The Unwritten Rules of Mentorship: Facilitators of and Barriers to Effective Mentorship in Pediatric Hospital Medicine
- Jana C. Leary, MD,
- Elisabeth G. Schainker, MD, MSc and
- JoAnna K. Leyenaar, MD, MPH
- Department of Pediatrics, The Floating Hospital for Children at Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
- Address correspondence to Jana C. Leary, MD, The Floating Hospital for Children at Tufts Medical Center, Tufts University School of Medicine, PO Box 7051, 755 Washington St, Boston, MA 02111. E-mail:
OBJECTIVES: Benefits of effective mentorship include career satisfaction and academic productivity. Given the youth of pediatric hospital medicine (PHM), effective mentorship is a widely acknowledged challenge. This study aimed to characterize successful pediatric hospitalists’ past and current mentorship experiences and identify facilitators of and barriers to effective mentorship in PHM.
METHODS: Semistructured phone interviews were conducted with peer-nominated pediatric hospitalists, exploring past and current mentorship experiences and approaches perceived to aid or hinder mentorship relationships from both the mentor and mentee perspectives. Interviews were recorded verbatim, professionally transcribed, and analyzed by using a general inductive approach.
RESULTS: Sixteen interviews were conducted and transcribed. Participants reported having a median of 3 mentors and 6 mentees. Three themes emerged regarding how mentors can optimize mentorship: (1) comprehensive focus on the mentee, (2) setting of clear expectations, and (3) acknowledgment of mentors’ limitations. Five themes emerged regarding how mentees can optimize mentorship: (1) preparation, (2) proactivity, (3) continual reevaluation of relationships, (4) willingness to seek mentorship outside of common venues, and (5) building of a mentorship team. Major barriers to effective mentorship included (1) mismatched expectations between mentor and mentee, (2) lack of available mentors in PHM, (3) lack of time/compensation for PHM mentors, and (4) geographic separation between mentor and mentee.
CONCLUSIONS: Several themes emerged regarding facilitators of and barriers to effective mentorship in PHM. These “unwritten rules of mentorship” may serve as a guide to establish and maintain beneficial mentorship relationships and overcome challenges.
Within clinical and academic medicine, effective mentorship has been shown to have many benefits for mentees, mentors, and their institutions. Mentees with successful mentorship relationships are more likely to exhibit advanced career development and academic productivity, increased career satisfaction and emotional support, and improved work-life balance.1–17 Mentors also report benefits including personal and professional rejuvenation and a sense of “giving back” to their profession.18,19 At the institutional level, mentorship programs have been shown to increase faculty retention rates.5,7,20–22
These benefits have made mentorship a natural cornerstone in research and academic promotion; however, development of effective mentorship relationships remains a challenge, as few guidelines exist about how to make the relationships most effective.5,12,13,23–25 This challenge may be particularly apparent to clinicians seeking mentorship beyond the traditional research mentorship infrastructure, in areas such as leadership, medical education, quality improvement, and professional development.26 Mentorship within pediatric hospital medicine (PHM) may be especially difficult given the field’s rapid growth, relative youth, and diverse practice settings, professional roles, and residency and fellowship training.27 Despite this, effective mentorship in PHM is likely to become even more desirable for hospitalists and their institutions, as the field is actively pursuing board certification as a subspecialty. Within this context, our study aimed to characterize successful pediatric hospitalists’ past and current mentorship experiences and to identify facilitators of and barriers to effective mentorship in PHM.
Pediatric hospitalists of any rank considered to have been successful within the fields of community pediatrics, education, leadership, and/or research were identified by peer nomination using the American Academy of Pediatrics’ Section on Hospital Medicine (AAP SOHM) national listserv from February to March 2013. Successful pediatric hospitalists were sought to identify individuals who had effectively climbed the ladder of career development, likely making them uniquely qualified to understand mentorship relationships from both the mentee and mentor perspectives. Participants were purposefully sampled from this list of nominees to reflect approximately equal numbers of male and female hospitalists working in diverse practice environments and professional roles, with prioritization given to hospitalists who received multiple nominations.
Given our interests in exploring the complexity of these issues and to encourage comprehensive responses, we used qualitative research methods.28 Participants completed an online questionnaire followed by a semistructured key informant interview by telephone. The questionnaire focused on demographic characteristics as well as self-reported leadership responsibilities in the areas of administration, education, research, quality improvement, and community hospital medicine. Interviews were conducted by a trained research assistant by using open-ended questions and associated probes to encourage comprehensive responses, and were audio-recorded with permission. Interview questions sought to explore past and current mentorship experiences, with particular focus on approaches perceived to aid or hinder mentorship relationships. Table 1 details areas of interview inquiry.
Interviews were professionally transcribed and all identifiable information was removed. Transcripts were then analyzed by using a general inductive approach to identify emergent themes regarding facilitators of and barriers to effective mentorship in PHM.29 Three members of the research team individually read all transcripts to identify preliminary themes and then collaboratively developed a series of codes and associated code definitions. Transcripts were then analyzed by applying these codes to relevant sections of each transcript; each unique coded transcript section was defined as a transcript excerpt. After code application, 2 members of the research team grouped related codes into themes and categories of themes. Analysis was iterative, and 3 members of the research team continued to meet periodically to determine when thematic saturation had been reached, after which interviews were discontinued.30 Our study qualified for exemption by the Tufts Medical Center Institutional Review Board.
A total of 44 pediatric hospitalists were nominated by 32 AAP SOHM listserv subscribers for participation in this study. Of these, 24 were recruited for the study, and thematic saturation was attained after 16 nominees, all from different institutions, were interviewed.
Demographic Characteristics and Mentorship Experiences
Participants were nearly equally distributed between male and female genders, with a wide range of ages and years of medical experience (Table 2). All participants worked full-time, holding formal leadership positions in multiple fields, including hospital administration, community medicine, medical education, quality improvement, and research. All participants endorsed currently having mentors, with a median of 3 mentors (interquartile range [IQR] 3–4), and most reported receiving mentorship in multiple areas, including leadership, academics/research, education, networking, navigation of hospital politics, quality improvement, and/or work-life balance. All participants also reported currently acting as a mentor to others, with a median of 6 mentees (IQR 5–9). Almost all participants (n = 15, 94%) stated that mentorship had contributed to their career success.
A total of 124 excerpts from interviews were coded and grouped into themes based on recurring content. These themes were then grouped into 3 categories: (1) facilitators of effective mentorship for mentors, (2) facilitators of effective mentorship for mentees, and (3) common barriers to effective mentorship. Table 3 illustrates these categories, themes, and representative quotations.
Facilitators of Effective Mentorship for Mentors
Three themes emerged regarding how mentors can optimize mentorship: (1) comprehensive focus on the mentee, (2) setting of clear expectations, and (3) acknowledgment of mentors’ limitations.
Participants reported that successful mentorship relationships maintain a comprehensive focus on the mentee (theme 1), stating that mentors must strive to get to know the mentee well on both a personal and professional level. One hospitalist described this by stating, “I think that when you mentor someone, you mentor that whole person.” Participants also stressed that mentors must strive to fully understand the mentees’ goals and needs, with 1 hospitalist describing a need to “… really understand that everybody’s coming from a different perspective and everybody has different goals of what they want.” Expanding on this, participants reported that mentors must avoid pushing their own agenda to keep the mentee the central focus of the relationship. One hospitalist described this by stating, “You want to have respect for someone…the mentor should not be trying to recreate themselves.” Some interviewed participants stressed the importance of this theme to the point of suggesting that a mentor’s dedication to the mentee should reach altruistic levels. They expressed that mentors must find a way to “be invested in the mentee as a person,” to “be supportive” and “available,” despite potential time limitations, differing interests, or other challenges.
Many participants stressed the importance of setting clear expectations (theme 2), preferably at the beginning of the mentorship relationship, for it to be successful. They reported that mentors and mentees often have very divergent expectations, and only if expectations are made transparent and “some parameters” clearly defined, can the relationship be better tailored to each individual’s style and made more effective. One hospitalist stressed this by stating, “I think setting expectations at the beginning is vitally important…not just the overall goal, but…specifics.”
Acknowledgment of mentors’ limitations (theme 3) was also identified by hospitalists as a key contributor to the success of mentorship relationships, recognizing that even the most capable mentor has limitations to his or her fund of knowledge or expertise. Multiple hospitalists suggested that to be an excellent mentor, you must “put egos aside,” acknowledge when “you’re out of your realm,” and know when to direct mentees toward another individual who may be better able advise them. One expressed this by stating, “I am not a mentor in research...if I’m someone’s primary mentor, one of the things I need to mentor them in is finding people who are good mentors in research.”
Facilitators of Effective Mentorship for Mentees
Five themes emerged regarding how mentees can optimize mentorship, with representative verbatim quotations presented in Table 3: (1) preparation, (2) proactivity, (3) continual reevaluation of relationships, (4) willingness to seek mentorship outside of common venues, and (5) building of a mentorship team.
Many participants identified robust preparation (theme 1) on the part of the mentee as a vital determinant of success in mentorship relationships. Many stressed the need for mentees to begin a mentorship relationship only after having thought intensely about their own lives and careers, allowing them to be “as specific as possible” with regard to “what they want to get out of the relationship.” This mindfulness was described as valuable to developing an organized approach from the onset. Participants reported that mentorship relationships were most effective when a mentee could know and share his or her needs, goals, and expectations, and have an agenda. One hospitalist expressed this by stating, “you have to put a lot of work into it…the mentor cannot give you good advice if you cannot really clearly explain what you’re doing and where you’re trying to go,” while another stated that mentees “…need to prepare. Mentorship is not a relationship where you show up and somebody tells you what to do.”
Participants also reported that the mentee’s degree of proactivity (theme 2) was paramount in the establishment and maintenance of effective mentorship relationships. Participants described the benefit of having a mentee who is willing to “take a lead” and “reach out” to the mentor. They reported that this quality not only increases the likelihood of finding mentors, but it also keeps the mentorship relationship current and active. One participant expressed this by stating, “mentorship is something that really depends on the mentee a great deal to seek out.” Another hospitalist expanded on this, stating that it is the mentee’s “…job to reach out to the mentor, because the mentor does have a lot of other things going on.”
Many participants stated that to maintain successful, functional mentorship relationships, continual reevaluation of relationships (theme 3) must occur. A recurring topic throughout many interviews was the fluid nature of mentorship, with many hospitalists reporting that the relationship must evolve and grow along with the individual participants to be successful. Many hospitalists acknowledged that during this evolution, some mentorship relationships lose their utility, and stated this should be recognized so as to appropriately discontinue those relationships, allowing the mentee to “regroup” and “find another mentor” who can contribute to a more functional relationship. One hospitalist described this by stating, “there’ve been people who I’ve needed at certain points in time, and then my utility for that part of the relationship went away as I moved on.” In response to these situations, another participant suggested, “if [the mentees] are not getting what they need, they need to be able to…find someone else to be a mentor.”
All interviewed hospitalists expressed a belief that mentorship is important to career success, with many suggesting that to achieve adequate and effective mentorship, it is helpful for mentees to have a willingness to seek mentorship outside of common venues (theme 4), potentially “beyond [their] institution,” at “national meetings,” or with peers. One hospitalist expressed this by stating, “I don’t think you should limit yourself to just those people in your own department or in your pediatric hospital…you want to be looking for…the type of physician that [you] would like to be ideally.” Some hospitalists expanded on the significance of this theme, stating it’s “really important, especially in our subspecialty (PHM),” as the relative youth of the field may not allow for a great number of senior mentors at any one institution.
Many interviewed hospitalists expressed that the building of a mentorship team (theme 5) could increase the likelihood of achieving effective mentorship, given that “there may not be 1 mentor that fits all [the mentee’s] needs.” They suggested approaching this in a deliberate fashion, acquiring different mentors to address specific needs and interests, effectively forming an individualized mentorship team. One hospitalist expressed this by stating, “you may need to work with more people on specific things, and that’s ok.”
Common Barriers to Effective Mentorship
Although interview questions probed barriers to effective mentorship from both the mentor and mentee perspectives, the same themes arose from both perspectives. Four common barriers to effective mentorship were identified and are represented with verbatim quotations in Table 3: (1) mismatched expectations between mentor and mentee, (2) lack of available mentors in PHM, (3) lack of time/compensation for PHM mentors, and (4) geographic separation between mentor and mentee.
Many participants described a detriment to the mentorship relationship when there are mismatched expectations between mentor and mentee (theme 1). One hospitalist stated, “I can think of times when the relationship was strained, probably because boundaries weren’t clear,” and another expressed, “it’s frustrating for the mentee and the mentor when you can’t even agree on what the issues are.” Some hospitalists offered personality or generational differences as potential sources of recurring difficulty. Shared projects and authorship were also cited as being particularly troublesome to a relationship if expectations were misaligned. One mentor stated, “I’ve had some mentees that really don’t follow through, and that gets frustrating,” and 1 hospitalist stated from the mentee perspective, “…sometimes, you know, you’ll do research, and then your mentor takes the credit.”
Multiple participants expressed that mentorship within pediatric hospital medicine may pose an even greater challenge, given the youth of the field and resultant relative paucity of senior faculty, causing a lack of available mentors in PHM (theme 2). One hospitalist described, “it’s a young field overall, so sometimes…you don’t feel like there’s anybody else to ask these questions of, especially if you’re at a community hospital….” Another participant stated, “I think locally it’s rare to have somebody senior in hospital medicine that has the experience needed to be a mentor.”
Many hospitalists reported that despite mentors’ best intentions to participate in mentorship relationships, lack of time/compensation for PHM mentors (theme 3) interfered with their ability to do so effectively. One hospitalist offered, “there are so many demands for your time, providing clinical service and…supervised education….” Another added, “it’s hard because we usually don’t get compensated for this.”
Seeking mentorship from nontraditional venues was acknowledged as being an important facilitator of mentorship, and some hospitalists provided options of e-mentoring or mentorship across institutional boundaries to accomplish this. However, these hospitalists also recognized that the inherent geographic separation between mentor and mentee (theme 4) in these types of relationships could be challenging. One hospitalist stated, “just not physically being around each other…it’s more difficult to get to know somebody…then it’s really hard to provide mentorship to them at a personal level.”
Very little is known about mentorship in pediatric hospital medicine; our study aimed to fill this void by identifying facilitators of and barriers to effective mentorship in PHM by using a qualitative research design to explore the complexity of these issues. Key facilitators of effective mentorship that emerged in our study, including the development of mentee-focused relationships, establishment of clear expectations, and acknowledgment of mentors’ limitations, may provide guidance for both new and established mentorship relationships. Themes regarding how mentees can optimize mentorship relationships, including being prepared, proactive, and willing to reevaluate relationships on an ongoing basis, may provide a concrete framework for junior faculty looking to develop or improve their mentorship experiences. Use of the facilitating strategies identified in our study, such as setting early and clear expectations, may also help to mitigate some of the barriers to effective mentorship, such as mismatched expectations. To facilitate discussion, we have reframed and summarized our results into a list of “unwritten rules of mentorship” illustrated in Table 4. These “unwritten rules of mentorship” can serve as a source of vital insight to section leaders, emerging and established mentors, PHM fellowship directors, junior faculty, and trainees interested in improving mentorship experiences.
Mentorship has been widely acknowledged as beneficial, but there are few available frameworks regarding how to make mentorship relationships most successful.5,12,13,23–25 In this context, some studies have sought to determine which characteristics of mentors are associated with positive mentorship experiences. Ramanan et al12 found that mentors who keep in touch regarding progress, do not abuse their power, provide advice regarding career plans and research, and aid in the development of mentees’ professional networks, are associated with more satisfying mentorship relationships. Probing for similar information, a more recent study by Cho et al23 sought to determine the characteristics of outstanding mentors by analyzing letters of recommendation for a Lifetime Achievement in Mentorship Award; it identified admirable characteristics, specific guidance of mentees’ careers, strength of time commitment, and support of personal and professional balance as key qualities in great mentors. Our research supports some of these findings but also identifies other facilitators, which, if used by mentors, may help to cultivate more effective mentorship relationships. Unlike the works by Ramanan et al12 and Cho et al,23 our research also identifies ways in which the mentee can contribute to or hinder the mentorship relationship. Within PHM, 1 recent study sought to characterize the adequacy and efficacy associated with research mentorship13; however, given the diversity of professional roles and training received by pediatric hospitalists, mentorship in more domains, such as community medicine, education, leadership, and quality improvement, may be particularly desirable and vital in PHM. Our research explores mentorship and its facilitators and barriers more broadly, reflecting the expansive reach and importance of mentorship beyond the traditional research infrastructure.
For pediatric hospitalists, the results of our study may prove particularly useful during this pivotal time in the history of their field. As the field of PHM pursues board certification, more PHM fellowships will likely emerge. New fellowships could provide a framework for the establishment of more formal mentorship programs, providing structured guidance for fellows’ professional and personal development. However, PHM remains a relatively young field, and the availability of senior mentors may become saturated with an influx of new fellows.27 Recognizing this, the results of our research could be used to guide both mentors and mentees regarding how to maximize the efficiency and effectiveness of mentorship meetings. Our research also revealed that mentees’ willingness to seek mentorship in other venues is a major facilitator for building mentorship relationships. Peer mentorship, and trans-departmental or even trans-institutional mentorship, may prove very useful during a time of rapid growth within the field.5,31–34
Although we anticipate that our facilitators and barriers may be useful tools for the medical community at large, our research was focused on the experiences of pediatric hospitalists and, as a result, may not be generalizable. Our relatively small sample size may also have limited the number of participants with expertise in particular fields, therefore the mentorship principles proposed may not apply equally to different fields of practice. Considering additional limitations, the use of a qualitative design may have caused our results to be inadvertently influenced by the research team’s personal biases. Last, by using the AAP SOHM listserv to solicit nominations for successful pediatric hospitalists, we may have disproportionately sampled more senior hospitalists working in tertiary care settings, therefore the perspectives of current junior faculty and community hospitalists may have been underrepresented.
Effective mentorship has been shown to have many benefits for mentors, mentees, and their institutions, and has therefore become a cornerstone of physician professional development.1–22 Despite this, there is a paucity of concrete tools available to aid in formation and maintenance of effective mentorship relationships. The results of our study may assist individual mentors and mentees in addressing challenges and in establishing and maintaining more beneficial mentorship relationships, and could be used to guide the development of more effective mentorship programs in PHM.
We acknowledge Grace Na's work in conducting the interviews for this project.
Dr Leary designed the data collection instruments, coordinated and supervised data collection, and drafted the initial manuscript; Dr Leyenaar conceptualized and designed the study and critically reviewed the manuscript; and all authors carried out the initial analyses, reviewed and revised the manuscript, and approved the final manuscript as submitted.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Dr Leyenaar was supported by grant K08HS024133 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- Copyright © 2016 by the American Academy of Pediatrics