Human interaction remains the keystone of medical education and practice. Reverence for the primacy of relationships in psychiatric theory and practice empowers psychiatrists with special skills as clinicians and as educators. Despite psychiatry's unique qualifications along these lines and the many seminal contributions by psychiatrists to crucial educational and therapeutic relationships such as those experienced by supervisors and supervisees and physicians and patients, a wide variety of other medical specialties as well as professions outside the realm of healthcare have espoused the benefits, attributes, and dynamics of the mentor—protégé relationship with more noteworthy ambition. The literature on this subject is very broad, therefore, and encompasses a wide range of disciplines.
The renewed interest in mentoring in the field of medicine has been ignited by recognition of its importance in faculty development (1), and, as a result, the earlier focus on its significance for medical students and residents has been sharpened. Therefore, just as mentoring has come to be regarded as a powerful complement to all aspects of medical education, the literature on mentoring in medicine has been expanding to encompass its newly recognized role. Many benefits accrue for students and residents fortunate enough to be involved in mentoring relationships, including 1) guidance with socialization into the profession (2); 2) assistance with stresses along the way (3); 3) help with the choice and fulfillment of a career path (4,5); and 4) inspiration for meaningful involvement in activities such as research and administration (6). Implications of mentoring for faculty include recruitment, promotion, retention, and satisfaction.
Although the psychiatry literature reflects appreciation for the concept of mentoring (7), our 1999 search of the literature confirmed Shore's (8) 1995 finding that there are no published articles with titles addressing medical student and psychiatric mentors. Likewise, we found no articles specific to mentoring and development of psychiatric faculty. The mentoring literature in psychiatric residency education is limited to interests in administrative psychiatry. Because of its enormous potential as a medium for educating students and residents, for attracting interest in the specialty, and for facilitating faculty development, greater attention to the mentor—protégé relationship would be advantageous to psychiatry.
This article addresses the elements and dynamics involved in the life cycle of mentoring relationships applicable to psychiatry, including a proposed model for explicating the developmental stages experienced by participants in the process. Based on a course inaugurated by the authors at the 1996 Annual Meeting of the American Psychiatric Association, this article provides a review of the mentoring literature for use in psychiatric education, research, and practice. We offer various perspectives, including skills for mentors, skills for protégés, the dynamics of the mentoring relationship, benefits and barriers, and issues related to gender, race, and culture.
The history of mentoring can be traced back to classical times. In The Odyssey, the goddess of wisdom, Athena, appearing in the form of Mentor, gave advice and counsel to Odysseus's son, Telemachus, in his journey to find his father (9). In reviewing mentorship in general-internal medicine, Shapira and colleagues (10) noted that many of the traits demonstrated by Mentor in Homer's saga—age, wisdom, friendship, nurturing , and guidance, for example—have remained fundamental to the concept. According to Levinson (11), author of The Seasons of a Man's Life, the responsibilities a mentor should fulfill include teaching, sponsoring, guidance, and socialization into a profession. He described the mentoring relationship as remarkably complex and extremely important developmentally. The psychologic implications of mentoring for personal development rest primarily in midlife. Individuals in midlife have a need to mentor, and midlife development suffers for those who have not experienced mentoring in their younger years (11).
Corporate and professional interest in mentoring has mushroomed in the past two decades. A 1979 article in The Harvard Business Review, "Much Ado About Mentoring" (12), established mentoring as a key concept for success in business, which is reported to be the first profession to take a major interest in the subject. This study reported an association between strong mentoring relationships and a variety of positive career outcomes, such as a greater likelihood of following initial career paths, higher earning power at a younger age, higher levels of educational achievement, and greater career satisfaction. A study of business school graduates a decade later revealed similar findings for those experiencing intensive mentoring relationships (13).
Reminiscent of the emphasis on mentoring in the field of business, the limited literature on mentoring in psychiatry has come from administrative psychiatrists, who have consistently placed a high value on mentoring. Sherwood and colleagues (14) surveyed 250 psychiatrists identified as leaders in their field and found that 92% had at least one influential role-model during their training. Silver and colleagues (15) also found mentoring relationships to be of particular significance among psychiatrist-administrators. More recently, we have recommended a mentoring model in residency education using multidisciplinary treatment-team leadership as a basis for learning about administration (16).
Mentoring has received significant attention in a wide variety of other fields, such as nursing, dentistry, the performing and creative arts, and law. In the latter categories, as is often the case in the business field, mentoring takes on a more formal connotation. The process could be referred to as "grooming." In the helping professions, particularly medicine, mentoring is more often a less vigorous, less obvious, informal process, wherein some mentors aren't particularly aware of being regarded as such.
In a variety of styles, and in accordance with a variety of interests, mentors in medicine serve as critical points of reference and provide some degree of guidance through example, education, collaboration, advice, sponsorship, and friendship. The successful mentoring relationship takes on a life of its own and evolves through stages. Similar to the process Watkins (17) described, in which the psychotherapy supervisor—supervisee relationship moves through separation/individuation stages over time, Levinson (11) described developmental changes in the mentor—protégé relationship. As each party in the relationship matures personally and professionally, separation is inevitable and often difficult.
Relations between mentors and protégés can be described in terms of those characteristics generally understood as inherent to the situation; however, it is important to note that every association has its unique qualities, contributed by the environmental context, the nature of what might be accomplished, the chemistry that unites the two individuals, the spark that ignites interest and enthusiasm, and the importance of the relationship to both parties, in a developmental sense. Issues in mentoring relationships include the ratio of power, mutuality of respect and support, and skills in communications. The last involves abilities to problem-solve, negotiate, and confront.
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Characteristics of the Relationship
Some generic characteristics in mentoring relationships, such as unequal distribution of power but evolving complementarity, the giving-away and the acquisition of "inside" knowledge, and its time-limited nature, can enhance bonding, mirroring, and the process of identification. Fostering autonomy is a superordinate goal in mentoring, and one of the energizing characteristics in a healthy mentor—protégé relationship is the competitiveness that can develop as a protégé progresses toward independence (18).
Although elements of mentoring relationships are distinctive and, in the aggregate, unique in comparison to other dyads, there are also similarities. Supervisors and employees, teachers and students, coaches and players, parents and children, and older and younger siblings share some of the same dynamic interactions that define the relationship between mentors and protégés. Although many dyads—including spousal relationships—might evolve into mentoring relationships, it is generally assumed that this would occur on the basis of choice. Mentoring relationships could be encouraged but should not be imposed, according to subjects interviewed by Collins (19), and some respondents question whether or not assigned mentor—protégé relationships should be called as such if they do not evolve spontaneously.
In his study of the elements of a significant mentoring relationship, Darling (20) identified three basic requirements: attraction, affect, and action. The mentor must recognize the qualities in the protégé he wants to develop, and the protégé needs not only to admire the mentor and his or her accomplishments but also possess a strong wish to emulate him or her. The successful mentor will demonstrate a deep interest in the welfare of the younger generation. This attitude has been described as fairly typical of midlife by Levinson (11). Furthermore, a positive regard toward the protégé will manifest itself through the mentor's respect, encouragement, and support. The action requirement described by Darling includes all the behaviors ascribed to effective mentoring, behaviors such as teaching, guiding, counseling, and sponsoring (20).
Although the mutual expectations within the mentor—protégé relationship might not always be explicit, a commitment to mutually agreed-upon objectives, a willingness to learn under the mentor's supervision, devotion of the necessary time and energy to the agreed-upon goals, and an expectation that the protégé become increasingly independent are sine qua nons.
Mentor—protégé relationships consisting of several mentors with one protégé (non-dyadic) may be more realistic in certain settings—for example, medical school—wherein students move frequently from course to course and service to service. This model complements normal development as individuals move from relying on one or two parents to having dependency needs disbursed across a wider social network. It also allows compensation for the deficits of one mentor by the strengths of another.
Several schematic representations have been put forth in the literature to describe the developmental stages in the mentor—protégé relationship. Collins (19) describes four interpersonal phases, each of which succeeds or fails on the basis of a developmental requirement: emulation, identification, internalization, and accommodation. Hunt (21) postulates an initiation stage, protégé stage, break-up stage, and, finally, if the relationship is successful, a stage of lasting friendship. Kalbfleisch and Davies (22) introduced a conceptual model of mentoring relationships in which the perceived risk of relational involvement serves as a moderating influence, and Davis and colleagues (9) address developmental phases of the mentor, citing the transition from peer to teacher as a difficult one for junior faculty and the relative comfort level of the mid-career mentor. Senior mentors may feel more alone, more vulnerable, and have more difficulty keeping up-to-date, and therefore may be more likely to have problems with letting go gracefully (9).
Our model of the developmental phases in the mentor—protégé relationship (t1) involves five progressions: from Initiation, which involves interaction, through a phase one step beyond Separation/Adaptation, called Redefinition. The developmental tasks at each phase are depicted on two planes—interpersonal, pertaining to the interaction between the two parties, and intrapsychic, pertaining to the personalities and related internal factors dynamically affecting or affected by the process and its characteristics. For example, the desirable interpersonal process we call bonding during the Initiation/Interaction phase will be affected considerably if the mentoring relationship is required rather than based on attraction and choice. In a coercive situation, hesitation would be an expected response, and bonding might suffer accordingly. The interpersonal component of the Cultivation/Investment phase can be conceptualized on a spectrum ranging from enrichment to impoverishment, which parallels the intrapsychic experience of continuity vs. disruption. Like Erik Erikson's (23) developmental stages in the life cycle, the successful negotiation of each phase in the mentoring relationship depends on a satisfactory resolution of the former phase.
If interpersonal synergy is not accomplished in the Maturation/Facilitation phase, the cause or effect might be distraction on the part of the mentor, the protégé, or both, and the misalignment in the relationship will predispose the parties to falter in the next phase, Separation/Adaptation. Here, autonomy is the desirable outcome at the interpersonal level, and opportunity-seeking would be the healthy intrapsychic equivalent. Ideally, Redefinition, the final phase, will result in perceived equality on the part of both individuals.
Career advancement, moving onto the next stage of training, relocation, retirement, disappointment and/or recognition of relationship limitations are some of the many reasons for terminating successful mentor—protégé relationships. It is important for both individuals to deal with their feelings about the loss. As a result of working through the grief process, the protégé will be better able to become a successful mentor, and the mentor will be better able to adapt to a new mentoring relationship.
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Qualities of a Good Mentor
In the context of mentoring for medical students interested in family medicine, according to Ricer and colleagues (24), "the mentor's most important qualities are willingness to share with the student (even doubts and fears) and the ability to trust and respect the student." Highly valued personal traits include charisma, compassion, empathy, competence, and leadership, as well as motivational skills. "A mentor must understand the stresses and excitement about the student's development and be interested in all phases of the student's life and career." (24)
Faculty new to academic medicine need to be socialized into three essential areas, according to Bland and colleagues (25). These are 1) adopting academic values; 2) managing an academic career; and 3) establishing and maintaining a productive network of colleagues. Morzinski and colleagues (26) described a five-stage model for developing a formal mentor program designed specifically to enhance these functions among junior faculty members.
Acknowledging the critical role of mentoring in building successful research careers in psychiatry, Ferris and Pincus (18) elicited the views of mental health investigators on the qualities of a good mentor, the mentor—protégé relationship, finding a mentor, and concerns related to gender. Characteristics of good mentors listed in their survey included skill, talent, knowledge, competence, respect among peers, genuine interest in the welfare and accomplishment of others, generosity, an enduring capacity for empathy, patience, enthusiasm, availability, personability, integrity, high moral and ethical standards, time, energy, and being "not too competitive" (18). According to Ricer and colleagues (24), "the tasks of mentoring are of less importance than the personal characteristics of the mentor."
Many benefits and rewards are inherent in the mentor—protégé relationship. Although the advantages for protégés will be addressed in a subsequent section of this article, it is important to note that enhanced self-esteem, as described in mentors by Murray (27) is a mutual benefit. Being a mentor is one of the psychological needs of midlife (28), and, conversely, the unavailability of mentors during an individual's 20s and 30s is associated with midlife problems (11). The mentoring relationship, therefore, has developmental implications for both parties.
Stimulation of ideas and revitalization of interest in one's own work as well as professional assistance with projects leading to their completion enhances satisfaction on yet another level. Another major benefit of mentoring is the close relationship with the protégé and the establishment of a long-term friendship, undoubtedly another dimension addressing developmental needs. For some mentors, there are direct financial rewards, but this result is less likely in the medical profession. However, indirect financial benefits, through success with grants or research or other professional pursuits, is always a possibility as a result of the assistance provided by protégés.
The potential problems or barriers to mentoring addressed by Murray (27) include pressure to take on the role, lack of requisite skills, not taking the role seriously, insufficient time to commit to working with protégés, lack of perceived benefits, possessiveness of protégés, curtailment of protégés' needs to take the risks necessary for learning, and resentment of protégés. Barr and colleagues (29) point out that relative newcomers or lower-ranking academicians might not perceive themselves as mentors, thus depriving potential protégés close-up access to their skills and abilities.
Gender and race issues are frequent barriers to effective mentoring. Mentors tend to choose protégés who remind them of themselves (29). In documenting applications of mentoring for the practice of radiology, Barr and colleagues (29) noted: "If the two differ by race, creed, or gender, the protégé may need to work harder to point out common interests to the potential mentor. Any combination of factors that increases the uniqueness of the protégé also increases the risks to the mentor if the protégé is a failure."
Other potential problems involve mismatches in terms of personality or interests or goals, multiple protégés (and favoritism), availability of suitable mentors, and age factors (29). "A mentor is ordinarily 8 to 15 years older than the mentee. He is enough older to represent greater wisdom, authority, and paternal qualities, but near enough in age or attitudes to be in some respect a peer or older brother rather than [someone] in the image of the wise old man or distant father" (11). Sexual attraction is another potential complication in the mentoring relationship (27).
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Issues of Gender, Race, and Culture
There is a moral and public health imperative to increase the participation of women and minorities in medicine. Levinson and Weiner (30) indicate that although the number of women entering medical schools has increased over a 10-year period, overall, women faculty members are more likely to hold lower academic rank than their white, male colleagues, and minority representation has stagnated. Black faculty are concentrated in black institutions, and minority faculty often face greater service demands than their white colleagues. Full integration of minorities into the workforce is stated to be one of the six greatest challenges facing American managers. The United States population is changing such that soon, one of every three Americans will be nonwhite, and race has been shown to affect leadership, job attitudes, and job satisfaction in the workplace (31). One of the benefits businesses derive from mentoring is increasing ethnic and gender diversity at senior management levels (32). Increasing diversity in gender and race could result in achieving egalitarian power relationships and effective organizational change (33).
Mentoring may be essential for women, and having a mentor influences the outcome of career success. Women with mentors have more publications, more time spent on research activities, and higher overall career satisfaction (30). It has been suggested that women's medical careers are handicapped by their unequal access to powerful mentors, and that having such mentors would improve their prospects for advancement (34). Women researchers in child and adolescent psychiatry at all ages identified a mentor program as a critical aspect of their training (35). Dreher (13) found that individuals experiencing extensive mentoring relationships reported receiving more promotions, had higher income, and were more satisfied with their pay and benefits than individuals experiencing less-extensive mentoring relationships.
Barriers to women's advancement in medicine and academia, as described by Matorin and colleagues (36), include professional discrimination, blatant sexism, lack of appropriate mentors, and unfair policies for faculty promotion. Analysis of a survey by Leibenluft and colleagues (37) revealed that men were more likely than women to have had research training, to mentor research trainees, to have ever been principal investigators, and to have attained high academic rank. Same-sex pairs are noted to be more productive than cross-sex pairs in early-career publications; however, women may find it difficult to secure a female faculty mentor. Also, attitudinal surveys reveal reservations about women's capacity to complete graduate education or make a significant contribution to their field (38).
Special problems for women in mentoring relationships include family obligations, sexual issues, paternalistic tensions, performance pressures, isolation, and limiting role expectations if the mentor is male. White and nonwhite female professionals have different mentorship needs (39). Items of more concern to women than men in a survey of New England surgery residents (40) included availability of role-models, mentors, or both. Of the respondents to a survey of the Association of Women Surgeons membership, only two-thirds reported having role-models at some point in their career, half of whom were men. In a comparison of women physicians' experiences with male or female mentors (34), respondents with high-ranking male mentors reported more career sponsorship, but lower-ranking female mentors provided more personal advice. There were fewer problems with retaining autonomy for protégés with female mentors. Women psychiatrists demonstrate concern for combining profession and marriage and combining profession and children (41). A survey by Levinson and colleagues (42) revealed that the majority of women found it possible to combine motherhood with a fulfilling career in academic medicine, but 78% of the women believe that motherhood slows the progress of their careers.
Ragins' (33) review of gender differences in mentoring relationships reports that women were more likely than men to cite benefits related to gains in self-confidence, useful career advice, counseling on company politics, and feedback about weaknesses. More mentors to women serve psychosocial functions, and male protégés may use their mentors more effectively than women protégées (33). Women are socialized to deny aggressive traits even in skills where these traits are necessary, and this denial may produce intrapsychic conflict in a competitive career such as medicine (43).
Women's development may affect career factors. Their development is tied to understanding and strengthening the self in relation to others. Women surgical residents were more concerned than men about comfort expressing emotions at work as well as initiating and maintaining personal relationships (40). Attachments and relationships play a central role for women in both identity-formation and conception of developmental maturity. Goodness and accomplishment become equated with self-sacrifice; separation and individuation might require decisions that deprive or hurt another; women may shy away from empowering themselves. The phases of a woman's life may incur certain developmental tasks. Early-adult transition years (ages 17—29) may find women concerned over a committed relationship; ages 30—40, in addition to requirements of career development, may require women to focus on the "biological clock;," and middle adulthood, (39; Jackson B: Stages of black identity development. Unpublished manuscript. University of Massachusetts at Amherst, School of Education, 1978) has traditionally been a time of increased assertiveness and professional accomplishment (44).
Considerations for minorities in mentor—protégé relationships are even more complex, especially for female minority members in medicine. Although minority female professionals are reportedly more likely to mentor other female professionals than are their white counterparts (39), the number of minority women available to serve as mentors in medicine is infinitesimally small. From the perspective of black protégés and mentors, however, the genders of the participants were not as important as the cultural group in predicting patterns of mentoring (22).
In one intraorganizational study, whites had almost no developmental relationships (defined as mentoring and sponsorship) with individuals of another race, whereas two-thirds of the developmental relationships formed by blacks were with whites. In this study, same-race relationships were found to be significantly more psychosocially supportive than cross-racial relationships, and blacks were more inclined to develop relationships outside formal lines of authority and outside their department (45).
Thomas (46) gives an extensive account of the nature of cross-racial dyads in his study of racial dynamics in cross-race developmental relationships. He reports that in cross-racial relationships, the racial perspective of the dyad might be mutually supportive regarding race and, therefore, complementary. In this case, both parties share similar views on race; or the perspectives regarding race might be noncomplementary, in which the pair have dissimilar views on race. Strategies for managing racial differences range from the use of intrapsychic mechanisms such as denial and suppression of race-related issues and associated affect, to direct engagement of race-related information and racial differences. In the first example, one or both parties have explicitly chosen not to discuss issues of race out of fear it might harm the relationship, the other person, or themselves. One or both parties may state that race has no relevance as a major factor affecting the experience of the relationship. Direct engagement implies open discussion about race and ongoing conversations about differences and possible issues. Some of the intrapsychic mechanisms described by Thomas (46) might apply to the findings of Palepu and colleagues (47), who surveyed over 3,000 United States medical school junior faculty regarding their experiences with recent mentoring. Although faculty with mentors rated their preparation for and skills in research higher than did faculty without mentors, 80% of the women faculty and 86% of the minority faculty who had mentors indicated that it was not important to have a mentor of the same gender or minority group (47).
Thomas (46) asserts that developmental factors relevant to racial identity in career relationships include two fundamental but interrelated issues: identity perspective—liberal assimilation or pluralism, for example—and the process of career integration for the member of the minority group. These same principles can be applied to an attempt at understanding cultural differences as well, even in the absence of racial differences. Liberal assimilation implies that "color blindness" (or culture blindness) is the ideal state, whereas in a pluralistic approach, individuals seek to maintain a positive sense of racial identity but adopt aspects of the dominant culture in order to function effectively.
The process of racial identity and career development may involve a progression of definable steps. Thomas and Aldefer (48) review theories of black identity development. Cited in their review are the works of Jackson (Jackson B: Stages of black identity development. Unpublished manuscript. University of Massachusetts at Amherst, School of Education, 1978) and Cross (49), who define four stages: 1) "Passive acceptance" occurs when the black individual internalizes the dominant culture's view that white values and culture are superior to black values and culture; 2) "Active resistance" is a stage in which the individual begins to question and reject white values and norms; 3) "Redefinition" is the phase in which the individual ceases to respond reactively to whites and begins to develop his or her own unique set of values and goals based on a positive sense of black identity; and 4) "Internalization," which is marked by the individual's feeling secure about his or her black identity and gaining a more whole sense of self.
Other theorists cited by Thomas and Alderfer (48) recount stages that may involve suppression of emotions and issues around race. The management of anger, in particular, requires considerable time and attention as the individual experiences dissatisfaction with perceived inequalities and frustration with barriers. Organizations in the dominant culture often pull minorities into suppressing their racial identity. As minorities struggle between life in the dominant culture and the minority subculture, individuals frequently address differences by walking the fine line of bi-culturalism.
Mentoring cannot be effective in the absence of sensitivity to the issues that perpetuate racial, cultural, and gender barriers. Minorities in medicine have poor access to same-race mentors as well as limited exposure to role models who can help their career. There is a need to increase the pool of minority students interested in careers in medicine, to promote graduate-student and house-staff awareness of career opportunities in academics, and to provide resources that enable students and junior faculty to develop their careers (45,50). Mentors may be an essential part of this development (51). Cross-race, cross-culture, and cross-gender mentoring relationships require dedication to ongoing exploration of differences and integration of the learning derived from open discussions. Otherwise, the process will lead to a reversal of mutual benefits and mutual disappointment for the protégé and mentor; this disappointment translates to frustration, isolation, and rage.
Much of the research regarding mentoring focuses on the active role of the mentor in providing the relationship. The ways in which the protégé engages and contributes to the mentoring relationship have been largely ignored; however, evidence exists that protégé behavior strongly influences the formation and maintenance of mentoring relationships (52). Most of the literature regarding protégé skills is theoretical, with little empirical support. The few empirical studies performed are mainly limited to cross-sectional designs rather than longitudinal studies. Many questions remain about the validity of the theorizing and the range of applicability of the concepts advanced from one setting to another.
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Skills Enhancing the Initiation of the Mentor Relationship
Because a mentor—protégé relationship is usually the result of an informal, mutual selection process, the qualities and skills of the protégés are important in its development. As noted previously, mentors tend to choose protégés who remind them of themselves (29). It is likely that protégés choose mentors who remind them of themselves or who they want to become. Certainly, the work setting, organizational characteristics, position, and social network will interact with protégé characteristics such as age, gender, and need for power (21). In those more formalized mentor relationship programs, in which mentors are assigned to protégés, the personal attributes and skills of the protégé become less important.
Barr and colleagues (29) recommend factors on which protégés may base their selection of a mentor. Factors for consideration include the questions: "What is the achievement record of the mentor in a variety of areas? How has the mentor determined his or her standard of excellence and are these standards high? Is the mentor respected as a key player in various networks throughout the department, regionally, nationally, and internationally? Does the mentor have enough faith in the protégé to provide wholehearted support? Does the mentor understand my needs and goals, both personal and professional? Is the mentor perceptive and honest enough to recognize when he or she cannot provide the protégé with the information needed? If the latter is the case, will the mentor help the protégé find someone who will provide the missing elements?" (29).
Probably most mentor relationships are initiated by the mentor (28). In mentor-initiated relationships, the protégé must be attractive (in the inclusive sense of the word) to the mentor and must reciprocate the mentor's interest. Protégés probably successfully attract their mentors by communicating competence or ability (53,54).
In protégé-initiated mentor relationships, the protégé must be more proactive. How does a protégé engage the attention of a mentor? Asking someone to mentor is one common method. In a study by Turban and Dougherty (52), the nature of the initiation predicted the mentoring received. Another method of attracting a mentor is to show interest and involvement in the projects of the mentor. Another is to show considerable promise and willingness to work toward the goals of the mentor. For example, Olian and colleagues (55) found that mentors anticipated greater rewards for themselves and were more willing to engage in mentoring behaviors the better the past performance of the protégé. Fagenson (56) showed that high achievement and power-oriented protégés are more likely to secure mentor relationships than their less-driven counterparts.
Turban and Dougherty (52) empirically studied the role of protégé personality in gaining mentors in a business setting. They found that internal locus of control, high self-monitoring (sensitivity to social cues), and high emotional stability (self-esteem and lack of negative affectivity) enhanced initiation, which influenced mentoring. The relationship between personality characteristics and mentoring received was mediated by the initiation.
Protégés who have well-developed social skills are more likely to form mentor relationships (57—60). Such social skills include networking and social boldness (e.g., the ability to initiate contact with strangers). Initially, protégés must be able to show interest (61) and promise. To make interest and promise discernible, the protégé may need marketing and self-promotion skills. Eventually, protégés must have the capacity to form a deep and enduring bond with another person.
Of course, not only do protégés need mentors, they need the best possible mentors for their stage of development and specific interests (62). The relationship must be compatible. They should also "click" in terms of personality. Can the protégé make a learning experience out of each mentoring relationship? Even negative mentor relationships can provide information about how not to be or what not to do. Most protégés will need to pick and choose from different people to pick up the necessary skills across different domains.
The problem with the informality of the selection process involved in mentoring is that many young professionals who could benefit from mentoring do not find a mentor. Can the protégé skills needed to initiate and maintain a mentoring relationship be taught, and, if so, should they be? This question awaits empirical testing. Conversely, some protégés assigned to mentors may not be developmentally prepared for a mentoring relationship. Noe (63) has suggested that a "readiness for mentoring" measure be used to select for participation in mentoring programs those who are most likely to benefit from the experience.
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Skills Enhancing the Maintenance of the Mentor Relationship
The skills necessary to maintain a mentor relationship are probably not unlike those of maintaining any other relationship with an authority figure (respect for authority, deference, showing promise, being appreciative, etc.) Kalbfleisch and Davies (22) found that protégés' communication competence and self-esteem were both directly and indirectly related to participation in mentoring relationships. Intelligence and ability (64) also seem important for predicting participation in mentoring relationships. The ability of the protégé to collaborate has also been cited as important (62).
Just as mentors have certain demands in effectively creating mentor—protégé relationships, so have protégés. Protégés are mutually responsible for building rapport with mentors, observing and modeling their mentor's desired characteristics, actively listening, extending their analytical skills, doing their homework and being prepared, and communicating clearly and effectively in order to cope effectively with conflict in the relationship. They must have relationship-maintenance skills, including those skills required to "weather the ups and downs" of relationships—the capacities for self-disclosure, emotional availability, authenticity, empathy, and emotional vulnerability; the ability to accept and value differences; the ability to disagree with negative consequences; judgment in risk-taking; and the ability to be personal. Persistence, as a character trait, is required. Given that time limitations, incompatible work schedules, and physical distance were the most frequently mentioned reasons for lack of interaction in Noe's study (63), protégés benefit significantly in the mentoring relationships by demonstrating flexibility.
The protégé who obtains an enviable mentoring relationship must also be able to cope with the sibling rivalry inherent in such situations (63,65—67). Individuals who lack mentors may present the protégé with resentment and jealousy, resulting in conflict between the protégé and these peers. Fagenson (59) failed, however, to find different promotion rates or fewer favorable workplace relationships for protégés. Although such issues can divert the attention of the protégé, and the ensuing guilt can prevent wholehearted entry into mentoring relationships, most protégé relationships do not alienate the protégé from the organization. However, when alignment with a mentor creates alienation from the larger organization, the loss of the mentoring relationship can make the protégé vulnerable to enemies within the professional organization.
Protégé behaviors that maintain the mentoring relationship include the following: being teachable and open, making oneself vulnerable by expressing needs for the mentor to fill, asking questions, temporarily accepting a "one-down" role, and showing interest in and trying to please the mentor. Protégés must be able to show the combination of compliance and challenge appropriate to their mentor. Too much compliance deprives the mentor of stimulation, and too much challenge is disruptive and may be irritating to the mentor. The protégé can endear himself to the mentor by being productive and helping the mentor meet his or her goals. For the researcher, that may mean completing the data collection on a study. For a clinician, that may mean covering the mentor's patients while the mentor is traveling.
Protégés should be responsible for their part of the creation of a learning climate, including asking the hard questions, sharing and receiving "difficulty" feedback nondefensively, utilizing support, and expressing a personal interest in the mentor. "Mentorship is an opportunity to be stimulated by the new ideas that protégés bring from the classroom and from different walks of health care life" (68).
The dynamics of other dyadic relationships tend to apply. Protégés must try to keep the relationship at a synchronous pace so that variables such as commitment and closeness are kept roughly equal. Boundary issues must be attended to so that the nature of relationships remains clear and does not develop into dual relationships. Protégés must be able to deal with fears inherent in unequal power relationships. They must be able to maintain their own identity while remaining open to change. They must be comfortable with sharing control with another.
Protégé attitudes toward the mentoring relationship are also important. Protégés must have realistic expectations about what mentors can do (69). Protégés must believe that they are ultimately responsible for their own development. Loyalty and trust have also been mentioned in the literature (58,64,70). Commitment to the task involves spending the time and making the effort necessary for success. Protégés need to work with mentors on learning plans with mutually agreed-upon milestones as signals of success.
Finally, it is important for protégés to communicate their needs to mentors (62). Sometimes protégés feel undermined, smothered, or abandoned. Sometimes workload or pacing problems occur—too much work, too little, too fast, too slow. Sometimes promises are made and not carried through. In all these instances, protégés need to be able to effectively and gently assert themselves with the mentor and negotiate solutions to the problems.
To be well served by the mentor relationship, protégés must be proactive rather than merely reactive to the mentor's agenda. Protégés must be able to articulate their own needs and desired directions and, at the same time, find a way to ensure that needs, purposes, commitment, and availability are symmetrical and mutually met. Not only do protégés need a clear sense of boundaries and the ability to maintain them, but they also need to guard an appropriate level of autonomy. They also need negotiation skills to make sure that the relationship has a win—win quality. Protégés must also be able at times to observe, make relationship dynamics explicit, and discuss the process of the mentoring relationship. Such discussions allow for mid-course adjustments necessary to keep the mentor relationship helpful.
To deepen the mentor relationship, protégés must be able to risk intimacy (22), to self-disclose, and to become professionally vulnerable by admitting to areas of ignorance. They must be able to trust and respect their mentors in order to identify with them. The capacity for loyalty, admiration, the desire to emulate, and commitments tends to be associated with deepening mentor relationships (20).
Protégés must be able to adjust to the various changes occurring as the relationship matures. They have to ensure mutuality and relative equality in contributing to the relationship. They must be able to manage problems that may result from unequal growth or from distractions from other life areas. They must be able to manage closeness in the relationship. They must be able to develop increasing independence of judgment and decision-making over time—to begin to separate intellectually and emotionally from the mentor. Finally, they must be able to end the mentor relationship when it no longer serves a useful purpose. At this point, protégés must be able to harmoniously assert equality with their mentors and to "divide the territory" (whether intellectual, programmatic, etc.).
Of the groupings of potential protégés in psychiatry and medicine, in general, medical students are most likely to suffer from a lack of mentoring or even role modeling. Because mentors are rarer for medical students, the skills of initiation are especially important. Medical students must typically adjust to multiple mentoring relationships, the intensities of which pale in comparison to the more traditional mentor—protégé relationships. Interests and needs differ through the curriculum, particularly in the transition from the preclinical to the clinical years. This transition typically requires changes in mentoring relationships. Flach and colleagues (71) suggested that there is a relative lack of interest on the part of students in finding a mentor. Because of the rapid rotations, rigid requirements, and busy workload, it is difficult to make a lasting mentor relationship (72). Some studies have suggested that intense mentor relationships may not be feasible or even advisable at this level. Ironically, mentorships may be considered more valuable by other disciplines early in the clinical training process (26). Because of such inherent systematic difficulties that overwhelm personal skills and attributes, formal systems such as the advising system may be required for medical students (73,74). Woessner and colleagues (75) addressed lack of personal contact between professors and students at German universities with a pilot program of assigned relationships to reduce faculty anonymity. There is some suggestion that the "protégé skills" required in formally assigned mentor—protégé relationships are somewhat different from those important in informal mentoring (63).
Mann's (73) review of the literature on faculty mentors for medical students acknowledges the students' needs for strong support throughout their medical education and examines the models on which medical school mentoring programs are based. Efforts are under way nationwide to repair the disruption of the master—apprentice relationship between physicians and physicians-in-training—a disruption that began when medical education increased class size and expanded the curriculum to include more basic and clinical science instruction, relying heavily on a lecture format to accomplish the task. Mann (73) concludes that the variability, diversity, and responsibilities of medical students are increasing, and formal support for career development is more and more crucial to their well-being. Shore (8) reported that "the Number One issue" in a survey of 40 psychiatric educators was "the linkage between a career decision in medicine and a mentor in a chosen field, often occurring during the clerkships."
Although residents are more likely to have mentors available or even assigned to them than are medical students, Kirsling and colleagues (76) have questioned the prevalence of mentoring among residents. Of the physical medicine and rehabilitation residents interested in mentorships (97.3%), less than one-third (28.1%) had a mentor at the time of the survey (77). Research productivity in family-practice residency has been found to be associated with the availability of a research mentor (78). Many psychiatrists who've become administrators have attributed their success to mentoring relationships during their residency training (6,14).
Opportunities for mentoring during residency education are based, of course, on availability of mentors in the prospective protégés' areas of interest. On the other hand, interests are often ignited by the chemistry of a relationship. Mechanisms to enhance applicants' awareness of faculty interests, both professional and personal, might positively influence residency recruitment and/or provide more meaningful mentor—protégé matches.
A desire to learn a skill that requires supervised practice over an extended period of time, such as psychiatric administration or psychotherapy, often leads to or is derived from a mentoring relationship. Likewise, interest in research or other skills considered above and beyond what is expected of a general psychiatry resident can draw mentors and protégés together. Development of advanced skills in psychopharmacology is one example. Although residents can use electives for such purposes, programs and trainees might find considerable value in formalized opportunities for ongoing relationships with potential mentors throughout the course of the residency.
Because resident—mentor relationships are typically longer and more intense than those of medical students, maintenance skills are highly important. Desjardins (69) advises those graduate students, residents, and junior faculty who do not have mentors to be proactive in their career planning, to set goals, and to define their expectations of the potential for a mentoring relationship. In some cases, it may be advisable to seek out more than one mentor in order to serve several different functions.
Mentoring may be especially influential for junior or mid-level faculty taking new academic positions (79). Stange and Hekelman (80) emphasize the need for junior faculty to be proactive in finding a mentor to help meet their needs and as a part of a larger career plan. The main concerns of new junior faculty are in establishing basic competence in the numerous new roles to be fulfilled (81).
Desjardins (69) has adapted Graen's (82) career rules to help faculty members clarify realistic expectations and assess the effectiveness of their mentor relationships, descriptors such as: "Provides you with information that allows you to learn how your school really operates; warns you about changes to be made in the school; assigns you challenging tasks; prepares you to handle more difficult tasks; gives you enough authority to complete important assignments; advertises your strengths to your peers and to your superiors inside and outside your institution; helps you plan your long range career; notifies you about any promotion opportunities; warns you in advance and in confidence about your academic or career problems; and asks for your input on decisions for which only he or she is responsible" (69).
Junior faculty need to make strong use of both types of "protégé skills," that is, initiation and maintenance. In faculty relationships, productivity and mutuality become increasingly important. In evaluative situations (e.g., tenure-track positions), strong pressures exist to rapidly benefit from senior-faculty mentoring. Junior faculty need to be able to adopt academic values and begin managing an academic career (25). They need to be open to assistance in establishing and maintaining a productive network of colleagues (25). Gruber and Cherry (83) recommend strategies for potential protégés on the basis of grassroots wisdom originally published in a handbook covering formal medical school and departmental guidelines on promotion and tenure.
Some formal programs for mentoring junior medical faculty exist (26). Intended benefits in one study (36) include improved understanding of academic values, whereas improved preparation to mentor others and increased perceptions of a supportive academic environment were unintended benefits.
The appreciation of the importance of relationships inherent in the theory and practice of psychiatry encourages exploration of the implications of mentoring as applied to psychiatric education. The benefits of mentoring are not unique to psychiatry, however. The literature on this subject is very broad, and the application of mentoring strategies currently cuts across all denominations in the business and professional worlds. Although mentoring is an integral part of medical students', residents', and junior faculty's development across specialties, psychiatrists are uniquely equipped to contribute to the field of medical education along these lines. The characteristics, benefits, skills, and strategies for mentors and protégés described in this article are generalizable to other medical specialties.
As applied to the specialty of psychiatry, mentoring has been described as not only part of the teacher—student (7) and supervisor—supervisee relationships (84), but also part of the psychotherapeutic relationship (85). Mentoring in psychiatry has implications for recruitment of medical students into the speciality, acculturation of residents into the theory and practice of psychiatry, support for career development in subspecialty areas, attraction to and encouragement of research as well as other academic pursuits, junior-faculty career development, and patient care.
The context of mentoring, whether it involves medical students, residents, or junior faculty, is important in determining the combination of skills required by both parties. Irrespective of context, however, a variety of skills is required of both parties to initiate, maintain, and dissolve a mentor—protégé relationship. Additional empirical research is needed to define the variables most important in mentor—protégé relationships and the skills required for satisfactory and successful outcomes.