Mentorship for female orthopaedic surgeons. Are we behind the curve?

08 Mar 2021

Authors:

     Antonia
     Hoylea

   Anna
   Walshb

     Somashree
     Chatterjia

   Helen
   McNeillc

 Naomi
 Davisd

aST8 T&O Health Education England North West
bST5 T&O Health Education England North West
cSenior Lecturer, Clinical Education, Edge Hill University
dConsultant Orthopaedic Surgeon, Royal Manchester Children's Hospital

The concept of 'mentorship' has been succinctly described as "using one’s wisdom (the product of reflection on experience) to help another person build their own wisdom"1. Originating in ancient Greek mythology, mentorship takes its name from the advisory role played to Telemachus by Odysseus’ friend Mentor in the Odyssey2. However, whilst Mentor has taken credit for this task, the most effective episodes of Telemachus’ mentorship were actually provided by a woman in disguise, the Greek goddess Pallas Athene3. Ironically, despite a woman occupying this fundamental, founding role in the very concept of mentorship, formal mentoring of women in surgery, and orthopaedic surgery in particular, remained obscure, and is only just emerging into clinical practice. Indeed, the first search returns for 'women surgery mentor' on a popular search engine comprise information on proprietary breast implants, rather than professional or academic information on surgical mentorship. Here, we evaluate the practice of mentoring in orthopaedic surgery, particularly for women.

What is mentorship?

A literature review yielded over 50 definitions of 'mentorship'4. One common theme across definitions is that mentorship is a learning relationship comprising a variety of functions, loosely categorised as psychosocial support (including role modelling), and career support (including career guidance, skills development and sponsorship)5. Similar dual role descriptions of mentorship include 'career' and 'psychosocial' cores6, and emphasis on both 'career and personal development'7.

Shared reflection and an open partnership between mentor and mentee are essential components of mentorship. Lancer, Clutterbuck and Megginson distilled mentoring as “using one’s wisdom (the product of reflection on experience) to help another person build their own wisdom.”1 This corresponds well to the descriptions offered by others including Clutterbuck’s idea that mentoring is “primarily listening with empathy, sharing experience (usually mutually), professional friendship, developing insight through reflection, being a sounding board, encouraging”8 and Connor and Pokora’s definition as “learning relationships which help people to take charge of their own development, to release their potential and to achieve results which they value”9. The importance of a mentor/mentee connection is emphasised, together with the concept of mentorship as a partnership9. Similarly, Parsloe and Wray note that mentoring “is usually understood as a special kind of relationship where objectivity, credibility, honesty, trustworthiness and confidentiality are critical”, and that the role of the mentor is to support and encourage mentees to “develop their skills, maximise their potential, improve their performance and become the person they want to be” through this relationship10.

Thus, mentorship comprises a mentor/mentee partnership, where learning, professional and personal development occurs through shared reflection and experience, working towards mutually agreed goals with the mentor acting as a more experienced guide to the mentee. Key components to enable a successful mentorship include mutual honesty, confidentiality and respect, and a careful balance between empathy and objectivity. But how far, and how well, have these aspects of mentorship practice implemented in the area of orthopaedic surgery?

Mentoring in orthopaedic surgical training

Within healthcare, mentorship has been described as “The process whereby an experienced, highly regarded, empathetic individual (the mentor) guides another individual (the mentee) in the development and re-examination of their own idea, learning, and personal and professional development”11. The Royal College of Surgeons gives some recognition to the importance of mentoring, advising that surgeons “take responsibility to act as a mentor to less experienced colleagues; to seek a mentor to improve your own skills at any point in your career and particularly when taking on a new role”12. This is the only mention of mentorship in a 30-page document, and arguably does not give sufficient detail or emphasis to reflect its importance in surgical practice. This attitude is reflected in the relative paucity of literature around mentorship in surgical training, particularly orthopaedic training, whilst literature evaluating the mentorship of women in orthopaedic surgery is more meagre still. Invaluable mentorship occurs throughout the orthopaedic community, but most is informal and unreported. Any evaluation of formal mentorship in orthopaedic training, whether specifically of women, or more generally, must draw from international literature, the majority of which is North American based. Whilst the themes and principles identified may be similar to those in the UK, their application must be carefully considered, given differences in healthcare systems and training structures.

Although surgical training has long followed an apprenticeship model, the concept of mentorship in surgical training was first formalised by US surgeon William S Halstead in the 19th century13. Most literature examining the role of mentorship in surgical training originates in the United States, yet even there, there is a relative lack of established mentorship schemes or formal training for mentors/mentees14. Similar themes are seen within UK surgical practice, where “a lack of a deliberate approach to mentoring in surgery” has been noted, and arguments made for more positive role models and mentorship in surgical training15. Only 49% of surgical trainees surveyed in 2014 reported having a mentor, with most UK surgical mentoring being of an “informal nature”16. Despite this, mentorship is highly valued by orthopaedic trainees, with 95.8% of US respondents indicating that “mentorship played an important role with respect to their development as an orthopedic resident”17.

Barriers to effective surgical mentoring include a lack of female mentors, time constraints and a lack of formal mentorship programmes18. In addition, in UK surgical practice, NHS work schedules, the rotational nature of training, and the European Working Time Directive, cumulate in trainees spending less time with their individual trainers19 perhaps reducing the opportunity to form closer working relationships that may develop into mentorships. The fact that the value of mentorship is being realised, yet obstructions to its effective practice remain, suggest that at present mentorship practice in surgical training remains in the “tactical phase”20.

Efforts have been made to embed mentorship into surgical training. Within this context, a mentor can be described as “a senior member of a field who guides a trainee in personal, professional, and educational matters” 18. This corresponds well to the multiple models of mentorship that highlight personal as well as career development. There is, however, considerable blurring of the lines between mentorship and training which calls into question whether surgical training has yet fully grasped the true concept of mentorship.

Given the relative paucity of UK literature, the report by Sinclair et al.16 of mentorship of surgical trainees provides the best insight. Analysis of its findings demonstrates both a relative lack of mentorship in surgical training, and conceptual tensions within the mentorship currently provided. Of surgical trainees surveyed, fewer than half reported having a surgical mentor. Of these, 52.5% and 45.5% respectively reported their educational supervisor or clinical supervisor as a mentor. Educational and clinical supervisors may well exhibit desirable mentor characteristics, distilled in systematic review18 as “acting as a professional role model, being supportive of and involved in a trainee’s progress, serving as a trusted evaluator of the mentee, and being a leader in their field”. However, the concept of an educational or clinical supervisor serving as a mentor conflicts with Clutterbuck’s assertion that mentorship should be separate from formal assessment processes20. MacAfee21 makes a similar argument for independent mentorship within surgical training, to allow for more “global support for personal and professional growth”. Given the formal role of educational and clinical supervisors in providing assessments of competence in speciality surgical training22, can either truly provide the degree of detachment and openness necessary for mentorship in its most authentic form? The National Association for Clinical Tutors explicitly recommend that a mentor be “a pastoral role separate from formal ES [Educational Supervisor] role”23. This is not to say that educational and clinical supervisors do not possess mentorship skills and characteristics. But in the absence of formal mentorship structures15, maybe surgical trainees are seeking out a (less authentic) form of 'mentorship' from trainers and supervisors with desirable mentor characteristics, and falsely identifying these trainers as mentors.

A similar conflict arises when considering the dual purposes of mentorship in facilitating both career and personal development. Of orthopaedic trainees surveyed in 2014, 51.2% reported having a surgical mentor16. The majority of this surgical mentoring focusses around clinical and professional matters, with much less attention given to pastoral and non-clinical matters. This lack of attention to pastoral and non-clinical matters sits in stark contrast to the multiple descriptions of mentorship that highlight personal as well as career development1,6,8,21, and again suggests that the majority of surgical trainees are receiving training and education from those they perceive as mentors, but not true mentorship. Although not explored, there is a suggestion that some surgical trainees are aware of this dualism of career versus personal development in the mentorship currently available, with 60% of trainees having more than one mentor, and 30% of these reported as undertaking different (i.e. clinical versus pastoral) mentorship roles16.

In addition to a surgical training system that has internalised a fundamental misunderstanding of mentorship, orthopaedic clinical practice presents several additional barriers to mentorship that must be overcome. These are described by Wilson24 as “a culture that does not favour seeking help”, “time constraints”, “the wide range of professional skills required for a mentor”, “lack of mentoring skills”, “lack of institutional support”, and “other potential problems” including interpersonal issues between mentor and mentee. Wilson does, however, offer insightful solutions to each of these barriers, including protected mentorship time, mentorship skills workshops and training, and openness and realistic expectations from both parties to the mentoring relationship. Indeed, the very title of his report, “An evolving need for nurture”, is reassuring in its recognition of the need for supportive professional mentorship in orthopaedic surgery, suggesting that growing interest and understanding of mentorship may improve its practice within orthopaedic surgery.

Mentorship for women in orthopaedic surgery

In UK clinical practice, women comprise 25% of orthopaedic trainees, and only 7% of orthopaedic consultants25. In a systematic review of mentorship in surgical training, the most frequently discussed essential mentor characteristic was “acting as a professional role model”18. When women form such a minority of orthopaedic consultants, does this leave a lack of role models and mentorship for female orthopaedic trainees?

The vast majority of UK surgical trainee respondents stated that having a mentor of the same gender was not an important attribute in their ideal mentor16. Similar trends are seen amongst American orthopaedic trainees, with the majority (79.4%) expressing no preference for the gender of their mentor26. A US study of female orthopaedic surgeons suggests that whilst mentorship and role models are important positive factors in determining an orthopaedic career, other internal motivators such as enjoyment of manual tasks, professional satisfaction and intellectual stimulation carried greater weight27. However, 69% of respondents to the same study also cited a lack of strong mentorship as a reason why women might not choose to pursue a career in orthopaedic surgery. Amongst American female medical students, exposure to same-sex mentors was highly rated as a positive influence on surgical career choices28. The effect of strong mentorship for female orthopaedic surgeons becomes more pronounced when choosing a career sub-speciality, having been identified as “the largest extrinsic/modifiable factor that affected the decision-making process”29.

This lack of mentorship for female orthopaedic surgeons was noted in 2015, with the observation that women experience “greater challenges in procuring effective mentorship”, which remains “a key factor in career progression”30. Mentorship is beneficial to the mentee within medical education and clinical practice, and associated with faster promotion, higher rates of publication, and greater career satisfaction31. A review of annual orthopaedic meeting programmes in North America demonstrated that men continue to hold “a higher proportion of more respected roles within orthopaedic academia”32. Similar trends are seen in the underrepresentation of women receiving orthopaedic society awards33. Whether this is an effect of women experiencing greater barriers to effective mentorship, or more widely related to the gender bias reported across the orthopaedic field34, it has obvious ongoing implications for the visibility of women in orthopaedic surgery, role modelling and mentorship of female orthopaedic surgeons.

In response to these perceived issues with female mentorship in orthopaedic surgery, professional societies have been established specifically targeted at mentorship for female surgeons. In the UK, Women In Surgery (WINS) advocates “to inform current and future trainees about the details of training in orthopaedics as a woman”25. In the United States, the Ruth Jackson Orthopaedic Society now comprises over 1,000 members, with a dedicated mentoring programme for female orthopaedic surgeons35. Professional orthopaedic societies are building initiatives to increase diversity and mentorship for female members36. Locally in the North West Deanery, a mentorship programme has been introduced for orthopaedic speciality trainees, with mentorship provided for junior speciality trainees by more senior speciality trainees, including gender matching where possible37Whether this mentorship programme will be effective, given the relative lack of seniority of mentors, is yet to be established, although research suggests that younger clinicians prefer mentors who are only a few years senior to them for personal mentorship38.

Looking forwards, mentorship practices for women in orthopaedic surgery should continue to improve. We should continue to advocate for specifically designed programmes to improve mentorship, and increase early exposure to orthopaedic surgery for women27. Mentoring and career counselling should form “a programmed activity within [the] job plan”, as per Department of Health recommendations to develop the position of women in UK clinical practice39. The increasing organisational and professional support for mentorship, and local and national initiatives, should bear fruit over the coming years.

Conclusion

Mentorship in the field of orthopaedic surgery lags behind the ideal of embedded mentorship culture. For women, this lag is even more pronounced. There has always been a rich seam of informal mentorship within the orthopaedic community. On this fertile background, with a continued shift in attitudes, emerging research, an increasing presence of women in orthopaedic surgery, and changing practices, we can be optimistic that mentorship practices will continue to improve and with continued professional and academic investment, a virtuous circle of improved mentorship and outcomes for women orthopaedic surgeons will result.

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