Surgical Mentoring
John Rombeau • Amy Goldberg Catherine Loveland-Jones
Surgical Mentoring Building Tomorrow’s Leaders
John Rombeau Department of Surgery Temple University Hospital 3401 N. Broad St. Philadelphia Pennsylvania 19140 USA
[email protected] Catherine Loveland-Jones Department of Surgery Temple University Hospital 3401 N. Broad St. Philadelphia Pennsylvania 19140 USA
Amy Goldberg Department of Surgery Temple University Hospital 3401 N. Broad St. Philadelphia Pennsylvania 19140 USA
ISBN 978-1-4419-7190-6 e-ISBN 978-1-4419-7191-3 DOI 10.1007/978-1-4419-7191-3 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2010935290 © Springer Science+Business Media, LLC 2010 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)
This book is dedicated to our mentors who have immeasurably influenced our careers and continue to improve the care of our patients. Clyde F. Barker Clarence J. Berne Thomas V. Berne Robert F. Buckman Daniel T. Dempsey Victor W. Fazio Charles F. Frey Alden H. Harken Jonathan R. Jones Christine F. Loveland Jonathan E. Rhoads Wallace P. Ritchie Robert J. Smith Rupert B. Turnbull, Jr. Douglas W. Wilmore
Preface
The relationship between a senior surgeon (mentor) and his or her protégé (mentee) is like no other; thus, mentors are acknowledged more in surgery than perhaps any other medical discipline. One of the reasons surgical mentors are so highly respected is that we want to emulate them. This is exemplified by most successful surgeons having had at least an association with other successful surgeons. Although one can argue the associative versus causative nature of this relationship, it is irrefutable that something “happens” between these individuals which makes each a better surgeon. Why a book on surgical mentoring? First and foremost is to articulate the importance of a mentor to the education and growth of a young surgeon. A second goal is to provide state of the art, hands-on and didactic information on the current status and new directions in this field. Every attempt has been made to integrate day-to-day mentoring practices with evidence-based information. Surgical training in the twenty-first century is undergoing many changes which clearly alter the available time and opportunity to mentor. These changes mandate new approaches to mentoring. For example, most of today’s mentees will benefit from multiple mentors in a variety of areas including personal life, technical skills, research, clinical aptitudes and administrative duties. Additionally, exciting advances in the surgical simulation laboratory and information technology expand the ability of the mentee to learn more safely and expeditiously when compared to previous eras. Finally, we strongly believe there is a need to integrate the “old” with the “new.” Distinguishing qualities of
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humanism, altruism and empathy of surgical mentors of the past are just as relevant today as when the senior mentor was a mentee. We are concerned these qualities are regrettably becoming lost in today’s frenetic world of surgery. By design, the collaborative efforts of the authors provide varied mentoring experiences. Catherine Loveland-Jones, a senior surgical resident and research fellow, is in the clinical and educational “trenches” in addition to being an active participant in new approaches to mentoring, surgical education and information technology. Amy Goldberg, Surgical Residency Program Director, Temple University, has dedicated her entire career to surgical education and she is intimately (and sometimes painfully) aware of the highs and lows of surgical residents and the unlimited help the mentor can provide to them. Having mentored surgical trainees for 35 years, senior surgeon John Rombeau has had the good fortune to have been mentored by several clinical and research giants whose ghosts continue to haunt him. This book is an expression of his gratitude. Our book is organized to clearly communicate several objectives: succinctly define the topic and relevant issues affecting the mentoring process; describe why, when and how surgical mentoring should be performed; suggest ways to mentor specific groups of mentees; and, finally, speculate on future directions. Chapters are organized to present both hands-on approaches and evidence-based reports in support of these approaches. An appendix of websites with particular relevance to each chapter is included. Most of the references have been obtained from North American studies with the recognition that different issues exist internationally. Despite this continental approach, a representative review of international studies reveals striking similarities in the issues of surgical mentoring throughout the world. Our book is specific to surgical mentoring. It is not intended to be an exhaustive review on mentoring; there are several texts solely devoted to this topic. One of the most difficult aspects of this book has been to differentiate between mentoring and teaching. As noted in the text, all mentors are teachers; however, very few teachers become mentors. This is due in part to the extensive personal commitment of the mentor to guide both the personal and professional growth of the mentee. Nevertheless, we acknowledge the vast overlap between these two areas. This book is written for the continuum of surgeons, as mentoring is a career-long process. Our hope is to “plant the seed” for the medical
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student rotating on surgery as to both the joy of mentoring and the importance of seeking a mentor(s) early and often in one’s career. The surgical resident and fellow will learn the value of having an accessible and committed mentor and the importance of being a mentor to junior trainees. The tremendous benefits to the young surgical attending of having a wise and seasoned mentor are endless, particularly in navigating the many obstacles along the journey for career success. Senior attending surgeons will appreciate that mentoring is indeed a two-way street as they both mentor to and learn from their mentees. Additionally, we hope the immense influences of these attending surgeons (both positive and negative) will be better understood. We are convinced that mentoring makes a significant difference in the surgical world and epitomizes our heritage. Enjoy the journey! John Rombeau Amy Goldberg Catherine Loveland-Jones
Foreword
This book is important for all present and future surgeons because every surgeon needs mentors, and sooner or later most surgeons should become mentors. These trusted, experienced, committed (usually older) advisors and counselors are essential to the professional development, success, and job satisfaction of the young surgeon. And providing mentorship to (usually younger) colleagues is one of the most important and gratifying parts of a surgical career. Drs. Rombeau, Goldberg, and Loveland-Jones have written this book on surgical mentoring to fill an obvious need. It is up-to-date, comprehensive, readable, and evidence-based. If one searches “mentor” on the Amazon.com website, there are over 10,000 hits. If one searches “mentor and surgery,” there are only 4 hits, and all these books have a different focus from the current volume which provides invaluable information for surgeons at all levels of their careers. It is well referenced and a variety of useful websites is included. We are proud of the fact that the authors are members of the Department of Surgery at Temple University where there has been a long and very strong emphasis on surgical education for students and residents. Dr. Jonathan Rhoads, an important mentor of Dr. Rombeau, and Dr. Wallace Ritchie, an important mentor of Dr. Goldberg, were also invaluable mentors to me in my surgical career. Surgery is a small world with many satisfying rewards behind each of the many doors. Good mentorship provides the right keys for the right doors for the young surgeon. Both the mentor and mentee should read this
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book to better understand the who, what, when, where, and how of surgical mentorship in the modern era. What you learn will likely make a difference in your career. Daniel T. Dempsey, MD George and Louise Peters Professor and Chairman of Surgery Temple University
Acknowledgments
This book would not have come to fruition without the help of Maureen Rombeau. Her innumerable suggestions, editing skills, tenacity and indefatigability helped transform an idea into its present form. Most importantly, her love, support and teamwork throughout the past 40 years have made the senior author’s journey all the more productive and enjoyable! The authors gratefully acknowledge the encouragement, insightful reviews, suggestions and comments of the following individuals who have enriched the quality of this book: Keith Apelgren, Dick Bell, Tom Berne, Jeff Carpenter, John Clarke, Carol Cohen, Pamela Craig, Karen Deveney, Charles Frey, Argenis Herrera, Colleen Gaughan, Sloane Guy, Alden Harken, Samantha Hendren, Karen Horvath, Jeremy Korteweg, Aditi Madabhushi, James McClurken, Marc Mitchell, Jon Morris, Donna Muldoon, Patricia Numann, Ronan O’Connell, Emily Carter Paulson, Hiram Polk, Kathy Reilly, Bob Rhodes, Rolando Rolandelli, Robert Roses, Ajit Sachdeva, Jack Sariego, Smit Singla, Chip Souba, Omaida Velazquez, Malcolm Wheeler, Alliric Willis and Heidi Yeh. We are indebted to our Chairman Dan Dempsey – master mentor, teacher and role model, who continues to show us that mentoring is indeed a top-down process.
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Table of Contents
1 What is Mentoring and Who is a Mentor?.......................
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2 Why Surgical Mentoring is Important and Evidence That it Makes a Difference.........................
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3 What are the Qualities of an Outstanding Surgical Mentor?.................................................................
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4 How and Where Should Surgical Mentoring Be Performed?.....................................................................
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5 Mentoring Women Surgeons..............................................
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6 Mentoring International Medical Graduates...................
93
7 How to Develop Faculty Mentors....................................... 113 8 How to Choose a Mentor.................................................... 133 9 Future Directions................................................................. 145 Appendix: Websites of Interest (Organized by Chapter)........ 165 Index............................................................................................ 167
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Chapter 1
What is Mentoring and Who is a Mentor?
“We must acknowledge that the most important, indeed the only thing we have to offer our students is ourselves. Everything else they can read in a book.” [or find on the Web] Daniel Tosteson, M.D. Dean, Harvard Medical School 1979
Key Concepts • Mentoring is the provision of personal and professional guidance usually to a younger individual. • A mentor is an experienced advisor and trusted friend who is committed to the personal and professional successes of the mentee. • Changing demographics in surgery mandate the need for multiple mentors for each mentee. • Future changes in mentoring will incorporate ongoing advances in information technology. Surgery has a long and proud heritage of mentoring. Perhaps more than any other group of physicians, surgeons are imbued with appreciation, respect, and a sense of awe for the seminal contributions by the “giants” in their field. This appreciation is exemplified by most major surgical texts containing a chapter on surgical history, replete with old portraits, photographs, and in some instances, monographs of famous surgeons. These venerated individuals have both directly and indirectly served as mentors to perpetuate our specialty and provide the foundation for surgical leaders of the twenty-first century. Many of today’s acknowledged surgical mentors trace their educational lineage to more than a century. In contrast to their more famous counterparts, the majority of today’s surgical mentors do not receive national or
J. Rombeau et al., Surgical Mentoring: Building Tomorrow’s Leaders, DOI 10.1007/978-1-4419-7191-3_1, © Springer Science+Business Media, LLC 2010
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international notoriety; however, they play important roles in the perpetuation of quality surgery and the training of tomorrow’s leaders. This chapter defines mentoring, tells who a mentor is and explains what mentoring encompasses. The distinctions, often subtle, among mentors, teachers and role models are discussed. The etymology of the term “mentor” as well as historic examples of the evolution of mentoring are presented. Historic changes in surgical mentoring are discussed as well as a brief commentary on the changing mentoring environment for surgeons of the twenty-first century. (This topic is discussed extensively in Chap. 9.)
Mentoring and Mentor – Definitions The term “mentoring” originates from the Greek language and literally translates as “enduring” [1]. Mentoring is defined as a process whereby an experienced, highly regarded, empathetic person (the mentor) guides another usually younger individual (the mentee) in the development and re-examination of their own ideas, learning, and personal or professional development [1]. It is essentially the provision of both personal and professional guidance, usually to a younger individual. Frey opines that the mentoring process “is about inspiring interest and excitement in others” [2]. In surgery, this interaction may vary greatly from communicating a “love of surgery” to medical students, to discussing ways to improve ABSITE scores with residents, to providing advice to junior colleagues as to which surgical society to join. For purposes of this discussion, a mentor is defined as an experienced and trusted advisor committed to the personal and professional successes of the mentee. This definition is both pragmatic and subjective. Understanding the three descriptors – experience, trust and commitment – is fundamental to appreciate and comprehend the complete concept of mentoring. Experience is indeed an important pre-requisite for being a mentor. For example, it is our belief that for a surgeon to be an outstanding clinical mentor, he/she must be a good operating surgeon. The surgical mentor has more experience than the mentee (student, resident, junior faculty) as to the particular aspect of surgery or type of operation being mentored. Experienced surgical mentors are well founded in the
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scientific basis and clinical rationale for their decisions as to when to operate, when not to operate, what to take out and what to leave in. They also have proven expertise in perioperative care. In some instances, experience includes performing hundreds of specific operations, whereas the operative experience may be very limited while caring for patients with rare or unusual conditions, yet still be a valuable asset to the mentee. Trust and commitment are inherent in mentoring and are perhaps the quintessential qualities which distinguish the mentor from the teacher (see section Differences Among Mentors, Teachers, and Role Models). Most importantly, trust encompasses a personal relationship and commitment of the mentor to the mentee with the ultimate goal to develop the mentee into a successful professional. The trusting relationship is often more intuitive than explicit and is most effective when it is voluntary and not mandated. This is significantly different than most teacher–student interactions. Barondess describes the mentoring process as “Implicit processes, conversely, are not consciously or deliberately displayed. They involve the exemplar role of the mentor: intellectual style, professional priorities, deliberateness, truth telling, and the flavor of interpersonal relationships. Elements of scholarliness, thoroughness and loyalty, as well as styles of interactions with patients, peers and juniors are also powerfully displayed in implicit fashion” [3]. Implicit processes also include the important set of qualities noted by McDermott as the Samaritan functions of the physician – support, empathy and identification with the suffering of the patient [4]. These qualities are deeply imbued in respected surgical mentors. As an effective advisor, the mentor assesses the aptitudes and abilities of the mentee particularly as to the appropriateness of projected goals. This does not mean that the mentor directly “spoonfeeds” or tells the mentee what to do. Most experienced mentors recognize that the most cogent advice is often communicated by defining problems or clarifying issues to guide the mentee to arrive independently at the solution. This process stimulates both active listening and critical reasoning in the mentee. By teaching the trainee to listen, think and question, the mentor helps to transform information into maturity and wisdom. Clearly, the transference of knowledge is integral to effective mentoring. According to Souba, “Challenging the mentee forces him to step out of his comfort zone (where there is predictability and minimal risk but limited potential
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for new growth) into the zone of discomfort (where there is conflict and greater uncertainty, but potential for growth and new learning)” [5]. A major function of the mentor is to communicate the importance of acquiring the “whole package” along the journey to become an accomplished surgeon. This “package” includes not only clinical expertise but knowledge of relevant research, good communication skills, and integrating empathy and humanism into the complete management of the patient (see Chap. 3). As eloquently expressed by Barondess, this unique relationship is a “multifaceted and complex relationship between senior and junior professionals which, when successful, serves to fortify and extend within the younger person characteristics and qualities integral to professional development” [3]. Mentoring is truly a partnership between the mentor and mentee. Is it no longer acceptable for the mentor to control the relationship through the use of intimidation, power and subservience [6]. Mentoring is a career long process for many; however, there is generally a time limit to most mentor-mentee relationships. As the mentee matures, gains self-confidence and feels empowered he/she naturally becomes less dependent upon the mentor. A great mentor genuinely wants his/ her mentee to do better than the mentor has done and takes to heart the old proverb “If the accomplishments of the student do not exceed those of the teacher, the teacher has failed.”
Differences Among Mentors, Teachers, and Role Models Mentors are both teachers and role models; however, only a few teachers and role models are mentors. Perhaps the most important differentiating quality among mentors, teachers and role models is the personal commitment of the mentor to the mentee; thus, mentors are engaged in not only the transference of information but in the personal and professional successes and growth of the mentee. Additionally, the mentoring process is characterized by frequent oneon-one informal interactions instead of being limited to a formal classroom setting. In some instances this interaction may evolve from an advisor or teacher into a mentor. Most importantly, surgical mentors do not just question the student as to didactic knowledge; they want
Defining the Mentee
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the mentee to understand why problems occur and the rationale for their treatments. Teaching the mentee to question dogma and to approach surgical problems in an organized and objective manner are major goals of the mentor. Although most mentors are role models to the mentee, most role models are not mentors. The major difference between the two is the extent and duration of interaction. In some instances role models may have very limited contact or even no contact with the student or mentee. For example, Michael Jordan is unquestionably a role model for many aspiring basketball players but he is not a mentor to them. In surgery, many influences of the role model are passive and often conveyed through publications, verbal presentations or professional awards. The mentor’s quest and qualities are summarized by Barondess: “Mentoring, to be effective, requires of the mentor empathy, maturity, self-confidence, resourcefulness, and willingness to commit time and energy to another. The mentor must be able to offer guidance for a new and evolving professional life, to stimulate and challenge, to encourage self-realization, to foster growth, and to help make more comprehensible the landscape in which the protégé stands” [3].
Defining the Mentee The mentee is the individual taught and guided by the mentor. Although the mentee is always a student, whether formally or informally, young or old, only a few students are truly mentees. Historically, the mentee was occasionally known as a protégé (favorite, dependent), a term derived from the French verb protéger – to protect. To a certain extent today’s mentor still “protects” the mentee; however, the mentee’s ultimate autonomy and personal identity are implicit in the relationship. Mentees are often inspired to “give back” as the result of the mentoring process. Souba proposes that the best way to become a mentor is to be mentored. He states, “At the core of being a mentor is a basic understanding of people – what motivates them and what gives their life meaning and fulfillment. Our mentors help us appreciate the value of sharing the potential they helped cultivate in us. In so doing they inspire us to want to reciprocate” [7].
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History and Evolution of Mentoring Literature The concept of mentoring is thought to have originated from Gilgamesh, a Sumerian king, who lived about 2600 BC. Gilgamesh’s life was replete with many adventures, battles and legends [8]. He was described as two thirds god and one third human (perhaps a little less god-like than promulgated by many surgeons!) Despite his purported deification, Gilgamesh was arrogant, vain and ruthless. During his wanderlust, he serendipitously met Enkidu, a mentor who, through many fights, disagreements and interactions, changed Gilgamesh’s errant behavior by channeling him into benevolence and being a responsible leader. This epic legend underscores the mentoring impact of Enkidu, a friend and advisor, to ultimately provide guidance and influence leadership for the betterment of mankind. The word “mentor” is first mentioned in Homer’s Odyssey [9]. Mentor, a wise and trusted friend of Odysseus (Ulysses), King of Ithaca, remained in Ithaca to educate and take care of Telemachus, Odysseus’ infant son, and his wife Penelope, while Odysseus left for 20 years to fight the Trojans (Fig. 1.1). Mentor’s dedicated commitment to the education and well being of Telemachus provided the initial inspiration for the use of the term mentor. Mentor was not only responsible for educating Telemachus, most importantly, and apropos to the concept of mentoring, he was charged with teaching personal values and integrity with the ultimate goal of communicating wisdom. The importance of mentoring in this epic is further emphasized by Athena, the goddess of wisdom. As Mentor aged, Athena disguised herself and assumed the form of Mentor and continued the mentoring process. Due to the prolonged absence of Odysseus, Mentor and Telemachus set out to find the Ithacan King. At the completion of his journey, Telemachus had truly matured and was able to function as a wise and trusted adult. Thus, Mentor, and Athena disguised as Mentor, were key individuals in the education and transformation of Telemachus. This story is perhaps the most important historic example of the qualities of a mentor as an experienced, committed, trusted friend and advisor and an important influence on the education of a younger person.
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Fig. 1.1 Telemachus conferring with mentor (public domain)
Additional historic examples of mentors and their respective mentees are evident in the early Greek literature with examples including Socrates (see Chap. 4, section Socratic Method) and Plato, Plato and Aristotle, and Aristotle and Alexander the Great. Major historic examples of mentorship are also noted in religions and include the Greek pederasty, the Hindu and Buddhist guru-disciple relationship, the Rabbinical and Christian systems of Elders and the medieval guild system of apprenticeship. Dante’s Divine Comedy is often acknowledged as a classic example of the metaphorical journey of mentoring. This epic highlighted the role of a guide in the journey of life. The ideal guide was the Roman poet, Virgil, who directed Dante through the treacherous pathways of Hell and Purgatory to be followed by Beatrice, Dante’s ideal woman, who directed him through Heaven.
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Nineteenth Century Early Surgical Mentoring (Preceptorships) Although not a true mentor–mentee relationship because of frequently selfish motives of the preceptor, a facsimile of surgical mentoring was provided by older, experienced preceptors during this period. Preceptorships varied from minimal, peripheral exposure between experienced and younger individuals to a more intense, closer interaction. In some instances preceptorship was harsh and physically demanding servitude of the preceptee. This relationship was an apprenticeship and the duration and quality of training varied immensely; in many instances there was not a well defined end point for completion of the preceptorship. The preceptee was often viewed by the senior surgical mentor (preceptor) as being “not quite ready” thus affording the preceptor prolonged and increasingly experienced assistance at a very low salary. Theodor Billroth (1829–1894) was perhaps the greatest surgical mentor of the nineteenth century (Fig. 1.2). His renowned surgical
Fig. 1.2 Theodor Billroth (1829–1894) (public domain)
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expertise attracted apprentices from throughout the world. A close friend of Johan Brahms, Billroth became known as an accomplished musicologist as well as the father of “modern” abdominal surgery. He mentored a prodigious number of surgeons in his Viennese clinic including Carl Langebush, who became Professor of Surgery at the University of Vienna and Theodore Kocher, a brilliant Swiss surgeon who founded thyroid surgery and was awarded the Nobel Prize for Medicine and Physiology in 1909. Billroth’s influence is evident today through his tutelage of the Polish surgeon Jan MikuliczRadecki (1850–1905) who discovered inflammation of the lacrimal and salivary glands (Mikulicz disease), the Heineke-Mikulicz pyloroplasty and gauze packing of open surgical wounds (Mikulicz pack [also known as a laparotomy pack] currently used by many surgeons). American surgery was directly influenced by another Billroth pupil, John B. Murphy (1857–1916), who became Professor of Surgery at Northwestern University School of Medicine. Doctor Murphy devised the Murphy “button” to join the intestine without the need for extensive sutures. This concept was ultimately incorporated into gastrointestinal stapling devices. Finally, the eminence of the Billroth Clinic and the enormous successes of its trainees served as a prototype for the Halstedian program at Johns Hopkins University. Mentoring by preceptorship continued well into the twentieth century and was a frequent mode of “refresher” training for surgeons returning home following military service in World War II and the Korean War. The University of Pennsylvania built the Graduate Hospital in Philadelphia to train and re-train returning physician veterans.
Halstedian Training The beginning of formal, structured surgical training and mentoring in the United States is credited to William Stewart Halsted (1852– 1922) at Johns Hopkins Medical School in the late 1800s and early 1900s (Fig. 1.3). One of Halsted’s seminal contributions to surgical mentoring was the emphasis upon scientific evidence for clinical decisions. This approach included integrating anatomic and physiologic principles and even the results of animal experimentation into decisions affecting patient care. Apropos to mentoring, Halsted strove to train outstanding surgical teachers and scientists and not
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Fig. 1.3 William Stewart Halsted (1852–1922) (public domain)
just technically competent surgeons. A classic example of Halsted’s effectiveness as a mentor was his tutelage of Harvey Cushing. Halsted stimulated Cushing to integrate surgical science into clinical care and encouraged him to go into neurosurgery. Halsted also introduced Cushing to William Osler, the most important physicianmentor of his time. Cushing and Osler shared a lifelong mentoring relationship. Many principles of Halstedian training have remained in surgery into the present. This is particularly true in research-oriented departments of surgery where the provision of surgical training and clinical care is strongly influenced by evidence-based research.
Twentieth Century Influence of Television Television became immensely popular in the 1950s and included many medical programs which portrayed the complex interactions between physician/surgeon role models and mentors. Marcus Welby epitomized the caring physician who routinely placed the
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patient first when making clinical decisions. Ben Casey revealed the intensity and clinical challenges of a young neurosurgeon who struggled with the complexities, rigors and responsibilities of caring for patients with potentially fatal conditions. Dr. Kildare personified the insecurities, triumphs and disappointments in the daily life of an intern in training. The popular theme of medical/surgical training continues today in programs such as Grey’s Anatomy and ER. These shows reflect contemporary changes and demands in surgical/medical training such as limited training hours and teambased care.
Twenty-first Century: A Changing Paradigm for Surgical Mentoring Many recent events of the twenty-first century have both directly and indirectly led to significant changes in surgical training and mentoring (Table 1.1). The demographics of surgical trainees are changing in a dramatic fashion reflective of an increasingly diverse population in the United States. The previous preponderance of white males has been replaced by varied ethnicities and gender equality. Most contemporary training programs include nearly equal numbers of men and women [10]. Current surgical demographics mandate changes in Table 1.1 Changes in surgery – twentieth and twenty-first centuries Twentieth century Twenty-first century Surgical Primarily white Gender equality demographics males Varied ethnicity Clinical schedules Every other night call 80 h work week Financial debts of Significant, but payable Significant, payable only resident over prolonged period Patient responsibility Autonomous Team based Operative decisions Unquestioned Insurance companies-major influence Transparency, liability Minimal accountability Public information Primary task Patient care Business/clients/customers; entrepreneurs Mentors Solitary Multiple, more fragmented
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mentoring to accommodate the needs of pregnancy, parenting, and shared marital responsibilities heretofore performed solely by women (see Chap. 5). Currently many surgeons have working spouses which in turn leads to less time for leisure and family activities. Shared marital responsibility for household and childcare tasks is becoming the norm. Increasing numbers of surgical trainees are international medical graduates. These individuals are frequently unfamiliar with many nuances and customs of American medicine and training programs. The cultural backgrounds and differences in medical school training of these individuals must be addressed to provide effective mentoring (see Chap. 6). The time available for surgical mentoring has significantly diminished. Surgical training in the twentieth century was arduous. Every other night call schedules often resulted in residents spending up to 120 h a week in the hospital (hence the term “resident”). Despite many hardships created by these rigorous schedules, there were positive sequelae. The extensive hours in the hospital provided numerous opportunities for mutual interactions between an experienced mentor and a young mentee-resident. These associations were strengthened by increased operative experience for the mentee. Additionally, this milieu provided more opportunities for intraoperative teaching and establishment of a close rapport between the mentor and mentee. The current 80 h work week in the United States has reduced operative experience for the trainee, decreased time for perioperative care and increased demands for the acquisition of surgical knowledge in an increasingly limited teaching environment. Decreased time in the hospital also reduces the surgical trainee’s clinical experience and interaction with seasoned mentors. Furthermore, senior surgical mentors are confronted with increasing pressures to generate more revenue, thus reducing their time for mentoring. Consequently, many younger surgeons are first confronted with certain diagnostic and therapeutic problems after completion of their training and well into clinical practice. These changes necessitate new strategies in mentoring such as having multiple mentors (see Chap. 9), and mentoring after the mentee is in clinical practice. Today’s surgical trainee has unprecedented financial debt due to increasing costs of medical training. These debts are compounded by relatively fixed incomes, increased costs of living, and the inordinately
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long duration of surgical training when compared to other medical specialties. Whereas previous eras were characterized by single mentor– mentee relationships, the need for multiple mentors is rapidly becoming dominant in today’s world of limited time for teaching. Multiple mentors include individuals with special expertise (e.g., research, clinical care, administrative, etc.) who, due to time constraints, limit their interaction with the mentee to well-defined areas. This approach is the antithesis of the classic, one-on-one mentor–mentee dyad relationship. Moreover, it intensifies the difficulties of maintaining a personal and close commitment between the mentor and mentee. It is therefore anticipated that future mentoring will be provided by many individual mentors for each mentee. As mentioned, this paradigm continues to be driven by decreased training hours of the mentee and increased demands enforced upon the mentor to generate more clinical revenue. The concept of multiple mentors is discussed in greater detail in Chap. 9. Regrettably, surgery is changing rapidly from a revered profession, primarily dedicated to helping patients, to a multibillion dollar business. In many instances the clinical relevance of diagnostic tests and treatments is ultimately determined by insurance companies rather than by physicians and surgeons. The term “patient” has been replaced by “customer” or “client” in many medical environments. These “new rules” are here to stay and must be incorporated into today’s mentoring process. The surgical mentee must therefore be taught to be an astute and informed business person to survive in today’s new world of medical economics; thus the importance of the business mentor (see Chap. 4). Despite these problems there are exciting aspects of today’s new surgical mentoring (see Chap. 9). Surgical simulators have greatly enhanced the learning of laparoscopic techniques and endoscopy. Within seconds, the computer and wireless aids provide access to unlimited amounts of clinical and research information both at the bedside and in the operating room. Teleconferencing and telementoring provide the opportunity to transmit a single operating room into hospitals and classrooms throughout the world. Initially restricted to selected broadband wave length transmission, telesurgery is now transmissible via the Internet [11]. Today’s younger surgeons are group learners and are comfortable providing care within this context.
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Summary and Conclusions Mentoring is the provision of personal and professional guidance usually to a younger person. A mentor is an experienced and trusted advisor who is committed to the personal and professional successes of the mentee. The personal relationship with the student or mentee differentiates the mentor from the teacher or role model. Examples and qualities of mentors are depicted throughout history from the Homeric legends to contemporary television programs. The twenty-first century has changed the traditional paradigm for surgical mentoring and provides exciting new opportunities.
References 1. Taherian K, Shekarchian M (2008) Mentoring for doctors. Do its benefits outweigh its disadvantages? Med Teach 30:e95–e99 2. Fernandez-Zapico ME (2008) Mentoring is about inspiring interest and excitement in others. An interview with Charles Frey. Pancreatology 8:415–419 3. Barondess JA (1997) On mentoring. J R Soc Med 90:347–349 4. McDermott W (1978) Medicine: the public good and one’s own. Perspect Biol Med 21:167–187 5. Souba WW (1999) Reinventing the academic medical center. J Surg Res 81:113–122 6. Souba WW (1999) Mentoring young academic surgeons, our most precious asset. J Surg Res 82:113–120 7. Souba WW (2000) The essence of mentoring in academic surgery. J Surg Oncol 75:75–79 8. Epic of Gilgamesh (2009) http://www.studylit.com/summaries/gilgamesh. htm. Accessed 17 Feb 2009 9. Homer (1979) The Odyssey. Simon & Shuster, New York 10. AAMC (2010) Women in U.S. academic medicine: statistics and benchmarking report 2008–2009. http://www.aamc.org/members/gwims/statistics/stats09/ wimstatisticsreport2009.pdf. Accessed 28 March 2010 11. Sterbis JR, Hanly EJ, Herman BC et al (2008) Transcontinental telesurgical nephrectomy using the da Vinci robot in a porcine model. Urology 71:971–973
Chapter 2
Why Surgical Mentoring is Important and Evidence That it Makes a Difference
I have learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel. Maya Angelou
Key Concepts • Most successful surgeons have had accomplished surgical mentors. • Mentoring provides evidence-based personal and career benefits to the mentee. • Immense personal satisfaction and a prolonged opportunity to help others are the principal benefits to the surgical mentor. Most surgeons continue to seek challenges regardless of the stage of their careers. Whether preparing younger surgeons for private practice or an academic career, mentoring is one such challenge. This is particularly true for senior surgeons working in teaching hospitals and academic institutions. Both the mentee and the mentor benefit from the mentoring process. The mentee receives personal and professional benefits to his/her career which are documented in evidence-based studies. Mentoring provides an enormous sense of satisfaction to the mentor as well. The patient is the ultimate and most important beneficiary. This chapter presents an example of an exemplary surgeon who mentored other surgeons, reviews the rationale for the mentoring process as determined by its benefits to mentees, mentors and patients and provides evidence for this rationale.
J. Rombeau et al., Surgical Mentoring: Building Tomorrow’s Leaders, DOI 10.1007/978-1-4419-7191-3_2, © Springer Science+Business Media, LLC 2010
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Jonathan E. Rhoads – A Successful Surgical Mentor It is meaningful to examine the careers of successful surgical mentors and their protégés as their lives and accomplishments provide inspiration for medical students and surgical residents to find mentors. A few of the many revered, successful surgical mentors from the latter half of the twentieth century include Professors Austen, Coller, Dunphy, Longmire, Moore, Sabiston, Spencer, and Wangensteen. One of us (JLR) was fortunate to have spent a considerable amount of time with an equally successful surgical “giant,” Jonathan Evans Rhoads (Fig. 2.1). Dr. Rhoads spent his entire professional career at the University of Pennsylvania where he was Professor and Chairman of the Department of Surgery 1959–1972, and Provost of the University of Pennsylvania 1956–1959. He is perhaps best remembered for his research in intravenous feeding. His persistence in this field, combined with the able and creative assistance of his many surgical mentees, particularly Stanley Dudrick and Douglas Wilmore, led to the discovery of total parenteral nutrition (TPN). Currently used in every major hospital worldwide, TPN has saved thousands of lives.
Fig. 2.1 Jonathan E. Rhoads, M.D. 1907–2002 (Credit Yousuf Karsh, 1984)
Jonathan E. Rhoads – A Successful Surgical Mentor
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Table 2.1 Surgical chairmen trained by Jonathan E. Rhoads, Chairman of Surgery, University of Pennsylvania 1959–1972 Clyde F. Barker University of Pennsylvania P. William Curreri University of South Alabama Stanley J. Dudrick University of Texas Houston Robert W. Crichlow Dartmouth University James O. Finnegan Medical College of Pennsylvania C. Everett Koop Children’s Hospital Philadelphia, U.S. Surgeon General Leonard D. Miller University of Pennsylvania F. Carter Nance St. Barnabas Medical Center, Livingston, NJ Charles C. Wolferth, Jr. Hahnemann University
Dr. Rhoads’ many career accomplishments have been chronicled elsewhere [1–3]; however, he is an outstanding example of how a single mentor/role model/surgeon can affect the creation of other successful surgical mentors. A list of his mentees who became surgical chairmen is shown in Table 2.1. The number of additional successful surgeons who trained under Dr. Rhoads’ mentees is exponential and their influences on today’s younger surgeons continue to be significant. On a personal note, Dr. Rhoads’ “ghost” continues to haunt me (JLR) as rarely a day goes by without my invoking his presence. At times when I’m confronted with a difficult clinical decision or even a seemingly mundane action is required, I find myself asking “What would Dr. Rhoads do?” Recently, following an especially challenging operative day interspersed with varied administrative tasks, I finished my last case about 9:30 p.m. exhausted and barely able to change out of my scrubs. All I could think about was heading straight home, skipping dinner and going immediately to bed! Then I hesitated, remembering there was one inpatient whom I had not seen earlier in the day. She was an elderly lady, several days postop, in a distant part of the hospital, whom the chief resident had previously told me was doing well and I could definitely see her the next morning. The nagging question arose – “What would Dr. Rhoads do?” The answer was obvious – Dr. Rhoads would see the patient. By now it was after 10 p.m. Suffused with fatigue I reluctantly trudged to her room where I was surprised to see four family members who had waited several hours to see me. A rapid chart review followed by a brief physical exam (both unnecessary) confirmed the prior feedback that the patient was doing well and was ready for discharge in the morning. Her family (and she) was effusive in their gratitude for my seeing
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their mother at such a late hour and mentioned it was definitely worth the wait. Once again Dr. Rhoads’ enduring mentoring influence had been felt. Never underestimate the far-reaching guidance of a good mentor!
Importance of Mentoring to the Mentee Most successful surgeons have had at least an association with an older, more experienced, successful surgeon. While one can argue whether this is an associative versus causative phenomenon, it is indisputable that something “happens” in this relationship which, in turn, influences the career success of the younger surgeon. This hierarchical experience permeates all levels of surgeons from the medical student rotating on a surgical service to the accomplished professor. There is a strong precedent for mentoring at the highest level of academic excellence as exemplified by more than 50% of US Nobel laureates having served under other Nobel laureates in the capacity of student, postdoctoral fellow or junior collaborator [4]. Mentoring benefits the surgical apprentice in many ways. Firstly, “doors of opportunity” are opened as the result of the acknowledged prestige, stature, peer recognition and accomplishments of the mentor. When referring to a young surgeon who has recently completed training, how often do we hear the compliment “He trained under the famous surgeon Professor X?” Whether or not completely justified, comments and associations such as these frequently provide an aura of instant credibility to the mentee. While one can dispute the appropriateness of this evaluation, associations with influential mentors continue to be vital in the twenty-first century to advance careers of young surgeons.
Evidence-Based Benefits to the Mentee Mentoring in Academic Medicine Many investigators have tested the hypothesis that mentoring actually benefits the mentee. A recent review by Sambunjak and colleagues of the importance of mentoring in academic medicine
Evidence-Based Benefits to the Mentee
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examined the actual prevalence of mentorship and its relation to career development [5]. Although this study did not address surgical training per se, many of the findings encompass all medical specialties. Based upon predetermined criteria, 42 reports describing 39 studies were selected for analysis from 3,640 citations and 142 full text articles. In a subset analysis of 24 US medical schools, faculty members with acknowledged mentors had significantly higher career satisfaction scores than those without mentors (p
