The Influence of Mentorship and Role Modeling on Developing Physician–Leaders: Views of Aspiring and Established Physician–Leaders

Abstract

BACKGROUND

Although the benefits of mentoring in academic medical centers have been amply discussed, the major focus has been on conferring traditional academic skills (e.g., grantsmanship, publications, etc.). In contrast, little attention has been given to the career development of physician–leaders (e.g., communication, vision, teambuilding, etc.).

OBJECTIVES

To understand the role and functions of mentoring and role-modeling in developing physician–leaders as experienced by aspiring and established physician–leaders.

DESIGN

Qualitative design using a stratified purposeful sample and inductive analysis.

APPROACH

Semi-structured interviews.

RESULTS

Twenty-five Cleveland Clinic faculty participated (14 established physician–leaders, 11 aspiring leaders). Three themes emerged: 1. Role modeling was differentiated as a valued experience separate from mentoring, with respondents describing the significant influence of purely observational learning and “watching leaders-in-action”. 2. Many respondents favored a series of “strategic” interactions with various individuals about specific professional issues rather than traditional, longitudinal mentoring experiences. 3. Emotional and psychological support was considered the most valued type of interventional activity.

CONCLUSIONS

In our small sample both established and aspiring physician leaders believed that mentorship and role modeling played a significant role in their career development. Short, focused “strategic” mentoring relationships were favored by many over the classic longitudinal experience. Our participants valued role-modeling as an experience separate from mentoring and described the impact of learning from direct observation of skilled leaders. The educational implications of these findings are summarized.

INTRODUCTION

Healthcare in the U.S. faces many complex problems that require effective leadership. As more physicians become leaders in healthcare institutions, the question of how best to prepare them for their future roles commands interest. A survey of academic chairs of internal medicine indicated that promotion to leadership positions has more to do with research skills or clinical expertise than to any background or training in important leadership competencies¹. At the same time, the need for training of physician–leaders has led some healthcare institutions to offer leadership training. For example, in 2005, Epstein² reported that 71% of responding healthcare institutions were currently offering some type of formal training programs aimed at developing physician–leaders.

Although the trend to enhance leadership development is encouraging, little scholarship exists on how to effectively develop physician–leaders. A literature search identified only two studies that directly addressed the issue of preparing physicians for leadership positions in healthcare.^3,4 In both, experiential learning—which included mentoring, coaching, and role modeling—was perceived by study participants to be the most effective method for teaching and learning leadership competencies. In addition, what has been written about mentoring in academic medical centers has focused more on cultivating traditional academic skills (e.g., gaining research prowess, grantsmanship, navigating the academic environment, etc.) than on developing leadership skills (e.g., emotional intelligence, negotiation, conflict resolution, etc.).⁵ A few studies measuring research productivity reported that those who had experienced mentorship reported greater productivity and rated their research skills more highly than those who did not identify a mentor.^6–9 Nonetheless, in reviewing available studies on mentorship between 1960 and 2006, Sambunjak et al.¹⁰ concluded that “mentoring is perceived as an important part of academic medicine, but the evidence to support this perception is not strong.” Indeed, this review pointed out significant variation across studies regarding the definition of mentoring, functions of the mentor, and the time devoted to the mentor-mentee relationship.

Similar methodological variation among studies and inconsistency in the definition of mentorship was observed in an earlier review of college undergraduate mentoring by Jacobi.¹¹ Jacobi noted three categories of mentors’ functions: 1) emotional and psychological support, 2) direct assistance with career and professional development, and 3) role modeling. Jacobi concluded that along with these three functions, a mentoring relationship could be distinguished from others because the relationship is “intentional and helping”; that is, there is an intention on the part of the mentor to provide guidance and assistance and for the mentee to receive it. In addition, mentorship is often “reciprocal”, providing benefits to both the mentor and mentee. Finally, the relationship is often “hierarchical”; that is, the relationship is generally between an individual more experienced or skilled in a field and one of lesser skill, experience or influence.

Role modeling too has been perceived as one of the most effective methods used by aspiring leaders to learn leadership skills.⁴ A “role model” has been defined as a “person whose behavior in a particular role is imitated by others.”¹² Role models can have a powerful effect on students and residents in training. Wright et al.¹³ found that interaction with a “sufficient” role model influenced career choice. Another study of physician executives found that most felt more comfortable with the label of “role model” rather than “mentor” when describing people who influenced their careers¹⁴. For the purpose of our research, we consider the role model function as one in which the learner is in a purely observational learning role. The role model him/herself may be unaware that he/she is providing instruction and therefore has no intention to help or guide. Mentoring differs from role modeling because it pre-supposes the intention to offer help or provide guidance.

In the absence of attention to physician leadership development we conducted a study to better understand the role and functions of mentoring and role modeling in aspiring and established physician–leaders.

METHODS

This study was approved by the Cleveland Clinic Institutional Review Board.

A qualitative, semi-structured interview design based on Inui and Frankel’s¹⁵ standards for qualitative research was adopted; an inductive approach was used to identify themes and a purposeful sampling model was used to provide a broad perspective on leadership.¹⁶ The sampling approach was designed to identify representatives from two groups; established leaders (both mid-level and senior leaders [e.g., deans, department and institute chairs, activity directors]) and more junior faculty who actively aspire to leadership roles.

Using a list of current physician–leaders at the Cleveland Clinic, we selected a diverse group of established leaders based on clinical specialty and leadership tenure (in order to include those with both longevity and more recent leadership experience). Aspiring leaders were identified by their participation in one of two physician leadership development programs offered at the Cleveland Clinic: 1) The “Leading in Health Care” Course,¹⁷ and 2) The “Distinguished Educator Program”. Both were designed to build skills and support physicians’ career development. Leading in Health Care (LHC) is a course that is offered to engage emerging physician–leaders by teaching leadership competencies (e.g., emotional intelligence, conflict resolution, negotiation, etc.) and specific technical knowledge (e.g., finance, strategic planning, etc.). The Distinguished Educator Program is a course which teaches clinicians how to be better educators and includes modules on teaching, advising, assessing and evaluating learners. As with their established colleagues, aspiring leaders were selected in equal numbers from each course and to assure diversity in clinical specialty.

All participants were interviewed by the same investigator (CT), and interviews were audio-taped and transcribed The transcriptionist used a “double pass” system to record each tape; first listening, typing and rechecking each passage for accuracy. When a passage was difficult to understand, the transcriptionist called on one of the authors (CT) for guidance. Each subject was asked the same two questions: 1) “How important do you think having an influential mentor is in reaching one’s career goals?” and 2) “If you have had a mentor, what is the most important thing your mentor ever did for you?” Transcripts of interview responses were independently reviewed by two investigators. In the first-pass, descriptive labels were applied to idea units within the narratives. Idea units were defined as comments focusing on one idea plus any elaboration or examples given. Inter-reviewer comparisons were made and discrepancies were resolved through discussion. Descriptive labels for common concepts were then reduced into more general categories. The categories were examined for overarching themes that provided insight about the subjects’ functional definition of mentoring. In a third pass, we compared our categories with Jacobi’s three functions (emotional and psychological support, direct assistance with career and professional development, and role modeling) and found them similar enough to adopt them.

RESULTS

Twenty-five Cleveland Clinic faculty members agreed to participate in this study. Of these, 14 were established physician–leaders and 11 were aspiring physician–leaders. In addition to their difference in leadership status, the aspiring leaders tended to be younger (mean 39.8 years) as compared to established leaders (mean 57.9 years). Seven of the established leaders held positions at an organizational policy-making level (deans, division chairs, institute chairs) while the remaining seven held more mid-level leadership positions (course directors, clerkship directors, residency program directors).

Several participants characterized their mentoring relationships as being intentional, hierarchical, and helping. Others described a more informal or transient experience that still embodied the same characteristics of mentoring, only strategically chosen to meet immediate needs. Still other participants described a purely observational learning experience. that was more consistent with “role modeling”.

In response to the first question, “How important do you think having an influential mentor is to reaching one’s career goals?”, 18 of the participants responded that it was important, two responded that it was not important and five responded that it may be important based on certain conditions. These “conditions” included personal attributes (e.g. charisma) and “career stage”.

Three main themes were identified from analysis of the respondents’ interviews, two of which emerged from analysis of the participants’ response to the first question (i.e., “How important do you think having an influential mentor is in reaching one’s career goals?”) Examples used in the paper were chosen for the degree to which the example represented the theme.

1. Role modeling was differentiated as a valued experience separate from mentoring, with respondents describing the significant influence of purely observational learning and “watching leaders-in-action”. A small number of the established leaders described role-modeling as superior to mentoring for their career development.

2. Mentoring was described by several of the respondents as a series of focused or “strategic” interactions with various individuals about specific professional issues, rather than a formal, longitudinal relationship. We propose the term “strategic mentorship” for this new variant.

3. Emerged from the analysis of the responses to the second question, “If you have had a mentor, what is the most important thing that your mentor did for you?” Most of respondents described emotional or psychological support as the most important activity provided by mentors. Both established and aspiring leaders were able to recall specific examples.

Examples of respondents’ comments that embodied the three themes:

1. Importance of Role Modeling

One senior leader described the importance of having a mentor as:

“…very helpful. I think that a mentor can help in a variety of ways, not only in terms of clarifying for a young staff person, but helping to clarify what you’re doing, where you’re going, that sort of thing. It certainly has sort of, almost a parental role or an advisory role…. I think that the other opportunity is when somebody takes you under their wings as a mentor.”

This first description cites some of the traditional characteristics of mentorship (intentional, hierarchical, and helping). Further, the activities described are characterized as both emotional and psychological support and direct assistance with career and professional development. Many of the remaining responses, however, included a description of observational learning or role modeling as a valued experience separate from mentoring.

An aspiring leader described mentorship this way:

“I think it is essential for two reasons. One is the practical reason to open doors for you and the second reason, like you said, a lot of these skills aren’t, you know, we are not just born with them, so to watch somebody else be a good example is something I think is the best way that a lot of people can learn”.

In this second example, the aspiring leader describes both “intentional” mentoring for career development and role modeling.

In contrast, a mid-level leader characterized the mentoring relationship much differently:

“It’s a really interesting thing, I think mentors are stories that we tell ourselves. A lot of life is sort of narrative and I think some fiction, but I think mentors are you know, we pick people out, we call them our mentor. It’s so interesting that it never is really formalized… I tell myself—(these people) were very influential in helping to get where I am and they probably were, but the intentionality that I mentioned earlier is sort of absent”.

In this description, the participant alludes to role modeling and suggests that mentoring may be more a collection of impressions about those who have been influential than an intentional set of encounters in the service of developing a particular type of relationship.

One of the mid-level leaders described a possible amalgamation of both mentoring and role modeling:

“There are people over the years that I have leaned on for advice on things, but at the time I wouldn’t have called them a mentor. They were people that I self-selected and I admired and I liked what they ‘brought to the table’ and work everyday.”

One senior level leader described the distinction between being a mentor and a role model this way:

“All the books say it’s very important. I guess, I think that role models are more important than mentors, I mean to see people. I think a mentor can help you at a particular level, but there are people I have seen in action, so to speak, who I wouldn’t describe as a mentor but has still influenced me”.

Importantly, several of the aspiring leaders described mentors and role models in the abstract, as a desired ideal, rather than clearly describing their relationships in concrete terms using specific examples. Although the abstract nature of the responses might reflect the way question 1 was posed, it was clear that the aspiring leaders were more likely (6/11) to describe their reasoning in abstract terms than the established leaders (2/14), who tended to comment on concrete current or past experiences. While this may simply reflect the possibility that the aspiring leaders’ experience was more limited than that of established leaders, it is possible that aspiring leaders had better developed visions of the ideal mentoring or role model experience, reflecting perhaps generational expectations or a greater desire for mentorship.

1. Strategic Mentoring

Views of mentorship by physician–leaders varied from classic definitions of mentorship that feature a “relationship over time”. Many established leaders (11/14) described a series of focused or “strategic” interactions with various individuals about specific professional issues, thereby consisting of informal, short encounters rather than formal, longitudinal experiences. Although this theme was most evident in the narratives of established leaders, approximately half (5/11) of the aspiring leaders also described this phenomenon.

One aspiring leader characterized mentoring this way:

…“So, my idea of one single mentor has changed. I think now I try to focus on the best qualities in multiple individuals I come across.”

One senior leader described his mentoring this way.

….“In my own career I’ve had many, many, many mentors that I’ve taken different things away, many of the mementos here in my office are emblematic of some of the mentors that I’ve had in my own professional career, very important. I think it’s essential”.

Another senior leader provided a similar view.

… “I think it can be very helpful, but they are not always readily available and I can’t personally for myself find one influential mentor, I had mentoring along the way from lots of people both within this organization and outside of the organization. None was a personal coach that I could turn to on every item.”

The concept of drawing on many individuals for specific guidance rather than looking for a single source of help was much more evident among the established leaders. Many of the aspiring leaders appeared to be still looking for their single mentor.

1. Emotional Support

The responses to the second study question, “If you have had a mentor, what is the most important thing that your mentor did for you?” were quite uniform and yielded many more concrete examples of mentoring activities. Many descriptions related to the concept of “emotional intelligence,”¹⁸ i.e., “the ability to perceive emotion, integrate emotion to facilitate thought and regulate emotion to promote personal growth”.¹⁹ Emotional or psychological support was frequently (64% of examples) considered the most important aspect of the mentor’s role. Interestingly, many instances of emotional support were coupled with an appropriate challenge for the mentee to change or deepen their view of themselves.

As an example, one of the established leaders recalled:

“Somebody I can trust to let my hair down with, to talk about the insecurities I had or the worries I had that I could ‘vent’ to, and that would give me the comfort of listening, but also reacting to what I had to say and didn’t necessarily tell me what I wanted to hear, but would tell me honestly what they thought.”

Another recalled:

“Just gave me the courage to take chances, they believed in me… but they would say something like, ‘I don’t know whether anyone could ever do this, but if anyone could it would be you’”.

One aspiring leader noted:

“It’s the confidence thing, a belief, making me believe in my own self. The mentors that I truly look back on and value are those and that all they did that was to significantly challenged me to be much more than I thought I could be”.

Many of the participants also cited the value of practical career and professional development advice and help that mentors offered.

One of the established leaders described emotional support this way:

“A mentor I had very early in my career, probably my second or third year when I was a young faculty member, really saw that I struggled with that (public speaking). Personally, I got reasonably proficient at it, but I really struggled with it, and he sent me off somewhere to New York City to a week-long program on communication skills”.

Another noted:

...“in pragmatic terms it was to give me stepping stones to my advancement in my career. So he gave me opportunities to speak on the international stage, he read my papers and turned them into English, he taught me how to write in a crisp and clear fashion, endorsed the fact that I had the courage of my convictions, but had me modulate that courage to make sure I listened to other people which I don’t always do, but try to do a lot of the time”.

Another mentioned:

“Got me a job! I was mentored by a program director when I was a resident and basically when I was ready to leave he had contacts in the area in the country I was planning to move to and made a phone call, got me an interview and basically got the job. I don’t know that I necessarily would have been able to do that without him, because they weren’t looking to hire at that particular time, but it was one of those situations where he called and said, this is someone you can’t let go, even if your not looking, you need to take him on and so that was it.”

Discussion and Educational Implications

Beyond extending the analysis of mentorship to the setting of academic physician- leaders, our findings describe the views of aspiring and established physician–leaders regarding the functions of mentors and role models and clarify the differences between the two. Our findings extend the sparse literature regarding physician leadership development by offering three principal observations:

1. Role modeling was viewed as distinct from mentoring, rather than a “type” of mentoring function as described by Jacobi.¹¹

2. In contrast to the description of mentorship in other settings,^10,11 mentorship of physician–leaders often occurred through a series of short-term interactions with different individuals rather than through a longstanding, longitudinal experience with a single individual.

3. Mentees described their mentor’s providing emotional and psychological support as the most valued feature of the relationship.

Our study extends the available literature about mentorship in several other ways. First, we are aware of only two prior studies that examined mentorship in physician leadership.^3,4 In the first study, a computer-based survey administered to 110 physician–leaders, physician-educators, and medical students indicated that coaching or mentoring from a leader was perceived to be the most effective method for developing physicians’ leadership skills, exceeding on-the-job managerial experience, leadership skill-building programs, and formal education (e.g., masters degree education). The second was based on interviewees’ responses to the question “If leadership skills could be learned, what methods would be most effective?” Most respondents agreed that experiential learning methods like case-based discussions, being mentored, and having a role model were most effective. In addition to adding to the small pool of published studies on this issue, our study offers a new perspective on the nature and desired features of mentorship according to physician–leaders, namely a so-called strategic mentoring relationship. Specifically, in contrast to traditional definitions of mentorship in studies of college undergraduates and others, aspiring and established physician–leaders described experiencing mentorship as a series of short, focused interactions with mentors. While our study offers no explanation for this difference, we speculate that mentorship relationships for physicians are framed by their experience of being time pressured and having characteristically goal-oriented behavior. Also, physicians are likely seeking specific types of guidance from their mentors about a range of issues (e.g., how to navigate their academic specialty, clinical expertise, work–life balance, etc.), which, in their highly specialized career paths, may be more likely to come from multiple individuals than from a single mentor whose expertise spans all areas of desired advice.

Two potential limitations of our study warrant comment. First, our findings are based on a small sample of physicians and are therefore, not generalizable. Second, the themes that we identified could be regarded as provisional and in need of confirmation in larger study populations. With these potential limitations in mind, we suggest the following for the design of educational programs for mentors and for aspiring leaders.

1. Because many respondents indicated that they desired multiple focused mentoring experiences and multiple role models, formal mentoring programs that match a single mentor with an aspiring leader may be of limited value and may not accomplish the desired outcomes.

2. Because the receipt of psychological support was viewed by many respondents as being a key element of being mentored, potential mentors may benefit from training in how to provide emotional and psychological support to junior faculty.

3. Because observational learning through emulating expert leaders appeared to be highly valued by participants, creating experiential learning and debriefing opportunities with leaders may be useful to consider in the mentor’s tool box.

In this interview-based study of aspiring and established physician–leaders, mentorship and role modeling were generally highly valued as a means to achieve career goals. Features of strong mentors included emotional intelligence, e.g., excellent listening, encouragement, and a nurturing spirit balanced by the ability to challenge and help set appropriate goals. Finally some considered that, strategic, short-term, task-specific mentoring experiences were equivalent to or even better than the traditional “single-mentor model”.