Mentorship in Postgraduate Medical Education

Abstract

Mentorship is critical to the development and professional growth of graduate medical education (GME) trainees. It is a bidirectional relationship between a mentor and a mentee. Mentorship has consistently been shown to be beneficial for both the mentor and mentee, with the mentee gaining valuable skills in education, personal growth, and professional support, and the mentor attaining higher career satisfaction and potentially greater productivity. Yet, there is a lack of research and in-depth analysis of effective mentorship and its role in postgraduate medical education. This chapter outlines different approaches toward mentorship and provides the reader with basic concepts relevant to the effective and competent practice of mentorship. The authors discuss the challenges that physician mentors and mentees face, the organizational models of mentorship, the approaches and techniques for mentorship, and the deleterious effects of mentorship malpractice. Our general discussion touches on best practices for both the mentor and mentee to allow for self-improvement and lifelong learning. The variety of applicable models makes it difficult to measure effectiveness of mentorship in GME, but there is an ongoing need for expanded research on the benefits of mentorship, as greater amount of supporting evidence will likely incentivize organizations to create mentorship-friendly policies and support corresponding institutional changes.

1. Introduction

Mentorship is the bidirectional partnership between a mentor, who acts as a guide or teacher, and a mentee, who acts as a learner. In graduate medical education (GME), mentorship serves to enhance mastery of curriculum content and is important in conveying various non-clinical aspects of training like professionalism, networking, values, clinical judgment, and other soft-skills that are not easily taught in a structured curriculum format [1, 2, 3]. This is an often overlooked aspect of personal and professional trainee growth process, as this chapter will outline in granular detail.

Mentorship is important for a variety of reasons, including the ability of participating parties to develop opportunities in education, personal growth, and professional support [4]. Because it is not a strictly defined process, mentorship may appear somewhat ambiguous to participants. As such, mentorship is not to be confused with advising, coaching or sponsorship [5]. Advising is a system in which one party offers advice and guidance to another party. This is often an administrative task to help ensure the ‘advisee’ is on track; thus it tends to be a unidirectional exchange [6, 7]. Sponsorship typically involves a well-connected individual advocating for the career advancement of a less established individual. Similar to advising, it is a primarily unidirectional relationship [8]. While mentors may also engage in sponsorship, the two concepts are definitionally distinct while having the potential for synergistic interaction [9, 10].

Mentorship, which is based largely on the difference in experiences between individuals at various stages of their careers, creates a space to “flatten” the vertical hierarchy that governs medical education and offers an opportunity for a more horizontal exchange of information and perspectives. While mentorship is not a new concept or practice in medicine, the analysis of effective mentorship and its role in addressing modern challenges in postgraduate medical education is relatively new, and an area that clearly warrants more investigation [11]. The goal of this chapter is to outline different approaches toward mentorship and provide the reader with basic concepts relevant to effective and competent practice of mentorship.

2. An overview of benefits of mentorship

Mentorship can be used as a tool to improve outcomes, professional transitions, research productivity, recovery from burnout, and can even teach resilience. The role of mentorship in easing the transition from being a medical student to becoming a practicing clinician has been demonstrated in several studies [12, 13, 14, 15]. Similar to medical students entering into residency training, nurse practitioners experience a similar transition and ‘reality shock’ when they move to a full-time hospital position [16, 17]. Of importance, a negative experience during this transition can have significant impact on preventing individuals from reaching their potential and may cause some to even leave the profession. The dichotomy between expectations and reality, along with increased responsibility, can take a toll as individuals navigate their new roles. When mentorship is utilized to ease such transitions, confidence and competence of mentees may increase [18, 19]. It may also be reasonably expected that mentorship-based interventions may produce a number of beneficial effects, including decreased burnout and turnover [18, 20, 21, 22].

3. Mentorship and burnout

Based on the above observations, it follows that mentorship is an emerging tool in combating burnout. In fact, residency training is the stage where physicians are most vulnerable to burnout [23, 24, 25, 26]. The annual cost of burnout-related medical errors and workforce turnover is estimated to be $4.6 billion excluding the emotional cost of these errors to patients, families, and physicians [23, 27, 28]. Burnout is largely due to work demands, personal relationship strain, lack of rest/sleep, and high levels of responsibility [29, 30, 31]. Residents who have experienced burnout identified mentorship from colleagues and attendings as an important part of recovering from this insidious condition [23, 32]. Additionally many of the factors related to burnout are ubiquitous to residency and by implementing peer mentorship from more advanced residents, programs have been able to normalize the intern experience and minimize difficulties, while promoting resilience and wellness in these vulnerable groups [33, 34].

4. Mentorship and academic productivity

It has been shown that mentees generate more peer-reviewed publications, receive more grant funding, report greater career satisfaction, and are more likely to be mentors themselves [8, 35, 36]. Mentees are also likely to achieve faster academic promotion and have greater faculty retention [37, 38]. Despite these benefits, the number of physicians engaged in academics and research is decreasing, the proportion of NIH-funded principal investigators over age 60 is increasing, and it is becoming more difficult for early-physician scientists to find mentors [37]. Furthermore, the expectations of physicians at the conclusion of their training are extensive, and include proficiency in clinical, teaching, scholarly, and administrative duties [39, 40, 41]. Mentorship is a means for mentees to develop soft skills such as written and verbal communication, team building, leadership, professionalism, and various other nontechnical skills – items that are often not included in our standard curricula or overlooked during training [39]. In addition, mentees benefit from professional coaching, emotional support, and networking opportunities provided by mentors [42], and mentorship meetings that include discussions of wellness, mindfulness, and coping skills add further benefit to participants [22, 43, 44, 45].

5. Mentorship and mentors

The many benefits of mentorship outlined above are not just limited to mentees. Of importance, mentors are also more likely to report higher career satisfaction, greater academic productivity and publications, personal gratification, and renewed passion for medicine [46, 47]. It is not uncommon for attending physicians to experience “monotony” of their everyday routines – a factor that undoubtedly contributes to burnout [48, 49]. Within this broader context, the opportunity to interact with enthusiastic trainees and seeing medicine from a fresh perspective can be both refreshing and rejuvenating [50, 51]. Furthermore, mentorship is a way to extend one’s legacy by supporting the professional longevity and acumen of the next generation of physicians [37]. It is in the best interest of society to train compassionate and competent physicians, and among the most important aspects of long-term sustainable development is the fostering of mentorship as an avenue of transmitting experience-based skills, knowledge, and the very important ability to self-reflect and embrace self-improvement [52]. The field of medicine is evolving rapidly, and physicians further removed from training may benefit greatly from knowledge of new approaches, schools of thought, technologies, and other trends shared by their mentees.

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, 55, 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, 58, 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, 74, 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, 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.

		Pros	Cons
Mentor Identity	Senior Model	Greater potential for sponsorship; Mentor conveys more collective experience, insight, and wisdom; Generally better for professional guidance	Lack of diversity amongst available attendings; Barriers to open discussion due to hierarchy
	Peer Model	Fewer barriers to open discussion due to diminished sense of hierarchy; Less formal, More flexible; Fresh memory of institution specific advice; Can be cathartic for mentor; Generally better for emotional guidance	Potentially less sponsorship and fewer networking opportunities for vertical career progress
Structure	One-to-One Mentorship	Potentially more rewarding for mentors; Mentee tends to model mentor’s path and behavior making it easier to attribute success; Fewer people for mentees to meet with	More time consuming; Less diversity in presented perspectives and more limited areas of focus
	Group/Multiple Mentorship	Less time strain on mentors; More collaborative and diverse network reinforces the team based care model; Mentee gets guidance in more areas	Limited discussion breadth with each mentor; Potentially less feeling of investment in mentorship; Increased time strain on mentees

Table 1.

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

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-to-one 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.

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 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).

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.

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, 93, 94, 95]. Mentorship can 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, 98, 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 self-directed, 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 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]:

• To what extent has the mentor helped build confidence and satisfaction within profession and career?

• Do I feel that my mentor is focused on my performance, career development, and personal well-being to the extent that I expect?

• Are our meetings productive and driven by outlined goals?

• Do I feel that our conversations are kept confidential?

• Am I comfortable disagreeing with my mentor and expressing my opinions?

• Am I encouraged to give feedback to my mentor?

• Are we considerate of each other’s time?

• Does my mentor motivate me to excel?

• Is my mentor open to hearing new ideas and perspectives?

• Do I appreciate and show gratitude towards my mentor?

• Do I follow through on commitments made?

• Do we meet on a regular basis?

• Do I feel valued as an individual and feel like I am encouraged to give feedback to my mentor?

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 advising-type 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).

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, 113, 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 ‘micro-mentorship’ 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].

10. Modern-day challenges to traditional mentorship in postgraduate medical education

While mentorships and mentor-mentee relationships may have been less structured in the past, they have always been crucial to most training and education. There may be specific factors in today’s clinical practice which impede one’s ability to mentor effectively. We have already mentioned time constraints as one barrier, and in order to preserve and improve mentorship in post graduate medical education there is a need to identify in what ways time constraints, particularly in the modern day, may be more of a barrier than before. The dawn of the electronic health record has certainly made many aspects of clinical life easier and more efficient. Still physicians may spend more time in front of computers, in cubicles and offices than out on the wards where the traditional “paper charts” would be, and hence render themselves less accessible to potential mentees. Notes used to be briefer in the past when they were hand written and more time may have been spent with students and trainees to nurture potential mentorships. Electronic health records also bring with them more “tick boxes”, asynchronous tasks and time spent on “filing” [117, 118, 119] which further could tighten existing time constraints. Additionally, the shift in employment of physicians by hospitals rather than being self-employed, along with the increasing administrative burden [120], highlights the need for “protected time” for teaching physicians to help promote and facilitate mentorship [121]. Non-physician managers may be less likely to understand the value of mentorship in medical training and may be more likely to be focused on optimization of clinical and financial efficiency. Another factor to consider could be the growing number of non-physician practitioners providing care and services in hospitals in the U.S. Where a medical or surgical team decades ago would most likely only have consisted of physicians at different levels of training, seniority and status, along with medical students, modern medical teams are much more diverse. Today a medical or surgical team is more likely to consist of a mix of physicians and non-physician practitioners. Given that the attending physician and the advanced practitioner are working together permanently over years and the trainee is only “rotating” through, he or she may feel more as an outsider, potential mentors may appear less available, and the landscape in which the mentee is navigating, may, in some ways appear more complex and intimidating. Physicians may actually be spending more time and resources mentoring non-physician practitioners and entrusting them with projects simply because of continuity. There is however little research into the effect that the growing number of non-physicians employed by hospitals have on training and mentorship, and more research into this topic may be beneficial. If the necessity of the mentor-mentee relationship in medical training could be elucidated, and robust data presented regarding positive outcomes with regard to diversity, retention of female physicians in the work place, and prevention of burnout, both for mentees and mentors, non-physician managers may see the benefits of more protected time to facilitate such relationships. Hence, it could be argued, that time set aside where faculty members are protected from clinical and administrative duties, in order to mentor physicians in training, may be an emerging and growing need in today’s healthcare system.

11. Mentorship in the era of COVID and beyond

The coronavirus disease 2019 (COVID-19) pandemic has certainly also posed its own challenges to medical education as a whole [122]. Over the last year students over several fields, not just medicine, have been kept out of class rooms and auditoriums and have been unable to congregate in student lounges, libraries, cafeterias and other places where healthy academic discussions may occur [122]. This is equally true for residents and fellows as well as medical students. Potential mentors are simply less visible and may be less accessible and overall harder to approach in the era of the pandemic. Research mentorships have also identified barriers specifically related to COVID-19, such as transitioning research forums and groups to virtual platforms, adapting the mentorship relationship to video conferencing platforms if needed and providing virtual research opportunities [123, 124]. It may also prove particularly valuable to consider promoting more mentor-mentee meetings in a time where social distancing and avoiding larger gatherings are mandated, given that this involves a two-person team only in most cases. Additionally the pandemic has opened the door for virtual gatherings through video conferencing platforms, which can include many of the advantages of a “face to face” meeting, while allowing for relationships to transcend geographical boundaries [125], a benefit which may outlast the pandemic itself. Mentorship may also be redefined given the already high burnout rate among physicians and trainees, even before the pandemic [126], to include not only academic support, but also emotional support and support of broadly defined ‘wellness measures’ through mutual compassion during a stressful time [123].

12. Challenging the traditional mentorship model

Modern day challenges to traditional mentorship in postgraduate medical education could be overcome by either addressing the challenges themselves or “challenging” the traditional model of mentorship. With more and more of the work that clinicians perform requiring information-technology (IT) skills and constantly being “up to date” with regard to the new features of medical software and EMRs, our physicians-in-training may find themselves at a unique advantage. New graduates from medical school would naturally be comfortable with IT skills and may also be more likely to evolve and pick up ‘new tricks’ pertaining to EMR use, enabling them to teach their mentors. This introduces the concept of “reverse mentorship”, where the less experienced physician could help the more experienced physician gain confidence and knowledge ultimately benefitting both the mentee and the mentor and “leveling the playing field” [127, 128]. Reverse mentorship may help those physicians with limited EMR knowledge or skills, lack of familiarity with modern electronic research tools, and even virtual and video meeting and teaching sessions. In addition, reverse mentorship may also be beneficial to some of the gender specific and ethnic barriers to mentorship mentioned earlier in this chapter. Female and minority physicians-in-training could mentor their faculty members in modern challenges which may be specific to females or minorities, ultimately increasing the understanding of these important topics among predominantly white, male mentor pool. Reverse mentorship may also be particularly relevant to postgraduate medical education during the current pandemic. Traditionally senior physicians have more knowledge and confidence in medicine because of decades of academic research and clinical experience. However, this advantage may be somewhat lost in the midst of a pandemic. The rapidity with which COVID-19 infiltrated and shook the very foundation of outpatient and inpatient medicine over the last year, made it important for physicians to constantly stay current on the newest guidelines for management and newest evidence pertaining to COVID-19. Many experienced physicians were humbled and may have found themselves receiving updates and tips from younger less experienced colleges. A “group mentorship” model which potentially could include physicians, advanced practitioners and nurse managers as well as hospital administrators as mentors, may improve the overall training of a physician-in-training mentee, and render them more equipped to practice in a rapidly evolving healthcare system.

13. Premedical mentorship

Having discussed mentorship in graduate medical education, it is important to emphasize that mentorship should not suddenly start during one’s residency training. Optimally, long-term mentorship relationships may begin during undergraduate years, especially once a future physician decides to commit to medicine as a career. One of the challenges of being an undergraduate medical student is receiving proper advice and mentorship, especially regarding various expectations and realities of modern healthcare. In this context, mentorship can be crucial in helping set up a premedical student for future success. Deciding to apply to medical school and gaining entrance into medical school can be difficult and anxiety-provoking [129]. Mentors can help reduce that anxiety and provide insight into the realities of a career in medicine. A mentor-mentee relationship can provide meaningful information, experience and confidence to a premedical student.

Many premedical students lack knowledge about the medical field or about entrance into medical school. Also, many of these students have no connections to individuals in the medical field [130]. A well-organized premedical advising program would serve students well by providing opportunities for direct mentorship by those in the medical field. Such programs could take the form of longitudinal mentorship, one-on-one physician mentoring programs, or periodic educational sessions with physicians.

A mentorship program could allow premedical students gain assistance in selecting undergraduate classes, completing medical school applications, crafting personal statements, preparing for medical school interviews, preparing for the medical college admission testing (MCAT), choosing extracurricular activities, understanding professionalism, developing leadership, or finding opportunities for research, volunteering or clinical experience. Mentorship programs can provide essential support for those who come from disadvantaged backgrounds or from groups underrepresented in medicine.

Having physician mentors can augment the advice of undergraduate premedical advisors and provide essential networking opportunities, as well as clinical experiences. Students can learn what a physician’s life is actually like and better understand the skills needed beyond excellent grades and test scores. They can witness real-life patient-physician interactions and communication [130], ask questions and may even gain exposure to different fields of medicine.

In conclusion, having a mentorship program could be beneficial in multiple ways to undergraduate premedical students. It would be a welcome resource if all undergraduate institutions had a well-developed program and mechanism(s) for assisting with the development and maintenance of mentor-mentee relationships.

14. Synthesis and conclusion

Studies have shown that rates of burnout and low motivation in residency can be linked to specific factors, including lack of adequate mentorship [23]. Thus, it is essential to conduct necessary research and strategize how to best implement key initiatives like mentorship programs so they are optimally effective and helpful in preventing burnout, disengagement, and loss of talent [23]. Within this broader context, the intention, initiation and execution of mentorship all warrant additional research. Mentorship has proven to be very beneficial, but because it is implemented in a variety of ways and for a variety of purposes, its effects can be difficult to measure. There is a great need for increased research on various benefits of mentorship, as increased evidence will likely incentivize institutions to create mentorship-friendly policies like protected time, which in turn would encourage more faculty to serve as mentors. Examples of measurable outcomes include grants, publications, mentorship evaluations and awards, quality improvement measures, academic advancement, career satisfaction and faculty retention [37]. However, intangibles such as stronger collegial relationships, enhanced learning opportunities, and greater interprofessional engagement and awareness also need to be examined in a more rigorous fashion [37]. These less tangible markers may lead to greater fulfillment within the profession, less burnout and even better patient outcomes. Formal, long term evaluation of the success of mentorship programs is needed in order to measure the true costs, benefits, and institutional outcomes. With a shift to pro-mentorship cultures, institutions and individuals could greatly improve their outcomes and satisfaction within medicine.