Mentors also need support: a study on their difficulties and resources in medical schools

ABSTRACT CONTEXT AND OBJECTIVE: Mentors have been recognized as important elements in the personal and professional development of medical students. However, few investigations have sought to understand their development, needs and difficulties. Our objective was to investigate the perceptions of a group of mentors regarding difficulties experienced over time and the resources used to face up to them. DESIGN AND SETTING: Qualitative exploratory study on mentors at Faculdade de Medicina da Universidade de São Paulo (FMUSP). In the FMUSP Mentoring Program, mentors follow and guide students throughout the course, and are responsible for heterogeneous group of students, in relation to the academic year. METHOD: Semi-structured interviews were conducted with 14 FMUSP mentors. RESULTS: For many of the mentors, the difficulties related to initial doubts about the role, frustration with the students’ attendance and overloading of daily tasks. To address such difficulties, these mentors used external resources and their own life experience and personal way of dealing with situations. Some mentors did not perceive difficulties for themselves or for students. CONCLUSIONS: Like in other mentoring programs, many difficulties perceived by mentors seem to be derived from the context of medical education itself. However, unlike in other experiences, FMUSP mentors do not feel that there is lack of support for their role, since this is regularly provided in the structure and dynamics of the program. The “difficulty in perceiving difficulties”, presented by some mentors, demands further investigation for better and greater understanding.


INTRODUCTION
In Homer's Odyssey, Mentor was a wise and faithful friend of Odysseus, King of Ithaca, to whom he entrusted the care of his son, Telemachus, while absent for the Trojan War.Mentor was responsible for the boy's education and character development, guiding the decisions and choices to be made, and especially encouraging Telemachus to keep going at critical moments.In this task, Mentor was not alone: he received help as well.Pallas Athena, the goddess of wisdom and bright eyes, often assumed Odysseus's friend's form to "help him to help" the young Telemachus. 1 Because of this relationship, the personal name Mentor has been adopted as a term meaning a trusted guide and counselor who supports and stimulates less experienced people in their personal and professional development. 2day, mentors are recognized as an important element in the personal and professional development of young medical students.
Mentoring programs have been introduced in medical schools, 3 through recognition that the journey of future doctors is filled with demanding tasks, vicissitudes and challenges to overcome.
There is great concern in studies in this field to list and describe the attributes of a good mentor.Such individuals should be able to share their life experiences and technical expertise, have a respected professional standing and show genuine concern for others, with respect for their choices and interests.5][6][7][8] However, while a lot is expected of a mentor, a recent review of the literature 9 showed that few investigations have been devoted to understanding mentors' development, needs and difficulties. 10,11nsidering that the mentoring relationship is inherently reciprocal, and that its satisfactory development depends on both mentor and mentee, investigations to understand mentoring from the mentors' point of view are necessary for both practice and theoretical advances in this field.
At Faculdade de Medicina da Universidade de São Paulo (FMUSP), a Mentoring Program (Programa Tutores FMUSP) was implemented in 2001 for all its 1,080 students. 12The main goal of the Mentoring Program is to provide a mentor for medical students, who will follow them throughout the course, with regard to their personal and professional development.Each mentor is responsible for a heterogeneous group of 12 to 14 students, in relation to the academic year, with the aim of stimulating exchanges of experience between different phases of the course.Students' participation is optional.There are some who always participate in the activities, others who sometimes participate and yet others who never do.
To be a mentor at FMUSP, it is necessary to be a physician actively involved in the educational context, to be close and empathetic to students' needs and to have sufficient time and willingness to participate in initial training and supervision over time.
In order to understand the mentoring process from the mentor's point of view, qualitative research was developed among a group of mentors at FMUSP, to explore their perceptions about their experiences over time.

OBJECTIVES
This study aimed to present and, specifically, to discuss the difficulties and resources identified by mentors in performing their role and tasks.

METHOD
Fourteen FMUSP mentors comprised the group of subjects investigated.In accordance with the methodological precepts of qualitative research, 13 numerical representation was not sought in this study but, rather, quality of information in the interviews.
The study group was formed in such a way that it would be het- It was deemed that the number of subjects included was adequate when it was perceived that redundancy of information or saturation of responses was starting to appear.
Through a semi-structured interview, the mentors responded to open-ended questions regarding their motivations, difficulties, support resources and changes over time.
In this study, the questions analyzed in order to understand mentors' difficulties and resources were: -What are mentoring meetings with students like for you?A total of 25 mentors were approached to participate in the study.Of these, four declined to be interviewed and five thanked us but said that they did not have time to schedule the interview meeting.A total of 14 interviews were conducted before data saturation was felt to have been reached.
All the interviews were conducted by the first author.The interviews lasted between 30 and 90 minutes and were conducted either in the teaching hospital or in the medical school, according to the interviewee's preference.
The interviews were recorded and transcripts were analyzed using the technique of content analysis. 14Empirical categories were formulated after repeated reading of the data.The authors performed parallel readings of the material and met to discuss the construction and final definition of the categories, by consensus.
The study was approved by the FMUSP Ethics Committee, and the participants signed an informed consent statement.

Participants
Out of the 14 mentors interviewed, eight were male.The group age ranged from 35 to 61 years.Most of them were from a clinical medical specialty.Half of the mentors were veterans within the program, i.e. they had been doing this activity since its beginning.In the view of the majority of the mentors, the students' attendance was unsatisfactory, i.e. out of the 10 planned meetings over the year, students had attended less than five.Similarly, most mentors poorly attended the supervisory meetings that were offered to them (Table 1).

Doubts at the beginning
Some mentors showed doubts about their task and role, which had been felt especially at the beginning of their experience:

Many mentors highlighted frustration over time because of the students' absence or their low attendance at the meetings:
The first-year students come at the beginning and then they stop coming...We always expect we will see more

Program Coordination and Supervision
Program Coordination and Supervision was recognized by some mentors as an appropriate and welcoming environment for ques-

Exchanges with other mentors
Contact with other mentors at the time of supervision was also recognized as an important source of help, thus making it possible to share difficulties and experiences.

We can talk to other colleagues and see if they have faced similar situations (Mentor 4);
The mentors send emails to one another, so I feel very comfortable in telling them everything (Mentor 10).

My life experience
Many mentors identified their own personal or professional life experience as a resource for dealing with difficulties.They accessed past experiences that had been satisfactorily resolved, and adapted them to the present moment:

My personal style
The personal way of dealing with situations also appeared as a resource in the mentors' relationship with students and tasks.

DISCUSSION
In this study, mentors were asked about their perceived difficulties and support resources in a mentoring program for an undergraduate medical course.Some mentors reported doubts and difficulty in dealing with the initial expectations about the role and the mentoring tasks.Such doubts, especially at the beginning of the experience, are understandable and natural.Mentors from other programs have also shown concerns about the role, and have presented anxiety and uncertainties about their personal skills.In the School of Medicine of the University of Washington, 11 the mentors interviewed also reported that they were concerned about not doing enough for their students or not having personal skills for managing the meetings.
It is known that motivation, knowledge and experience as a doctor, teacher or researcher are not enough to be a good mentor or to establish a satisfactory mentoring relationship. 15In the FMUSP Mentoring Program, there is initial training, but the mentors interviewed showed that this is not enough, thus reinforcing the notion that in mentoring, "when you start working with your student, you're never sure what will happen". 16er time, when mentoring meetings took place, the greatest difficulty perceived by most of the mentors was the students' low attendance.Similar problems have been reported in other studies.In a program designed to support freshmen, mentors of the Ribeirão Preto Medical School (Faculdade de Medicina de Ribeirão Preto, FMRP), in Brazil, reported difficulty in motivating students to participate, and felt discouraged due to the students' low attendance. 17Mentors of the Karolinska Institutet Teaching Hospital in Sweden have also reported that it is very easy for students to escape from contact and that the relationship with them did not become as deep as expected. 10udents' attendance is a challenge for formal mentoring programs since it results from of a complex relationship that involves mentor, student and institution.It is known that mentors and students should have interpersonal skills and should understand and agree with the proposal.It is also necessary for the school to establish clear reasons why mentoring should take place and be prepared for it. 18,19However, there are many events and behavioral patterns in mentoring that cannot be predicted and controlled.Studies have recognized that the mentoring relationship is not like a formula: it develops naturally, and the most important element is the "chemistry" between mentor and student. 8,20he FMUSP Mentoring Program is characterized by students' voluntary participation, which results in naturally heterogeneous attendance.Although the mentors understood the nature of students' attendance in a rational manner, when the students did not attend the meetings or attended them in small numbers, this gave rise to feelings of frustration, anger and devaluation.
Another difficulty perceived by several mentors was their everyday academic and professional tasks and the pressures of time to accomplish all of them.The many teaching, research and care activities are perceived by mentors as elements that create difficulties in mentoring relationships.This context, which is typical of medical teachers, leads them "to squeeze" mentoring into an agenda that is already full of commitments. 15The mentors also highlighted the students' involvement in many activities due to the strong competition among them.In fact, studies on the FMUSP medical student profile have shown that 17% of freshmen already perceive the school to be very competitive.In the second year, this percentage rises to 51% and then increases to 65% in the final years. 21These mentors' perceptions reinforce studies that indicate that the structure and dynamics of medical schools are barriers to mentoring, thereby negatively affecting the establishment of intense connections and long-term relationships between students and professors. 22,23While it is known that mentoring relationships go through phases 24 and require commitment from both parties over time, 23,25 and that regular interactions are significantly associated with satisfaction, 26,27 the results from the present study show that there is a need for institutional strategies to protect the time allocated to mentoring meetings in medical schools.There were mentors who did not identify any difficulty in being a mentor.For some of them, the situations experienced were regarded as inherent to the work; for others, there were no difficult situations to report because the students did not have problems.Stenfors-Hayes et al. 10 also reported that mentors commonly presented the reaction that the job was easy because the students did not present problems, and thus concluded that solving problems was part of teachers' expectations in mentoring.
The mentors' perception of "no difficulty" in mentoring, for them or for students, can be understood in different ways.9][30] Another could be that mentoring has a developmental goal and it is not necessarily focused on problems.Even though the academic life cycle is a process with some natural crises, this does not imply that these moments are synonyms for disasters.It can be also considered that physicians, because of their medical training, only consider a situation to be a "problem" when it is viewed as something involving significant risks, in the sense of "life or death".
In Other elements such as life experiences and personal ways of dealing with things were perceived by the mentors interviewed as important sources of support.It is not surprising that personal or professional experiences were considered by the mentors in their relationships with the students.
By definition, mentors are precisely the kind of individual who through their histories can guide younger people at the beginning of their journeys.However, while past experience is important for mentors, on the other hand, they cannot forget that the "route" and "destination" will be determined by the young. 1 In mentoring relationships, it is sometimes easy for mentors to develop a paternalistic attitude, and it is important not only be aware of this, but to resist it as well. 34e personal way of dealing with situations shows that personality, like in any other human relationship, is an element also present in mentoring.There are mentors who are more thinkingoriented, while others emphasize action and there are also those who are more focused on emotion and intuition.There are no studies on medical education, as far as we know, in which the influence of personality characteristics on mentoring relationships is examined.However, there is the recognition that a good mentoring relationship involves mentor self-awareness and identification of his own style, strengths and limitations.For a mentoring relationship to be effective, as highlighted by Taherian and Shekarchian, 34 there is no requirement to incorporate any ideal This study also revealed, interestingly, that some mentors did not perceive difficulties in being a mentor.Such "difficulty in perceiving difficulties" is a result that requires further investigation in order to better understand the impact of this perception on mentoring relationships from the students' perspective, as well as with regard to mentors' own personal development.
erogeneous (intentional sampling) regarding demographic variables and experiences in the mentoring program.The following factors were taken into account: gender, age, specialty (clinical or surgical), length of time in the program (veteran: in the program since 2003; beginner: in the program since 2006), students' attendance at mentoring meetings (satisfactory: out of the 10 planned meetings over the year, students attended five or more) and mentor's attendance for supervision (satisfactory: out of the 10 supervision encounters of the year, mentors attended more than half of them).

-
When faced with any difficult situation in mentoring practice, you... -What resources do you have for dealing with the difficulties encountered?Data were gathered during the second half of 2008 and in January 2009.During this period, the program comprised 81 mentors.
tions and guidance when difficulties were faced: I'm in contact with the program coordinator and I also take my doubts to the supervisor (Mentor 11); I have a group of people who I know that I can rely on.In the mentoring program, there are many people who I can talk to about doubts and I'm absolutely secure because of this (Mentor 12).

First, I have
to understand the situation, and what is happening.Then I will try to solve it in the proper way (Mentor 7); I always ask direct questions (Mentor 12); I think the best resource I have is "feeling" (Mentor 13).
attribute, but mentors need to have an open-minded attitude, with commitment and willingness to actively maintain the relationship over time.CONCLUSIONSIn this exploratory study, many mentors of an undergraduate medical program recognized difficulties in their activity: there were doubts at the beginning of the work, frustration with the students' attendance over time and difficulty in inserting mentoring meetings into an overloaded work agenda.To address these difficulties, mentors used the support resources offered by the program, exchanged experiences with other mentors and also used their own life experience and personal way of doing things.Other mentors in different mentoring programs withinMedicine have reported similar difficulties, thus indicating that the context of medical training could be, through its very nature, a barrier to mentoring.However, unlike other programs in which mentors have demanded training and ongoing support, the FMUSP mentors perceived themselves to be supported by the program support resources, even if they did not participate very assiduously in the supervisory meetings.

Table 1 .
Characteristics of the mentors interviewedDifficult? I don't know if there was any difficult situation… Nothing has ever hit me directly.In every job, you have situations that are easy to solve and others that are more difficult.It is inher- Daily tasksAn overloaded academic-professional agenda and limited time for the different activities were mentioned by several mentors as barriers to maintenance of a mentoring relationship:I'm always anxious because, beyond mentoring, I have to think about several other things during the day (Mentor 10);I understand that it is hard for both mentors and students to be there during the mentoring period (Mentor 10);The students always use the mentoring period to do something that, in their minds, is more important.The medical school overload and competition among students are very strong (Mentor 2).II.Difficult situations?No…What is a difficult situation?Some mentors were unable to identify what exactly a difficult situation would be:These are very rare.They come only with occasional doubts, mostly concerning medical school and careers (Mentor 5).