Mentoring Medical Students in Academic Emergency Medicine

MEMC-V INTERNATIONAL MEETING, VALENCIA, SPAIN (Sept 2009)

Gus M. Garmel, MD, FAAEM, FACEP
Co-Program Director, Stanford/Kaiser Emergency Medicine Residency Program
Medical Student Clerkship Director (Surg 313D), Stanford University
Clinical Associate Professor, Emergency Medicine (Surgery), Stanford University
Senior Emergency Physician, Permanente Medical Group, Kaiser Santa Clara, CA
Introduction
Mentoring is an important aspect of career development for medical students,
residents, and junior faculty. It is vital to the professional growth and maturation of
individuals early in each phase of their careers. Additionally, mentoring has a
critical role throughout all career stages, because the mentor-mentee relationship
provides mutual benefit to both participants. This article will describe the role of the
mentor, suggest ways to increase the likelihood of successful mentoring, and
identify pitfalls in the mentoring process predominantly related to medical students.
In contrast to role models, mentors play an active part in the development of a young
physicians career. This difference will be discussed. Finally, this article will
describe the responsibilities of career guidance and recommendation letter
authorship that mentors assume for medical students.
History
The literature consistently comments that professionals with strong mentors are
more productive and have greater career satisfaction, both in the short and long
term.1-4 Research suggests that academic physicians with mentors publish more
articles in peer-reviewed journals and have more confidence in their abilities than
their peers.5 Individuals describing positive mentoring relationships, as well as
those with any mentoring, report greater perceived success. One research report,
despite its acknowledged selection bias, found that subjects without mentors
reported lower salaries than their peers with mentors.6 Furthermore, strong
mentoring relationships have been reported as having the most influence on a
mentees ultimate career selection.7,8 The advantages of mentoring appear to hold
especially true for women, despite its less frequent occurrence.5 Unfortunately, a
large proportion of physicians never experience a true mentor relationship, and
identify this as one of the most important factors hindering career progression.8,9
Many professional societies have formal mentoring programs, especially in business
and nursing. Medical specialties generally encourage mentor relationships, although
often of an informal nature. This has become increasingly common in our specialty.
Of historical interest, the famous surgeon Harvey Cushing had as his mentor
internist Sir William Osler. Such a relationship between specialists would be
uncommon today because physicians with differing backgrounds collaborate
infrequently.

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The word mentor derives its roots from Homers Odyssey, in which Odysseus leaves
his son Telemachus in the care of a trusted friend (Mentor) when he goes off to fight
in the Trojan War. Mentor served as Telemachus loyal guardian and wise advisor,
and later leads Telemachus to find his father when he does not return. Under
Mentors guidance, Telemachus matures and develops his own identity. Athena, the
goddess of wisdom, intermittently takes the form of Mentor, imparting advice and
wisdom of a personal nature.7,10,11 In Greek, mentoring has become synonymous
with the term enduring.
Ancient Chinese kings used a form of mentoring called Shang Jang to pass the
crown to a successor. A literal translation of Shang Jang is the enlightened
stepping aside to create room in the center for the next deserving person to step in
and take charge.11 The responsibilities of a mentor have not been taken lightly
throughout history.
Modern day definitions of a mentor include an artist of enlightenment, and
a trusted and experienced advisor who has a direct interest in the development and
education of another individual. Mentoring has been described as an intentional
process of interaction between two individuals that includes nurturing to promote
growth and development of the protg (mentee). It is an insightful process in
which the mentors wisdom is acquired and modified as needed, as well as a process
that is supportive and often protective. The successful mentor-mentee relationship
therefore requires the active participation of both parties.
The mentoring relationship can be structured or loose. It can be a relatively short
process or an ongoing one. There can be breaks in the relationship, with its
reestablishment at some future time. Both individuals should be enriched by this
relationship, although the gains of the mentee appear far greater initially than those
of the mentor. In that sense, altruism and volunteerism towards a younger
professional colleague is inherent in every mentor-mentee relationship. Mentors
often benefit from these relationships in unanticipated ways (see table 1).
Table 1. Benefits to the mentor
Rekindled passion and excitement about the specialty, increasing professional
satisfaction
Rewarding to participate in the development of a colleague
Exposure to new ideas and opportunities
Pride in the mentees successes (includes promotion, retention, and tenure)
Personal growth
Increased creativity
Sharing ones values with others
Advancement as a result of mentoring (many academic departments now
recognize the mentoring process)

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The process of mentorship

Mentoring is a special form of educational service that is highly personal and
individualized. The mentoring relationship is a dynamic one, evolving over time,
during which both parties continually define and redefine their roles.12 It should be
considered a process, not an end result. This relationship must remain
noncompetitive. Mentors may see qualities in or opportunities for their mentee that
the mentee does not see, and should attempt to foster successes in areas their mentee
did not think possible.
Due to advanced knowledge and experience, the mentor is more powerful than his or
her mentee. This may complicate the relationship. Mentors must use caution if they
suggest shortcuts privileged by seniority, such as those related to direct patient care,
research proposals and projects, or authorship. They must also be careful not to
exert undue pressure over their mentees decisions, with respect to patient care,
scheduling, project selection, committee participation, or career direction. Many
mentees will have more than one mentor, which is healthy and should not be
interpreted as the mentors failure. Rather, this offers mentees the opportunity to
gain knowledge from more than one experienced individual. Mentors must not be
threatened by their mentees having more than one mentor.
Students should be encouraged to seek out mentors from faculty committed to their
well-being, personal and professional growth, and success within the specialty.
How students find faculty mentors is challenging, as their exposure to a broad
selection of Emergency Medicine faculty may be limited early in their training.
Biographies of faculty interested in mentoring, that include professional and
personal interests as well as previous mentoring experiences, should be made
available to students. This information can be offered through the deans office or
the emergency department early in medical school.13,14 If necessary, students should
be comfortable changing mentors without reason, and without concern of retribution
to them or their mentor. It is common for several restarts or mentor changes to
occur during a career, as this relationship is dynamic and often requires intense
personal interaction.
Medical student clerkship directors, residency program directors, research directors,
EMS directors, or other administrators (including departmental chairs, chiefs,
assistant chiefs, or medical directors) who are interested in the process are ideal
mentors for medical students.15 Also, junior faculty who are closer in age and
experience to students should be encouraged to participate in this noble
responsibility. Faculty can make themselves available to medical students through
the deans office, emergency medicine interest groups, lectures, or mentoring
programs. Medical students often shadow attending physicians during their
introduction to clinical skills courses. Emergency physicians participating in these
programs have more exposure to students, which provides students additional
exposure to our specialty as well.

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For students at medical schools without emergency medicine residency programs,

the SAEM medical student virtual advisor program can provide information about
our specialty from an experienced individual. This program is intended for medical
students considering a career in emergency medicine, linking them with physicians
available electronically to answer questions about the residency application process,
clerkships and careers in emergency medicine, rotation recommendations, or other
questions which come up.16 There is no reason why these interactions can not
develop into the much more intense mentor-mentee relationship, in which the
mentor continues to offer advice and support, yet watches over and fosters the
progress of the student as he or she progresses in training. The responsibilities
assumed by a mentor are far greater as this relationship develops. The SAEM
website address is provided as a reference at the end of this article.
The role of mentoring in medical education
Medical education has changed, with behavior modeling and bedside skills assuming
a much greater role for students. Many medical schools have modified their
curricula to get students out of the classroom and into the examination room earlier.
As a result, students model their professional behaviors after clinicians earlier in
their training. Positive attitude, compassion for patients, and personal integrity are
qualities they respect and emulate. According to surveys of students and young
physicians, enthusiasm for the specialty and the practice of medicine are critical
characteristics of role models and mentors. Although role models do not play as
active a role in student development as mentors, they share an equally important
one. In fact, many students select mentors based on personal qualities rather than
academic accomplishments, and many mentors started out as role models for
students, only to be selected as mentors at a later time (see tables 2 and 3). Clearly,
students today place great emphasis on doctor-patient relationships and psychosocial
aspects of medicine. They are more likely to discuss personal issues with peers and
supervisors than in the past. These are all reasons why meaningful and successful
mentoring relationships should be encouraged at all levels of training.
Table 2. Qualities of a good mentor1,12,17,18
Committed to his/her mentee and the mentoring process
Has realistic expectations of the mentee-mentor relationship
Is available and approachable
Listens well and demonstrates patience
Maintains confidentiality
Keeps promises and follows through
Is non-judgmental and accepting of personal differences
Demonstrates sensitivity to mentees needs
Has mentees best interest in mind
Enjoys watching his/her mentees development
Exhibits high professional and moral character
Treats others with respect (and is respected)

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Table 3. Responsibilities of a mentor

Commits time and energy on a regular and ongoing basis
Encourages positive behaviors in and excellence from mentee
Holds mentee to high but obtainable standards
Encourages mentee to reach his/her potential, assisting whenever possible
Assists in mentees identity development
Protects mentee from possible threats
Informs mentee about new opportunities, and suggests alternate resources for
information about academic opportunities, political culture, and networking
Gives honest feedback in a constructive and caring manner
Receives feedback from mentee without threat
Shares personal knowledge (medical and non-medical), including failures
Serves as a champion or advocate for mentee
Allows a confidential forum for mentees concerns, difficulties, or
dissatisfactions
Despite the successes that many individuals having mentors experience, not all
students enter a mentoring relationship. Unfortunately, a paucity of mentors exists.
Furthermore, there is insufficient awareness of the importance the mentoring
relationship has by many students, residents, and junior faculty. Students may feel
as if they are bothering a busy faculty member, and therefore do not pursue such
relationships. Faculty may feel that the commitment of time, energy, and resources
to a student distracts them from other more important academic and personal
responsibilities.19 Nevertheless, one of our roles as academic faculty members is to
serve as mentors for our specialtys future physicians whenever possible, especially
if common interests exist. Even more important is making time for this important
growth experience once it is initiated, which includes being approachable, available,
and enthusiastic about this role. Exposure to prospective mentees is one important
aspect of this process, including interest group participation or leadership, volunteer
activities at clinics or spectator events, or informal career lectures. Offering
preclinical students the opportunity to shadow or spend time in the ED is another
way to share enthusiasm for the specialty and be available to potential mentees.
Goals of mentoring
One goal of mentoring is to facilitate the acquisition of skills and knowledge
required for long-term academic productivity (see table 4). The primary goal of a
mentor is to fully prepare the student, resident, or junior faculty member to ensure
future career success.17 However, just what success is must be addressed, with
clear yet flexible definitions discussed between mentee and mentor, as this definition
often differs between parties. Furthermore, a mentees definition of success is likely
to change over time, as will the mentors. Other pitfalls of mentoring are described
in table 5.

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According to the literature, there are fewer effective mentors for women and underrepresented minorities in academic medicine.6,20-22 Specifically, there are less
women than men with extended careers and advanced academic rank in Emergency
Medicine.23-27 This is also true of minority faculty in Emergency Medicine. Our
specialty attracts a higher percentage of women and minorities than many other
specialties. The number of female medical students now nearly equals the number
of male students. As such, there are inadequate numbers of experienced female and
minority faculty available to serve as mentors for students who prefer female or
minority mentors. Inherent gender differences in styles of communication,
interaction, and competition have been described by one author, which may
influence academic promotion.20 It is important that future female emergency
physicians receive mentoring that accommodates these differences. Similar cultural
issues exist for minority students. Some institutions lack minority EM faculty, or
faculty prepared to mentor students on minority issues. Several recent
recommendations of the SAEM Under-represented Minority Research/Mentorship
Task Force include targeting under-represented minority medical students through
early mentorship and clinical opportunities, in addition to encouraging the presence
of EM faculty at minority organizations.28
Table 4. Mentor topics
Career choice, including fellowship training
Course work, especially clerkships and electives (EM and non-EM)
Application process
Residency programs
Clinical issues, including interpersonal skills with physicians, nurses, and staff
Medical errors, ethics, professionalism (dealing with difficult situations)
Academic advancement, including research and administrative roles
Career satisfaction
Financial advice
Wellness, balance, and other life skills (including family issues)
Table 5. Pitfalls of mentoring17
Having inappropriate expectations (either mentee or mentor)
Accepting responsibility or credit for work that is not ones own (includes
authorship or grants)
Lacking availability or schedule flexibility
Inappropriateness or insensitivity in interpersonal interactions, especially
gender-, culture-, or age-related
Inability to recognize limitations, and not providing alternative resources
Expecting exclusivity
Doing work for mentee
Discomfort sharing own failures or missteps
Breaching confidentiality

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Not anticipating challenges or obstacles in the mentoring process, or giving up

on the process too soon
Career Guidance
One of the best ways to mentor medical students planning careers in Emergency
Medicine is to become familiar with student-related issues.29-31 Faculty members
experienced in counseling students, the application process, and post-graduate
training have valuable information to share. Students often select their careers
during exposure to clinical rotations, perhaps their most formative time. Topics to
discuss include the number and location of EM rotations, how to get the most from
each rotation, when (and how) to schedule clerkships, and how to be outstanding
during the clerkship.32 It is equally important to encourage other activities during
medical school, to assist students with planning non-EM electives, and to discuss
research projects and the merits of research electives. Many students will express an
interest in geographic areas other than their medical school, so discussions about
programs and audition rotations in these regions should occur. The residency
interview process is also important to discuss with students.
Resources from published literature, student organizations, and the internet should
be recommended or made available to students if possible. A discussion of threeyear versus four-year training programs should occur without prejudice.33-35
Fellowship training opportunities might also be described, sharing their advantages
and disadvantages.36,37 Short- and long-term goals are best discussed in a nonthreatening, non-judgmental atmosphere. A realistic appraisal of the benefits,
rewards, frustrations, and difficulties of our specialty must be addressed without bias
or cynicism, as well as issues related to career satisfaction.38 At a minimum, an
introduction to the political climate within our specialty, as well as a discussion of
both internal and external pressures influencing our practice, should take place.
Finally, an honest assessment of a students abilities and potential is crucial, as
students are not always aware of the challenges of our specialty or the level of
competition for residency positions.
Letters of Recommendation
One responsibility of faculty is writing recommendation letters for students
interested in training in our specialty. This can be particularly challenging, as there
is no absolute gauge of future success within the specialty. At best, this
recommendation estimates a students potential based on his or her performance and
the authors experience.39 However, faculty members with whom students have the
most clinical exposure, and seem the most approachable and available, are often
recent residency graduates with increased clinical hours. There is tremendous
pressure on junior faculty to provide an honest appraisal of a students potential for
residency programs without compromising the students opportunities. In turn, this
results in great difficulty for readers to accurately interpret these letters. There is a
lot of unspoken stress among these letters authors.

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In an attempt to standardize the information contained in letters of recommendation,

the Council of EM Residency Directors (CORD) developed a Standardized Letter of
Recommendation (SLOR) in 1995-96, and has encouraged EM faculty authors to
use this format.40 There has been much debate over the merits of a form that
attempts to standardize something as subjective as human potential. The SLOR has
been modified several times since its development, and is likely to be revised again.
There is an opportunity for faculty to provide narrative comments with each letter.
Authors should indicate in their letters how well they know the student, including
the extent to which they have worked with him or her. This letter should disclose
any personal relationship that may result in an unfairly supportive letter. The letter
should attempt to communicate a summary of an entire months rotation, with input
from the entire faculty, or provide information about a research project, rather than a
snapshot of one outstanding case, shift, or final examination.
Students have the option to waive access to their letters of recommendation,
according to the Family Education Rights and Privacy Act of 1974. If students seek
advice about this, it is probably best to encourage them not to see their letters, as this
may create a question in the readers mind that the student (or author) may be hiding
something. It is uncommon, however, for letters in the business environment to be
confidential; this must be taken into account when advising students with previous
experiences. A box at the bottom of the SLOR should be checked if the student has
waived his or her right to see the letter. In addition, it is unwise to give copies of
letters directly to students. As students are likely to share information, they will be
aware if authors selectively share letters with some students and not others, which is
likely to raise concern. This further maintains the confidential nature of the letter,
protects the authors privacy, and prevents students from comparing letters written
by the same or different authors. The deans office is responsible for all
submissions using the Electronic Residency Application Service (ERAS).
Students may ask a faculty member if he or she is comfortable writing a strong letter
of recommendation. Most faculty members will honestly tell a student if they are
not able to author a strong letter, and will respectfully decline. This may be unfair
for the specialty, because if students submit only favorable (their best) letters, their
potential may be inaccurately elevated. However, it is common that applicants
request letters from authors who regard them in the best light and will write the best
letter possible. Therefore, with the exception of medical student clerkship directors,
who have the responsibility of composing at least the clerkship summary for the
deans letter, this practice will remain.
Controversy exists in terms of whom students should approach for their letters of
recommendation.41 Medical student advisors and educators should be willing to
advocate for students, directing them to the best faculty authors. Those individuals
who know the student best, and who are in positions of judging potential (such as
clerkship or residency directors) should be encouraged as authors. Similarly,

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research advisors (especially if EM research has been performed) or faculty with

extended contact through special activities should be suggested. If more than one
EM rotation has been completed, it is wise to encourage students to obtain a letter
from a key individual at that institution. Things are less clear with respect to core
rotations such as Medicine, Surgery, or Acting Internships. Faculty members who
direct these rotations often spend longer periods of time with students, and observe
patient care activities and interpersonal interactions on an ongoing and more direct
basis. It is reasonable to recommend that a student obtain a letter regarding his or
her potential in Emergency Medicine from at least one of these individuals. The
amount of weight readers place on letters from non-EM faculty varies considerably.
This is due in part to the knowledge that adjectives commonly used to describe
students by EM faculty are not always the same in different specialties or between
institutions. For example, the terms outstanding, excellent, very good, and good
have a certain chronology in EM on which authors (and readers) agree, as these
appear as boxes on the SLOR. This may not be the case in narrative letters, in
which authors use numerous adjectives, including (with no particular ordering)
superior, star, educable, teachable, potential to be, pleasant, with appropriate
guidance, future chief resident, stellar, etc. These can mean almost anything by
themselves. Authors outside of EM may use their own collection of adjectives with
their respective interpretations to describe students.
Despite this uncertainty over what these terms mean, mentors and advisors (often
with little experience) are responsible for judging a students potential and putting it
in writing. With practice, however, and with the mentoring of senior faculty, junior
faculty will learn these skills and pass them on to future authors. Table 6 lists
several characteristics of a quality letter of recommendation.
Table 6. Characteristics of a quality letter of recommendation
Authentic
Honest
Explicit
Balanced
Confidential
Appropriately detailed and of appropriate length
Technically clear
Information has been published about the ethics of authorship for letters of
recommendation, including what is appropriate and inappropriate to include in these
letters.42,43 If something might seem inappropriate, yet is felt to be an integral part
of the letter, legal advice is encouraged. This may protect the author as well as the
student, and possibly prevent subsequent consequences. In addition, it is always
good practice to provide reliable contact information in the event that the recipient
would like additional information.

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Gus M. Garmel, MD, FACEP,

Writing letters of recommendation is challenging, because faculty wish to make a

student seem as strong as possible to help with his or her career, without overstating
his or her potential. Furthermore, the authors credibility is at risk, as future letters
may be interpreted based on the validity of previous letters. One suggestion is for
novice authors to contact program directors where students for whom they have
authored letters are training and request feedback on their prediction of that
individuals success. With enough feedback, a sense of how accurate these
predictions have been can be gained. Finally, authors should be wary of telephone
or electronic communications with individuals about students. At all times,
descriptions should be accurate, supported, not defamatory, and must not violate an
individuals right to privacy.
Summary
Mentors take the time to encourage, support, challenge, and believe in their mentees.
A healthy mentoring relationship is likely to strengthen ones moral compass
essential to continued learning and self-improvement. Ideally, all students and
physicians, no matter how senior, should be in such a relationship and have the
opportunity to benefit from this component of medical education and growth. The
investment of time through mentoring medical students is likely to influence the
specialty of Emergency Medicine, as some of these students will develop into future
leaders. At a minimum, these students will provide care to patients seen in
emergency departments, or serve as their primary care providers or consultants
should they chose to train in other specialties. Providing students with productive
and meaningful mentoring relationships sets an example for future mentors, and may
be translated into successful generations of physician mentors.
Two quotations from the Chinese philosopher Lao Tzu are appropriate for mentors
to consider as they approach the responsibilities, challenges, and rewards of
mentoring. It is indeed a privilege to hold a position of such potential impact.
A journey of a thousand miles must begin with a single step.
Give a man a fish and you feed him for a day. Teach him how to fish and
you feed him for a lifetime.
Acknowledgment: I am indebted to Glenn C. Hamilton, MD, MSM, who continues
to inspire me and thankfully remains a mentor after 18 years.
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