**6. Mentorship and gender**

Mentorship is important in guidance regarding setting and managing expectations for daily practice and career trajectory. As such, it is a very effective method for achieving better professional outcomes and retention. This type of intervention is especially needed to address women leaving medicine, a trend that is increasingly costly and dangerous for the medical system and patients. Of concern, nearly 40% of women physicians decide to pursue part-time work or leave medicine altogether within six years of completing residency [53]. Among reasons for this phenomenon are discrimination, salary inequity, and harassment, but the main challenge to women in medicine continues to be the difficulty of balancing work with family demands [54–56]. While systemic changes, such as expanded parental leave

policies, need to be made to ease this tension for female physicians, mentorship is one of many tools that can help. Mentorship provides an avenue for women (and men) to come together and discuss the real challenges that women face in medicine, help younger trainees manage their expectations, and may ultimately yield increased research projects to create useful solutions [57–59].

There are important additional gender-specific considerations. For example, research shows that it may be more challenging for women to find mentors [42]. One proposed reason for this is the lack of availability of mentors with similar backgrounds and/or experiences. For example, there are fewer women mentors available to mentor surgery residents [60]. This is not only due to the relatively fewer women in the field, but also due to the additional unique time pressures in personal life faced by women surgeons [61]. Similar considerations apply to other male-dominated disciplines where there is already a lack of female mentors, and women in those fields often do not have the time to commit to mentorship due to competing priorities and external demands [62, 63]. Women may also feel somewhat uncomfortable reaching out to male mentors due to gender dynamics [64]. It naturally follows that the paucity of female mentors in certain areas is deleterious to diversity in the medical profession, since it has been noted that specialty fellows-in-training consistently indicate that they chose their subspecialty largely due to having had a mentor in the field [42].

As a consequence, without sufficient representation of female mentors in subspecialties, fewer women have the support and the opportunity to enter those fields, which ultimately perpetuates the cycle of exclusion. Institutional support such as dedicated time for mentorship could be a helpful factor in increasing numbers of female mentors. It is also harder for individuals from underrepresented groups to find mentors [65, 66], and despite the best intentions the experiences of microaggressions or outright bias continue to occur [67, 68]. Peer mentorship has been especially helpful in bridging this gap for underrepresented minority trainees, since successive classes of trainees have been increasingly diverse [69, 70]. Due to the uneven opportunity for organic mentorship, formal mentorship programs have also been important to ensure fair and equitable access to mentors. In summary, there continues to be an unmet need for mentors, with large numbers of residents and other medical trainees reporting that they wish they had mentors or that they had difficulty initiating a mentorship [42, 71]. This crisis is negatively affecting the medical profession and requires urgent and durable resolution.

## **7. Organization of mentorship**

#### **7.1 Senior mentorship**

The senior mentorship model is the traditional mentorship model in which the mentor is a well-established faculty member who can provide guidance informed by personal experience and professional connections [72]. Senior mentors are well positioned to serve as sponsors and can provide mentees with more opportunities for professional advancement. A major barrier to the success of this type of relationship is the presence of an institutional hierarchy – and thus power gradient(s) - that insidiously influences all interactions between mentor and mentee [73–75]. The power dynamic results in mentees feeling uncomfortable showing vulnerabilities, speaking honestly, and challenging the mentor when appropriate [75, 76]. It also can lead mentees to overextend themselves in a pursuit to meet their mentors' expectations, which ultimately may degrade the relationship [77]. Finally, there is much less diversity among senior attendings, thus limiting the diversity among available mentors.

#### **7.2 Peer mentorship**

Peer mentorship is a very successful approach that facilitates access to mentorship experience for individuals early on in their careers, thus increasing the likelihood that they will continue to serve as mentors throughout their career [67]. It also eliminates a certain level of formality and hierarchical barriers that exist in traditional mentorship relationships, thus providing a more flexible and relaxed environment. For example, it is not as daunting to reschedule a meeting with a peer as it may be to do the same with a senior leader. In various studies, residents have noted that it is easier to go to a peer resident mentor than to a faculty member [78]. This is potentially due to increased approachability and lessened fear of being criticized or judged.

Peer mentorship has been especially successful for underrepresented minority students who may experience cultural challenges in medicine, especially when there is a lack of representative attendings or faculty mentors [79, 80]. Connecting residents at different levels of training addresses some of the barriers to diversity in mentorship. Beyond technical skills, there are certain 'unspoken rules' that residents must pick up in the hospital and postgraduate environment. Having a peer mentor can help assuage this discomfort and facilitate learning these unspoken rules and expectations, especially related to being a minority in medicine [67]. The peer mentorship model helps both parties gain confidence, connect with colleagues, broaden professional networks, and can be a powerful tool for experience-based knowledge sharing between senior and junior residents [67]. Such peer mentorship programs have been implemented successfully for residents and staff from underrepresented minority groups [67, 81, 82].

The peer mentoring model is also an effective way to build a growing cadre of female mentors – a factor important in addressing some of the gender-based issues associated with male predominance across certain medical disciplines [83, 84]. The increased flexibility of a peer-based mentoring approach makes it more attractive for female residents to mentor each other and can make mentees feel more at ease by eliminating the hierarchy.

#### **7.3 Individual model**

Also known as one-on-one mentorship, this is a more traditional approach in which there is one mentor and one mentee, usually working together in a long-term professional relationship. The primary advantage of this model is the opportunity to invest deeply in a single, more dedicated relationship [85]. However, because time constraint is a concern for many mentors, it is important to note that weekly and monthly meetings were both shown to have equal success rates, which may make it easier for individual mentors to commit to more mentees [86]. A significant drawback of this method is the lack of diversity offered from a single mentor.

### **7.4 Group model**

Group, 'team-based,' or 'multiple-mentor' model is an approach where a mentee has several mentors, each facilitating growth in different, often complementary areas [87, 88]. This method allows for more diversity in both content and perspectives; however, it is possible that mentors and mentees are more likely to develop a more superficial bond through this practice. This model also puts a higher burden on mentees as they must coordinate logistics and time-manage multiple mentors, all while requiring less time from individual mentors. Furthermore, as discussed pre previous sections, it can be difficult to find one mentor, let alone multiple,


*Senior mentors provide more experience and connections but have limited availability and less candid conversations. Peer mentors provide less formality and more candid discussion but offer fewer career progress opportunities. One-toone mentorships provide the opportunity to develop deep relationships but can be more time consuming for mentors and provide less diverse perspectives to the mentee. Multiple mentorship reduces the strain on mentors, and offers more diverse perspectives, but increases the logistical work for mentees. All combinations of mentorships organization outlined in the table can be adapted to a virtual environment which can potentially lead to larger and more global mentorship programs.*

#### **Table 1.**

*Mentorships include either a peer or senior mentor and either a one-to-one or multiple mentorship structure.*

so supply of mentors remains a major limiting factor. A version of multiple mentoring is a 'team-based' approach in which the various mentors communicate among themselves in order to facilitate more efficient mentoring of an individual mentee [78]. A summary of commonly employed mentorship models is provided in **Table 1**.

#### **8. Approaches and techniques for mentorship**

#### **8.1 Micromentorship**

Micromentorship is a model proposed by Waljee, et al., in which the mentorship relationship changes based on goals, and focuses on frequent, brief, informal communication and feedback, targeting improvement in very specific areas [89]. This is better suited to younger generations who have grown up in the technology era, as it has been shown that they are more purpose-driven, show preference toward collaboration and horizontal/flat social structures, are more focused on end product

#### *Mentorship in Postgraduate Medical Education DOI: http://dx.doi.org/10.5772/intechopen.98612*

deliverables, and above all are accustomed to instant access to information [89]. It also provides benefits to the mentor – primarily because time constraint is a major concern – by decreasing the amount of time set aside for mentorship meetings. Under this paradigm, a simple intervention such as a quick text message, email, or phone call may be sufficient to meet a particular mentee's needs and expectations. The micromentorship model can be adapted and scaled to include the increasingly virtual social interaction landscape, with informal meetings, which typically involve less planning, and the ability to more readily connect people across the globe.

Micromentorship is highly compatible with the group mentorship model in which a mentee has many mentors, all focused on providing guidance in diverse areas. This also prepares the mentees for more effective participation in modern team-based medicine approaches, addresses some issues of isolation among residents, and strengthens the feeling of community [39]. This model also empowers mentees by reducing the effects of the hierarchical structure of the traditional mentorship model and by eliminating a level of formality which, within the medical system, can be very beneficial to sharing knowledge, experience, and bidirectional feedback. By providing trainees with a greater stake in their community and collective decision-making, institutions will likely reduce attrition and improve retention of talent at the same time.

#### **8.2 Adapting Maslow's hierarchy of needs to mentorship**

Maslow's Hierarchy of Needs is a general principle stating that foundational needs must be met before higher level developmental processes like self-actualization can be met. Hale, et al., adapted this hierarchy to help tackle the issue of burnout among medical residents and to address critical wellness issues [90]. In their model, mentorship is placed at the highest tier as a method of accomplishing self-actualization. However, this model could be reasonably expanded to view mentorship as a tool to address various levels of needs rather than just self-actualization (**Figure 1**).

For example, when initially setting general goals for the mentor-mentee relationship, there should be a discussion of where to focus efforts so that the needs can be optimally met. If the mentor and mentee agree to emphasize wellness, then implementing reflection and wellness check-ins during regularly scheduled meetings could address the corresponding domain components [91, 92]. Implementation of reflective practices may help emphasize wellness, with benefits in both mental and physical health domains [92–95]. Mentorship can

#### **Figure 1.**

*Remapping Maslow's Hierarchy of Needs to represent general focus areas of mentorship. Mentorship practices can focus on fostering a sense of belonging, esteem, self-actualization, safety, and improving physiologic conditions.*

target self-actualization through discussions about professional identity or career mapping. Building of one's esteem can be accomplished by treating each other with respect and fairness and working on various projects (including research) together to reinforce the value that each member of the team adds to the final outcome [96, 97]. The general domain of "safety" can be addressed by exchanging advice on practical life matters, including financial topics, as well as having candid conversations about personal boundaries [97–99]. While this framework is not universally applicable across all mentorship relationships, it may help in setting goals and creating actionable items for the pair to work on. This model also works very well with the 'multiple mentor' model, where different mentors could be responsible for addressing different aspects of the mentee's growth. This method could also be helpful in addressing the need for diversity within a mentorship team; for example, matching a female mentor with a female mentee to discuss work-life balance or wellness [77].

### **8.3 Intentional mentorship**

Prior to engaging in mentorship, mentors should reflect on their own education and experiences at various levels of training [100]. They should identify what skills, behaviors, or thought patterns they found helpful and formative. They should reflect on good advice given to them by their own mentors or colleagues. Do they remember how they felt as a student, so they can understand what (and how) the mentee is experiencing? What were elements of successful mentorships and professional interactions that they have had? What do they wish they had been taught? What characteristics do they hope their own doctors possess? What do they hope for the future of medicine? What do they want to pass on to the next generation? Mentors should use this thought exercise to inform their mentorship technique and goals. They should revisit their answers regularly to ensure they are staying on track and mentoring with intention [34, 101].

#### **8.4 Motivation and life-long learning**

Among key benefits of a fruitful mentor-mentee relationship is the generally higher intrinsic motivation among mentees [102]. This is important because intrinsic motivation is positively associated with ongoing focus on self-improvement and life-long learning. Thus, measures to increase intrinsic motivation amongst medical trainees could have positive implications for one's entire career. Opportunities that support autonomous learning were shown to cultivate intrinsic motivation, which could be implemented in mentorship. For example, the mentor could invite his or her mentee to conduct research and present information on any topic of their choosing. This, in turn, provides the mentee with valuable skills related to selfdirected, independent work.

#### **8.5 Division of responsibilities between mentor and mentee – best practices**

#### *8.5.1 Mentee responsibilities*

Mentees must enter into a mentorship knowing that the onus of cultivating the relationship rests primarily on them [77]. First, they must identify a potential mentor with consideration of personality fit, field of expertise, career and life experience, and professional network. In the absence of an organized mentorship structure, the mentee should initiate contact and set up a meeting to discuss

#### *Mentorship in Postgraduate Medical Education DOI: http://dx.doi.org/10.5772/intechopen.98612*

the viability of a potential mentorship relationship. If both parties agree to move forward, a series of meetings should outline the general goals of the mentorship, specific goals and topics of interest, frequency and type of communication, as well as various work and learning styles [77]. Both parties should consider outlining expectations for the relationship and for each other – something discussed in more detail in a subsequent section on mentorship malpractice. After that, general and specific goals can be set, optimally in an orderly, well-outlined fashion.

The mentee must come to subsequent meetings prepared with discussion points, including challenges that they seek guidance on, as well as the status of any projects they are working on with their mentor. Optimally, they should leave the meeting with a list of 'action items' to complete by the next meeting, as well as a mutually agreed date for the next meeting. Mentees should seek feedback at regular intervals, frequently enough to ensure continuity of experience. Feedback should encompass mentee-specific goals and objectives. Some guiding questions to help evaluate the relationship include [103]:


Evaluation of these answers could be on a graded scale from 0 to 5 as suggested by Wadhwa, et al. [103]. In terms of attitude, mentees should be generally appreciative and show gratitude for their mentor's time. They should be honest about their limitations, take initiative, follow through with tasks, take risks and be willing to leave their comfort zone [77]. They should be eager to learn from their mentors and show respect in all interactions.

#### *8.5.2 Mentor responsibilities*

In order to ensure high quality of mentors and excellent mentee experience, involvement in a mentorship program must be voluntary, otherwise an advisingtype relationship tends to emerge [86]. While there could be incentives such as dedicated time for mentorship in more academically-oriented institutions, mentors have to be willing to engage for personal reasons. Likewise, mentorship pairs must not be imposed but rather mutually chosen [78]. Most mentees choose mentors based on personality/style rather than academic achievements.

Before mentoring commences, individuals should reflect as outlined in the intentional mentoring section above. Mentors should also be aware that the best indicator of a successful mentorship relationship is when mentees feel that their mentors are invested in their day-to-day progress [104]. Among the most common reasons for mentorship failure is 'mentor neglect,' thus mentors must be effective communicators to minimize this threat [104, 105]. For example, one way to avoid neglect is to communicate effectively if meetings need to be cancelled and even give a clear message that mentorship might not be possible under a specific set of circumstances or conditions; leaving mentees in suspense is the primary mode of neglect and is largely avoidable. Another common threat to the success of mentorships is the power dynamic and negative impacts of hierarchy (e.g., 'the power gradient') within the relationship [106, 107]. To mitigate the above issues, mentors need to clearly indicate that mentees should avoid engaging in activities or projects that do not align well with their interests, skill set, or capacity to complete. This may be challenging for mentees because of the above-mentioned 'power gradient' and potentially mentee concerns of appearing ungrateful or unappreciative for opportunities offered to them.

To help optimize mentor-mentee interactions, mentors should make efforts to make routine information exchange less formal and to reduce either the presence or the appearance of hierarchical barriers. For example, mentors could preface the mentorship with statements of support and encouragement, while emphasizing that the ultimate signs of strength, maturity, and leadership include the ability to self-assess, know when to seek advice or help, and estimating one's ability to take on more work. A mentor should also inquire early on about the mentee's preferred work and motivational styles [77]. There should be mutual awareness of reasonable expectations, comfort levels, resources and generally speaking support (e.g., both in terms of resources and encouragement). At the same time, a balance should be struck between the amount and relative proportions of encouragement, support, and praise. Imbalance among those three factors may lead to mismatched expectations (e.g., praising poor effort will likely be counter-productive).

Throughout the entire mentorship process, mentors should embrace opportunities for mentees to engage in reciprocal teaching. This both enhances the mentee's teaching (and leadership) skills and provides the mentor a fresh perspective on mutually relevant topics. This input can be solicited, for example, by asking a mentee a question about technology or changes to medical education. Mentors should embrace their commitment to life-long learning and regularly and frequently seek feedback about their performance as a mentor and the effectiveness of the mentorship on the whole. Other factors in creating a successful mentorship include implementing micro-motivational behaviors as well as awareness and avoidance of exposing mentees to unintentional microaggressions [108, 109]. In terms of their general approach, mentors should keep an open mind and be eager to learn from their mentees [77]. They should treat mentees with respect and view them as valuable colleagues. Mentors should be honest with mentees while at the same time exhibiting patience and generosity (**Figure 2**).

#### *Mentorship in Postgraduate Medical Education DOI: http://dx.doi.org/10.5772/intechopen.98612*


#### **Figure 2.**

*Mentees bear the majority of work in mentorship and have the responsibility for cultivating the relationship; however, actionable items for both mentor and mentee can help facilitate a successful relationships. Having clearly defined tasks and responsibilities increases likelihood of success [86].*

#### *8.5.3 Mentorship malpractice*

Mentorship malpractice is an important topic within the overall context of this chapter. It is critical that both mentors and mentees understand the scope of their mentorship relationship, and that education regarding manifestations of "bad mentorship" is provided to all stakeholders. For example, Chopra, et al., grouped mentorship malpractice into active and passive types [110]. The authors further categorize active mentorship malpractice into three subtypes – the hijacker who takes hostage a mentee's idea, project, or grant, often for self-gain; the exploiter who torpedoes a mentee's success by saddling them with low-yield activities; and the possessor who dominates the mentee across various areas of collaboration [110]. Passive mentorship malpractice can be divided into the following three subtypes – the 'bottleneck' mentor who is preoccupied with own competing priorities and does not have the bandwidth or the desire to attend to mentees; the 'country clubber' mentor who focuses on conflict evasion and avoids difficult but necessary conversations; and the 'world traveler' mentor who spends little to no time or effort on mentoring while often exploiting the mentee for self-promotion [110]. In addition to educational efforts, more formal 'mentor-mentee agreements' may help enforce accountability within the overall relationship [111]. Finally, active prevention of mentorship malpractice requires mentees to be proactive, including the establishment of a 'mentorship team,' setting boundaries, communicating needs, knowing when to walk away, and not being complicit by facilitating negative mentor traits [110].

### **9. Challenges to mentorship**

It is generally accepted that physicians at all levels of training carry tremendous amounts of responsibility and face significant time constraints due to multiple competing clinical and non-clinical priorities [112–114]. A major concern among potential mentors is the time commitment required for a successful mentorship.

This is a valid concern, and while new approaches to mentorship like 'micromentorship' and group mentorship provide avenues to lessen the time demand, mentorship is still an added responsibility. Consequently, it is up to the individual to evaluate if the benefits of mentorship are worth the time commitment [2, 115, 116].
