced to prepare by reviewing appropriate, evidence-based information. This “reverse mentoring” and “reverse teaching” is where good mentors continue to learn; the preparation enhances the fund of knowledge of the resident-mentor as well as the student. The importance of this topic has been commented upon from the surgical resident’s perspective by Hernandez [7]. Surgical residents influence the career choices of medical students. Musunuru and colleagues examined medical student evaluations of surgical residents over 5  years with respect to the medical students’ career choices at the University of Wisconsin [8]. Medical students who pursued surgical residencies evaluated the surgical residents significantly higher on teaching and effectiveness as role models when compared to students entering non-surgical careers. Twelve percent of the medical students who worked with the top 20 highest scoring residents chose a surgical residency compared to only 5% ( p = 0.022) of the medical students who worked with all the other surgical residents. (Table 4.2) The authors concluded that surgical residents who are effective educators and mentors influence medical students to pursue surgical careers. Nguyen and colleagues surveyed 117 third year medical students at the completion of their surgical clerkship at the Mount Sinai School of Medicine [9]. Ninety-one percent completed the anonymous survey regarding a career in surgery and characteristics of a surgical residentmentor. Ninety-five percent of the students who had a positive view of surgery at the end of the surgical clerkship identified surgical residentmentors during their rotation. Fifty-two percent of students who did

Table 4.2   Overall teaching scores and percentage of ­students pursuing a surgical residency (Modified from [8]. With ­permission from Elsevier) Students choosing Overall score surgical residency Top 20 residents 1.16 ± 0.03 12% Other residents 1.91 ± 0.04 4.9% p Value 0.001 0.022 Data are expressed as mean ± SEM Scoring system: 1, outstanding; 2, very good; 3, OK; 4, poor

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not have a positive view of surgery identified either attending or resident mentors. Residents outscored attendings in 12 of the 14 qualities noted as important for a clinical mentor ( p < 0.001). The authors concluded that surgical residents have an important influence on medical students’ decisions to select a surgical career. In summary, resident teaching of medical students provides an important message to the students that teaching is a high priority among surgeons. Additionally, interaction with a good residentmentor may stimulate the student to consider a career in surgery. In some institutions surgical residents are recognized for their teaching by being awarded academic titles such as Clinical Instructors.

Negative Mentoring Negative mentoring frequently has a more lasting effect on a mentee than a positive experience. Mutha and colleagues conducted focus group discussions with third and fourth year medical students from three California medical schools [10]. Negative role models, based on the students’ assessments of interpersonal interactions and career satisfaction, significantly influenced career selections. Attendings who are overtly unhappy with their careers and relate poorly to their patients and ancillary health care personnel are examples of negative mentors. Negative mentoring also affects surgical residents. A resident observing a faculty member berate an operating room nurse can significantly diminish or even negate all their previously positive interactions. Of further concern, the resident may believe that yelling in the operating room is not only acceptable but a behavior he/she should emulate. The perceptions of negative mentoring experiences have been reported in highly sophisticated studies by Eby [11].

Failed Mentoring Similar to all interpersonal interactions, there are failures as well as successes in mentoring. There are several reasons for these failures (Table 4.3). Firstly, the chronologic and social generation gaps between mentor and mentee may be too great to ensure effective communication.

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Table 4.3    Reasons for failed mentoring • • • • • •

Disparity of age between mentor and mentee Perception that seeking a mentor is a sign of weakness Mentor’s unreliability and lack of time commitment to mentee Unrealistic goals set for mentee Mentor taking inappropriate credit for mentee’s work Mentor’s reluctance to give sufficiently critical, negative evaluations

In certain instances these differences can be bridged by having junior attending mentors, with closer age proximity to the mentee. Secondly, surgical trainees pride themselves on self-confidence and the ability to make incisive decisions. In some instances, the young trainee may feel that seeking a mentor will be viewed by his/her resident colleagues as a sign of weakness or inability to learn independently [12]. Asking for help is a sign of maturity not weakness. It is imperative that Department leaders strongly communicate this dictum. A third reason for failed mentoring is the mentor’s unreliability and lack of commitment. Despite minimal interest and insufficient time for mentoring, some attending surgeons are nevertheless assigned to this activity. If you don’t want to mentor you should not have to. This is clearly a “prescription for failure” inasmuch as most professionals ultimately do best what they truly want to do. Voluntary mentoring and the creation of reciprocal “comfort levels” between mentor and mentee will prevent this failure. A fourth cause for failure is when the mentor sets unrealistic goals for the mentee. This mentoring failure can be prevented by a reasonable appraisal of the strengths and weaknesses of the mentee and appropriate mutual identification of mentoring goals. A fifth reason for failure is when the mentor usurps the credit for significant accomplishments of the trainee. This problem occurs more frequently in research than in clinical practice. While the mentor arguably provides requisite funding, personnel, and an environment conducive to research productivity, the mentee should receive appropriate credit if he/she formulates the study hypothesis, performs most of the work and is the major interpreter of the study results. Ironically, when the mentee is acknowledged appropriately, the mentor receives far greater recognition than falsely usurping credit for the mentee’s work. This problem can be prevented by the mentor clearly defining potential credits, listing of authorship and opportunities for presentation at the inception of the research study. Finally, failed mentoring occurs when the mentor is reluctant to give sufficiently critical (negative) evaluations. Human nature is such that

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most mentors want to be known as “Mr./Ms. nice guy.” Delivering negative evaluations is a painful experience for both the mentor and mentee, however, it is a disservice to the trainee and his/her patients when underperformance is not candidly discussed. Regrettably, these deficient trainees continue to be promoted with the comment “they should improve next year.” Unfortunately, “next year” never comes. In the most extreme situations these individuals can endanger the patient, causing significant morbidity with ensuing legal liabilities.

Written Evaluations and Verbal Feedback to Student and Resident Mentees Written Evaluations Periodic written evaluation and direct verbal feedback to the mentee are critical components of every mentoring experience. “If it isn’t written, it didn’t happen.” This is not quite true, but the written appraisal is especially helpful if it is supportive and constructive. These evaluations provide an objective assessment of the strengths (to be emphasized) and weaknesses of the mentee, help identify and correct deficiencies, and provide an opportunity for the mentee to respond and improve. There is no perfect written form for evaluating students or residents. In most institutions evaluation forms are easily completed and submitted electronically. Electronic evaluation is a two-edged sword; it saves time for the evaluator, however, the omission of written comments depersonalizes the evaluation and may provide little guidance to the mentee as to strengths and weaknesses. Although more time consuming, written comments are extremely helpful and should be included with the electronic submission. Basic categories of assessment include personal attitudes such as motivation, team work and receptivity to being taught. Although sometimes difficult to evaluate due to limited interaction, evaluations should address the mentee’s fund of knowledge and evidence of external reading about the patient’s diagnosis and operative treatment. In addition to the personal attitudes and knowledge of the patient, surgical residents must be assessed as to their understanding of both perioperative and intraoperative care.

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Verbal Feedback Regardless of the method of written assessment, it is incumbent upon today’s surgical mentors to provide direct verbal feedback to the mentee. These sessions should be conducted one-on-one in a private setting. Verbal feedback is performed preferentially at the mid-point and end of 2 month rotations. In 1 month rotations, one meeting at the end of the rotation is realistic. Again, communication of the resident’s strengths enhances the legitimacy of comments on observed weaknesses. Direct discussions of resident performance are sometimes “painful,” particularly if major deficiencies are present. When worrisome deficiencies require detailed explanations, it is valuable to have the Surgical Residency Program Administrator “sit in” on the conversation in order to witness the appropriate communication. No one likes to hear bad news and bad news is easy to “edit out.” Constructive “negative” conversations are frequently forgotten and the Program Administrator “witness” is helpful. Nevertheless, the mentor is obligated (to the resident and ultimately to his/her patient) to be forthright, candid and receptive to explanations. When the attending is concerned the resident has acted improperly or has specific deficiencies, it is often informative at the beginning of the session to ask the resident for an explanation for an event or the behavior in question. Occasionally, information will be provided, unbeknownst to the attending, which will in turn mitigate the mentor’s concerns. This approach of initial inquiry prevents false indictment by the attending at the outset of the discussion. Effective verbal feedback should be provided by the attending surgical mentor in a constructive manner. Criticisms without substantive suggestions and recommendations for improvement produce frustration and disappointment for the mentee. In the feedback/discussion the mentor should inform the mentee as to the quality and level of his/her performance when compared to un-named peers at the same level of training. Written acknowledgement of this feedback session should be included on the final evaluation form submitted at the end of the resident rotation. A major component of the evaluation and feedback for medical students is best submitted by the Chief Resident or resident who has spent the most time with the student. Following discussions with the evaluator-resident, final feedback should be communicated by the

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faculty member in charge of medical student rotations or a responsible attending surgeon on the student’s service. Some studies have questioned the effectiveness of verbal feedback to medical students and have found written evaluations to be sufficient [13–15]. Regrettably, many surgeons view assessments of residents and students as onerous and another one of an endless number of evaluation forms. Of the many forms that we fill out, these are among the most important. The ability to insightfully evaluate the student is often limited by insufficient interaction by the attending. Moreover, these evaluations are frequently submitted hastily, en masse, and either immediately prior to or following a grading deadline. These types of inadequate evaluations are a disservice to the residentmentee who has usually worked very hard and effectively and, in the case of the medical student, is paying a substantive tuition for the “privilege” of being taught. Prior to completing these evaluations, and to improve the quality of the assessment process, it is pertinent for the mentor to reflect when he/she was in a similar training position. It is better to frankly acknowledge insufficient contact with the student or resident rather than submit a perfunctory, meaningless evaluation. Most importantly, the residents and students are members of the clinical service and treatment team and a substantive evaluation, submitted in a timely manner, is a small token to pay in return for their help in caring for the attending’s patients. Colletti questioned the quality of the evaluations of medical students by surgical attendings [16]. She investigated a new evaluation process for the third year medical students when completing their surgical clerkship at the University of Michigan. Their previous system required all attending surgeons and residents to submit an evaluation form on each medical student on the service. The new system allowed the medical students to choose their evaluators, two attendings and one senior resident, who completed a modification of the old evaluation form and subsequently discussed the results with the medical student in a face-to-face meeting. Each medical student received an evaluation using both methods and the findings were compared. A significant degree of grade inflation was noted with the new evaluation system. This difference was more pronounced for students who were poorer performers. The author concluded that surgical faculty are resistant to give constructive, negative feedback, particularly in a face-to-face setting [16]. These results are not surprising. One would presume that students would only select potential evaluators with whom they had a favorable experience.

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Dobbie and Tysinger [17] developed recommendations for providing feedback to medical students and residents on their performances in the outpatient setting. They stressed the importance of providing feedback to learners especially interested in self-improvement. They concluded the process of the feedback should (1) inform the mentee when and where feedback will be given, (2) provide both written and oral evaluations, and (3) give constructive feedback privately.

Where to Mentor? The easy answer is everywhere! Mentoring can (and does) occur at any place and time; however, certain locations foster better communication. The mentoring location is an important determinant of both the teaching method and type of information to be communicated (see Chap. 3). During outpatient visits or inpatient rounds, mentoring must be modified as to time constraints, sensitivity to the patient, and anticipated educational goals. Moreover, caution must be exercised when conducting clinical discussions with the housestaff in the presence of new patients. You are clearly talking to both the resident and the patient in this setting. This approach can be particularly effective if the patient believes that they are intentionally included in the conversation. When in doubt and due to privacy concerns, verbal (and sometimes written) permission should be obtained from the patient prior to openly discussing their clinical condition.

Office of the Attending Surgeon The office of the attending surgeon affords optimal conditions for mentoring. A designated time in the attending surgeon’s office with pagers and cell phones turned off is conducive to productive discussion. To enhance privacy and provide more effective communication, the attending’s administrative assistant should be aware of the importance of the mentoring session and the need to restrict interruptions during the designated time. Forty-five minutes is usually sufficient. During this time the resident or student should have the mentor’s undivided attention. The scheduling of this protected time communicates to the mentee the importance

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and prioritization of these interactions. This location is suitable for discussing either predetermined content or impromptu topics. Some attendings prefer to have the door left ajar especially when a negative evaluation is to be presented. This provides the opportunity for an additional staff person to become involved if matters get out of hand.

Hospital Inpatient Rounds Hospital rounds of inpatients provides an opportunity for residents and students to listen and observe the attending’s direct interactions with patients, their families, nurses and ancillary staff. Patients and their families often wait long hours to see their surgeon. Every attempt should be made to make this quality time as exemplified when attendings thoroughly answer questions and respect the patient’s privacy. Sitting down, drawing the curtain or closing the door communicates to the patient that the attending is willing to listen. Students/residents will watch you listen. Sticking your head in the room for a perfunctory visit is an classic example of negative mentoring. The mentor’s adherence to infection control principles will also be noted by the inpatient and the mentee. Wearing a gown and gloves in an isolation room confirms that “best practice” does apply to the attending and dispels any perception that “these silly rules don’t apply to me” – another example of negative mentoring. The content and quality of the attending’s note on the chart lends itself to further scrutiny. Handwriting should be legible with appropriate signature and extension number if relevant. Although detailed re-writing of information, clearly discussed in preceding notes, is often redundant, new observations and recommendations are informative. The evolving transition to completely electronic hospital records will undoubtedly improve efficiency of entering and retrieving information.

Outpatient Clinic The aforementioned mentoring principles apply to both the outpatient and inpatient settings. As discussed in Chap. 3, interactions with the

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patients and their families are particularly relevant to mentoring in the outpatient clinic. Most outpatient rooms are relatively small and barely large enough for the patient and family member. Due to the space constraint, only one or two housestaff or students should be present during direct patient discussions. Similar to interactions with patients in other locations, the attending must be discretionary when discussing the patient’s condition. The outpatient setting is an outstanding venue for the attending to mentor by example. Mentees may benefit from listening to the attending’s dictation as well. Similar to inpatient rounds, there are frequently variable numbers of residents and students in attendance. The attending surgeon’s punctuality is a sign of respect for the patient and the mentee. If the attending is inadvertently delayed, the mentee should be notified accordingly. The attending’s absence based upon the excuse of being too busy should only be used when it really occurs. These perfunctory excuses send subliminal messages to the mentee which undermine the stature of the mentor. Infection control principles such as hand washing both before and after seeing the patient should be followed explicitly. In addition to careful documentation of clinical findings in the outpatient records, surgical mentors should emphasize the importance of sending copies of dictated letters to all ancillary physicians. The success of the surgeon’s clinical practice “lives and dies” as the result of referrals. Appropriate communication with all the patient’s physicians is extremely important for practices to grow. Too often the surgeon restricts written communication to the referring physician and neglects the family physician who has cared for the patient for many years. A good principle is to err on the side of over communicating. E-mail communication to referring physicians immediately after the patient’s operation is a good way to communicate operative findings, the type of operation performed and the patient’s anticipated prognosis.

Operating Room The operating room experience embodies surgery and is an unparalleled site for surgical mentoring. If utilized appropriately, the operating room provides a unique setting for discussing the rationale of an operation and demonstrating the patient’s diagnosis and treatment “in vivo.”

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4 How and Where Should Surgical Mentoring Be Performed? Table 4.4  Mentoring conditions in the operating room Favorable Unfavorable Co-morbidities Minimal + Extensive + Anesthesia Minimal risk + High risk + Previous operations at proposed site None + Multiple + Body habitus Normal + Obese + Surgical assistants Adequate # + appropriate level + of training Less experience than usual + Attending experience Extensive for proposed operation + Limited for proposed operation +

Similar to all treatment settings, the attending mentor must place the outcome of the patient as his/her highest priority. Once the operation begins, any mentoring discussion prolongs the duration of the operation. In most instances this time increase is minimal and does not affect the postoperative outcome. Veteran mentors are acutely aware of preoperative conditions such as extensive and potentially life-threatening co-morbidities which are unfavorable to mentoring. (Table 4.4) Additionally, while operations can have the same name, they do not necessarily share the same complexity. For example, a seasoned surgical mentor recognizes that repair of an inguinal hernia, although often relatively straightforward, may vary greatly in technical difficulty, duration of the operation and operative risk. Mentoring Students in the Operating Room The initiation of student mentoring in the operating room occurs either in the pre-operative conference, at the scrub sink or at the start of the operation. Knowing the student’s name and acknowledging his/her presence is important. Every effort should be made to engage

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the student as long as the operation is not prolonged unduly. It is “fair game” to query students as to the patient’s history, specifics of diagnosis and the indication for the operation. Directing the student to palpate the liver or feel the aortic pulsation engages the student in the operation and signifies his/her role as part of the team. Interactions such as these often impact upon the student’s decision to become a surgeon. Learning to tie knots and handle instruments in the operating room is no longer tenable. These skills should be taught in the surgical skills/ simulation laboratory (see Chap. 9). Mentoring Residents in the Operating Room The operative training of a competent, safe surgical resident involves an appropriate balance between observed autonomy and detailed supervision. When questioning the resident before surgery the expected knowledge base includes a thorough knowledge of the patient’s history and technical aspects of the operation, alternative operations, clinical data to support the proposed surgery and a well thought-out plan for postoperative care. Differing opinions in the operating room as to how the operation should be performed are not uncommon. Inherent in these differences is the indisputable fact that the attending surgeon is primarily responsible for the patient and the postoperative outcome. Despite this responsibility, experienced surgeons recognize that surgical residents often make insightful suggestions and comments which in turn directly improve the outcome of the operation. Due to this recognition, many senior surgeons routinely query the resident during the operation as to suggestions and recommendations. If a suggestion by the resident seems reasonable and is presented with justifiable rationale, it is appropriate to incorporate it into the procedure at hand. If the attending believes the suggestion is inappropriate, the rationale for his/ her position should be explained. Further operative suggestions, usually solicited, may be proffered from either the circulating nurse or scrub technician. These individuals spend their entire professional careers working in the operating room with many different surgeons. Lessons learned from this diversity can be applied efficaciously. Mentoring in the operating room is a continuum beginning with the surgical “time out” and concluding with the postoperative “huddle.” These practices are not only part of a JCAHO requirement; they enable proper communication among the operative team and improve

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patient safety. Constructive criticism of operative performance should be largely in real time. If tissue is torn or handled roughly, a suture placed poorly, excessive bleeding ignored, wrong instruments used, inadequate exposure accepted, retractor placement poor, and excessive electrocautery applied, these errors should be immediately pointed out to the resident-assistant and the misstep should be corrected expeditiously. This explicit intraoperative commentary should be followed by a confidential discussion with the resident as soon as possible after the operation. Most importantly the attending-mentor should explain why such activities were unsatisfactory and he/she should point out how such deficiencies can be either prevented or corrected. When relevant, a written account of these meetings should be maintained. Occasionally, a surgical attending may propose an operation which the resident does not believe (based upon evidence-based medicine) is the standard of practice for the condition at hand. This is where the value of the pre-operative conference is most evident. The operating room is an inappropriate location for philosophical controversy. You do expeditiously what you know you’re going to do. Coats and Burd examined the intraoperative disagreements between residents and attending surgeons [18]. Surveys were administered to both surgical residents and faculty regarding the frequency of disagreements in the operating room. Additionally, residents were queried as to whether they had options to resolve these disagreements. Estimates of frequency of major disagreements did not differ significantly between residents and attendings. Most residents and faculty noted two to three yearly disagreements in the operating room. Both groups concluded that the residents should ask the attending about the disagreement, but not leave the operating room if differences in opinions persist. However, faculty, more often than residents, recommended the resident leave the operating room if substantial concerns continued. Most residents were only occasionally comfortable confronting intraoperative decisions with their attendings, while most faculty believed their residents were always comfortable with these issues [18].

Research Laboratory The research laboratory provides a unique environment for interaction between the mentor and mentee. In many laboratories there are

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frequent opportunities for one-to-one mentor/resident interactions. These sessions can be especially productive because of less stressful environment when compared to locations such as the operating room. The research laboratory presents an opportunity for the mentee to learn an array of new skills and acquire knowledge not taught within the standard curriculum of most surgical residencies. The skill of “focused” interrogation will benefit the resident when he/she returns to the SICU. Planning and preparing prior to entering the laboratory are essential to the success of the research experience. Input of the research mentor is invaluable in these activities. In some laboratories the research mentor requires the resident/mentee to write a preliminary grant prior to entering the lab. This requirement insures a preliminary knowledge base for the mentee and may help to defray some of the salary costs. In other settings the resident is required to write a collective review suitable for publication prior to entering the lab. As a rule, the more extensive the preparation prior to entering the laboratory, the better the lab experience. Most importantly, the young surgical researcher learns the importance of reading and thinking before doing. This principle is often difficult for young surgeons particularly at the outset of the resident’s research experience. In some instances this “reading first” approach is very different from the resident’s clinical training in areas such as trauma surgery which requires immediate decisions and urgent responses. For example, when a patient is bleeding rapidly, the surgical resident, with his/her knowledge and technical expertise, stops the bleeding as expeditiously as possible. This immediate and potentially life-saving response is ingrained in experienced surgical trainees. Moreover, the resident would be strongly admonished and the patient might be harmed if he/she initially took time to read about operative hemostasis prior to actually doing it! In research, the problem solving approach is just the opposite. When a pertinent research question is being proposed, the wise research mentor instructs the new mentee to read extensively concerning the problem at hand and to formulate testable hypotheses. This preparatory process may require many weeks before the first preliminary experiment can be conducted. Young surgeons entering the research laboratory are frequently frustrated and impatient during this prolonged preparatory process; however, the ensuing research has a better likelihood of success when a well reasoned, step-wise approach is implemented.

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Surgical residents with research experience readily acknowledge that the skills learned in the laboratory made them both a better cognitive and (perhaps surprisingly) technical surgeon. Learning how to ask appropriate questions and to critically evaluate the literature makes the mentee-resident a better clinical surgeon. Most importantly, the mentee learns how to carefully evaluate data, assess appropriateness of statistical analyses and determine the adequacy of control groups. Successful surgical laboratories emphasize hypothesis-based studies and avoid descriptive and repetitious “me too” protocols. Organizational skills and the adherence to deadlines are necessary for research projects to be successful. As data accrue, discussions of how to apply these results to solving clinical problems provides an opportunity for the mentee to help patients far beyond the immediate interaction with the mentor. These tasks hopefully culminate in the submission of a well composed manuscript to a peer-reviewed publication. If published, the clinical results may influence the lives of patients far beyond the career capacity of the individual surgical investigator. Prior to beginning the research, the distribution of authorship should be discussed and adjudicated fairly as to the contribution of each author.

Future Directions Despite the “gloom and doom” environment perceived by some inveterate “chicken littles,” mentoring opportunities continue to be available for interested surgeons. Surgery remains gratifying, rewarding and fun. Spreading the “gospel of surgery” remains an enviable opportunity and a real privilege. One such opportunity is for surgeons to more actively integrate mentoring into their growing clinical practices. When attending surgeons see more patients (and generate more revenue), have more outpatient visits and perform more operations, increased opportunities are created for mentoring students and residents. It is therefore incumbent upon the attending surgeon (senior mentor) to proactively transform this enhanced clinical experience into a mentoring “gold mine.”

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Summary and Conclusions Surgical mentoring is a career-long opportunity, responsibility and gratifying experience. The best surgical mentors begin this process early in their careers. Positive and negative influence and opportunity is what you make of it. It is easy to make surgical mentoring inspirational and meaningful. Key principles of mentoring include leading by example and incorporating the Socratic Method into the learning process. Successful mentors tailor their interactions to the clinical background and academic level of the mentee. Never miss an opportunity to applaud, congratulate and acknowledge constructive behavior. Written evaluations and verbal feedback are mandatory components of formal mentoring programs. The operating room is an effective site for mentoring but mentoring should not be restricted to the hospital. Surgical mentoring failures can be prevented by appreciating generation gaps, mandating voluntary mentoring, and creating realistic goals within the context of the abilities, aptitudes and interests of the mentee. Future surgical mentors must use creative strategies to incorporate enlarging clinical practices into dynamic teaching experiences. Ultimately, surgical mentors can bask in the realization that we are communicating the philosophy of Katherine Graham, former editor of the Washington Post who said, “The luckiest people in the world are those who are doing something that they think is important and that everyone else thinks is important.” That’s us!

References 1. Thokme Z (2009) The Greek Philosopher: Socrates. ViaTouch.com. Accessed 4 May 09 2. Oh RC (2005) The Socratic Method in medicine – the labor of delivering medical truths. Fam Med 37:537–539 3. Rohrich RJ, Johns DF (2000) The Socratic method in plastic surgery education: a lost art revisited. Plast Recontr Surg 105:1803–1805 4. National Resident Matching Program (2001) Results and data. http://www. nrmp.org/data/resultsanddata2001.pdf. Accessed 4 May 10 5. Schroen AT, Brownstein MR, Sheldon GF et al (2003) Comparison of private versus academic practice for general surgeons: a guide for medical students and residents. J Am Coll Surg 197:1000–1011 6. Dunnington GL (1996) The art of mentoring. Am J Surg 171:604–607 7. Hernandez JM (2009) Mentoring medical students: a resident’s perspective. Bull Am Coll Surg 93:27–29

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8. Musunuru S, Lewis B, Rikkers LF et al (2007) Effective surgical residents strongly influence medical students to pursue surgical careers. J Am Coll Surg 204:164–167 9. Nguyen SQ, Divino CM (2007) Surgical residents as medical student mentors. Am J Surg 193:90–93 10. Mutha S, Takayama JI, O’Neil EH (1997) Insights into medical students’ career choices based on third- and fourth-year students’ focus-group discussions. Acad Med 72:635–640 11. Eby LT, Durley JR, Evans SC (2008) Mentors’ perceptions of negative mentoring experiences: scale development and nomological validation. J Appl Psychol 93:358–373 12. Pellegrini VD (2006) Mentoring during residency education. Clin Orthop Relat Res 449:143–148 13. Schum TR, Krippendorf RL, Biernat KA (2003) Simple feedback notes enhance specificity of feedback to learners. Ambul Pediatr 3:9–11 14. Paukert JL, Richards ML, Olney C (2002) An encounter card system for increasing feedback to students. Am J Surg 183:300–304 15. Greenberg LW (2004) Medical students’ perceptions of feedback in a busy ambulatory setting: a descriptive study using a clinical encounter card. South Med J 97:1174–1178 16. Colletti LM (2000) Difficulty with negative feedback: face-to-face evaluation of junior medical student clinical performance results in grade inflation. J Surg Res 90:82–87 17. Dobbie A, Tysinger JW (2005) Evidence-based strategies that help officebased teachers give effective feedback. Fam Med 37:617–619 18. Coats RD, Burd RS (2002) Intraoperative communication of residents with faculty: perception versus reality. J Surg Res 104:40–45

Chapter 5

Mentoring Women Surgeons

Look beyond our prejudices and unsupported convictions toward full use of the gifts women bring to medicine and surgery. J.N. Haug

Key Concepts • More women are becoming surgeons. • Women bring distinct strengths to surgery. • Issues specific to women surgeons must be understood to provide effective mentoring. • Male mentors and colleagues must know what is offensive to women surgeons. • The American College of Surgeons and the Association of Women Surgeons have established programs to mentor women. • Mentors should encourage women surgeons to seek teaching and leadership positions, integrate lifestyle issues, obtain multiple mentors and establish networking contacts. Women bring distinct qualities to surgery including: enhanced abilities to multi-task, superb communication skills, strong humanistic identities, and an abundance of fine motor skills [1]. Women comprise nearly 50% of medical students in the U.S., however, they only make up 32% of surgical residents and up to 15% of surgical faculty, primarily clustered at junior ranks [2]. This is concerning due to the projected shortage of general surgeons in the United States [3, 4]. Only 12–14% of the actively practicing general surgeons in the U.S. are women [5]. Every surgical mentee should receive comparable mentoring regardless of gender; however, issues of pregnancy, childcare and a surfeit of family responsibilities create a distinct milieu that must J. Rombeau et al., Surgical Mentoring: Building Tomorrow’s Leaders, DOI 10.1007/978-1-4419-7191-3_5, © Springer Science+Business Media, LLC 2010

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be understood, appreciated and navigated to effectively mentor women. Furthermore, because the mentor provides both professional guidance and personal tutelage to the mentee, a thorough appreciation of the special needs of women surgeons is vital to optimize the mentoring process. Women medical students, residents, fellows and young attendings frequently cite the lack of senior female mentors as an impediment to their careers [1]. The limited numbers of these potential mentors preclude their availability for most junior women surgeons. The logical extension of this discussion is to train more women surgeons and create incentives for them to join teaching faculties. An erudite discussion of the extensive literature on how to recruit more women into surgery is beyond the scope of this chapter. Moreover, the majority of today’s female surgical leaders have been mentored by men. Thus, a major premise of this chapter is: in order to provide optimal personal and professional mentoring (rendered by either female or male mentors) to women surgeons, it is mandatory to understand the issues specific to women mentees. This premise, in turn, is consistent with the working definition throughout this book of a mentor’s role to establish both a personal relationship with the mentee and to provide professional guidance. This chapter is directed specifically to mentoring women surgeons. It is not intended to be a comprehensive review of women in surgery. Issues of particular concern to women surgical residents and surgeons in private and academic practices are reviewed. Every effort is made to include studies unique to mentoring women surgeons; however, it is appreciated that age-matched, male control groups are lacking in many reports and are necessary for definitive comparisons. Furthermore, it is not definitively known if issues concerning women surgeons differ from women in internal medicine or professions such as law and engineering. Additionally, it is acknowledged that many of the issues (e.g., family responsibilities), thought by some to be unique to women surgeons may also apply to men. Special advantages of women mentoring women are discussed. A description of the mentoring resources of the American College of Surgeons and the Association for Women Surgeons (www. womensurgeons.org/) is included. Recommendations are provided to improve the overall mentoring process for women surgeons. Finally, a section briefly acknowledges a few of the female leaders in American surgery.

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General Issues Confronting Women Surgeons Women surgical residents leave surgical training programs more often than men. General surgery programs in New York, Texas, Minnesota, and Georgia report their attrition rates for women to be double those of men [6]. Areas of particular concern to women include role model or mentor availability, initiation and maintenance of personal relationships, comfort in expressing emotions at work, and childbearing during residency [7]. Additional concerns are gender-based discrimination, disproportionate family responsibilities, insufficient maternity leave and lack of institutional childcare facilities (Table  5.1). Moreover, it is incumbent upon senior mentors to help remove these barriers and create a more humane and gender equitable environment.

Lack of Effective Mentors The lack of effective mentors may be due, in part, to lack of initiative by the female mentee. It has been noted that women are less likely to have adequate mentoring relationships than men and do not ask advice from professors (usually male) as often as men do [8]. It is not known why this is so, however, it may be related, in part, to the lack of female faculty and presumed discomfort for a woman to ask a man for advice, especially if the issues of concern are innate to women. Presumably, the availability of more female faculty will help resolve these issues. An additional concern is the fear the woman will be perceived as “weak” or “needy” (personal communication). Some universities have organized programs to mentor women and utilize women faculty who also mentor students and residents. A survey designed to increase women’s interest in surgery was conducted with 1,000 medical students. Male medical students found a surgical

Table 5.1  Issues confronting women surgeons • • • •

Lack of effective mentors Gender-based discrimination Disproportionate family responsibilities Insufficient maternity leave and lack of institutional childcare facilities

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mentor of their same gender considerably more often than their female counterparts (71% vs. 45%, p < 0.001) [9]. Successful academic careers for women are positively affected by the involvement of an effective mentor [10]; however, the disproportionate lack of women in major leadership roles is particularly evident in academic surgery. In a study of 36 clinical department chairs and division heads in US medical schools, the lack of adequate mentors for women was noted to be a significant barrier to career advancement [11]. A survey of the American College of Surgeons fellows, who were academic surgeons, found that a relative lack of effective academic surgeon mentors continues to be a concern for women embarking on a surgical career [12]. Furthermore, in a recent survey of 100 Board certified women surgeons, 81% reported the lack of an effective mentor during the formative years of their careers [13]. Interestingly, reports note between 79 and 85% of female faculty who reported having a mentor had male mentors [5, 14].

Gender-Based Discrimination Despite major societal advances for women professionals during the past decade, both overt and covert gender-based discrimination continues [15]. In a study of both men and women in a teaching hospital, women were far more likely than men to perceive sex discrimination (47% vs. 20%, p = 0.002), most often from male attending physicians (33%) or residents (31%) [16]. In a review of female surgical leaders, 80% identified discrimination or gender prejudice as a major obstacle in their careers [1]. Overt discrimination such as public expression of derogatory or sexist comments has fortunately declined. Most institutions have mixed gender committees to adjudicate these issues and enact penalties. It is still troubling, however, that in a recent survey of 150 Board certified women surgeons with 100 responses, 63% reported being demeaned or bullied and 29% experienced inappropriate sexual advances [13]. Covert discrimination is more difficult to identify and, in some instances, may not be fully realized. For example, when a surgical Chair is recruiting junior faculty, a highly qualified married woman surgeon with children is frequently given less consideration when compared to a man with lesser credentials and a wife and children.

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Furthermore, when male surgeons are recruited, institutions often make major efforts to accommodate female spouses while this courtesy is rarely extended to the husbands/partners of female surgeons. Moreover, a recent study revealed that male academic surgeons had a less favorable perception of surgery as a good career for women than did female academic surgeons [17]. Some males undoubtedly perceive women as having too many extra commitments to devote sufficient time to their surgical careers. Gender prejudice may also be subtle and therefore difficult to identify and avoid. A female resident may never be the one called to help out on the “great case” or may always be the one sent to talk to families. Subtle gender-based slights such as these may accrue over time, potentially leading to isolation from male peers (e.g., she is not “one of the boys”).

Disproportionate Family Responsibilities The uneven distribution of family and household obligations is a widely acknowledged concern for most women surgeons. As described in Eva Singletary’s eloquent Society of Surgical Oncology Presidential Address entitled Mentoring Surgeons for the 21st Century, “Effective mentoring for women is especially important because traditional gender roles continue to dictate that women assume a larger share of the care of homes and children than their male colleagues. This is exacerbated by institutional infrastructure and culture that makes no allowance for family obligations: meetings scheduled in the evenings and on weekends; hardwired promotion timelines, with no part-time tenure track available, no emergency child care; and no formal ­parental leave policy” [18]. In a recent survey of 128 (64% response rate) members of the Rhode Island/Southern Massachusetts physician-mother mentoring/ networking group, Mom Doc Family, only 3% had a partner who worked less than full time and only 6 and 4% of respondents reported that their partners were more responsible than the physician-mothers in terms of household duties and childcare respectively [19]. The conflict between family and career is also an increasing concern for male surgeons; however, when both male and female academic surgeons were surveyed, twice as many women as men considered leaving academia (20% vs. 11%); with one of the most important

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reasons being personal time requirements, presumably due to family responsibilities [12]. Parenting creates another academic limitation for women surgeons. Compared to their male counterparts with children, impediments to women in academic medicine include decreased number of publications, less career progress and overall decreased satisfaction [20, 21]. Although not specific to surgeons, a recent study at a Canadian medical school noted that at all career stages (medical school, residency, practice, and teaching) women were less likely than men to recommend parenting to their peers, were more dissatisfied than their male colleagues with the amount of time they spent with their children, and were more likely to consider flexibility with regard to academic responsibilities (such as working part-time) as beneficial [22]. General surgery residency programs might improve efforts to recruit women by addressing the perception of the lifestyle associated with choosing a surgical career [5]. At a practical level, programs such as in-house daycare centers with extended, flexible hours could tremendously change the perception that training programs ignore child rearing, perhaps because it disproportionately impacts women surgeons and is therefore less important. Regrettably, there are very few ongoing programs directed to meet these needs. The resolution of issues related to family and personal time was noted to be a more significant determinant of career satisfaction for women than men (34% vs. 9%, p < 0.05) in a recent study at the Brigham and Women’s Hospital [17]. Although rarely acknowledged publicly, concerns regarding the increased family demands of women surgeons undoubtedly affect their job recruitment.

Insufficient Maternity Leave and Lack of Institutional Childcare Facilities Similar to their more senior female colleagues, childbearing is a major concern to surgical residents. Surgical residents most commonly are experiencing their first pregnancies and, in some instances, gestational issues create significant hardships for an already overworked resident. Snyder and colleagues concluded there are varied influences on a woman’s perception of childbearing during surgical residency, including both the stress and impact of pregnancy and childrearing on completion of their training [9].

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Leave limitations, set by the American Board of Surgery, and redistribution of work responsibilities to fellow residents often result in women delaying having children until the completion of all surgical training [12]. From 1997 to 2001, only 2% of all female surgical residents had a child during their training [23]; however, it is our impression this percentage is much higher today. For example, in Temple’s Department of Surgery there were seven pregnancies in 22 female residents (32%) between 2005 and 2010. As the result of more women having children during medical training, the needs for greater flexibility in residency programs as to maternity leave and childcare have increased [24, 25]. These are complex issues, hence there continues to be marked differences in maternity leave policies among surgical training programs. A 2001 survey of general surgery residency graduates revealed two of three surgeons who did choose to have children during residency would have preferred to have had more time off during residency, with men wanting a 1–3  months leave and women preferring 3  months [26]. Nearly 80% recommended that employers provide childcare facilities at work. Clearly, these requests are laudable; however, ways to fund such programs, issues of resident coverage, and less operative experience are significant, unsolved problems.

Pitfalls When Men Mentor Women Men (particularly those born before the “baby boom” generation) must avoid pitfalls to effectively communicate with women professionals. Firstly, the constant use of male descriptors such as “man” should be avoided. For example, when a woman is in charge of a committee the descriptor “chairwoman” or “chair” is preferable to “chairman.” Secondly, the use of sexual innuendos should be avoided at all times; women prefer the term “woman” to “girl,” “gal,” “honey,” or “dear.” The negative effects and repeated derogatory use of these descriptors are not trivial, as exemplified by the recent $1.6 million dollar award in favor of a female neurosurgeon at the Brigham and Women’s Hospital who was repeatedly discriminated against by her chairman [27]. Thirdly, the extraneous use of the term “woman” should be avoided. This descriptor is demeaning to women surgeons; for example, a woman prefers to be called a colorectal surgeon and

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not a woman colorectal surgeon. Remarks such as these further the impression that women are novel rather than colleagues. Finally, comments about personal appearance, though possibly well-intended, should be avoided in a professional setting. All surgeons want to be acknowledged for their professional accomplishments rather than their appearance.

Women Mentoring Women Due to the paucity of women surgical faculty, it is not unusual for female medical students to never be exposed to a woman surgeon, therefore, these students are unable to observe female role models and are denied the opportunity to discuss a possible surgical career with a member of their own gender. If women medical students have the opportunity for greater exposure to women surgical faculty they are more likely to select surgery as a specialty [28]. This deficiency may particularly impact women who may consider mentors as role models for both professional and personal life. As discussed, personal considerations such as family and childrearing issues are presumed to have major impacts on choosing a surgical career while career satisfaction does not appear to be affected by the proportion of women surgeons on the faculty [29]. While demographics dictate that the majority of today’s women surgeons have had male surgical mentors, it is undeniable that female surgical mentors have a better understanding of the myriad issues unique to women surgeons when compared to their male counterparts. While gender should theoretically not be considered a major characteristic of an effective mentor, the many unique issues confronting female surgeons underscore the importance of women mentors. In one study, female mentors were sought particularly for guidance on family and lifestyle issues or as role models [1]. Many of today’s students and junior residents need to be reassured that balance of personal and professional responsibilities is possible and they will not regret becoming a surgeon due to inability to have a fulfilling family life. To quote Jo Buyske, former surgical Chair, mother of two sets of twins, and ­current Associate Director of the American Board of Surgery, “As long as one can tolerate some chaos it should all work out” [30]. To train more women to mentor other women physicians, Files and co-investigators established a peer mentorship pilot program at

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the Mayo Clinic, Scottsdale [31]. Experienced female physicians acted as facilitators to a group of junior women who served as their own peer mentors. All the peer participants increased their academic activity as to publications, promotion, and skills acquisition. These benefits resulted in enthusiasm for continued participation in the program. The authors concluded that the pilot program was successful; however, further studies with larger numbers of participants were needed. Strengths of this report include identifying the problem (limited academic advancement for women faculty) and proposing a practical solution (providing experienced female facilitators). Whether similar results would occur with an expansion of this program is not known. Furthermore, it is unknown as to whether the same results would be obtained with well trained, “enlightened” male mentors. An effective program for senior women surgeons to mentor their more junior colleagues has been established jointly by the American College of Surgeons and the Association of Women Surgeons (see sections  Program to Mentor Women Faculty and Association of Women Surgeons and American College of Surgeons).

Program to Mentor Women Faculty Association of Women Surgeons (AWS) and American College of Surgeons (ACS) These organizations have jointly developed a mentoring program to facilitate the advancement of women in US surgery coordinated through the ACS Women in Surgery Committee under the direction of Margaret Kemeny, M.D. The Program’s goals are “to promote recruitment and retention of Fellowship within the ACS among women in surgical specialties; to aid in the development and enhancement of the leadership roles for women surgeons within the ACS as well as other surgical and medical organizations.” The purpose of the program is to help early career assistant professors achieve promotion and tenure [32]. Each mentee must submit a written statement identifying her professional goals and what she hopes to accomplish through the mentoring program. This information aids in identifying potential matches and facilitates introductions. The mentoring program is open to women who are assistant professors in academic practice

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in general surgery or a general surgery subspecialty. Members of the Mentorship Committee are matched with the mentee to assist with promotion to associate professor and to reach other professional goals. This program provides forums for young women surgeons to meet with peers, attend educational programs, and enhances their professional and personal lives. A searchable mentor database has been developed for members and the AWS supports networking breakfasts throughout the year. Formal programs should be viewed as synergistic to and not a substitute for informal mentoring relationships.

How to Mentor Women Surgeons More Effectively Many methods to mentor women surgeons do not differ significantly from those used with their male counterparts (see Chap. 4); however, it is imperative for mentors to incorporate the generic issues unique to females. This section includes mentoring recommendations (Table 5.2) based upon contemporary surgical culture and the collective needs of women surgeons.

Stimulate Interest in Teaching and Leadership The most important way to improve mentoring of women surgeons is to recruit and train more effective female surgical mentors. Inasmuch as many effective mentors are also accomplished teachers and respected leaders, women surgeons must be encouraged to seek advanced positions in teaching and leadership early in their careers. The mentor must realize that career trajectory frequently differs for women due to child bearing and inordinate family commitments. There are numerous ways to stimulate the interests of the mentee in teaching and leadership. At an early career stage, she should be

Table 5.2  Ways to more effectively mentor women surgeons • • • •

Stimulate interest in teaching and leadership Encourage mentee to seek multiple mentors Incorporate lifestyle issues into the mentoring process Facilitate networking

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encouraged to join societies such as the American College of Surgeons, the Association of Women Surgeons and Association of Academic Surgery. These organizations have entry level memberships, minimal dues, and programs specifically directed to young surgeons. The mentee is subsequently introduced to a new world of surgery beyond her institutional experiences. Most importantly, communication is established with a peer group of both future and current surgical leaders who, in some instances, will be mentors, advisors, confidants and friends for life. Mentees should be encouraged to lead formal case discussions, and present at morbidity and mortality conferences. The veteran public speaker and surgical leader is well aware of the importance of giving formal presentations at a very early stage in one’s career. It has been noted by women mentors that female mentees frequently need coaching in public speaking as they are apt to speak softly and unassertively (personal communication). To be fair, however, women express that it is often difficult to balance assertiveness and “professionally accepted humility” as the male dominated world of surgery tends to refer to women with more negative descriptors regardless of their approach. For example, women surgeons may be either timid or aggressive whereas similar attitudes in a male surgeon are described as “being a gentleman or a go-getter.” An effective mentor (male or female) should help the mentee understand these biases (often subtle, and prevalent in men and women) to confront the potentially demoralizing sequelae to women surgeons. Research psychologists have discovered that self-perception is influenced by gender. Women tend to underestimate themselves when engaging in “male-type” activities. When a woman executes a job poorly, she assumes a lack of skill, whereas her male peer assigns failure to “bad luck” [33]. Women surgeons may need more positive feedback and encouragement than their male counterparts [34]. Female and male surgical student self-assessments were compared with faculty evaluations by Lind and colleagues [35]. Male students consistently overestimated themselves, whereas women significantly underrated themselves compared with faculty ratings. This occurred despite higher mean final clerkship grades for women than for men. Finally, mentors should encourage the mentee to organize short teaching sessions with medical students. This forces the mentee to review the topic, is an excellent introduction to leading interactive teaching sessions and provides the opportunity for female students to be introduced to women role models.

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Encourage Mentees to Seek Multiple Mentors Similar to male mentees and consistent with the theme of this book, female surgical mentees should seek multiple mentors. Ideally, at least one of these mentors should be a woman surgeon to serve as a personal advisor for lifestyle issues in addition to professional ­matters. These mentors should be identified at an early stage of the mentee’s career and will most likely parallel the evolving interests of the mentee. Examples of areas of expertise include specialty interest (vascular, breast, colorectal, etc.), administrative guidance (managing a practice, coding, academic progression, etc.) and identification of research projects. A mentor can help the mentee initiate a research project (if possible in an area of mutual interest to the mentor and mentee) as well as serve as a co-author for a collective review that may be suitable for publication. The mentor’s knowledge as to the most appropriate journal for submission of a manuscript benefits the ­mentee’s career. These projects should be planned and implemented within the female mentee’s lifestyle demands as discussed earlier. Of particular importance for young female surgical mentees is finding an experienced mentor who understands ways to circumvent the ­obstacles and confront the many issues unique to women. Additionally, the woman surgical mentee must take the initiative in selecting a mentor (female or male) who believes in gender equity and ­eliminating gender-based career obstacles.

Incorporate Lifestyle Issues into the Mentoring Process As long as medical students increasingly select specialties with controllable lifestyles, surgical mentors must strive to implement these considerations to make surgery more competitive as a specialty. In a recent survey of choosing surgical specialties, women were more concerned with family responsibilities than job market, job security or future income potential [36]. For some women ­surgeons, emphasis upon surgical specialties with controllable lifestyles should be encouraged. Mentors should support and facilitate appropriate maternity leave, onsite childcare facilities, parttime residencies, and revised tenure tracks for part-time faculty. The importance of these issues is highlighted in a recent survey of

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American Board Certified surgeons conducted by Troppmann and colleagues [37]. As the result of more single-parent families and women physicians married to other professionals, it is less common to have a full-time person available to address the domestic and family aspects of these households. Hence, the mentor must advocate new policies to accommodate the lifestyle requirements of women surgeons.

Facilitate Networking Networking is a crucial component of career advancement. Implicit in this process is knowing the hidden, undisclosed, unwritten “rules.” In a survey of young female academic surgeons, the ability to network was the second most important quality sought in a mentor [10]. Despite professional advances in gender equality, many of today’s recruitments are still initiated through contacts within “the good old boys club.” Women perceive, more broadly than men, that opportunities for collaboration, networking and support are missed because of gender, rather than training, academic credentials and experience. Additionally, the lack of established networking for women surgeons is thought to affect patient referral patterns [13]. The lack of established networking has been identified as a major impediment for women to advance in academic surgery [14]. Despite the aforementioned programs designed to mentor and help women surgeons, surgery is still viewed by many as a male bastion [16]. This view is particularly relevant to networking because the overwhelming number of male surgeons, combined with established fraternal communication patterns, continue to dominate and perpetuate the “glass ceiling” – a metaphor to describe the difficult ascension for women to more advanced positions [13]. Early professional contacts are invaluable and open doors to career advancement. Creating a network at the outset of the mentee’s career is an important task for mentors although it is acknowledged that the networking pattern will change. Introducing young women surgeons to their senior female counterparts is a key step in initiating the networking process. These networking contacts are best established initially within one’s own institution but can be expanded locally or regionally as indicated.

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Networking is crucial when the mentee is seeking fellowship p­ ositions or clinical jobs. Most senior surgeons remain indebted to their mentors’ contacts, affiliations and networking skills. Another goal of networking is to facilitate communication with graduates, particularly alumna, from the mentee’s training program. The shared experiences common to both the mentee and alumna serve to break down social “barriers” and facilitate interaction which, in some instances, may enhance job opportunities. As the result of extensive family commitments, women surgeons have expressed an increased need for social networking (family, friend, and neighbor support) [17]. Contemporary young women are comfortable with online social networking sites and these may also prove helpful for the busy woman surgeon. Although not specific to surgery, a report of online community and social support for women in science and engineering concluded that online support networks allow women in traditionally male-dominated fields to expand their professional networks, increase their knowledge, constitute and validate positive social identities, bolster their self-confidence, obtain social support and information from people with a wide range of experiences and areas of expertise, and find community [38].

Women Leaders in Surgery While there are few senior female academic surgeons in the United States, these individuals nevertheless provide substantive leadership and are playing major roles in mentoring a new generation of women and male surgical leaders. A few of these leaders, briefly described in this section, have been selected both for their influences on advancing women in surgery and their overall contributions to surgery. Additionally, these individuals remain strongly committed to their families and exemplify the adage that pursuit of a rewarding career need not come at the expense of the personal satisfaction of being a mother and engaged family member. A comprehensive listing of women leaders in American Surgery is beyond the scope of this chapter; the reader is referred to the Association of Women Surgeons (http:// www.womensurgeons.org/) for more complete information. A discussion of women leaders in American surgery would be deficient without the inclusion of Olga Jonasson (Fig. 5.1). An NIH funded transplant surgeon, she became Chair of the Department of Surgery at

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Fig. 5.1  Olga Jonasson, M.D. (http://www.nlm.nih. gov/changingthefaceof medicine/physicians/ biography_174.html)

Cook County Hospital in 1977. She was noted to be “unquestionably the preeminent woman among academic surgeons in the United States” at that time [39]. Kathryn Jonasson was named the Robert M. Zollinger Professor and Chairman, Department of Surgery, Ohio State University in 1987 – the first woman in the United States to head an academic department of surgery at a coeducational medical school. An internationally renowned pioneer in esophageal replacements in children, Kathryn Anderson served as Chief, Division of Pediatric Surgery, Children’s Hospital Los Angeles (Fig. 5.2). She is professor emeritus of the Keck School of Medicine, University of Southern California. Subsequently, Dr. Anderson became the first woman President of the American Pediatric Surgical Association and the American College of Surgeons. A surgical scientist and innovator in kidney transplantation, Nancy Ascher is Professor and Chair Department of Surgery, University of California San Francisco (Fig.  5.3). She is past President of the American Society of Transplant Surgeons and has served on the Presidential Task Force on Organ Transplantation and the Surgeon General’s Task Force on Increasing Donor Organs. She is also a

88 Fig. 5.2  Kathryn D. Anderson, M.D. (photo courtesy of Dr. Anderson)

Fig. 5.3  Nancy L. Ascher, M.D., Ph.D. (photo courtesy of Dr. Ascher)

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member of the Secretary of Health and Human Services Advisory Committee on Organ Transplantation. Most importantly, she is a strong advocate for restoring humanism in medicine. A breast and gastrointestinal surgeon and innovative educator, Barbara Bass is the Chair, Department of Surgery, Methodist Hospital, Houston (Fig. 5.4). She has also served as Senior Director and Chair of the American Board of Surgery and President of the Society of the Alimentary Tract. She is currently a Regent of the American College of Surgeons. An accomplished surgical scientist and nationally renowned vascular surgeon and Chief of Vascular Surgery at UCLA (1998–2003), Julie Freischlag was appointed Chief of Surgery, Johns Hopkins Medical School in 2003 (Fig. 5.5). Her research interests include the effects of smoking on atherosclerosis, and she is co-principal investigator of a VA Cooperative Trial on the endovascular treatment of abdominal aortic aneurysms. She remains deeply committed to creating more opportunities for the advancement of women in U.S. surgery. An accomplished endocrine and breast surgeon of national and international repute, Patricia Numann remains one of today’s strongest advocates for advancing the role of women in American surgery (Fig. 5.6). She was the first woman chair of the American Board of Surgery and founder of the Association of Women Surgeons. Dr. Numann has worked tirelessly on behalf of improving working conditions for her female surgical colleagues. She was recently honored with SUNY Upstate’s first endowed chair in surgery.

Fig. 5.4  Barbara L. Bass, M.D. (photo courtesy of Dr. Bass)

90 Fig. 5.5  Julie A. Freischlag, M.D. (photo courtesy of Dr. Freischlag)

Fig. 5.6  Patricia J. Numann, M.D. (photo courtesy of Dr. Numann)

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Summary and Conclusions More women are becoming surgeons thus substantiating the need for mentors who are familiar with the many issues unique to females. Established programs to mentor women are available through the ACS and AWS. Recommendations to mentor women surgeons include encouraging matriculation to teaching and leadership positions, helping to resolve lifestyle issues, obtaining multiple mentors and facilitating networking.

References 1. Kass RB, Souba WW, Thorndyke LE (2006) Challenges confronting female surgical leaders: overcoming the barriers. J Surg Res 132:179–187 2. AAMC (2010) Women in U.S. academic medicine, statistics and benchmarking report, 2008–2009. http://aamc.org/members/gwims/statistics/stats09/start.htm. Accessed 23 Jan 2010 3. Quinlan RM (2007) Gender and the surgical workforce. Arch Surg 142:321–328 4. Stabile BE (2008) The surgeon: a changing profile. Presidential address, Pacific Coast Surgical Association. Arch Surg 143:827–831 5. McCord JH, McDonald R, Leverson G et  al (2007) Motivation to pursue surgical subspecialty training: is there a gender difference? J Am Coll Surg 205:698–703 6. Dodson TF, Webb ALB (2005) Why do residents leave general surgery? The hidden problems in today’s programs. Curr Surg 62:128–131 7. Gabrum SG, Allen LW, Deckers PJ (1995) Surgical residents in the 1990’s. Issues and concerns for men and women. Arch Surg 130:24–28 8. Reckelhoff JF (2008) How to choose a mentor. Physiologist 51:152–154 9. Snyder RA, Bills JL, Phillips SE et  al (2008) Specific interventions to increase women’s interest in surgery. J Am Coll Surg 207:942–947 10. Wryzykowski AD, Han E, Pettitt BJ et  al (2006) A profile of female academic surgeons: training, credentials, and academic success. Am Surgeon 72:1153–1157 11. Yedidia MJ, Bickel J (2001) Why aren’t there more women leaders in academic medicine? The views of clinical departments chairs. Acad Med 76:453–465 12. Schroen AT, Brownstein MR, Sheldon GF (2004) Women in academic ­general surgery. Acad Med 79:310–318 13. Longo P, Straehley CJ (2008) Whack! I’ve hit the glass ceiling! Women’s efforts to gain status in surgery. Gend Med 5:88–96 14. Sonnad SS, Colletti LM (2002) Issues in the recruitment and success of women in academic surgery. Surgery 132:415–420 15. Colletti LM, Mulholland MW, Sonnad SS (2000) Perceived obstacles to career success for women in academic surgery. Arch Surg 135:972–977 16. Gargiulo DA, Hyman NH, Hebert JC (2006) Women in surgery: do we really understand the deterrents? Arch Surg 141:405–408

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17. Ahmadiyeh N, Cho NL, Kellogg KC et al (2010) Career satisfaction of women in surgery: perceptions, factors, and strategies. J Am Coll Surg 210:23–30 18. Singletary SE (2005) Society of surgical oncology. Presidential address: mentoring surgeons for the 21st century. Ann Surg Oncol 12:848–860 19. Lechner BE, Gottlieb AS, Taylor LE (2009) Effective mentoring physician mothers. Letter to the editor. Acad Med 84:1643–1644 20. Palepu A, Herbert CP (2002) Medical women in academia: the silences we keep. CMAJ 167:877–879 21. Carr PL, Ash AS, Friedman RH et al (1998) Relation of family responsibilities and gender to the productivity and career satisfaction of medical faculty. Ann Intern Med 129:532–538 22. Cujee B, Oancia T, Bohm C et  al (2000) Career and parenting satisfaction among medical students, residents and physician teachers at a Canadian medical school. CMAJ 162:637–640 23. Cochran A, Melby S, Foy HM et al (2002) The state of general surgery residency in the United States: program director perspectives. Arch Surg 137:1262–1265 24. Potee RA, Gerber AJ, Ickovics JR (1999) Medicine and motherhood: shifting trends among female physicians from 1922 to 1999. Acad Med 74:911–919 25. Brian SR (2001) Women in medicine. Am Fam Physician 64:174–177 26. Mayer KL, Hu HS, Goodnight JE (2001) Childbearing and child care in surgery. Arch Surg 136:649–655 27. Kowalczyk L (2009) Surgeon awarded $1.6 m in sex bias case. The Boston Globe; 25 Feb 2009. http://www.boston.com/news/local/massachusetts/artcles/ 2009/02/25/surgeon_awarded_16m_in_sex_bias_suit/. Accessed 6 Feb 2010 28. Park J, Minor S, Taylor RA et  al (2005) Why are women deterred from ­general surgery training? Am J Surg 190:141–146 29. Neumayer L, Kaiser S, Anderson K et al (2002) Perceptions of women ­medical students and their influence on career choice. Am J Surg 183:146–150 30. Buyske J (2005) Women in surgery. The same, yet different. Arch Surg 140:242–244 31. Files JA, Blair JE, Mayer AP et al (2008) Facilitated peer mentorship: a pilot program for academic advancement of female medical faculty. J Women’s Health 17:1009–1015 32. Butcher L (2009) Mentorship program designed to advance women in ­academic surgery. Bull Am Coll Surg 94:6–10 33. Minter RM, Gruppen LD, Napolitano KS et al (2005) Gender differences in the self-assessment of surgical residents. Am J Surg 189:647–650 34. Borman KR (2007) Gender issues in surgical training; from minority to mainstream. Am Surg 73:161–165 35. Lind DS, Rekkas S, Bui V et  al (2002) Competancy-based student ­self-assessment on a surgery rotation. J Surg Res 105:31–34 36. Reed CE, Vaporciyan AA, Erikson C et al (2010) Factors dominating choice of surgical specialty. J Am Coll Surg 210:319–324 37. Troppmann KM, Palis BE, Goodnight JE Jr et al (2009) Women surgeons in the new millennium. Arch Surg 144:635–642 38. Kleinman SS (2003) Women in science and engineering building community online. J Women Minor Sci Engineer 9:1 39. Husser W, Neumayer L (2006) Olga Jonasson, MD. Surgeon, mentor, teacher, friend. Ann Surg 244:839–840

Chapter 6

Mentoring International Medical Graduates

The medical arena is quickly becoming a world stage. We need to embrace this progression by dismantling the unfounded prejudices toward IMGs that many have constructed from hearsay and anecdotal offerings from colleagues. Dean R. Cerio, M.D. Cyrus F. Loghmanee, M.D.

Key Concepts • The number of IMGs in US surgery continues to increase. • IMG applicants should be evaluated as to their overall qualifications rather than solely as an IMG. • IMG mentoring must be implemented early, preferably by designated IMG faculty and resident mentors. • To optimally mentor IMGs it is necessary to understand their unique challenges upon entering a new country and medical culture. • Structured mentoring programs efficaciously mentor IMGs entering US residencies. International medical graduates (IMGs) strengthen US surgery in many ways. (Table  6.1) Their diverse language capabilities as well as their openness and sensitivity in caring for members of different ethnic groups are outstanding prerequisites to interact in cross-cultural settings [1]. IMG surgeons provide much needed care, especially emergency surgery, to underserved and rural populations when compared to US medical school graduates (USMG) [2]. This care is particularly relevant due to the declining surgical workforce in rural areas [3, 4]. IMGs are also important contributors to basic surgical research and are prominent members of academic departments of surgery in the USA [5]. As noted by Leon, the “presence of IMGs can be seen as enriching the U.S. medical

J. Rombeau et al., Surgical Mentoring: Building Tomorrow’s Leaders, DOI 10.1007/978-1-4419-7191-3_6, © Springer Science+Business Media, LLC 2010

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6 Mentoring International Medical Graduates Table 6.1  Contributions of IMGs to US surgery • Diverse language capabilities • Broad appreciation for diverse cultures • Partial solution to impending surgeon shortage • Care for underserved and rural populations • Significant contributions to basic surgical research • Membership in academic faculties comparable to USMG

system because of the addition of plurality in the medical field in a country that was founded and built by immigrants” [6]. Requirements for IMGs to be successful in a US program include expert receptive and expressive language capabilities, the ability to multitask, and a reasonably good level of computer skills [7]. Conversely, poor performance negatively affects the IMG, surgical residency and ultimately patient care. As Karen Horvath, M.D., Director of the University of Washington IMG Surgery Residency Program suggests, the IMG can represent either a major loss (“brain drain”) for their native country when they remain in the USA or a major gain when they return to their country of origin and set up new programs and systems. Graduates who return usually become prominent members of academic or community practices and, because of their advanced surgical education, reach positions of influence within their society. This allows the USA to influence healthcare in developing nations and adds another dimension to the training of these individuals [7]. In some countries, Lebanon for example, there are more medical school graduates than needed to meet healthcare demands. Therefore, immigration provides a unique opportunity for these young physicians without affecting native resources for healthcare. Greater numbers of IMGs are entering US surgical residencies to meet the demands for general surgeons. This increased need has come from the projected shortage of USMG surgeons, an aging population, retirement of practicing surgeons at younger ages and a significant shift in medical students choosing specialties with more controllable lifestyles [8]. Moreover, in 1995 Whitcomb reported 12% of general surgical programs were IMG-dependent [9]. This percentage is presumably much higher today. Despite many diverse challenges, IMG surgical residents are expected to adapt quickly to their new settings and culture. Furthermore, it is not unusual for IMGs to work twice as hard to prove themselves when compared to USMG. The traditional method of evaluating IMG residents solely on their performance in the research laboratory may not be the best way

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to assess candidates for clinical training. Mentors and structured mentoring programs (see section Programs to Mentor IMG) provide opportunities to aid in the transition and ensure personal and professional growth commensurate with USMGs. Whereas this chapter focuses on foreign-born IMGs applying to US surgical residencies, it is acknowledged there are US-born IMGs as well. Comparisons of these groups have been noted [10]. This chapter reviews background/demographics of IMGs in US surgery and the pertinent challenges they face during training. Recommendations on how to mentor IMGs during surgical residency are proposed and programs to mentor IMG residents in the USA are reviewed. Short profiles of a few IMG leaders in US surgery are presented.

Background/Demographics The current decline in USMG entering surgery underscores the importance of recruiting more IMGs into US training programs. The value of IMGs to the future of US surgery is supported by the projected shortage of practicing surgeons [6, 11]. Furthermore, IMG surgeons provide much needed surgical care for rural and underserved regions in North America. A summary of the characteristics of IMGs in US surgical residencies and clinical practice is shown in Table 6.2. In 2010, 17% of the categorical general surgery positions were filled by IMGs. Of the total non-US citizen IMG applicants, 39.8% matched in PGY-1 positions in 2010 [8]. Approximately 9% of IMGs who complete their surgical training in the USA enter academic departments. This pattern is comparable to 13% USMGs [5]. Many IMGs are accepted as preliminary residents into US surgical residencies. Whether the acceptance of a preliminary general surgery resident position is “indentured servitude” or a “golden opportunity” has been questioned by Christein and colleagues at the Mayo Clinic [12]. The authors concluded that this Table  6.2  Demographics of IMG surgeons in the US (Data from [8, 13, 14]) • • • •

17% Categorical Positions 2010 40% IMG applicants in 2010 matched in a PGY-1 position 20% Practicing general surgeons in U.S. 21% Principal investigators on NIH research projects

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6 Mentoring International Medical Graduates Table 6.3  Comparisons 2007 US general surgery match (Data from [10]) Foreign-born IMG USMG Mean age (years) 33.0 28.9 Males 86% 70% Advanced degrees 19% 11% Mean time graduation to application (years) 7.7 0.3 Mean USMLE Step 1 202 206 Multiple attempts to achieve passing score (%) 24% 9% Mean USMLE Step 2 203 213 Multiple attempts to achieve passing score (%) 19% 11% Scholarly works (#) 3.9 0.9

was a positive experience by noting that the vast majority of these individuals (the majority of whom are IMGs) progress toward completion of surgical or medical residencies. Approximately 25% of practicing physicians and 20% of general surgeons in the USA are IMGs [13]. Additionally, 21% of principal investigators of NIH grants are IMGs [14]. Schenarts and colleagues compared USMGs with US-born and foreign born IMGs. Five hundred seventy-two applicants were evaluated. Comparisons between foreign born IMGs and USMGs included the following (Table 6.3): IMGs are older (33 years vs. 28.9 years), are more frequently male (86% vs. 70%), hold more advanced degrees (19% vs. 11%), produce more scholarly works (3.9% vs. 0.9%), but require multiple attempts to pass the United States Medical Licensing Examination (USMLE). The mean time between graduation from medical school and starting a surgical residency was longer for IMGs (7.7 years vs. 0.3 years) [10].

Challenges Confronting IMGs To optimally mentor IMG surgeons, it is important to understand their numerous challenges when entering a new country and medical culture. (Table 6.4) Although to a lesser extent, these experiences are also encountered by IMGs with surgical training outside the USA who are immigrating to new practice settings in the USA.

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Table 6.4  Challenges confronting IMG surgeons and residents in the USA • • • •

Discrimination/negative stereotype Language difficulties Cultural impediments Variability of medical school curriculum

Discrimination/Negative Stereotype Discrimination and negative stereotype are among the most concerning barriers to the advancement of IMGs in US residencies and private practice settings. These unsubstantiated biases are expressed both overtly and subtly and promulgated by laypeople, medical students, residents, program directors and institutions [15]. A frequent, unsubstantiated argument to support this bias is that foreign trained physicians are not as well trained as their US counterparts. Presumably, many negative comments relate to language difficulties and misinterpretations rather than errors of commission. Institutions discriminate against IMGs as well. There is anecdotal belief that the reputation of a surgical residency is negatively affected by the presence of a number of IMGs despite the lack of evidence to support this bias. It is therefore incumbent upon surgical chairs and residency directors to keep an open mind on this topic and evaluate applicants on an individual basis rather than solely as an IMG. In a survey of residency program directors, 70% believed IMGs were discriminated against, 20% admitted to being pressured to rank a less qualified USMG above a more qualified IMG and 22% reported that they had ranked a USMG higher than an IMG to avoid a reduced complement of USMGs [16]. A review of discrimination against IMGs in the US residency program selection process was conducted by Desbiens and Vidaillet [17]. Although the review included other residencies in addition to surgery, the authors concluded there was sufficient evidence to support action against discrimination in the selection process. They recommended medical organizations publish explicit proscriptions concerning IMGs (as the American Psychiatric Association has done) and promote them in diversity statements. Additional recommendations included the development of uniform and transparent policies for program directors to select applicants. These policies should minimize the

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possibility of non-academic discrimination; the parent academic organization should monitor compliance. As expressed by Cerio and Loghmanee, “Let us not show the world our naiveté toward the globalization of medicine and surgery. Let us accept into the privileged ranks of a U.S. surgical residency and train only those who are the best, both academically and personally, and not just those who are from the U.S.” [15]. Despite the aforementioned stereotypical and discriminatory concerns, prestigious programs such as the Mayo Clinic actively seek to match well-qualified IMGs [18].

Language Difficulties English is a second language for most IMGs. Difficulties with spoken and written English occur for both medical and non-medical information. The ability to communicate clearly with colleagues, attendings, nurses, patients and their families is mandatory for IMGs to become competent surgeons and succeed in US training programs. English proficiency is a prerequisite to apply to US residencies. As explained by Horvath, “I think the IMG’s are anxious to ‘get on with it’ once they’ve decided to pursue training in the United States. Some of them jump in too quickly and their English isn’t good enough. They might feel it’s okay during an observership, but being a resident is completely different. Our health care system is just so fast-paced that they fall behind very quickly if their English isn’t strong. We’ve had a few very good people fall short of their general abilities simply because of their English. Once they fail, it’s extremely difficult for them to be competitive again for a residency spot. IMG’s should be counseled to not jump into our system until their English is excellent. If they possess all the other attributes, it’s a shame to fail because their English puts them 10 steps behind” (K. Horvath, personal communication).

Cultural Impediments Cultural impediments for IMGs are two-tiered – the transition to the practice of medicine and the challenge related to interpersonal communication [19]. Cultural differences vary widely as to the IMGs

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country of origin and may impede their data synthesis and clinical reasoning abilities. As noted by Horvath, “IMG’s from some parts of the world come from a very paternal and hierarchal system of training where they only need to collect data and present it. They don’t need to synthesize it and make their own plan because they watch someone else make all the decisions. These people may have very high USMLE Step 1/2 scores. On the other hand, our U.S. system requires a resident to demonstrate their data synthesis skills and make plans because if you can’t do it you can’t be a surgeon. Most IMGs are able to overcome cultural internal barriers and do this – but some simply are unable to acquire independent skills necessary” (K. Horvath, personal communication). The severity and extent of cultural impediments for IMGs vary widely as to the native country of the graduate. For example, the cultural transition to the USA for some Latin American IMGs is minimal because of the geographic proximity to the USA and the strong influence of US medicine. Most treatment guidelines, procedures and protocols used in Latin American academic and community hospitals originate from the USA. Additionally, residency training is based upon the US prototype (personal communication). In many parts of the world the authority of a physician is seldom questioned as it is in the USA, and in some countries male physicians are not permitted to perform gynecologic examinations. These backgrounds may pose difficulties for IMGs. In certain cultures, physical examinations between genders (men touching women, women touching men) is not practiced, therefore making it difficult for the IMG to adjust to a new system. The cultural differences in approaches to and beliefs about communication, authority, gender roles, interpersonal relationships and role or status of physicians have been emphasized by Bates and colleagues [20]. In some cultures the open admission of not knowing information or forgetting to perform a task is unacceptable and personally damaging. This culture has major adverse effects on the IMG when transitioning to a US surgical resident [21]. IMGs should be informed that honesty is always the best policy and the fabrication of information such as test results leads not only to poor patient care but to personal indictments. Surgical vernacular in the USA is unique. The frequent use of acronyms and abbreviations such as AKA, CVP, etc. is initially daunting to IMGs. Interpersonal communications such as addressing some colleagues (especially senior individuals) by their first name is

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simply unacceptable in many medical cultures. Additionally, colloquial phrases such as “give the patient some bug juice” or “drop in a line” must be explained to the befuddled IMG surgical neophyte.

Visa Limitations, Variability of Medical School Curriculum and Pre-requisites to Enter US Surgical Residencies Successful migration of an IMG into a US surgical residency includes three major steps: receiving ECFMG certification, obtaining a visa, and acceptance into a US medical program. In some instances the IMG’s matriculation in a training program is limited by visa stipulations. As the result of visa restrictions and the long duration of surgical residencies, many IMGs are unable to take 1–2 extra years of research training during the residency, which in turn limits their competitiveness for post-residency fellowships. In some instances, IMGs are required to return temporarily to their native country while still in the midst of their clinical training. As mentioned, traditional pathways for IMGs to enter US surgical residencies have been through working in a research laboratory or being an observer on a clinical service. The quality of these experiences is variable and highly dependent upon availability of attending and senior resident staff. To provide a more uniform evaluation, the Clinical Skills Assessment Test has been implemented since 1998 [22]. This test improves the evaluation of quality candidates to residency programs [5]. Current criteria for selecting IMGs are heavily weighted on the USMLE, an outstanding medical school record and candidate interviews. As the result of more than 1,900 medical schools throughout the world, it is impossible to objectively assess the quality of didactic and clinical teachings at each institution. As forcibly articulated by Cerio and Loghmanee, “By logical reasoning, therefore, after having established proficiency in the English language (either by examination or being granted citizenship) – and considering that the biochemical equations of glucose metabolism are the same across the world, that the flexor digitorum profundii of the human hand all have the same origins and insertions regardless of where in the world they are dissected, and that deductive reasoning

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on a clinical question posed during an exam occurs through similar neural pathways regardless of that brain’s ethnicity – it could be fair to assert that two medical students with equal scores on the USMLE have been trained at equivalent levels and should be considered equally for a residency program. The decision to accept one student over the other should only be based on supplemental application materials and the interview process” [5]. Moreover, to our knowledge there are no controlled clinical studies demonstrating significant differences in patient outcome between patients managed by IMGs vs. USMGs. Many institutions have relied upon performance on standardized tests which predict the success of graduate students [23]. The USMLE offers standard comparisons as well as any comparative variable, however, it does not predict resident performance [24, 25]. Additionally, the perceived prestige of an applicant’s medical school is not predictive of residency performance [26]. The ideal setting for evaluation is direct observation of perioperative care. Prior to applying to a US residency, the IMG has to fulfill medical science and language requirements. Medical science requirements are met by passing the USMLE Steps 1 and 2 Clinical Knowledge tests. Clinical skills requirements are met by passing Step 2 Clinical Skills Examination which includes a separately scored component that assesses spoken English proficiency. This part must be passed to achieve an overall passing result. Additionally, one must also pass the test of English as a Foreign Language (TOEFL).

Recommendations to Mentor IMG Surgical Residents Similar to mentoring other groups of mentees, a mentoring culture for IMGs must be established and supported by the surgical Chair. This culture should contain strategies to address the previously discussed challenges (discrimination, language difficulties, cultural impediments and varied educational backgrounds) which confront IMGs. Recommendations to mentor IMG surgical residents include: (1) creating an IMG resident introductory orientation, (2) assigning IMG faculty mentors, and (3) assigning IMG resident mentors.

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Introductory Orientation for IMG Residents The beginning of a US surgical residency for an IMG can be overwhelming as relayed by a former resident, “I remember my first day of training very well. Besides the fact that I had to have my brother drop me off at work (since I did not have a license or a car), the service was very busy and I didn’t know what a SOAP (progress) note was. Training in my country is very different and medical students never wrote notes. I didn’t know how to admit people, discharge them, what the concept of a case worker/social worker was” (personal communication). This anecdote underscores the importance of an orientation program for IMGs. As a prelude to the actual program and to better prepare the IMG resident, online orientation information should be devised to at least provide a rudimentary understanding of US surgical training. Alternately, this information can be specific to an institution which in turn describes the vagaries of such a program. Although not specific to surgeons, more generic information is available for the IMG through the American Medical Association and its ECFMG certified membership (see Appendix). The institutional IMG surgical residency introductory orientation should be conducted at the outset of the residency, devoted to approximately 1 day, and consisting of two parts – a morning generic session and an afternoon segment devoted entirely to surgery. Similar orientation programs for IMGs have been conducted for family practice trainees [21]. To avoid duplication of information with the standard residency orientation (primarily directed to USMGs), the program should be IMG-specific and scheduled 1 day earlier. The orientation should preferably be conducted, at least in part, by IMG residents at the PGY 2 or 3 levels who have experienced the many challenges of adapting to new medical and nonmedical cultures. To optimize educational efficiency, the morning generic session should be coordinated with other medical departments (internal medicine, pathology, etc.) within the institution. Often ignored in many orientation programs, the introduction of new IMGs, to IMG residents in training, is a vital component of the orientation process. Not every clinical department has a concurrent resident from each country represented by the new IMG trainees; therefore, initial contacts and liaisons are best established across departments. In some

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institutions the research divisions of departments are replete with foreign-trained investigators who can serve as vital liaisons to the new trainees. Names of advisors (including cell phone, e-mail, fax) to contact in the event of difficult problems or urgent questions should also be provided. A 24  h “hot line” should be available to IMGs. Contacts should also be extended to spouses. IMG-specific content such as support groups, international student retreats, cultural sensitivity training and simulation or video of encounters with standardized patients may be helpful [27]. Attention should be given to recognition of patients’ regional dialects, colloquial speech, body language and speech inflection. IMG residents caring for patients transculturally note that sensitive issues such as patient rejection based on ethnicity, inability to communicate emotional support for patients and their families, and the difficulty of caring for non-compliant, drug-dependent patients affect their ability to care for patients [21]. The inclusion of these topics and ways to overcome them should be included in the orientation. Additionally, something as simple as where to find an IMG’s favorite ethnic food can go a long way to smoothing his/ her transition. The afternoon segment of the orientation should be devoted solely to surgery. If there are only a few new IMG surgical trainees, this session can be conducted informally under the aegis of the current IMG residents. All surgical departments have orientation sessions for new trainees. The surgical segment of the IMG orientation should be more extensive, perhaps including some of the same introductory content used for medical students rotating on surgery. Attention should be directed to those issues which have been problematic for IMGs in the past, as identified by current IMG surgical residents. These include the indications for urgent and emergent interaction with patients, medical students, residents and attendings. As noted, communication challenges for both IMGs and USMGs can be especially stressful at the outset of training, thus every effort should be directed to help the IMG communicate better. The surgical orientation for IMGs should include a local tour accompanied by a written explanation of hospital sites, particularly those relevant to surgery, and those with designated acronyms (PACU, SICU). A glossary with commonly used surgical abbreviations (TEA, AKA, SBO, etc.) should be provided as well.

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Assign Faculty Mentor Providing a mentor for IMGs is particularly important prior to and during residency training. Throughout this book the dictum has been promulgated that mentors should be sought by and not assigned to the mentee. The IMG is an exception to this dictum. Designated mentors (preferably IMGs) should be assigned at the outset of their surgical training. Only mentors truly committed to this process should be assigned. To optimize this experience, IMG mentors from the same country as the mentee are preferred. The assignation of an IMG faculty mentor leads to a smoother transition at the outset of the residency; however, many IMG new trainees are anxious to have an American mentor after the initial acculturation (personal communication). The American mentor enhances the IMGs understanding of culture, language, career advancement and research. Faculty mentors should designate meetings with structured agenda at scheduled intervals. The frequency of meetings should be determined by the faculty mentor. Contrary to USMG mentees, the IMG mentee should not be presumed to be proactive. In many foreign medical cultures, trainees are dissuaded from initiating meetings with senior faculty. As the IMG mentee becomes well adjusted to the clinical program, he/she may seek other mentors with whom there is even closer clinical or research interests or better “chemistry.” Steinert and Walsh have a faculty development program for Canadian teachers of IMGs [28]. The word teacher is used broadly to refer to all individuals involved in teaching IMGs (e.g., clinical supervisors, mentors and preceptors). The goals of this program are twofold: to help prepare teachers in diverse settings to work with IMGs in an effective and collaborative manner; and to enhance the learning and practice experiences of IMGs. The four main sections of their program include: orienting teachers and IMGs, educating for cultural awareness; working with IMGs – a faculty development “toolbox”; guidelines for site-specific activities; and faculty development principles and strategies. Every effort is directed to an individualized approach to faculty attendees with an emphasis upon problem-based learning. The importance of comprehensive faculty development courses for mentoring has been emphasized by Sachdeva [29] and Souba [30].

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Assign Resident Mentor Assigning a resident mentor may be the most significant step in the entire IMG orientation. Most IMGs do not have the networking benefits (family, friends, institutional contacts, etc.) when compared to their USMG counterparts. Similar to the initial faculty mentor, it is preferable if the resident mentor is also an IMG. The resident mentor should be given pre-mentoring instruction as to the specifics and importance of this task. Additionally, the resident mentor serves as the facilitator through the “maze” of institutional rules and regulations, most of which the IMG has never experienced. As the result of the nearness in age to the mentee, and having already experienced similar encounters, the IMG’s interactions may be easier with the resident when compared to a faculty mentor.

Programs to Mentor IMGs Bates and Andrew evaluated their training of IMGs in a Family Practice Residency at the University of British Columbia. They emphasized the following: (1) review the trainee’s undergraduate, postgraduate and clinical experiences, (2) investigate the trainee’s personal circumstances, (3) explore the trainee’s expectation of medical education as well as perceived interactions with other health care professionals, (4) explore doctor-patient relationships in the trainees’ countries of origin, (5) provide a clear articulation of the program’s expectations of physicians, and (6) identify experienced faculty with the time and interest in correcting academic difficulties [20]. The integration of IMGs into US surgical residencies has been spearheaded by the University of Washington. Under the direction of its Chair, Carlos Pellegrini, also an IMG, and with the leadership of Karen Horvath, Professor of Surgery, they developed a Certificate Program that provides IMGs a unique 8 week clinical experience in a busy US training program. Most importantly, this program is conducted by surgeons for the sole purpose of educating and evaluating the IMG surgical trainee. The University of Washington’s program is analogous to the sub-internship for fourth year students in US medical schools except for greater emphasis upon perioperative care and less involvement in the operating room. It provides IMGs with a robust educational experience and enough practice to successfully integrate

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into a US residency. Additionally, it provides the program director enough time to correct deficiencies, to get to know the IMG, to directly observe clinical performance and to identify those with a better chance to succeed [31]. The program enrolls 4–10 IMGs a year into an intensive 8-week surgical sub-internship program giving the IMG firsthand clinical experience. Candidate prerequisites are shown in Table 6.5. IMGs are required to take full responsibility for clinical activities under direction of residents and attendings. During the program, the IMG learns about the US healthcare system and tests his/ her abilities to multitask and prioritize work. Successful graduates receive 16 CME credits, a certificate of completion and letters of recommendation from the faculty. As noted in their initial report, 15 of 29 IMG participants joined the University of Washington general surgery residency as preliminary residents and three individuals were accepted into other surgical residencies. This program not only provides a valuable educational format to evaluate residents, it also helps to identify those individuals who are less apt to succeed in a US surgical residency. Appropriate counseling is provided at an early stage of training before significant emotional and financial expenditures have been invested. Factors associated with IMG poor performance and failure during surgical residency are shown in Table 6.6. Introductory programs are offered to IMGs at the Miller School of Medicine, University of Miami and the Michael E. DeBakey Department of Surgery, Baylor College of Medicine. The Baylor program is strictly an observership and does not permit patient contact or clinical service [32]. A search of the internet reveals a plethora of websites and blogs, many conducted by former IMGs, which offer Table 6.5  Application checklist and prerequisites (From [31]. With permission from Elsevier) 1. Copy of current ECFMG certificate issued after 1998 2. Transcripts of USMLE Step 1 score and Step 2 score (USMLE Step 1 score of 175 or better with examination Taken in last 3 years) 3. Copy of medical school transcript with a medical degree In the last 10 years 4. Current curriculum vitae (CV) or resume 5. Three letters of recommendation 6. Written statement explaining your career goals and why You are seeking this opportunity. Only those applicants Planning to apply for a 2-year preliminary position in Surgery at the University of Washington are accepted 7. E-mail, address, telephone number 8. Valid certification of US citizenship, landed immigrant Status, or qualify for an F-1 student visa

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Table  6.6  Factors associated with failing a US residency (From [7]. With permission from Elsevier) Reasons for failure I. Credential issues II. Poor performance A. Knowledge-related problems 1. Inadequate level of medical/surgical knowledge 2. Poor command of English, both receptive and expressive 3. Difficulty in adapting to the technology/procedures in US hospitals 4. Poor time management and multitasking techniques 5. Poor synthetic reasoning skills and inability to understand how to execute standard surgical algorithms in patient evaluation and management B. Personal/cultural problems 1. Interpersonal difficulties with faculty, residents and staff 2. Lack of acceptance of deficiencies and inability to accept constructive criticism 3. Poor work ethic 4. Poor adjustment to the fast pace of residency training in large, multihospital systems

suggestions to aid IMGs. Additionally, surgical societies of the IMGs country of origin may provide guidance and financial support.

IMG Leaders in US Surgery The many IMG leaders in US surgery provide further justification for the importance of mentoring IMGs. Several IMG surgeons have risen to the highest levels of leadership and recognition in US surgery. The American Surgical Association is among the most exclusive and well respected organizations in the world and three recent Presidents are IMGs: Murray Brennan, Haile Debas and Carlos Pellegrini. Additionally, each of these individuals is or has been the Chair at a major US institution. A native New Zealander, Dr. Brennan (Fig. 6.1) received his M.D. from the University of Otago, New Zealand. Similar to many IMG surgeons practicing in the USA, he took two surgical residencies – one at the University of Otago and Peter Bent Brigham Hospital, respectively. Dr. Brennan is Chairman Emeritus, Memorial Sloan Kettering Cancer Center (1985–2007), Department of Surgery. Additionally, he served as Director of the American Board of Surgery, Chairman of

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Fig. 6.1  Murray F. Brennan, M.D. (photo courtesy of Dr. Brennan)

the American College of Surgeons Commission on Cancer, President of the Society of Surgical Oncology, and Vice-President of the American College of Surgeons. He is internationally recognized for his clinical expertise and research contributions in surgical oncology, endocrinology, metabolism and nutrition. He is a recipient of the American College of Surgeons’ highest award – the Distinguished Service Award. A native of Eritrea, Dr. Debas (Fig.  6.2) received his M.D. from McGill University and completed his surgical training at the University of British Columbia. He served as Chairman, Department of Surgery, University of California San Francisco (UCSF) for 6 years to be followed by being appointed Dean, UCSF. Dr. Debas has received the Abraham Flexner Award of the AAMC and is one of only a few surgeons to be elected a fellow of the American Academy of Arts and Sciences and the Institute of Medicine. Dr. Debas is widely recognized for his contributions to global health. A native of Argentina, Dr. Pellegrini (Fig. 6.3) received his M.D. from the University of Rosario Medical School, Argentina. Dr. Pellegrini took

IMG Leaders in US Surgery Fig. 6.2  Haile T. Debas, M.D. (Credit Elizabeth Fall) (photo courtesy of Dr. Debas)

Fig. 6.3  Carlos A. Pellegrini, M.D. (photo courtesy of Dr. Pellegrini)

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surgical residencies at the University of Rosario Medical School and University of Chicago, respectively. He is internationally renowned for his contributions to esophageal surgery, disorders of swallowing and surgical education. He is the Henry N. Harkins Professor and has been Chairman, Department of Surgery University of Washington, since 1996. Currently, he is the Director of the American Board of Surgery and a regent of the American College of Surgeons.

Summary and Conclusions IMGs are major contributors to US surgery. Due to the need for more surgeons in the USA and the relatively modest increase in USMG surgical applicants, the numbers of IMGs are projected to increase. Mentoring is vital to the success of IMG surgeons and it must be established early and preferably by IMG resident and faculty mentors. To be effective, mentors must understand the challenges unique to IMGs. Structured mentoring programs efficaciously mentor IMGs entering US surgical residencies.

References 1. Itani KMF (2008) Presidential address: international medical graduates in surgical workforce and the Veterans Affairs hospitals: where are we coming from? Where are we going? Am J Surg 196:315–322 2. Polsky D, Kletke PR, Wozniak GD et al (2002) Initial practice locations of international medical graduates. Health Serv Res 37:907–928 3. Thompson MJ, Lynge DC, Larson EH et al (2005) Characterizing the general surgery workforce in rural America. Arch Surg 140:74–79 4. Terhune KP, Abumrad NN (2009) Physician shortages and our increasing dependence on the international medical graduate: is there a mutually beneficial solution? J Surg Educ 66:51–57 5. Arahna GV (1998) The international medical graduate in US academic general surgery. Arch Surg 133:130–133 6. Leon LR, Ojeda H, Mills JI et  al (2007) The journey of a foreign-trained physician to a United States residency: controversies surrounding the impact of this migration to the United States. J Am Coll Surg 206:171–176 7. Horvath K, Pellegrini C (2006) Selecting international medical graduates (IMGs) for training in US surgical residencies. Surgery 140:347–350

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8. National Resident Matching Program (2010) NRMP advance data tables: 2010 main residency match. www.nrmp.org. Accessed 19 Mar 2010 9. Whitcomb ME, Miller RS (1995) Comparison of IMG-dependent and nonIMG-dependent residencies in the national resident matching program. JAMA 274:696–699 10. Schenarts PJ, Love KM, Agle SC et al (2008) Comparison of surgical residency applicants from US medical schools with US born and foreign born international medical school graduates. J Surg Educ 65:406–412 11. Sheldon GF, Ricketts TC, Charles A et al (2008) The global health workforce shortage: role of surgeons and other providers. Adv Surg 42:63–85 12. Christein JD, Cook JK, Enger TM et al (2006) Preliminary general surgery residents: indentured servitude or golden opportunity? Curr Surg 63:85–89 13. Gozu A, Kern DE, Wright SM (2009) Similarities and differences between international medical graduates and US medical graduates at six Maryland community based internal medicine residency programs. Acad Med 84:385–390 14. Alexander H, Heinig SJ, Fang D et al (2007) Contributions of international medical graduates to U.S. biomedical research: the experience of U.S. medical schools. J Invest Med 55:410–414 15. Cerio DR, Loghmanee CF (2007) International medical graduates in American surgery: past, present, future. Bull Am Coll Surg 92:39–42 16. Moore RA, Rhodenbaugh EJ (2002) The unkindest cut of all: are international medical school graduates subjected to discrimination by general surgery residency programs? Curr Surg 59:228–236 17. Desbiens NA, Vidaillet HJ Jr (2010) Discrimination against international medical graduates in the United States residency program selection process. BMC Med Educ 10:5 18. Lamb MN, Farley DR (2006) The Mayo Clinic, Rochester experience with IMGs as general surgery trainees. Surgery 140:351–353 19. Kaafarani HMA (2009) International medical graduates in surgery: facing challenges and breaking stereotypes. Am J Surg 198:153–154 20. Bates J, Andrew R (2001) Commentary: untangling the roots of some IMGs’ poor academic performance. Acad Med 76:43–46 21. Fiscella K, Roman-Diaz M, Lue BH et al (1997) ‘Being a foreigner, I may be punished if I make a small mistake’: assessing transcultural experiences in caring for patients. Fam Pract 14:112–116 22. Whelan GP, Gary NE, Kostis J et al (2002) The changing pool of international medical graduates seeking certification training in U.S. graduate education programs. JAMA 288:1079–1084 23. Kuncel NR, Hezlett SA (2007) Standardized tests predict graduate students’ success. Science 315:1080–1081 24. Black KP, Abzug JM, Chinchilli VM (2006) Orthopaedic in-training examination scores: a correlation with USMLE results. J Bone Joint Surg Am 88:671–676 25. Lee AG, Golnik KC, Oetting TA et  al (2008) Re-engineering the resident applicant selection process in ophthalmology: a literature review and recommendations for improvement. Surg Opthalmol 53:164–176 26. Boyse TD, Patterson SK, Cohan RH et al (2002) Does medical school performance predict radiology resident performance? Acad Radiol 9:437–445

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27. Fiscella K, Frankel R (2000) Overcoming cultural barriers: international medical graduates in the United States. JAMA 283:1751 28. Steinert Y, Walsh A (2006) A faculty development program for teachers of international medical graduates. The Association of Faculties of Medicine of Canada 2006 Copyright. www.afmc.ca/img. Accessed 29 Aug 2009 29. Sachdeva AK (1996) Preceptorship, mentorship, and the adult learner in medical and health sciences education. J Cancer Educ 11:131–136 30. Souba WW (2000) The essence of mentoring in academic surgery. J Surg Oncol 75:75–79 31. Horvath K, Coluccio G, Foy H et al (2004) A program for successful integration of international medical graduates (IMGs) into U.S. surgical residency training. Curr Surg 61:492–498 32. DeBakey ME (2010) Department of Surgery website. Opportunities for physicians from abroad. http://www.debakeydepartmentofsurgery.org/ home/content.cfm?menu_id=18. Accessed 25 Apr 2010

Chapter 7

How to Develop Faculty Mentors

Plant a mentor – grow a tree of trainees. M. Bishr Omary

Key Concepts • The absence of financial incentives is a major obstacle to developing faculty mentors. • Structured approaches are needed to develop faculty mentors. • Recruiting individuals with vested interests, providing protected time, and monetary and career incentives will help develop faculty mentors. • Structured written evaluation and objective verbal feedback are mandatory for optimal development of faculty mentors. • There are resolvable and irresolvable causes of faculty discontent. • Current needs to develop faculty mentors provide opportunities for research. Effective approaches to develop faculty mentors should be inculcated into every academic department of surgery. Surgical departments expend significant time and revenue to train their faculty in relevant technical advances in surgery. Why not properly train faculty to teach and mentor medical students and residents? Improved mentoring activities in turn foster communication among faculty members and strengthen the scholarly identity of the department. Additionally, the development of quality faculty mentors enhances their academic careers as evidenced by greater numbers of publications, increased receipt of research grants and more rapid promotions [1–3]. Thus, junior faculty should be taught to mentor early in their careers.

J. Rombeau et al., Surgical Mentoring: Building Tomorrow’s Leaders, DOI 10.1007/978-1-4419-7191-3_7, © Springer Science+Business Media, LLC 2010

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The importance of mentoring in academia has been confirmed in observational reports. In a study of faculty from several institutions, over 95% of participants identified lack of mentoring as either the first or second most important factor hindering their academic progress [4]. Individuals without formalized mentoring relationships were encouraged to look to peers and colleagues to gain assistance in navigating the academic system. It was recommended that junior faculty mentees be diligent and persistent in finding a mentor. Both mentees and institutions were encouraged to foster such relationships. The authors concluded that having a mentor is critical to a successful career in academic medicine. Importantly, this study provides evidence to support mentoring junior faculty. This chapter reviews the obstacles to developing faculty mentors and ways by which they can be prevented or corrected. Recommenda‑ tions on how to develop faculty mentors are presented. The need for effective written evaluation and verbal feedback is emphasized and the causes for and resolution of faculty discontent are discussed. Finally, potential areas of research are proposed.

Obstacles to Faculty Mentoring Obstacles to mentoring are present in every department of surgery and are listed in Table 7.1. Removal of some of the constraints on mentoring may be as important as its development and implementation.

Lack of Equitable Financial Remuneration Surgical faculty seldom acknowledge publicly the inequitable remuneration for mentoring and teaching; however, private conversations strongly support this view (JLR personal communication). In many hospitals, surgical revenue is the financial “motor” that runs the Table 7.1  Obstacles to faculty mentoring • Lack of equitable financial remuneration • Insufficient protected time • Perception – mentoring activities undervalued • Lack of formal training in how to mentor

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institution. As more surgical departments transition into incentive/ bonus, and away from strict, salary-based practice plans, it is unlikely this process will change. Moreover, surgical Chairs are increasingly pressured to exert every conceivable effort to generate more departmental income in today’s revenue-stressed environment. Mentoring and teaching activities are viewed as money losers and economically counterproductive. Furthermore, it is difficult to directly measure the objective benefits of mentoring (see section Objective Assessment) and the “payback” to departments may take several years, if ever. Mentoring and teaching create a “double hit” for departmental revenue (Fig. 7.1). The first “hit” is the surgeon’s participation in non-revenue generating activities and the second “hit” is the need to provide financial incentives to attract and retain good mentors. There are no relative value units (RVUs) for mentoring. Perhaps a mentoring value unit (MVU) should be devised! As the result of these concerns and to reduce the need to teach and mentor, a few surgical divisions have even eliminated resident and student rotations on their services. The reasons for this decision are primarily financial. Not surprisingly, these division chiefs have learned that their services are more clinically productive, cost effective, and generate more revenue when residents and students are replaced by physician assistants and nurse practitioners. To quote one division chief, “I’m tired of having to rediscover the wheel with new students and junior residents every 1 or 2 months.” When this division chief was asked how he learned to become a surgeon a long Surgeon participates in non-revenue generating activities

Need to provide financial incentives to attract/retain good mentors

Fig. 7.1  Mentoring and teaching – “double-hit” to departmental revenue

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pause ensued followed by the response, “Times have changed.” It is reprehensible that such practices occur in teaching institutions; if making money is the primary reason for being a surgeon, such individuals are better off working in non-academic environments. Despite the aforementioned comments, the glass remains “half-full.” In some departments it is believed that the costs of supporting faculty mentors are probably made up by decreased faculty turnover, increased productivity and efficiency, in part due to the rewards derived from mentoring. In spite of this impression, it is impossible to place an accurate cost on these activities.

Faculty Time Constraints Faculty time constraints create significant obstacles to mentoring. Dunnington notes that despite a 600% increase in full-time medical school faculty over the last several decades, there has been a dramatic change in the availability of faculty to mentor students in clinical teaching settings [5]. This is presumably due to increasing demands on the surgeon’s time. Surgeons are surgeons because they love to operate! Although the operating room is an important site for mentoring (see Chap. 4), extensive intra-operative teaching and mentoring prolong the operation and prevent the attending from performing more cases and generating additional revenue. In incentive-based salary programs, the faculty, therefore, are financially penalized for such non-revenue generating activities. This same time constraint-effect applies to teaching and mentoring during outpatient clinics and inpatient rounds. Consequently, mentoring and teaching are often viewed by an already overworked faculty as onerous tasks without financial remuneration.

Mentoring Activities Devalued An additional hindrance to faculty mentoring is the perception, and frequent reality, that mentoring and teaching activities simply do not have equal value when compared to high operative volume, number of peer-reviewed original publications, and receipt of research grants.

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This is a nearsighted view because the majority of senior surgeons with successful clinical and research careers know that mentoring provides a mutually receptive relationship for learning and they readily acknowledge the major influences of their own mentors and mentees. Moreover, mentoring skills complement and are not competitive with clinical and research expertise, thus helping the would-be mentor and mentee to acquire the “whole package.” This perception of devaluation of mentoring in medical school departments is clearly different when compared to university departments of English and mathematics where outstanding teachers and mentors continue to be valued highly.

Lack of Formal Training in How to Mentor The lack of formal faculty training in how to mentor is another stumbling block. Surgical faculty, for the most part, are extremely well trained in their respective clinical areas and have the highest quality credentials. However, this does not always correlate with the ability to mentor, teach, communicate and stimulate critical thinking. There is a prevailing misconception that just because a surgeon has enormous clinical experience he/she can communicate this experience in an effective and intelligible manner and serve as a resource for professional and personal guidance. Surgical faculty are usually experts on what to teach; however, they may have had little or no training on how to teach and mentor.

How to Develop Faculty Mentors As listed in Table  7.2, several processes must be implemented to develop effective faculty mentors.

Establish a Mentoring Culture A “mentoring culture” must be endorsed and strongly supported by the Chair for a program to be successful. This concept is multifactorial

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7 How to Develop Faculty Mentors Table 7.2  How to develop faculty mentors 1. Establish a mentoring culture. 2. Recruit faculty with a background and interest in mentoring. 3. Provide financial incentives. 4. Grant protected time. 5. Establish highly valued awards. 6. Facilitate faculty instruction on how to mentor. 7. Delegate selective mentoring responsibilities to appropriately trained surgical residents/fellows.

and is clearly a team effort [6]. Mentoring and teaching activities will not be pursued independently unless the dictum is promulgated and enforced “from the top” (top-down process) that these activities are valued equally to clinical care, administrative expertise and basic and clinical research. The recommendations discussed in this section are synergistic in establishing a mentoring culture.

Recruit the “Right” Faculty When the right faculty are recruited and a department is known for prioritizing mentoring and teaching, its reputation is enhanced in all areas of surgical expertise. The cumulative successes of surgical departments are largely dependent upon the quality of the faculty, house staff and support staff. Hence, it is all about recruiting, retaining and nurturing quality people to attain their full potential. This process takes time and is not inexpensive. The financial consequences of replacing an individual faculty member in 2002 were estimated to be $250,000 [7]. Today’s costs are presumably much higher. As mentioned in Chap. 1, most successful surgeons have been mentored by surgeons of similar repute. Thus, selecting a faculty member who is the protégé of an outstanding mentor increases the likelihood of further success. This recruitment pattern expands into attracting the best and the brightest medical students into the residency and serves as a stimulus for attracting additional outstanding faculty. The “domino effect” of excellence begetting excellence cannot be overemphasized and is an impetus for new ideas and innovative departmental programs. Future departmental recruits, regardless of professional level, are attracted to unique opportunities of working in an educationally supportive environment structured to enhance their

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Mentoring as a faculty member

intellectual and professional growths. Finally, mentoring activities foster communication among faculty and surgical residents which in turn improves working relationships and enhances departmental identity and esprit de corps. Surprisingly, it is unusual to inquire about an applicant’s teaching and mentoring skills during faculty recruitment despite the importance of these qualities to the overall mission of the department. A partial explanation for this omission is the extreme difficulty in objectively measuring teaching abilities and mentoring skills (see section Objective Assessment). However, the wise Chair recognizes that faculty composition must include members dedicated to mentoring and teaching. This inclusion is preferable to resorting to assigning faculty to these tasks when they have neither interest nor aptitude, as this is almost always counterproductive. In short, people do best when they are doing what they really want (and love) to do. Moreover, the Chair recognizes it is not imperative for every faculty member to be a dedicated mentor inasmuch as many individuals best contribute through clinical, administrative or research activities. Nevertheless, these faculty may become effective mentors in their respective areas by virtue of mosaic mentoring which requires less time and effort than in the traditional one-onone mentoring model (see Chap. 9, section Mosaic Mentoring). Although most programs emphasize the importance of mentoring regardless of academic rank, Omary proposes a unique approach of a reverse progression of mentoring (Fig.7.2) [8]. This approach emphasizes the gradual progression of mentoring activities throughout one’s career while assigning the major commitment to older and more experienced faculty. This approach creates more time for instructors

Assistant professor

Student Technician

Associate professor

Fellow Assistant professor Associate professor

Professor

Professor

Fig.  7.2  The reverse pyramidal progression of mentoring (Reprinted from [8]. With permission from Elsevier)

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and assistant professors to initiate their clinical and research careers and builds upon the more extensive experience of senior faculty. Senior surgeons either nearing retirement or simply wanting to modify their clinical activities because of the extensive physical and psychological demands of surgery are ideal potential mentors. They bring a wealth of clinical knowledge and experience coupled with the satisfaction of having fulfilled most of their career goals. Mentoring may be particularly appealing to attendings whose primary interests are teaching and clinical care and not committee meetings and administrative tasks. Additionally, the potential challenge of a new career focus is intellectually and professionally stimulating and allows for rejuvenation by living vicariously through the accomplishments of younger mentees (see Chap. 2). Most importantly, mentoring provides continued opportunities to communicate surgical principles, especially valued by the senior surgeon, and to perpetuate teachings inculcated by previous mentors.

Establish Mentoring-Related Financial Remuneration and Incentives To enhance the scholarly reputation for mentoring in the Department, financial remuneration and promotional incentives must be provided. The inclusion of teaching/mentoring clauses in faculty contracts and financial incentive packages is a means to communicate the high priority of mentoring within the department. Moreover, mentoring programs created without financial and promotional incentives are doomed to failure. Regrettably, it is uncommon for a surgeon to receive a salary increase or academic promotion solely based on his/her mentoring and teaching skills. If these issues are not addressed, it is unrealistic to expect faculty to devote considerable time to mentoring and teaching. The objective basis for these awards is multifactorial and is discussed later in this chapter (see sections  Written Evaluation and Verbal Feedback and Objective Assessment). As discussed repeatedly in this book, it is extremely difficult to objectively separate mentoring from teaching, especially from a remunerative standpoint. One possible solution is to more accurately account for these activities in the submission of faculty effort reports required at most institutions. These reports, often submitted quarterly,

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include accounting of efforts devoted to teaching (often couched as to “working with students, residents or both”), clinical care, administration and research over a representative time period. Such assignations help determine the allotment of funds to clinical departments by the medical school and hospital and provide a means for at least partial remuneration for mentoring and teaching activities. It has been suggested that an arbitrary designation of teaching and mentoring RVUs to effort not devoted to either clinical or research activity within the attending’s overall effort expended may boost the percentage of such funding (JLR personal communication). Other approaches to help fund educational activities such as mentoring and teaching include collecting taxes on revenue from clinical income, medical school teaching and research grants, and transferring hospital funds and indirect medical education dollars. Additional funding is available through organizations such as the Robert Wood Johnson Foundation and the American College of Surgeons Women’s Mentorship Program (see Chap. 5). Modest financial incentives should also be created for resident/ fellow mentors as well. This recognition will reinforce the prioritization of mentoring within the Department.

Provide Protected Time To create an effective mentoring program protected time must be provided with requisite salary to the faculty mentor. As the result of the close interaction between mentoring and teaching it is implied that these activities will overlap. Additionally, this time should be allocated for intentional and unintentional mentoring sessions (see Chap. 4, sections Intentional and Unintentional Mentoring). As mentioned (see section  Establish Mentoring-Related Financial Remuneration and Incentives) the amount of time devoted to these activities should be accounted for in faculty effort reports. The amount of time to be “protected” varies with the interests of the faculty and is determined in part by departmental budgets, mentoring expertise and the needs of resident and student mentees. Ten to twenty percent time is a reasonable allotment contingent upon the aforementioned variables. This still provides considerable time for clinical, administrative and research activities. Similar to most major faculty commitments, documentation of mentoring and teaching activities

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should be maintained and accountability assessed accordingly (see section Objective Assessment).

Establish Highly Valued Awards Specifically for Mentoring Mentor recognition expressed solely by giving a written certificate or an engraved plaque is passé. Highly valued awards should be created to further emphasize the mentor’s importance. These awards should be based upon predetermined criteria and be clearly differentiated from teaching awards which are usually given annually by most surgical departments. Criteria for mentoring awards should include objective evidence of career advancement of the mentee or similar outcome measures. Additional criteria are discussed subsequently in this chapter (see section Written Evaluation). A committee to evaluate potential candidates should include the Chair, one or two additional faculty, a resident and student. A cash stipend should be provided to enhance the value and prestige of the award. Potential funding sources include gifts from grateful patients and support from established graduates of the surgical residency. Because of the stringent criteria and special recognition of this award, it probably should only be given every few years. It takes this long to fully assess the contributions of the mentee specifically guided by an individual mentor. The award should be publicized throughout the parent university as well as the medical school and hospital.

Provide Formal Training on How to Teach and Mentor As mentioned, most surgical faculty do not have formal training in mentoring and teaching. Surgical Chairs readily disperse funds for junior faculty to learn a new surgical technique or procedure; why shouldn’t similar funds be allocated to train faculty to mentor and teach? Time and funds must be allocated, especially to new faculty, to attend instructional courses and workshops. Successful mentoring programs have been implemented in the UK since 1994 [9]. These programs are highly valued by the ­participants, particularly as to being part of a network of senior

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d­ octors, developing mentoring skills, and engaging in personal and professional development. Individuals who receive the greatest benefit from instructional programs on mentoring include junior attendings, newly appointed individuals and selected senior faculty who feel the need to update their mentoring and teaching skills. To understand how physicians learn to teach, interviews of ten experienced medical teachers (including surgeons) were conducted by faculty from Cambridge University [10]. Four areas were important in teacher development: acquisition of educational knowledge and skills, modeling and practice of teaching skills, encouragement and motivation of teachers, and constraints on teaching and learning. Results of this analysis suggest a model for teacher development that begins with doctors as learners, learning to learn and watching teachers teach. Subsequently, they start to teach, acquiring and practicing skills, and move on to reflect on their teaching. Formal instructional courses were valued for the time they allowed for reflection; they also provided opportunities to discuss issues with like-minded colleagues. A key theme included teachers’ experiences as learners. These individuals described themselves as learner facilitators and promoters of critical thinking. They generally disliked giving formal lectures and preferred teaching individuals either singularly or in small groups. All of the attendees identified the importance of role models and mentors in their own careers.

Delegate Selective Student Mentoring to Appropriately Trained Surgical Residents/Fellows Surgical residents and fellows with appropriate training in teaching and mentoring can help reduce the enormous teaching commitments currently required of an already overworked faculty. This is particularly relevant when mentoring medical students and interns whose main educational goals are to learn basic principles and rudimentary aspects of perioperative care. In some departments this concept is an integral component of the overall resident training program. The important role of resident/fellow teaching to other residents and medical students has recently been acknowledged by the Accreditation Council for Graduate Medical Education (ACGME) and Liaison Committee on Medical Education (LCME) [11, 12]. The benefits of increased usage of

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residents/fellows for mentoring are described in Chap. 4. These activities are best performed by residents who are at least at the PGY 3 level or, if relevant, while they are on research rotations. Additionally, resident/fellows supervised mentoring provides the opportunity to ­re-review topics which in turn aids in preparation for the ABSITE and specialty accreditation examinations. Resident-delegated mentoring must be tempered within their patient care responsibilities and the 80 clinical hours work week. Additionally, when mentoring of medical students is partly delegated to residents/fellows, faculty mentors must not totally abrogate their own educational commitments to these individuals.

Developing Surgeon-Scientist Mentors The era of busy clinical surgeons “dabbling” in research is no longer tenable. Academic departments of surgery must recruit specific faculty with strong interests in contributing to surgical science, challenging dogma and investigating unanswered clinical questions. These individuals are just as important to the overall mission of surgical departments as the high volume clinician, and they provide unique mentoring contributions to surgical residents (see Chap. 4, section Mentoring in Research Laboratory). As fully trained clinical surgeons with dedicated research backgrounds, surgeon-scientists are most familiar with basic and clinical scientific issues in surgery. This awareness differs from the non-surgeon Ph.D. researcher who has limited clinical knowledge and functions best in surgical departments when complementing the surgeon-scientist. How can the development of surgeon-scientist mentors be improved? Firstly, to become a credible surgical scientist and mentor, sufficient protected time must be allocated to perform quality research. Smythe prefers the term academic flexibility rather than protected time. He notes that the Chair must support changes in clinical schedules to accommodate scholarly activities [13]. To fulfill this goal and provide the requisite time to write quality grants, competitive with full-time Ph.D. researchers, many surgical departments have gone to an 80:20 program with 80% of time allocated to research. Additionally, the provision of seed money to initiate a lab is mandatory. This can be expensive due to major investments in

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supplies and equipment, the allocation of salaries and benefits for research technicians, Ph.D. collaborators and post-doctoral research fellows. Furthermore, these initial financial investments are often not “repaid” for many years. Similar to other faculty members, the surgeon-scientist must meet achievement deadlines and be accountable to the department. This accountability is manifest in obtaining peer-reviewed grants such as those offered by the NIH. Most importantly, the NIH considers time dedicated to training post-M.D./Ph.D. trainees or graduate students as grant-related activity [14]. The NIH provides several career awards where mentoring is an important feature of the award including the K05, K24, and K26 awards. Information concerning these awards is available at http://grants1.nih.gov/training/careerdevelopmentawards.html. The U.S. Institute of Medicine has recommended improved mentoring in clinical departments to better guide the physician-scientist [15]. To address this problem, Blixen and colleagues developed a mentorship program at the Cleveland Clinic [16]. They conducted a case study review of the role of mentors in developing and sustaining clinical investigators. Although not directly involving surgeons, they concluded that interactive group formats lead to development of a code of mentorship and increased awareness of faculty regarding clinical investigation. To reinforce their commitment to research, the new Cleveland Clinic Lerner College of Medicine of Case Western Reserve University is a 5 years program instead of four, with the additional year solely devoted to research. It has been suggested that senior surgical faculty become more active at the NIH and provide appropriate financial support and mentorship for residents and junior faculty engaged in research [17].

Faculty Mentor – Written Evaluation and Verbal Feedback Written evaluation and verbal feedback are important to all faculty including those with significant commitments to teaching and mentoring. These evaluations can be used for academic promotion and salary increases. Admittedly, there is considerable overlap in evaluating faculty who are primarily teachers but not particularly known as mentors. The content of these evaluations is based, in part, upon written

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submissions (usually requested anonymously) from resident and student mentees and includes both written and verbal observations of the junior mentor by more senior faculty surgeons. When solicited comments from the young faculty’s personal mentor are used in the evaluation, it is best to keep the source of this information confidential to maintain the personal nature of the mentor-mentee relationship. The evaluation of faculty mentors does not have to be solely based upon comments by senior colleagues, mentees and accomplishments at the mentor’s own institution. Acceptances of abstracts for national meetings such as the Association for Surgical Education and publication of manuscripts in peer-reviewed journals are additional criteria for mentoring-based promotion and special awards. The word spreads quickly when a faculty member is a good mentor and teacher. This reputation results in requests from students and residents to take an elective clinical rotation or to join the attending surgeon’s research laboratory. The aforementioned criteria are important for the mentor’s evaluation; however, the final assessment should not be based on a popularity contest.

Written Evaluation Inasmuch as all mentors are teachers, there is considerable overlap in these roles within the written evaluation. Content should include quality of continuing education activities, accessibility and impact on the personal and professional development of the mentee. Further criteria include clarity of teaching objectives, quality of handouts and visual aids, innovative approaches to teaching and mentoring and invitations for guest lectures. Evaluation of teaching and mentoring is difficult and is often based more on impressions than empiric evidence. A difficult yet meaningful component of the evaluation is to determine whether the mentor definitely contributes to objective accomplishments by the mentee. Berk and colleagues have developed a mentorship profile and effectiveness scale to be completed by the mentee [18]. The mentorship profile is divided into two parts. Part I consists of a description of the mentoring relationship to include primary role of the mentor, frequency of interaction, length of the relationship, and strengths and weaknesses of the mentor. Part II includes outcome measures for the mentee such as publications, presentations, research grants, service

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activities, and promotions. A final component consists of a mentorship effectiveness scale based upon 12 objective criteria. Although primarily designed to evaluate nursing faculty, most of this information is relevant to surgeons. Most importantly, it is an attempt to provide an objective basis to evaluate faculty mentors and the accomplishments of their mentees.

Verbal Feedback Verbal feedback to the faculty mentor is part of every complete evaluation. Its content is similar to the written evaluation with the added advantage of providing an opportunity for direct discussion. The verbal feedback session should be conducted one-on-one by either the Chair or a senior surgeon with more mentoring experience than the junior faculty mentor. If it is perceived that an extremely critical evaluation is to be discussed, it is prudent to have another senior faculty present in the event the evaluation might be “challenged” legally. To preserve the personal relationship between the faculty mentor and mentee it is preferable to maintain the anonymity and confidentiality of mentees’ comments during the verbal feedback (analogous to the written evaluation). These comments should not be the sole determinant of the mentor’s final evaluation. Written documentation of verbal feedback sessions should be included in the junior faculty’s record for proper documentation, accountability and legal protection. Most importantly, the mentee should be given the opportunity to respond accordingly.

Objective Assessment As mentioned, a major difficulty in evaluating the mentor’s performance is the lack of validated criteria for objective assessment. To address this problem an analytical expression of the “mentoring experience” was devised by Rogers and colleagues at Baylor College of Medicine [19]. The investigators sought to develop a quantitative measure of the dimensions of the process from the experience of the mentee. A previously developed instrument was revised and distributed to 108 faculty

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members of one medical school department. The response rate was 89%. Similar to Pololi et al. [7] and Jackson et al. [4], factors identified as being valid evaluators included personal exploration – identification of core values, practical guidance – structured career planning and growth, mentor support – close, collaborative relationship and mentor advice – skill development. It was concluded that this composite may be useful to guide and evaluate mentoring initiatives in a larger sample and other target populations. Whether a similar objective assessment could effectively evaluate surgical mentors is not known.

Faculty Discontent Inherent to mentoring young faculty are the needs to support personal and professional growth and enable each person to reach his/her full potential. Despite optimal efforts to retain young faculty, such individuals may become frustrated, unhappy and ultimately leave a department long before attaining their career goals. In some instances the environment is simply not a good “fit.” Many of the causes of faculty discontent are outside the ability of the Chair or parent institution to either eliminate or modify. Issues such as inordinate stress, substance abuse, marital discord, impending divorce or a debilitating illness must be addressed on an individual basis. Professional counseling and medical consultations should be obtained when appropriate. In some instances the job may be “saved”; however, in surgery, it is not unusual for the junior faculty to transition to a less stressful environment. Other causes of discontent are potentially resolvable, although, in some instances, not without considerable time and effort. These include personality clashes among faculty (particularly those within the same sub-specialties), varied distribution of support staff (physician’s assistants and nurse practitioners) and salary differences. Medical school faculty discontent and the prevalence and predictors of intent to leave academic careers were investigated by Lowenstein and colleagues from the University of Colorado [20]. A 75-question survey was administered to faculty at the School of Medicine. Major topics included quality of life, faculty responsibilities, support for teaching, clinical work and scholarship, mentorship and participation in governance. Forty percent stated their careers were not progressing satisfactorily and 42% were seriously considering leaving academic medicine

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in the next 5 years. Significant predictors of “serious intent to leave” included: difficulties in balancing work and family, inability to comment on performance of institutional leaders, absence of faculty development programs, lack of recognition of clinical work, absence of teaching critiques in promotion evaluations, weak or non-existent “academic community” and failure of chairs to evaluate regularly academic progress. The investigators recommended that medical schools refocus efforts of faculty retention on professional development programs, regular performance feedback, balancing career and family, tangible recognition of teaching and clinical services and meaningful faculty participation in institutional governance. When examining these recommendations, one of the first conclusions is the enormous amount of time and resources required by institutions and respective departments to fulfill these demands. It would seem impossible for over-worked senior faculty to meet all of these recommendations to better nurture junior faculty. Clearly, priorities must be established and regular feedback provided to bolster the success of any program. Although not always easy, it behooves surgical chairs to recruit young surgeons who are self-directed and focused on achievement, rather than “high maintenance” individuals in need of intensive guidance and frequent interaction (see section Recruit the “Right” Faculty). As mentioned, financial incentives and contractual rewards for teaching and mentoring may help retain faculty. Additionally, the tasks of mentoring junior faculty must be distributed among senior faculty. This is often challenging in surgery due to the high volume clinical practice and revenue generated by many senior surgeons. Despite these concerns, and apropos the personal commitment of the mentor, creative strategies must be devised to reduce faculty transition and dropout.

Potential Areas for Research Many of the unanswered questions relating to faculty mentoring are potential areas for research. These include (1) Are formal, structured mentoring programs preferable to informal, improvisational settings? (2) Should formal instructions on how to mentor be directed to senior surgeons as well as junior faculty? If so, should the curriculum differ? (3) Does the presence of outstanding mentoring translate to improved clinical and academic performance of the mentee? (4) How can

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mentoring increase departmental revenue? (5) Can the results of mentoring be truly measured objectively? If so, what are the best tools? (6) Is mentoring of medical students by surgical residents/fellows as effective as that performed by junior faculty? and (7) Should a larger proportion of surgical mentoring be performed by the most senior faculty to permit more time for career advancement of junior members?

Summary and Conclusions A quality mentoring program provides cumulative benefits to a department far beyond the individual activities of its members. The lack of financial incentive is a major obstacle to develop faculty mentors. Surgical chairs must endorse a mentoring culture, provide requisite resources and recruit faculty with vested interests in this area. Written and verbal feedback are mandatory components of faculty evaluations. Attention should be directed toward early resolution of faculty discontent. Current demands to improve faculty mentoring provide opportunities for research.

References 1. Scandura TA (1992) Mentorship and career mobility: an empirical investigation. J Organ Behav 13:169–174 2. Palepu A, Friedman RH, Barnett RC et  al (1998) Junior faculty mentoring relationships and their professional development in US medical schools. Acad Med 73:318–323 3. Taylor CA, Taylor JC, Stoller JK (2009) The influence of mentorship and role modeling on developing physician-leaders: views of aspiring and established physician-leaders. J Gen Int Med. doi:10.1007/s11606-009-1091-9. Published online 27 Aug 2009 4. Jackson VA, Palepu A, Szalacha L et al (2003) “Having the right chemistry”: a qualitative study of mentoring in academic medicine. Acad Med 78:328–334 5. Dunnington GL (1996) The art of mentoring. Am J Surg 171:604–607 6. Singletary SE (2005) Society of surgical oncology. Presidential address: mentoring surgeons for the 21st century. Ann Surg Oncol 12:848–860 7. Pololi LH, Knight SM, Dennis K, Frankel RM (2002) Helping medical school faculty realize their dreams: an innovative, collaborative mentoring program. Acad Med 77:377–384

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8. Omary MB (2008) Mentoring the mentor: another tool to enhance mentorship. Gastroenterology 135:13–16 9. Connor MP, Bynoe AG et al (2000) Developing senior doctors as mentors: a form of continuing professional development. Report of an initiative to develop a network of senior doctors as mentors: 1994–99. Med Ed 34:747–753 10. MacDougall J, Drummond MJ (2005) The development of medical teachers: an inquiry into the learning histories of 10 experienced medical teachers. Med Ed 39:1213–1220 11. Accreditation Council for Graduate Medical Education (1 July 2007) ACGME institutional requirements. http://www.acgme.org. Accessed 15 Apr 2010. 12. Liaison Committee on Medical Education (updated June 2008) LCME standards. http://www.LCME.org/standard.htm. Accessed 15 Apr 10. 13. Smythe WR (2004) Protected time. Surgery 135:232–234 14. Bhattacharjee Y (2007) Postdoctural training. NSF, NIH emphasize the importance of mentoring. Science 317:1016 15. Gershon D (1999) Improving the plight of the physician-scientist in the US. Nature 402:215–216 16. Blixen CE, Papp KK, Hull AL et al (2007) Developing a mentorship program for clinical researchers. J Contin Ed Health Prof 27:86–93 17. Suliburk JW, Kao LS, Kozar RA et al (2008) Training future surgical scientists – realities and recommendations. Ann Surg 247:741–749 18. Berk RA, Berg J, Mortimer R et  al (2005) Measuring the effectiveness of faculty mentoring relationships. Acad Med 80:66–71 19. Rogers J, Monteiro FM, Nora A (2008) Toward measuring the domains of mentoring. Fam Med 40:259–263 20. Lowenstein SR, Fernandez G, Crane LA (2007) Medical school faculty discontent: prevalence and predictors of intent to leave academic careers. BMC Med Ed 7:37–44

Chapter 8

How to Choose a Mentor

Mentoring is a brain to pick, an ear to listen, and a push in the right direction. John Crosby

Key Concepts • • • •

Mentors should be selected early in the mentee’s career. Mentees require multiple mentors throughout their careers. The selection process should be initiated by the mentee. The mentee must be well prepared for meetings with the prospective mentor and make appropriate follow-up. • The mentee must be proactive to maintain mentoring relationships. • Most mentoring relationships are transient. Mentoring is a dynamic process. As careers evolve and professional interests change, most surgical mentees will benefit from multiple mentors. For example, a medical student rotating on surgery can receive invaluable advice and guidance from a respected senior resident. The resident, in turn, acquires critical and practical directives from consultations with junior faculty, especially those who have recently completed their training. As they begin to navigate the academic ladder, the junior faculty will benefit from advice and guidance of the more senior mentors of their department; hence the importance of having multiple mentors throughout one’s career. Effective mentoring is not solely limited to these hierarchical interactions. For example, medical students receive meaningful career suggestions from attendings as well as from residents, particularly as to post-residency lifestyle. As noted by Jackson, mentors can teach mentees how to “promote themselves” within the rules of the game [1]. In certain instances, mentors identified early on will continue to provide guidance to the mentee by suggesting J. Rombeau et al., Surgical Mentoring: Building Tomorrow’s Leaders, DOI 10.1007/978-1-4419-7191-3_8, © Springer Science+Business Media, LLC 2010

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new, more appropriate mentors befitting the evolving professional career of the mentee. Multiple mentors (i.e. clinical, research, administrative) may be valuable, not only over time, but also simultaneously [2]. The interaction with multiple mentors exposes the mentee to varied disciplines, opinions and experiences, each of which help the mentee develop the “whole package” (see Chap. 9, section Mosaic Mentoring). This chapter focuses on the mentee. It discusses the mentee’s acknowledgement of the importance of mentoring, including his/her responsibilities to the mentor. Suggestions are provided regarding how to find potential mentors and ways to maintain the relationship. Finally, termination of the mentoring relationship is discussed and the importance of seeking new mentors is emphasized.

Responsibilities of the Mentee To improve the likelihood of establishing a successful relationship, the mentee must make mentoring a high priority. Unless the mentee truly believes in the value of the process, it will never succeed. Zerzan explains that the mentee is not an empty vessel receiving “the mentor’s advice and wisdom but, rather, an active participant, shaping the relationship. The ideal mentee aspires to self-assessment, receptivity, initiative, responsibility, honesty and appreciation for his or her mentor” [3]. Similarly, the mentor must also be an enthusiastic participant in the mentoring process. Lack of enthusiasm occurs when mentors are assigned rather than volunteer. For the mentee to “buy into” this process he/she must be convinced that the mentor is committed to providing sound and useful advice. This concept is articulated by Lee and colleagues who state, “At the crux of mentoring is an interpersonal relationship between two people, which like many other elective interpersonal relationships, will not last unless both parties derive some benefit. This characteristic makes mentoring relationships difficult to produce artificially. Successful mentoring relationships cannot be manufactured or legislated, but rather develop fully only when both parties work at creating the relationship” [4]. The anticipated benefits of the mentor/mentee relationship cannot be based upon platitudes or vague predictions such as the mentee is “more apt to become successful or famous.” Proposed goals for the mentee to achieve desired benefits must be determined in response to

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his or her professional level and career aspirations. If the mentee is junior faculty, these goals include developing a successful clinical practice, obtaining a research grant, earning a higher salary or being awarded a more rapid promotion. Reasonable objectives for the senior resident mentee include improved opportunities to join a well respected surgical practice, or obtain a valued research or clinical fellowship. For the medical student, a good mentor can provide guidance as to what specialty to pursue and where to apply for residency. The career of the student mentee is also helped through the mentor’s letters of recommendation for a residency. When well written and individualized, these letters may improve the probability of acceptance into a residency. Analogous rewards occur when a mentor strongly endorses applicants for fellowships, clinical, academic and administrative positions and memberships in distinguished societies (also see Chap. 2, section Importance of Mentoring for the Mentee). The mentoring relationship is usually initiated by the mentee. Prior to choosing a mentor, the mentee must have realistic expectations as to potential goals. Most importantly, the mentor should be relied upon for guidance and advice and should not be expected to have all the answers. Experienced mentors generally ask more questions than provide definitive answers (see Chap. 4, section Socratic Method). The mentee plays a major role in creating an interactive, compatible and productive mentoring relationship. Inherent to this interaction is the willingness to invest considerable time. The extent of this commitment varies with the goals of the relationship and the professional level of the mentee. Interactions may be frequent and structured at the outset and more intermittent as the mentee and the mentoring topics “mature” in the relationship. For example, when a research study is being devised, frequent mentoring sessions are required to carefully refine the study question and to formulate testable hypotheses. Once these tasks are complete and the methodology agreed upon, meetings are less frequent and contingent upon accrual of data. The mentee must be receptive to feedback which, in some instances, may be critical. This is exemplified in one of the definitions of a mentor as a “tough friend.” Also, the mentoring process may initially cause conflict, especially if the anticipated goals are inappropriate or ill-defined. As mentioned, the process is often more time consuming than envisioned at the outset. Thus, the mentee must accept that the journey will not always be smooth sailing. Additionally, mentees must realize that ultimate goals are for them to work independently and to mentor others.

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General Principles for Selecting a Mentor The type of mentor sought depends, in part, upon the professional stage of the mentee. The stage helps to determine anticipated goals of the relationship (e.g. research project, clinical investigations, administrative guidance) and generally restricts the list of potential mentors. Although there is no absolute as to age of the mentor, Levinson suggests that “a mentor should be ideally 8–15 years older than the mentee – old enough to represent greater wisdom, authority and experience, but not too old to be in the image of the wise old man or distant father, although age is probably not as important as the desire to mentor” [5]. There is no proven formula for this selection process; however, there are general principles which will improve the ability of the mentee to select a mentor who is a “good fit” (Table 8.1). The degree of initiative, specific interests and career goals of the mentee are foremost in the selection process (Fig. 8.1). Table 8.1  Guidelines for selecting a mentor 1.  Start early in your career. 2.  Accept the need to invest considerable time and effort. 3.  Identify an individual who is respected and trusted. 4.  Select a mentor with a proven track record. 5.  Find a mentor with whom you are comfortable. 6.  Be sure the potential mentor is accessible and truly committed to mentoring. 7.  Restrict initial inquiries to one’s own department or institution. 8.  Be prepared prior to and during meetings and make appropriate follow-up.

Wanted:

active, energetic, and insightful individual, willing to share knowledge and connections with impressionable underling. Requires diligence, support, and an occasional “leap of faith.” Commitment may be lifelong. No financial compensation. Unapproachable, busy, enigmatic boors need not apply.*

Fig. 8.1  Selecting a mentor (Adapted from [8]. With permission from Elsevier)

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General Principles 1. Mentors should be selected early in each stage of the mentee’s career. The earlier the selection the greater the opportunity to make focused career decisions guided by the more experienced mentor. It is far more productive to prevent fires than to expend inordinate amounts of time trying to extinguish them. 2. Accept the need to invest considerable time and effort in the selection process. It is not unusual to participate in many different brief meetings before settling on the right mentor. As mentioned, most mentees will need concurrent mentors. 3. Identify an individual who is respected and trusted and who is committed to the mentoring process. This is best determined by speaking with current or previous mentees. 4. Find a mentor with whom you are comfortable – but not too comfortable. This is described euphemistically as “having the right chemistry.” If the relationship is based solely on friendship, there will generally be minimal constructive criticism thus making the process less effective. Although difficult to define, the mentor’s personality and communication skills are major determinants for success in most mentoring relationships. 5. Identify a mentor with a proven “track record.” Experience is an important asset in this process and is particularly relevant if there are many political, clinical and administrative hurdles to overcome. The criteria for determining the track record of the mentor obviously varies with the professional goals of the mentee. For example, success as a clinical practitioner may not be a valuable benchmark when selecting a research mentor. In certain settings, the mentor’s stage of career is an important determinant in the selection process. Inquiries should not be limited to professors and “gray haired” faculty. Moreover, the mentee should beware of the over-extended mentor before making a decision. In many instances, junior faculty are more available and more familiar with recent advances and future directions in their respective fields than their older colleagues. This “cutting edge” information is attractive to the potential mentee. It must be appreciated, however, that younger faculty are under considerable pressure to produce and develop their own identities. Despite the best of initial intentions, these demands may create major time constraints and restrict availability for mentoring. Finding the right balance between experience and availability is a difficult but critical part of the selection process.

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6. Select a mentor who is accessible and truly committed to the mentoring process. In most instances this type of individual enjoys living vicariously through the successes and achievements of others. Despite having good intentions, the experienced mentor may have too many mentees and insufficient time to devote to a new recruit. 7. Restrict initial mentor selections to individuals in your department or institution. Due to greater accessibility and the improved opportunity for more frequent interactions, mentoring relationships are best established in one’s own department or institution. Additionally, departmental productivity and recognition is enhanced when mentor-based grants, publications and awards emanate from one’s own department. Furthermore, the department has a vested interest in the mentoring process when it is paying the salaries of the mentor and mentee. If the interest or availability of potential mentors in one’s own department is unknown, formal appointments should be arranged with possible prospects. If appropriate mentoring candidates are not present in one’s department or institution, overtures to local or regional surgical societies, or national organizations such as the American College of Surgeons may then be beneficial (see Appendix – Mentoring Websites) 8. Be prepared prior to, during and following meetings with prospective mentors. Mentees will benefit from reviewing a checklist as shown in Table 8.2, prior to the initial interview. Regardless of the professional level of the mentee, he or she must be well prepared for the initial meeting. Prior to the meeting, this preparation should include providing the mentor with an updated curriculum vitae or resume, familiarizing oneself with the mentor’s areas of interest and expertise and discussing areas for potential interaction. The mentee should be well prepared during the meeting. If a research mentor is being sought, well thought out scientific or clinical questions should be presented accompanied by knowledge of evidenced-based literature. Additionally, the mentee should be prepared to discuss carefully considered rationale for wanting to pursue similar clinical and/or research activities as the proposed mentor. Regardless of the reasons for seeking a mentor, a clear articulation of the mentee’s short and long term professional goals should be provided. Mentors are less receptive when the potential mentee is ill-prepared and begins the meeting with “What should I do?” Moreover, experienced mentors often begin such sessions by asking the mentee what he/she would like to accomplish and

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Table 8.2  Checklist for initial meeting with prospective mentor Prior to the meeting • Do not schedule a meeting the day after emergency call. • Send copy of CV or resume and anticipated mentoring goals. • Reconfirm time and location with mentor’s administrative assistant. • Think carefully as to why you would like to work with this particular individual. • Review anticipated goals. During the meeting • Do not appear as if you just got out of bed! • Convey gratitude for the interview. • Briefly review your own background. • Carefully articulate well thought out goals and objectives including projected time tables. • Provide brief evidence-based rationale for choosing such goals. • Ask insightful questions and listen attentively to responses. • Accept criticism. • Respect time constraints and professional demands of the mentor. Following the meeting • Send thank you note or email. • Schedule another meeting if the mentor appears to be receptive. • Ask for recommendations for other individuals if the mentor is either inappropriate or overly committed.

the reasons for this decision. The failure to provide carefully considered responses to these questions is damaging and frequently results in the mentor declining to participate in the relationship. Written handouts developed by the mentee assist with this initial meeting and provide a visible reminder of the meeting and potential relationship. Every meeting with a potential mentor should be followed by either a thank you note or email. If it is apparent the mentor is either too busy or not an appropriate “fit,” it is “fair game” to ask for suggestions for alternative mentors.

Mentor Selection Tailored to the Professional Level of the Mentee The Medical Student Mentee There are several reasons for the medical student rotating on surgery to seek a mentor. The student may be undecided regarding his/her

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future career, and discussions with both faculty and resident mentors help to clarify the realities of the surgeon’s world. These discussions are particularly relevant for students considering surgical careers while maintaining a “controllable lifestyle” which indeed has different meanings to different generations. Interestingly, a study of medical students rotating on surgery from the University of Utah concluded that those who choose surgical careers are not deterred by a negative perception of lifestyle and workload considerations [6]. The student may need advice regarding where to apply for a surgical residency. Although this advice can also be obtained from PGY 1 and PGY 2 residents who have recently gone through the application process, surgical faculty may be aware of information unbeknownst to residents that might affect application patterns. Examples of this include familiarity with the long-term track record of the programs, knowledge of key surgical faculty who might be leaving the department and awareness of disciplinary and probationary actions imposed upon a residency training program. Medical student mentees are frequently willing to participate in small, clinical research projects with a mentor. These projects may serve as an impetus to seek further clinical and research training. This research experience provides an opportunity for the student-mentee to learn more about the academic side of surgery and also improves the student’s credentials for residency applications.

The Surgical Resident Mentee The junior resident will receive the most cogent advice concerning the intricacies of the residency from the senior resident (see Chap. 4, section Mentoring by Surgical Residents). Mentoring of junior residents by their senior colleagues provides important guidance in learning technical skills, acquiring basic surgical knowledge and familiarity with relevant literature, learning optimal time management and multi-tasking, and realizing the importance of professionalism. This may be particularly helpful for the junior resident who is struggling to keep up with peers, and who a faculty member may have difficulty helping with day-to-day advice on “how to improve.” The surgical resident should also identify a faculty mentor early in his/her career. Content of mentoring discussions include advice on matriculating through the residency and potential research projects. The

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mentor is extremely important in evaluating and advocating programs for fellowship applications as the mentee becomes more senior. Faculty mentors may also be aware of potential job openings in private practice groups or academic departments. The junior resident can also receive cogent advice concerning the intricacies of the residency from senior residents (see Chap. 4, section Mentoring by Surgical Residents).

The Junior Faculty/Private Practice Mentee Selecting the “right” senior faculty or private practice mentor is a critical, early step in the career of most young surgeons regardless if they are in academic or private practice. Much of the information discussed in these mentoring sessions relates to the “politics” of the institution or practice group setting. Many of the aforementioned considerations for selecting a mentor also apply to the junior faculty mentee. In private practice, a clinical mentor can provide insight into expanding a surgical practice and building a clinical reputation in the surrounding healthcare community. Junior faculty with a research focus require research mentors particularly to help obtain extramural research funding. The research mentor’s input regarding grant writing and the preparation of scientific manuscripts is invaluable.

Maintaining the Relationship – Being a Proactive Mentee Once a mentor has been selected it is incumbent upon the mentee to maintain the relationship. As the result of the mentor’s greater responsibilities and commitments, accessibility is limited; therefore the mentee must take the initiative. The mentee should never wait for the mentor to initiate the mentoring session. This concept is known as “managing up” in the corporate world. According to Zerzan, managing up requires the mentee to take responsibility for his/her part in the collaborative alliance and to lead the relationship by guiding and facilitating the mentor’s efforts to create a satisfying and productive relationship for both parties. “The principal concept is that the mentee takes ownership of and directs the relationship, letting the mentor know what he or she needs and communicating the way his or her

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mentor prefers. Ideally, a motivated mentee manages the work of the relationship by planning and setting the meeting agenda, asking questions, listening, completing assigned tasks and requesting feedback.” [3]. The concept of managing up underscores the importance of the mentee being proactive, assertive and well organized to ensure a productive relationship. When this concept is followed, the mentor will be more effective in optimizing guidance and providing wise counsel. Time management is crucial to ensure effectiveness. Most importantly, the mentor’s time must be respected. Most sessions should be limited to less than an hour, therefore one or two topics for discussion are usually appropriate. Although the content changes as the mentoring relationship progresses, written handouts and visual aids continue to enhance communication. Similar to the initial mentor selection meeting and regardless of the mentee’s professional level, preparation should include critical thinking about the topic at hand. This is particularly relevant if a research proposal is being considered. Meeting deadlines is mandatory to maintain the mentoring relationship. The ability to meet deadlines is a crucial determinant of career success and is deeply ingrained in most accomplished surgeons. Completing assignments before the stated deadline is an excellent way to begin a productive mentoring relationship. If the mentee repeatedly fails to meet assigned deadlines, the mentoring relationship will most likely fail. To prevent the risk of failure, deadlines must be reasonable at the outset. Seasoned mentors should effectively identify deadlines and determine if the proposed accomplishments are realistic given the allotted time. Additionally, a mentee needs to recognize his/her limitations and not commit to unrealistic deadlines.

Terminating the Relationship Most mentoring relationships are transitory, which actually benefits the mentee, mentor and the surgical department. The mentee continues to matriculate by moving on to the next mentor (e.g. seeking multiple sequential mentors) and acquiring new knowledge. For example, it is implied that a new mentor will be needed when the resident completes general surgical training and is accepted into a cardiothoracic fellowship. The transitioning of mentors also prevents overdependence of the mentee on the initial mentor. Terminating the relationship provides the

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opportunity for the mentor to interact with new mentees and to “re-plant the seeds” for professional growth. As the result of embracing new mentees, the surgical department in turn perpetuates the mentoring culture. Ending the mentoring relationship is either voluntary or involuntary. Most interactions are terminated due to mutual agreement. In many instances the decision reflects the need of the mentee to seek new knowledge and clinical expertise. In others, the relationship ends due to changes in the mentee’s career interests. For example, if the initial mentoring relationship was based on a research project and the career interests of the mentee shift to a more clinical focus, different mentors prove useful. Seasoned mentors realize when they are unable to further help the mentee and know when it is time to “let go.” Thus, the mentor will frequently terminate the relationship by suggesting new mentors with expanded areas of expertise. Additionally, mentors realize the importance of “nudging” the mentee to function more independently. Regardless of the reasons for voluntary termination, it usually results in resolution of the roles of the previous mentors [7]. Occasionally the mentoring relationship ends involuntarily. In some instances this is due to inappropriate behavior of the mentor such as usurping credit for the mentee’s work or frequently missing scheduled mentoring sessions. The mentee may be responsible for the dissolution of the relationship as well. Poor quality work and repeated failures to meet deadlines are intolerable to most mentors. Regardless of the reasons for termination, it is incumbent upon both the mentor and the mentee to make the separation as amicable as possible. Many promising young careers have been “detoured” as the result of inappropriate comments from both disgruntled mentors and mentees.

Summary and Conclusions Most mentees require multiple mentors throughout their careers. Regardless of the professional level of the mentee, a mentor should be selected early in each stage of one’s career. The selection process should be initiated by the mentee and general principles should be observed. Careful consideration should be directed to preparing for issues before, during and following the meeting with the mentor. The content of the mentoring sessions varies as to the professional level and goals of the mentee. It is incumbent on the mentee to be proactive

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to maintain the relationship. Most mentoring relationships are transient as the mentee seeks new mentors to enhance personal and professional growth.

References 1. Jackson VA, Palepu A, Szalacha L et al (2003) “Having the right chemistry”: a qualitative study of mentoring in academic medicine. Acad Med 78: 328–334 2. Reckelhoff JF (2008) How to choose a mentor. Physiologist 51:152–154 3. Zerzan JT, Hess R, Schur E et al (2009) Making the most of mentors: a guide for mentees. Acad Med 84:140–144 4. Lee JN, Anzai Y, Langlotz CP (2006) Mentoring the mentors: aligning mentor and mentee expectations. Acad Radiol 13:556–561 5. Levinson DJ, Darrow CN, Klein EB, Levinson MH, McKee B (1978) The Seasons of a Man’s Life. Ballantine Books, New York 6. Cochran A, Melby S, Neumayer L (2005) An internet based study of factors influencing medical students’ selection of a surgical career. Am J Surg 189: 742–746 7. Ragins BR, Scandura TA (1997) The way we were: gender and the termination of mentoring relationships. J Appl Psychol 82:945–953 8. Cothren C, Heimbach J, Robinson TN et  al (2001) Academic Surgical Mentoring. In: Souba WW, Wilmore DW (eds) Surgical Research. Academic, San Diego, pp 1343–1347

Chapter 9

Future Directions

If I have seen further, it is by standing on the shoulders of giants. Isaac Newton

Key Concepts • Multiple forces are catalyzing change in the traditional model of surgical mentoring. • Surgical mentoring will increasingly occur during simulation sessions. • Telementoring will be used for surgical mentoring over long distances. • Personal computers will provide a 24-7 virtual surgical university. • Mentees will have multiple mentors, each with a specific role. • Assessment of technical skill will become more objective, allowing for competency-based training. Surgical training is changing and with it the nature of the mentor– mentee relationship. This chapter reviews the forces catalyzing change in surgical education as well as new high-tech methods of mentoring. Mosaic mentoring is also addressed. The chapter concludes with a discussion of the shift toward objective assessment of technical skills.

Forces of Change Multiple forces are changing surgical education and the traditional mentoring model developed by William Halsted at Johns Hopkins Hospital in the late 1800s (Table 9.1). Overall, these forces are promoting safer and more efficient training. Halsted’s model used the resident apprenticeship, a form of “on the job” training performed under the close direction of an expert surgeon. As a resident progressed through J. Rombeau et al., Surgical Mentoring: Building Tomorrow’s Leaders, DOI 10.1007/978-1-4419-7191-3_9, © Springer Science+Business Media, LLC 2010

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Table 9.1  Forces of change in surgical mentoring • Public pressure for greater supervision and fundamental competence of residents as well as recertification of surgeons in practice • Publicized surgical outcomes • Reduced resident clinical experience • Greater clinical and research demands on faculty, leaving less time for teaching • Need to reduce costs

years of training, he was granted greater responsibility. The mantra “see one, do one, teach one” is based on this model and has been the foundation of surgical training for over 100 years. However, the new millennium public opposes this method and insists on more intense supervision and at least a basic level of competency prior to participation in live operations. With the advent of the Internet, surgical outcomes are public information and surgeons are less willing to allow trainees to fully engage in the operating room. Unfortunately, concomitant with the rapid increase in number of complex, highly technical operations, the clinical experience of residents has decreased and faculty have less teaching time available. The 80 h workweek, efflux of surgical volume from teaching hospitals to surgicenters, and shortened hospital stays have contributed to the decline in surgical training opportunities. Additionally, faculty are under pressure to be more productive in the clinical and research arenas with educational activities often becoming a ­tertiary priority. Surgeons in practice also find themselves targets of change, as public interest groups and professional societies call for career-long recertification. This is particularly true if these ­surgeons desire to offer the best and most advanced technologies to patients. Finally, and perhaps most importantly, pressure on institutions to reduce cost has increased exponentially. One arena under intense scrutiny is operative cost, which is dependent on variables such as time and material utilization. Residents have been shown to increase operative cost. In 1999, the mean operative time with a resident was 103 min, in contrast with 61 min for the same operation if the attending surgeon was alone. This time difference translates into nearly $50,000 lost per graduating resident [1]. Cost pressures will increasingly impact the freedom of mentors to provide detail-oriented operative training.

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Simulation Surgical mentoring in the future will increasingly occur during simulation sessions. According to David Gaba, M.D., the Stanford University anesthesiologist who was the first to utilize computerized mannequins for anesthesia education in the 1980s, “Simulation is a technique, not a technology, to replace or amplify real patient experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion” [2, 3]. Simulation has been used for many years by the aviation industry for training and assessment. Similar to surgery, aviation is complex and challenging. Failure is unacceptable because it produces disastrous consequences. Both industries require superior safety and reliability. Simulation has been shown to help both industries achieve these goals. Surgical simulation takes place primarily in a laboratory setting and is used by both residents and expert surgeons as a supplementary educational tool. Surgical simulation uses animals, cadavers, bench models, mannequins, virtual reality, and team practice scenarios. As of 2008, the Residency Review Committee (RRC) for Surgery, a division of the Accreditation Council for Graduate Medical Education (ACGME), has mandated that all surgical residency programs have a skills lab for accreditation. Furthermore, the American College of Surgeons now accredits well-developed simulation programs as Comprehensive Education Institutes. The military also has an advanced simulation center called the National Capital Area Medical Simulation Center. The ACGME mandate for surgical skills labs is supported by vast amounts of data on surgical simulation. In a 2007 survey of 26 program directors with skills labs, all considered the labs a valuable element of surgical education [4]. After reviewing nine randomized controlled trials, Sutherland and colleagues concluded that computerized surgical simulation training is superior to no training [5]. In addition, skills acquired during simulation sessions transfer to the operating room. Sturm and co-authors arrived at this conclusion after reviewing 11 trials, 10 of which were randomized and controlled [6]. At Duke University, faculty ratings of resident performance in the operating room were significantly better after the residents had participated in a 7 week laparoscopic skills session [7]. These studies show that skills labs are a valuable tool for surgical education and should be held in high regard. The development of fundamental skills outside the operating room allows mentors and mentees to focus on more complex

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tasks during a live case, enabling the pair to make the best use of their time together. It is important to realize, however, that much of the data on surgical simulation is flawed. Studies are often characterized by small sample sizes. Confounding factors such as time on a simulator or presence of the mentor during simulation sessions are prevalent, limiting comparison within and among studies. In addition, the outcome variables of many studies have unproven validity and reliability. Nonetheless, it is clear there are numerous advantages to surgical simulation. Most importantly, greater patient safety is achieved when trainees have the opportunity to first develop fundamental skills prior to patient contact. Simulator training of central venous catheter insertion reduces the rate of catheter-related bloodstream infections [8]. In addition, simulation provides trainees with an opportunity to learn how to approach uncommon situations and address errors before they occur in the operating room. Unlike the patient-centered settings of the hospital and operating room, simulation labs are learner-centered. Activity is driven by the educational needs of the trainee rather than the clinical availability and needs of the patient. The mentor is able to devote his complete attention to the mentee, an opportunity rarely encountered in the “real world”. In addition, the mentor–mentee interaction is not unduly influenced by time constraints; learning can consequently occur at an individualized pace. In the simulation lab, a surgical mentee performs a skill repeatedly and receives immediate feedback from the mentor. This allows for “deliberate practice,” a concept elucidated by Ericcson and considered critical to the development of expertise [9]. Deliberate practice also results in shorter times to learner proficiency. Obviously, the operating room is not the ideal setting for deliberate practice. In the past, a surgical trainee depended on the presentation of multiple patients with acute cholecystitis in order to practice dissecting the gallbladder off the liver bed. With a skills lab, this dissection can be practiced multiple times within 1 h under the watchful and guiding eye of the mentor. Simulation exposes trainees to multiple scenarios over a short time, enhancing educational efficiency. Rare emergencies that must be dealt with rapidly can be repeated. For example, a mentee may spend several weeks rotating through an intensive care unit before being exposed to a life-threatening arrhythmia. In contrast, mannequins

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can be programmed to develop several arrhythmias within one simulation session, providing an opportunity for the mentee to practice code algorithms in a condensed and efficient manner. Furthermore, mistakes are permitted (and even desired) during simulation so that mentees may explore their limits and learn lessons only gleaned from failure. Sessions can be paused in the middle for discussion, a situation not possible in the operating room but ­particularly helpful during learning. Such “teaching moments” are wonderful opportunities for mentors to divulge the secrets of the trade. Simulation sessions, compared to the operating room, are also less burdened by distractions. Similarly, unlike in the clinical world, mentees may take a break from simulation when they are fatigued and learning has reached the point of diminishing return. Simulation also allows for standardization of training. In the current system, it is quite possible that one resident will have performed 50 laparoscopic cases by the time he/she has finished the second clinical year whereas another resident may have performed only 20. Hence, simulation sessions provide an opportunity to level the playing field between residents. Mentors must be able to reliably depend on the trainees having fundamental skills before they participate in live cases. In other words, trainees should acquire a consistent progression of skill level. This prevents mentors from having to review basic tasks with an upper year resident during complex cases and enables mentees to derive the greatest educational benefit when in the operating room. Interestingly, simulation labs may be used to stimulate medical students about surgery. Unlike in the operating room, medical students can be fully engaged in a procedure, performing tasks usually only delegated to residents and attendings. In a 2009 study, medical student participation in a vascular surgery course utilizing a high-fidelity endovascular simulator resulted in a significant increase in the percentage of students considering vascular surgery as a career. Before the course, 8.5% of students expressed high interest in vascular surgery. Astoundingly, after the course, 70% seriously considered a career in vascular surgery ( p = 0.001) [10]. Finally, training in a surgical simulation lab is more cost-effective than training in an operating room. After learning fundamental skills in the lab, mentees can then spend valuable operating room time and materials learning advanced skills, strategy, and problem solving from mentors.

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Of note, simulation labs provide exceptional teaching opportunities for attending surgeons devoted to resident education. Importantly, only those surgeons with an interest in mentoring and teaching should be invited to lead these sessions. The simulation lab is also an opportunity for mentors to hone their teaching skills. For instance, with the advantage of multiple teaching sessions, a mentor will have determined the best way to explain a surgeon’s knot to a junior mentee. David Leach, M.D., past executive director of the ACGME, summarized the advantages of simulation as follows: “Simulation enhances both safety and predictability; and it will be part of the new system of graduate medical education. Every patient deserves a competent physician every time. Every resident deserves competent teachers and an excellent learning environment. Simulation serves both of these core principles” [11]. This directive, in addition to the recent RRC mandate for surgical skills labs, clarifies that surgical mentoring will increasingly occur during simulation sessions. The start-up cost for a skills laboratory is one of the main disadvantages of surgical simulation. A department must invest in space, equipment, and staff. In 2007, the average start-up cost for a laparoscopic skills laboratory was $450,000, with a range from $5,000 to $3,000,000 [4]. Surgical departments, in addition to applying for grants and corporate donations, have approached this large expense by obtaining contributions from other departments within the hospital system. Some experts argue that surgical simulation borrows already limited time from important patient care responsibilities. Although this is true, it is important to remember that simulation is ultimately in the patient’s best interest in that it reinforces the importance of patient safety. It does not matter if the trainee is at the bedside an extra hour if he/she is not able to safely and efficiently perform the tasks required. Others believe simulation will never be as good an educational tool as when a mentor and mentee work together with live patients. Yet simulation is meant to complement, not replace, this interaction. It is an introductory and supplementary tool to make the live clinical experience more safe and meaningful. Simulation is most effective when it is integrated into a diverse educational program which also includes lecture and live operative experiences. It should be organized into progressively more difficult sessions based on a trainee’s level and previously demonstrated competence in the simulation lab. Notably, simulation should take place more commonly during the junior years of residency. Studies show

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that junior level trainees derive more benefit and more thoroughly enjoy simulation than their senior counterparts [12, 13]. The use of lower fidelity (and generally less expensive) models for junior level training will help contain costs without sacrificing benefit. In one study, first-year residents performed equally well after training on low-fidelity bench models as on cadavers [14]. The optimal instructor to student ratio for teaching basic skills in the lab is 1:4 [15]. After learning a skill in the simulation lab, the trainee should return multiple times for practice. This is a key point. Practicing with skills lab equipment for a couple of hours every few months is unlikely to result in significant technical improvement. Mentees must be committed to enhancing their skills via the simulation laboratory. Moreover, motor skills are best acquired through multiple brief practice sessions as opposed to one long practice session [16]. The mentor should be present during a few sessions to provide immediate feedback, prevent bad habits, and offer strategic advice. Constructive feedback from a live expert is superior to that from computers during surgical skills training [17]. However, the presence of live experts may be less important during the acquisition of basic technical skills [18]. As a practical example, mid-level residents might mentor knot-tying sessions for medical students whereas attending surgeons or fellows would mentor vascular anastomosis training for residents (Fig. 9.1). Trainees, attending surgeons, and the administration must regard simulation as a valuable activity. Demonstration of skill proficiency in the simulation lab by the trainee should be required for advancement in the simulation curriculum, graduation through the training program, and active participation in the operating room. Furthermore, proctoring simulation sessions should count toward promotion for mentors. The simulation lab presents an opportunity for the mentor and mentee to develop a relationship; however, most sessions are unlikely to be one-on-one. The majority will occur within groups, and so the mentee must be comfortable with interactive learning. In addition, the mentee will likely have a variety of mentors for different skills. For example, an experienced laparoscopic surgeon might lead laparoscopy simulation sessions and be the laparoscopy mentor to many trainees. Senior residents, fellows, first assistants, and retired surgeons may also become mentors via the simulation lab, reducing the burden on

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Fig.  9.1  An attending vascular surgeon mentors a third year resident on the technical points of a vascular anastomosis

busy attending surgeons. Involvement of senior residents and fellows will enable them to hone their mentoring skills and may also spark a desire to pursue academia. Usually, first assistants have remarkable operative-specific skills and generally have fewer demands on their work schedules. These factors make them excellent mentor candidates. Additionally, their involvement in simulation sessions allows them to feel more included in the surgical department “family.” Lastly, retired surgeons have a career’s wealth of information to share and often desire to remain active in surgery. Mentoring simulation sessions provide a means for these individuals to influence the outcomes for patients for years to come. Animals, cadavers, bench models, mannequins, virtual reality, and team practice scenarios are the main modalities of surgical simulation (Table 9.2). Animals and cadavers have been used for many years and offer the trainee an opportunity to work with real tissue. Mentors often recall training on such models. Surgical skills are taught directly by the mentor through explanation and demonstration. Nonetheless, drawbacks exist and include the limited availability and high cost of animals and cadavers. Trainees are not able to practice

Simulation Table 9.2  Main modalities of surgical simulation

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• • • • • •

Animals Cadavers Bench models Mannequins Virtual reality Team practice scenarios

independently on their own time since mentors must be present during the sessions to guide the dissection or procedure. Also, support personnel are required for maintenance and preparation of the animals and cadavers. In addition, the tissue may be difficult to work with and the anatomical structures and relationships may be different from the human. Biohazard exposure also remains an issue. Finally, the use of animals for medical/scientific purposes often incites loud public disapproval. Bench models and mannequins range from simple (i.e. knottying board) to advanced (i.e. SimManTM). Bench models are ­task-specific. Examples include the Abdominal Opening and Closure TrainerTM (Limbs and Things) and the standard laparoscopic ­box-trainer. Bench models have proven to be effective learning tools. In 2005, Jensen and colleagues demonstrated that the use of a porcine organ-containing laparoscopic box-trainer to develop fundoplication skills increased resident comfort during live laparoscopic fundoplication cases [19]. Mentees can use the bench ­models to practice specific skills independently as well as under the guidance of a mentor. The attention of both the mentor and mentee can be devoted to a few specific maneuvers, rather than an entire operation, enabling deliberate practice. Of note, a box trainer is employed in the Fundamentals of Laparoscopic Surgery course now required in order to take the American Board of Surgery qualifying written exam. Proficiency in the five skills ­presented in this course, namely peg transfer, precision cutting, placement and securing of a ligating loop, as well as intracorporeal and extracorporeal knot tying improved laparoscopic performance in the operating room in a randomized controlled trial [20]. Mannequins may be used for trainees at different levels to learn physiology, pharmacology, and procedures such as endotracheal intubation, central venous catheterization, and tube thoracostomy. Mannequins are instructor or model-driven. SimManTM (Laerdal) is an example of an instructor-driven mannequin. Its responses are

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dictated externally by an instructor. In contrast, model-driven mannequins such as the Human Patient SimulatorTM (Medical Education Technologies, Inc.) respond according to the directive of an internal computer. Model-driven mannequins are more realistic and require fewer teaching resources. Not surprisingly, they are also more expensive. The cost of SimManTM is approximately $40,000 whereas the cost of the Human Patient SimulatorTM is about $200,000. Valuable mentoring can occur during simulation sessions that make use of the mannequins. For example, a mannequin can be programmed to demonstrate signs of sepsis. After observing the mentee respond to these signs by voicing intended procedures and medications, the mentor can offer critical feedback. In addition, the mentee may have the opportunity to work with others during the session as well as observe other trainees.

Virtual Reality Satava proposed the use of virtual reality for surgical simulation in the early 1990s [21]. Virtual reality employs haptic technology to recreate tactile sensations, thereby enabling the user to manipulate objects in a three-dimensional environment. Most virtual reality simulators replicate laparoscopy and endoscopy; open surgery has proven more difficult to simulate. Today, virtual reality simulators exist for laparoscopy, colonoscopy, bronchoscopy, arthroscopy, pericardiocentesis, and vascular anastomosis. Most virtual reality platforms simulate more than one procedure and the most advanced can be programmed to present patient-specific conditions. The latter option enables both mentors and mentees to review the specifics of a case prior to the live operation. This review may include the planned steps of the operation, discussion of aberrant anatomy, and options for approaching technical challenges. Many virtual reality simulators have a module-based curriculum with a didactic component. These versions can track the performance of each user over time. Mentors can thus monitor the progress of the mentee, ensuring that he/she possesses the skills appropriate for level of training and required to participate in particular operations. Following an introductory session, mentees can use the virtual reality simulators without supervision, reducing time demands on mentors.

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Number of Errors per Procedure

Virtual reality’s great utility for surgical mentoring arises out of its likeness to the real surgical scenario. It is the closest approximation of a real operation that a mentee can experience. Mentoring takes place in an extraordinarily realistic dimension without the added stress of harming patients. Nevertheless, debate exists as to whether the benefits of virtual reality justify its significantly higher cost. Taken as a whole, the data suggest virtual reality training is effective for surgical skills training and should be used as a tool for mentoring. In a prospective, randomized, and blinded trial from 2002, 16 surgical ­residents were randomized to one of two groups for laparoscopic cholecystectomy training. The first group received virtual reality training in addition to standard training; the second group received standard training only. The results of the study supported the authors’ hypothesis. That is, virtual reality training transfers surgical skills to the operating room. The virtual reality group committed significantly fewer errors than the standard group when observed during live laparoscopic cholecystectomy. Specifically, the mean number of errors in the virtual reality group was 1.19 whereas that in the standard group was 7.38 (p < 0.006) [22] (Fig.  9.2). Although the sample size was small, this study is notable because it was the first to investigate the transfer of virtual reality skill to the operating room in a prospective, randomized, and blinded fashion. The study made use of objective technical criteria to prove its hypothesis and its results were subsequently duplicated. For instance, Aggarwal and colleagues demonstrated that competency-based virtual reality 10 9 8

Standard Training

7 6 5 4 3 2 1

Virtual Reality Training

0

Fig. 9.2  Virtual reality training results in fewer errors per procedure when compared to standard training (Adapted from [22]. With permission from Wolters Kluwer Health)

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training in conjunction with abbreviated standard training enhances operative performance [23]. The data are conflicting regarding the utility of virtual reality training when not used in conjunction with standard training [24, 25]. In a meta-analysis of six studies, virtual reality training reduced task completion time and error rate in the operating room. With respect to task completion time, the effect size was −1.117 (95% CI −1.465, −0.769), indicating a significantly shorter time for those with virtual reality training. Similarly, the effect size for error rate was −1.325 (95% CI −2.125, −0.525), indicating a significantly lesser error rate for those with virtual reality training [26]. As with other forms of simulation, virtual reality training is more useful during the early stages of learning a procedure. In one study, four gastroenterology fellows were trained using virtual reality. During their first 15 live colonoscopies, these fellows outperformed another four who did not receive virtual training. However, no difference in skill level was observed after 30 colonoscopies [27].

Telementoring Telementoring is another important future direction of surgical mentoring. It is defined by the use of sophisticated communications technology to connect two or more people separated by a distance for mentoring purposes. Telementoring has great applicability to surgery. Using this technology, an expert surgeon in one location can mentor a novice at another site. Excessive time away from clinical practice and costs of travel are generally not required. Telementoring is particularly useful for training surgeons in remote locations. Additionally, it can be used to continue a mentoring relationship long after the mentor and mentee have gone elsewhere. As described by Challacombe and co-authors, there are three components of surgical telementoring: teleproctoring, telestration, and teleassistance. Teleproctoring refers to the supervision of the mentee by a mentor from a distance. Telestration involves interaction of the mentor drawing on remote operating room monitors to guide the mentee’s actions. Lastly, teleassistance enables mentors to participate in remote operations via camera navigation or robotic instruments [28]. In 1965, DeBakey became the first surgeon to report the use of telementoring. Dr. DeBakey used broadband satellite technology to

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guide European surgeons during open heart surgery [29]. Today, t­elementoring is similarly being used to connect expert surgeons, mostly in urban areas, to surgeons in remote areas. In this era of rapid technological development, telementoring is particularly well-suited to the training of surgeons unable to leave their practices for prolonged training periods, but who still want to offer their patients the most advanced procedures. In addition to operative guidance, telementoring can be utilized for pre- and post-operative patient care. Several studies suggest telementoring is as effective as on-site mentoring, therefore providing rationale to convince governing bodies and funding agencies of the safety and utility of telementoring. In one study, student surgeons were randomized to one of two mentoring groups after receiving general laparoscopy and then Nissen fundoplication training. In the first group, a student surgeon performed a Nissen fundoplication with the mentor in the operating room. In the second group, a telementor was located 5 mi away and connected to the student surgeon using communications equipment. No significant differences were found between the two groups with respect to operating time, blood loss, or duration of hospital stay [30]. In a more recent study, 20 medical students were randomly assigned to either local or telementored groups. Using a virtual reality surgical simulator, grasping, cutting, clip-applying, and suturing skills were evaluated before and after the mentoring process. Both groups showed a similar degree of skill improvement after the mentoring sessions, suggesting that telementoring is as effective as local mentoring [31]. Surgeries performed with telementoring or teleassistance have acceptable outcomes, as demonstrated in prospective evaluation of 18 telementored or teleassisted laparoscopic colon cases [32]. In this study, four community surgeons lacking advanced laparoscopy training were telementored or teleassisted by an expert surgeon. The outcomes of the 18 surgeries performed were as follows: no major intraoperative complications, two minor intraoperative complications (serosal tears), two postoperative complications requiring reoperation (bleeding and small bowel obstruction), and two conversions to open due to the mentee’s inability to locate the appropriate plane of dissection. Although the sample size is small and the external validity is inherently limited, this study is important because it demonstrates that telementoring can be used to facilitate the adoption of new, more advanced operations. Specific techniques can be learned over a distance and do not necessarily require an on-site fellowship [32].

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The use of telementoring to provide minimally invasive surgery to rural patients by several Canadian groups offers a general example of how telementoring is put into action. Firstly, mentees participate in a course designed to hone laparoscopic skills. Secondly, the mentor and mentee work together on a number of live cases. Once the mentor is satisfied with the mentee’s skill level, the mentee is permitted to do the remainder of his training via telementoring [33, 34]. Several issues must be resolved before telementoring can be widely adopted. It is unclear to what degree the mentor is liable for iatrogenic errors occurring during telementored surgery. Furthermore, there are insufficient regulations regarding whether a mentor must be licensed in the state in which the telementored surgery is taking place. The level and payer of the mentor’s financial compensation must still be determined and firm guidelines on patient confidentiality established. Mentor–mentee relationships may arise via telementoring without regard to distance. However, this lack of proximity will likely inhibit the initial development of the relationship. A meaningful mentoring rapport may only be established if communication is frequent and ties are maintained over a significant duration.

Personal Computers The widespread use of personal computers for surgical education also influences surgical mentoring. In essence, personal computers provide a 24-7 virtual surgical university. Mentors and mentees are able to communicate with each other in real-time via online messaging, email, chat groups, and videoconferences. No longer must they meet in person to maintain a relationship. Textbooks, lectures, and videos of operations are also available on personal computers. Today, a trainee can watch an operation multiple times before ever entering the operating room. Online quizzes enhance a trainee’s study program and allow the mentor to track the mentee’s progress. Moreover, threedimensional anatomy images provide for spectacular study of spatial relationships. A trainee can rotate and look underneath the pancreas merely through several clicks of a mouse, hence viewing the important relationships of the gastroduodenal artery to the pancreatic head before a Whipple operation. Lastly, video games are beginning to be

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used for surgical training. For instance, “Pulse!!,” a video game developed by Texas A&M University in conjunction with BreakAway Ltd., employs advanced gaming technology to engage the user in medical scenario simulation.

Mosaic Mentoring As the surgical trainee’s educational requirements become more diverse and time constraints of attending surgeons (mentors) become more severe, it will no longer be feasible for one surgeon to satisfy the broad learning needs of the trainee. In the future, surgical mentoring will need to incorporate “mosaic mentoring” which utilizes multiple mentors with different types of expertise, either concurrently or sequentially, to fulfill the varied and changing needs of the mentee [35, 36]. To optimize mosaic mentoring, a personal mentor/advisor – the “captain of the ship” – helps to identify and coordinate the mentee’s relationships with clinical, research, and administrative mentors (Fig. 9.3). The mentor/advisor also guides the mentee as to personality conflicts and work-life balance. The personal mentor/advisor should be chosen by the mentee based on respect and compatibility (see Chap. 8, section General Principles for Selecting a Mentor).

Personal Advisor MENTOR

Surgical Resident Mentor

Administrative/ Business Mentor

Clinical Specialist Mentor

Surgical Resident MENTEE

Fig. 9.3  Mosaic mentoring

Research Mentor

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The different types of mentors vary with the interests and aptitudes of the mentee. For example, a clinical or basic researcher may serve as the laboratory mentor while a clinical specialist such as a laparoscopic surgeon will mentor this technique accordingly. A surgical department or business administrator might advise as to systemsbased practice and healthcare economics while a hospital attorney will help the mentee appreciate medico-legal issues. Finally, a senior resident might mentor the surgical intern or junior resident as to how to successfully navigate the nuances of the residency.

Objective Assessment of Technical Skill Surgical training in the future will involve more objective assessment of technical skill. Currently, expert surgeons evaluate the technical skill of a trainee; however, evaluations are subjective, prone to bias (especially if the expert is also the mentor) and have poor inter-rater reliability [37]. Additionally, technical competence is assumed after the completion of a predefined number of cases. Obviously, this assumption is not always true. Some trainees possess inordinate innate ability and may be competent after fewer than the arbitrary number of cases required by the ACGME or other professional organizations. Conversely, others may require more training. It is ­self-evident that good surgical outcomes correlate better with demonstrated ­competence versus completion of a specific number of cases. In short, it is clear that technical skill assessment is currently neither standardized nor systematic. Interest emerged in the objective assessment of technical skill with the advent of laparoscopy. Examples of objective variables of technical skill include efficiency of movement and time required for task completion. Implementation of objective assessment of technical skill should promote a shift toward competency-based training, potentially enabling naturally talented surgeons to complete training in a shorter time. Furthermore, objective assessment of technical skill will enable the mentor and mentee to interact in a manner less influenced by grading issues. One assessment instrument currently in use is the Objective Structured Assessment of Technical Skill (OSATS) developed at the University of Toronto by Richard Reznick, M.D., and colleagues.

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This process uses animal and bench models at six stations. The skill of a trainee is evaluated as to specific criteria, such as respect for tissue, flow of operation, and instrument handling [38]. The Operative Performance Rating System (OPRS) and OpRate are two internet-based assessment instruments that evaluate a trainee’s performance on real cases. They use procedure-specific evaluations focusing on preparedness, technical skills, and operative decision making. These instruments have been shown to be feasible, reliable, and valid [39, 40]. The Blue Dragon is another instrument to assess technical skill. Developed at the University of Washington, the Blue Dragon is a robot with arms attached to standard instruments. Sensors measure such variables as force and angle when applied by the surgeon [41]. ROVIMAS is unique motion-tracking software used during live operations to measure laparoscopic skill [42]. Virtual reality simulators with the capacity for technical skill assessment are in development but do not yet have sufficient validity and reliability. In addition to assessment of technical skill, surgical trainee evaluations in the future will include a more global assessment of competence by a variety of health care professionals. For instance, nurses, pharmacists, and other staff will evaluate the leadership and communication skills of the trainee. Students will evaluate the trainer’s dedication to teaching. These “360 degree” evaluations recognize the importance of the myriad of skills beyond technical aptitude required to be a successful surgeon.

Summary and Conclusions The exciting future directions of surgical mentoring discussed in this chapter will undoubtedly change the classic mentor-mentee relationship. Mentees of the future will be more comfortable with technology and group learning. Technological advances such as virtual reality simulation and telementoring will supplement the educational process and help overcome issues related to patient safety and time limitation. As technology develops, it will become more realistic and affordable. Moreover, the mentee will have multiple mentors from different fields and will spend limited time with each specialist. In order to effectively integrate mentoring into a busy surgical training program,

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9 Future Directions

the mentor and mentee should set aside time for regular meetings. During specialized periods of the training program, a mentee will spend substantially more time with a particular mentor. Despite the aforementioned changes, there are defining characteristics of the classic mentor–mentee relationship that should be preserved. To be a true mentor, the surgeon must be an experienced and trusted advisor. Technology will never be able to assume this role. Furthermore, the mentee will always have to develop clinical judgment and professionalism in addition to technical skill and didactic knowledge. A strong relationship with a mentor will best serve the mentee’s development in these areas. In summary, many forces are influencing change in the traditional surgical mentoring model. These forces primarily involve close attention to patient safety as well as time and cost limitations. New methods such as introductory and advanced simulation, telementoring, and mosaic mentoring are being developed to address these issues and will define the future directions of surgical mentoring.

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Appendix: Websites of Interest (Organized by Chapter)

1. What is mentoring and who is a mentor?   I. http://managementhelp.org/guiding/mentrng/mentrng.htm • An informative site from the Free Management Library with multiple well-written articles describing the subject of mentoring. 2. Why mentoring is important and evidence it makes a difference   I. http://www.business.brookes.ac.uk/research/areas/ coachingandmentoring/ • The homepage of the International Journal of Evidencebased Coaching and Mentoring, a biannual publication with research-based articles on mentoring. 3. What are the qualities of an outstanding surgical mentor?   I. http://www.inparaeducators.org/mentoring/mentoring.html • A self-learning module from the field of education on mentoring, with a focus on qualities of good mentors. 4. How and where should surgical mentoring be performed?   I. http://www.socraticmethod.net/ • A comprehensive description of the Socratic method. 5. Mentoring women surgeons   I. http://www.womensurgeons.org/ • The homepage of the Association of Women’s Surgeons, with many resources for the female surgeon.  II. http://bms.brown.edu/wim/momdocfamily.html • A site offering mentorship and support for multidisciplinary women physicians facing the challenges and rewards of combining a medical career with motherhood. III. http://www.mentornet.net/ • E-mentoring network particularly but not exclusively for women in the sciences, mathematics and engineering. Relevant generic information on mentoring. 165

166

Appendix: Websites of Interest (Organized by Chapter)

6. Mentoring International Medical Graduates   I. http://www.ama-assn.org/ama/pub/about-ama/our-people/ member-groups-sections/international-medical-graduates. shtml • The homepage of the International Medical Graduate division of the American Medical Association, with guidelines and resources for the international graduate. 7. How to develop faculty mentors   I. http://www.faculty.harvard.edu/development-and-mentoring • A Harvard University website dedicated to faculty development and mentoring. 8. How to choose a mentor   I. http://www.hrsonline.org/CareerCenter/CareerPracticeMgmt/ CareerManagement/choosing_mentor.cfm • A webcast with advice on selecting a mentor, featuring Ralph Lazzaro, M.D. 9. Future directions   I. www.sp.tamucc.edu/pulse • A website about “Pulse!!,” an advanced video game that simulates health care scenarios.  II. www.ssih.org • The homepage of the Society for Simulation in Healthcare. III. www.simcen.org • The Uniformed Services University’s medical simulation website, detailing its publications, workshops, people, projects and hardware. IV. www.immersion.com/medical • The website of Immersion, a company active in medical simulation. V. www.harvardmedsim.org • The website of Harvard’s Medical Simulation Center.

Index

A Aggarwal, R., 155 Agle, S.C., 96 American College of Surgeons (ACS), 31, 33, 34, 73, 74, 76, 81–83, 87, 89, 91, 108, 110, 121, 138, 147 Andrew, R., 99, 105 Anthony, A., 147 Anzai, Y., 134 Apprenticeship, 7, 8, 145 Association of Women Surgeons, 73, 81–83, 86, 89 Availability, 38, 42, 55, 74, 75, 100, 116, 137, 138, 148, 152 B Balasundaram, I., 155 Barker, C.F., 17 Barondess, J.A., 3–5 Bates, J., 99, 105 Berg, J., 126 Berk, R.A., 126 Berman, L., 22 Bills, J.L., 78 Blair, J.E., 80 Bland, C.J., 42 Blixen, C.E., 125 Buchwald, H., 33 Bui, V., 83 Burd, R.S., 68 Business mentoring, 52 Buyske, J., 80

C Cerio, D.R., 98, 100 Challacombe, B., 156 Character, 29–35, 43 Childcare, 12, 73, 75, 77–79, 84 Christein, J.D., 95 Ciardi, J., 38 Coats, R.D., 68 Cochran, A., 42 Colletti, L.M., 62 Coluccio, G., 94, 98, 99, 105 Cook, J.K., 95 Copeland, E.M., III, 31 Cosman, P.H., 147 Crane, L.A., 128 Cregan, P, 147 Crichlow, R.W., 17 Cultural differences, 98, 99 Curiosity, 25, 26, 37–38 Curreri, P.W., 17 Curry, L.A., 22 Curtis, P., 21 D Daloz, L.A., 25 Darrow, C.N., 136 DeAnda, A., 147 DeBakey, M.E., 106 Dennis, K., 128 Desbiens, N.A., 97 Discrimination, 75–77, 97–98, 101 Divino, C.M., 57 167

168 Dobbie, A., 63 Dudrick, S.J., 17 Dunnington, G.L., 37, 54, 116 Durley, J.R., 58 E Eby, L.T., 58 Effort report, 120, 121 Elzubier, M.A., 41 Enger, T.M., 95 English proficiency, 98, 101 Ericcson, K.A., 148 Evans, S.C., 58 F Faculty discontent, 113, 114, 128–130 Failed mentoring, 58–60 Family responsibilities, 73–75, 77–78, 84 Fedorka, P., 24 Fernandez, G., 128 Files, J.A., 80 Financial remuneration, 114–116, 120–121 Finnegan, J.O., 17 Foreign medical graduates, 12, 93–110 Foy, H., 94, 98, 99, 105 Frankel, R.M., 128 G Gaba, D.M., 147 Gaughan, J., 153 Gender-based discrimination, 75–77 Gender equity, 84 Goodnight, J.E., Jr., 85 H Hernandez, J.M., 57 Hess, R., 134, 142 Hewett, P.J., 147 History of mentoring, 6–7 Holt, R., 29, 31 Homer, 6 Horvath, K., 94, 98, 99, 105

Index Hull, A.L., 125 Humanism, 4, 29, 35–37, 89 I IMG. See International medical graduates Incentives, 36, 74, 113, 115, 116, 120–121, 129, 130 Integrity, 6, 24, 29–35, 43 Intentional mentoring, 48 International medical graduates (IMG), 93–110 leaders in U.S. surgery, 95, 107–110 mentors, 104 J Jackson, V.A., 128, 133 Jensen, A.R., 21, 153 Johns, D.F., 47 K Karamanoukian, R., 23 Kavoussi, L., 156 Klein, E.B., 136 Knight, S.M., 128 Knowledge proficiency, 30, 33, 38–40 Ko, C.Y., 23, 24 Koop, C.E., 17 Kreckler, S., 20, 21 L Lack of female mentors, 74 Langlotz, C.P., 134 Language barrier, 35 Lanphear, B.P., 21 Leach, D.C., 150 Lee, J.N., 134 Leon, L.R., 93 Levinson, D.J., 136 Levinson, M.H., 136 Levy, A.E., 21 Lewis, B.J., 22, 57 Lind, D.S., 83

Index Loghmanee, C.F., 98, 100 Love, K.M., 96 Lowenstein, S.R., 128 M Maddern, G.J., 147 Maintaining mentoring, 13, 140, 141 Marušić, A., 18, 19 Maternity leave, 75, 78–79, 84 Mayer, A.P., 80 McCord, J.H., 24 McDermott, W., 3 McDonald, R., 24 McKee, B., 136 Meetings with mentors, 104, 133, 137–139, 143, 144, 162 Men mentoring women, 73 Mentee, 1–5, 7, 8, 12–21, 23, 26, 27, 31, 32, 35, 36, 38–41, 45–50, 52–54, 56, 58–61, 63–65, 68–71, 73–75, 81–86, 104, 105, 117, 122, 126, 127, 129, 133–145, 148–156, 158–162 definition, 5 responsibilities, 134–141 Mentoring, 1–27, 29, 30, 38, 39, 41–43, 45–71, 73–91, 93–110, 113–130, 133–147, 150, 152, 154–162 culture, 101, 117–118, 130, 143 devalued, 116–117 by example, 23, 36, 46–47, 65 moments, 48–49 in operating room, 13, 22, 31, 45–48, 51, 65–67, 156–158 rationale, 15 in research laboratory, 68–69, 94, 100, 126 by surgical residents, 24, 56–58, 130 techniques, 46 Mentors, 1–19, 21–27, 29–43, 45–70, 73–76, 79–85, 91, 93, 95, 96, 101, 104–107, 110, 113–130, 133–148, 150–154, 156–162 Mentor selection, 139–141 Middleton, P.F., 147 Miller, L.D., 17 Miller, R.S., 94

169 Mills, J.I., 93 Milner, R., 153 Monteiro, F.M., 127 Mortimer, R., 126 Mosaic mentoring, 119, 145, 159–160, 162 Mouhlas, A., 40 Multiple mentors, 1, 12, 13, 73, 84, 91, 133, 134, 143 Murphy, M.A., 20, 21 Musunuru, S., 57 Mutha, S., 58 N Nance, F.C., 17 Neequaye, S., 20, 21 Negative mentoring, 45, 46, 58, 64 Negative stereotype, 97–98 Networking, 73, 77, 85–86, 91, 105 Nguyen, S.Q., 57 Nora, A., 127 O Objective assessment of technical skill, 145, 160–161 Obstacles to mentoring, 113, 130 O’Herrin, J.K., 22 Oh, R.C., 47 Ojeda, H., 93 Omary, M.B., 119 P Palepu, A., 128, 133 Palis, B.E., 85 Papadakis, M., 35 Papp, K.K., 125 Parsons, T., 33 Patriciu, A., 156 Paukert, J.L., 42 Pellegrini, C., 94, 98, 99, 105 Pellegrino, E.D., 33 Personal computers, 145, 158–159 Phillips, S.E., 78 Pololi, L.H., 128 Pregnancy, 12, 54, 73, 78

170

Index

Professionalism, 29–33, 43, 141, 162 Protected time, 37, 63, 113, 114, 118, 121–122, 124

Surgical simulation, 147–150, 152–154 Sutherland, L.M., 147 Szalacha, L., 128, 133

Q Qualities of mentor, 14

T Takayama, J.I., 58 Teaching skills, 30, 40–41, 57, 120, 123, 150 Technical expertise, 29, 30, 39–40, 43, 69 Telementoring, 13, 145, 156–158, 161, 162 Terminating mentoring, 142 Thankur, A., 24 Thomasma, D.C., 33 Training mentors, 19, 21, 24, 95 Troppmann, K.M., 85 Tysinger, J.W., 63

R Rekkas, S., 83 Relative value units (RVUs), 115, 121 Resident-delegated mentoring, 124 Resident selection, 23–25 Reverse mentoring, 47, 52, 57 Rhoads, J.E., 16–18 Rikkers, L.F., 22, 57 Rizk, D.E.E., 41 Rogers, J., 127 Rosenthal, M.S., 22 RVUs. See Relative value units S Sachdeva, A.K., 104 Sambunjak, D., 18, 19 Satava, R.M., 154 Scales, E.M., 42 Schenarts, P.J., 96 Schur, E., 134 Simpson, D.E., 42 Simulation, 19–21, 32, 40, 67, 103, 145, 147–154, 156, 159, 161, 162 Singletary, S.E., 77 Sippel, R.S., 24 Smythe, W.R., 124 Snyder, R.A., 78 Socratic method, 7, 45–48, 71 Souba, W.W., 3, 5, 32, 104 Steinberg, S.M., 32 Steiner, J.F., 21 Steinert, Y., 104 Stern, D.T., 35 Straus, S.E., 18, 19 Sturm, L.P., 147 Surgeon-scientist mentor, 124–125 Surgeon shortage, 73, 94, 95 Surgical mentoring, 2, 8–9, 11–27, 29, 39, 45–71, 130, 145–147, 150, 155, 156, 158, 159, 161, 162

U Ullian, J.A., 42 US medical school graduates (USMG), 93–97, 101, 104, 105, 110 V Verbal feedback, 45, 60–63, 71, 113, 114, 120, 125–127, 130 Vidaillet, H.J., Jr., 97 Virtual reality, 147, 152, 154–157, 161 W Walsh, A., 104 Ward, J., 155 Whitcomb, M.E., 94 Whang, E.E., 23 Wilmore, D.W., 17 Windsor, J.A., 147 Wolferth, C.C., Jr., 17 Women mentoring women, 74, 80–81 Wright, A.S., 21 Written evaluation, 45, 60, 113, 114, 120, 122, 125–127 Z Zerzan, J.T., 134, 141