Coaching and mentoring modern surgeons

Mentorship is a tool used to help surgical trainees develop the skills they need to succeed in various aspects of life—both personal and professional.¹ According to Healy and colleagues, mentorship 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 and professional development.”² In his presidential address at the 2011 annual meeting of the American Association for Thoracic Surgery, Irving Kron, MD, FACS, said that in surgery, “mentorship is more than just about technical surgery, but also about life.”³

The concept of mentorship first emerged in the Greek myths. In Homer’s Odyssey, the character of Mentor guided the development of Odysseus’ son, Telemachus, from adolescence to adulthood while Odysseus was away.⁴ The character name Mentor has been adopted in English to refer to an individual who imparts wisdom to and shares knowledge with a less experienced associate. Today, a mentor is defined as a “developer of talent, a teacher of skills and knowledge of the discipline, an assistant in defining goals, and one who shares social and professional values.”⁵

Surgical training has been a topic of discussion since medieval times. In England, surgeons-in-training were taught under the apprenticeship model, which continued to be the standard of training for 400 years. Using this paradigm, a master of the arts and sciences or the hospital surgeon taught “the whole of education of the pupil” until the student was deemed ready to write certification exams.⁶

The apprenticeship model of one-on-one training changed in 1890, when William Halsted, MD, introduced the concept of surgical residency.⁶ In this system, trainees spent five or more years in a teaching hospital training in human anatomy, clinical skills, surgical skills, and research, under the guidance of a tutor and other teachers.⁶ This process quickly became the standard of surgical training in the U.S.⁷

Recently, changes in surgical residencies have created challenges for the traditional mentoring relationship between surgeon and resident.¹ These changes include shortened periods of inhospital time for residents due to duty-hour restrictions, subspecialty and diversified training programs, and technological and surgical innovations.¹ There is an increased focus on patient safety, a switch to a competency-based training model, and constraints on teaching time, both in and out of the operating room (OR).

This article examines the issue of mentoring in the face of these changes and challenges, describing various mentoring styles, elements of successful mentoring, and the development of a successful mentor. The authors also provide practical guidelines to ensure quality training for the next generation of surgeons.

Mentoring styles

Mentorship in surgical training can take many forms. The Socratic dialectical method—a form of inquiry and discussion between individuals centered on asking and answering questions to stimulate critical thinking and to illuminate ideas—was a strong influence on Dr. Halsted. As a result, this style of learning and teaching developed into what is now known as the Halstedian apprenticeship model of training.^8,9 The popular phrase, “See one, do one, teach one,” is central to this model, and many training institutions used this style. To this day, in some programs, a resident is assigned to an attending surgeon for the entire rotation, gaining increased responsibility as he or she progresses. This method allows for maximum exposure in a short period of time. The surgical resident is exposed to and develops clinical knowledge and a range of technical skills, patient-physician interaction competencies, and disease management techniques.

Ensuring that residents have adequate exposure in an era of work-hour restrictions, many institutions have established formal mentorship programs.10 Through these mentorship programs, each resident is assigned to a faculty member, who serves as a mentor with the expectation that the surgeon and the trainee will meet regularly.

A mentor is more or less analogous to an athletics coach. Athletes require strong and healthy relationships with their coaches to succeed in their sport. Coaches push athletes to the limit, forcing them to perform under pressure and stress. Sometimes, coaches can be tough, even harsh on their players, which may strain relationships, but the end goal for the coach is to help the athlete succeed, grow as an individual, and build character.¹¹ Similarly, surgical training is intense, and residents are often asked to perform in high-pressure situations. Surgical mentors teach technical and clinical skills to guide the resident to transition to independent practice. However, the traditional style of coaching/mentoring may not prove optimal for all surgical trainees and its effectiveness may depend on the personality of the mentor and resident. Singletary has suggested that the traditional mentor/mentee relationship may have become a style of the past.¹² Due to current changes in surgical training and culture, different models of mentoring are developing.

At the 2014 American College of Surgeons (ACS) Leadership & Advocacy Summit in Washington, DC, John Rombeau, MD, FACS, staff surgeon, U.S. Department of Veterans Affairs, Palo Alto Health Care System, CA, and emeritus professor of surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, discussed four new directions in surgical mentoring for the millennial generation. First, he addressed the reverse academic mentoring pyramid. With this approach, the most experienced surgeons are mentors to those individuals who are just beginning their surgical career. Dr. Rombeau explained that this method takes advantage of the fact that emeritus professors or professors who are near retirement have an enormous amount of experience and may have fewer clinical responsibilities than younger surgeons, which allows them extra time for mentoring junior faculty and residents. Simultaneously, junior faculty and assistant professors are free to focus on operating and establishing their own career paths.

Another new direction discussed by Dr. Rombeau was mosaic mentoring. Under this model, mentors fill different roles, such as resident mentors, administrative/business mentors, clinical specialist mentors, research mentors, and so on, based on their specific interests and abilities. This model is based on the theory that each aspect of a surgical career should have a specific mentor.

A third approach takes advantage of innovations in technology and uses the simulation lab as a place where the mentor and mentee can develop a relationship.¹³ Simulation labs comprise a vast amount of resources and modalities, allowing surgical residents to learn a range of surgical skills and to benefit from detailed explanations and demonstrations. The Accreditation Council for Graduate Medical Education (ACGME) mandates that residents undergo dedicated surgical skills lab training. David Leach, MD, a past-director of the ACGME, made the following observation in an article published in the Bulletin, “Every resident deserves competent teachers and an excellent learning environment. Simulation serves both of these core principles.”¹⁴ These teaching sessions are not limited to building surgical skills; they may be used to instruct students on other topics, as well. Unlike the OR, simulation labs are free of time constraints and alleviate fear of complications or operative mistakes. A stress-free environment is created, which fosters teaching and mentoring opportunities.

The final mentoring model highlighted by Dr. Rombeau is the return of the scrub sink and OR mentoring styles. The scrub sink—a more traditional surgical mentorship technique—is a place where surgeons pose such questions as, “What is the operation? Why are we performing it? How is it done? What is the evidence to support this operative decision?” in an effort to teach and motivate trainees.

Mentorship does not always have to be structured, and may occur outside the clinical environment at journal clubs, while working on research projects, in lectures, in discussions, and at other events.¹⁵ Peer-group mentoring supports collaboration in a non-hierarchical environment as mentees receive guidance from their peers who share similar challenges.¹³ Peer mentorship may even take on a larger role as the trainee progresses, with the possibility of mutual mentoring by peers after training is complete.¹⁶ Tele-mentoring or mentored skills courses, in which experienced surgeons evaluate recordings of participants’ skills, may assist trainees and even fully trained surgeons to quickly master new skills and technologies.¹⁷ Each method has its own benefits and may be used at different stages in a surgeon’s training and career.

Mentorship for different facets of surgical life

Each of the different roles that surgeons play requires a mentor.¹⁸ Hence, a mentor can satisfy a mentee’s need for guidance in one or many aspect(s) of professional and individual development, including clinical/patient care, academic surgery, research, practice management, and personal growth.¹⁸ The mosaic mentorship model identified by Dr. Rombeau allows residents to find mentors who best fit specific aspects of training so as to place fewer scheduled demands on each mentor.¹ At the outset, mentor and mentee should clearly define their roles, and set clear goals with time-lines and end-points.^1,18

Traditionally, clinical mentorship has been heavily weighted in surgical training due to its focus on surgical technique, intraoperative decision making, pre- and postoperative care, and communication among the team members.^1,19 The importance of academic mentorship to an individual should be explored by a mentor early in the relationship so that the mentee can form a solid plan for achieving his or her career goals. An academic mentor provides guidance to navigate sometimes turbulent institutional politics, and eases the mentee’s integration into the social environment of a health system, academic institution, or regional/national/international organization.¹⁸

Research mentorship is an area that has received little attention. In one study, Monn and colleagues found that trainees perceive research as one area in which they received consistent but insufficient mentoring.¹⁹ Mentoring in this area is time-intensive, and PhDs are perhaps best-suited to playing the mentor role. Mentees benefit from this relationship by receiving assistance in setting realistic goals and deadlines to achieve academic milestones and building professional relationships with individuals who the mentor knows—giving rise to opportunities for collaboration.¹⁸

Mentorship in the financial and business aspects of clinical practice is often viewed as lacking in residency training.¹⁹ This shortcoming may be best addressed if the trainee is able to interact with a diverse assortment of surgeons from a range of practice settings, including academia, private practice, and rural surgery. Additionally, a financial counselor may help in the transition to clinical practice.

The personal side of surgical life is perhaps the most idiosyncratic of all mentoring areas. Work-life balance may be insufficiently addressed in training, and it is up to the mentee to find a suitable mentor, as goals and circumstances differ widely among individuals.¹⁹ The gender of a mentee may be an important factor when choosing a mentor for work-life balance.¹⁸ Some mentees may seek the guidance of a life coach or spiritual mentor, which may be of benefit as they seek personal enrichment while establishing a practice.

Elements of successful mentoring

A successful mentor/mentee relationship requires dedication and commitment from both parties, and it is essential to recognize that the needs of each individual change and evolve over time.20 Time constraints are a major concern in a surgeon’s life, so ensuring that both mentee and mentor are committed to finding the necessary time to interact is crucial, especially at the beginning of the relationship. Clarifying the needs and expectations of both parties at the start of the mentoring relationship to avoid role confusion, confidentiality breeches, and pre-existing biases will help both individuals save time. Changing needs, for both the mentor and the mentee, are in fact a defining characteristic of successful mentoring, as it indicates that both parties are evolving, developing new aspirations, and finding fulfillment. Mentoring requires dedication to the process, which includes substantial investment not only of time, but also of energy and resources. The quality with which the parties listen to each other is also very is important; mentors and mentees must be active listeners to build productive and fruitful relationships.

A good mentor should be flexible and willing to serve in different capacities as needed.¹ A mentor makes adjustments to suit the environment and may serve several functions, including role model, teacher, manager, friend, administrator, and even a coach in an effort to accommodate the mentee’s changing needs. Perhaps most importantly, the mentor should introduce the mentee to new professional networks and partners for collaborative projects. These individuals, groups, and institutions will provide a lifelong foundation of support for the mentee’s personal and professional development. Creating a new research or clinical team with carefully selected associates can be challenging, especially in the initial stages of a surgeon’s career, and the importance of mentor-driven guidance to choose these team members cannot be stressed enough.

The two most important measures of productive mentoring are the mentee’s success and the mentor’s and mentee’s perception of the relationship.²⁰ It may be difficult to evaluate a mentoring relationship, but it is important to regularly review progress. If both parties agree the relationship is succeeding and if the mentee is achieving his or her goals, then the relationship is, by definition, successful.

Values of a successful mentor

In 2012, the ACS identified a set of values to guide its work. In his Presidential Address at the 2013 Clinical Congress, Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), urged Initiates to adopt the same set of standards and apply them in their practices: Professionalism, Excellence, Innovation, Introspection, and Inclusion. Successful surgical mentors also embody the following values:

• Professionalism focuses on accountability and honesty, and a good mentor is open with his or her mentees and accepts responsibility for his or her charges’ professional growth and success.
• Excellence is necessary for the mentor to act as a “role model” for his or her mentees and to promote the highest quality of patient care.
• Innovation and creative thinking are requisite skills for the mentor who wants to fully lead his or her mentees in new directions and forge a better future.
• Introspection consists of self-improvement and self-assessment, qualities that an active listener and mentor must possess to lead by example.
• Inclusion is centered on the active engagement of both the mentor and the mentee and encompasses productive collaboration aimed at harnessing collective intelligence and creativity.

A 2011 systematic review of mentorship in surgical training described the five most frequently cited qualities of a mentor. These characteristics are outlined in the table.¹⁵

Most Frequently Mentioned Qualities of a Mentor

1	Serves as a professional role model
2	Stays involved in terms of time and effort
3	Is compassionate, kind, and supportive
4	Acts as a critic, evaluator, and assessor
5	Is a leader in the field and challenges the mentee

The following are general recommendations for good mentoring:

• Be present and prepared. In preparation for the first meeting, review the mentee’s grades, curriculum vitae, research interests, job description, and so on. Talk to other colleagues who have worked with the individual. Help the mentee develop and structure a specific goal.
• Make time in your schedule. Your time is valuable, but strive to have meaningful contact with your mentee every one to two months.
• Market your mentee. Introduce your mentee to colleagues; encourage and facilitate their participation in local or national research committees and organizations.
• Check in. Between meetings, send an e-mail to make sure your mentee is on track with tasks, and assist with any challenges that have developed.
• Evaluate. With each meeting, assess how the mentee is progressing toward his or her goal and help to keep him or her on the appropriate time-line.

Finding the right mentor and being a good mentee

Finding the right mentor or mentors can be one of the more challenging tasks for the mentee. Mentees may benefit from seeking a specific mentor to focus on one area of their development. For example, the mentee may select a research mentor who has engaged in a body of work that they respect and choose a different work-life balance mentor whose family life they would like to emulate.

Securing a mentor at one’s institution affords the benefits of being able to conduct regular in-person meetings and having a mentor who is familiar with the mentee’s educational requirements and demands. Conversely, national mentorship programs, such as the ACS Junior Faculty Empowerment Program and the Association of Women Surgeons mentoring program for Early Career Women Faculty, have opened the door to long-distance mentoring.¹⁸ Many institutions have implemented formal, assigned mentorship programs, but if mentees are tasked with finding their own mentors, some have recommended testing out the relationship by first asking for advice from a potential mentor to see if personalities and communication styles are a good match.¹⁸

The role of the mentee is not typically well-defined in literature. The following are commonly suggested guidelines for mentees:

• Have a clearly defined goal. At the first meeting, clearly define your goal and outline your ideas and plans to achieve your goal. Include details on how you think your mentor can help.
• Be respectful of your mentor’s time. Be punctual, be prepared, and allow your meeting to end on time.
• Follow through on tasks. Finish tasks on time and to the best of your ability.
• Self assess. Spend time preparing before your next meeting. Reflect on your progress, the tasks you have completed successfully, and the steps that remain to achieve your goal.
• Refine your goals. Throughout your training or professional advancement, re-evaluate your goals and, with the help of your mentor, refine them and develop new ones.

 

Conclusion

Mentorship styles and structures are multifaceted, and will likely continue to develop in the future. Increased specialization means that mentors will likely play a specific role for one mentee and play a different role for the next. As surgery changes at an ever-increasing pace, the practice of mentoring the next generation must evolve to produce new surgeons of the highest quality.

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 References

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