Mentoring for Subspecialty Training Program Directors: An Unrecognized, Unmet Need? Open Access

The benefits of mentoring residents have been studied,1–5 but there is no research about mentoring new program directors. New faculty can feel unprepared for careers in academic medicine6,7; directors of internal medicine subspecialty programs in particular may be unaware of the many requirements and details of the role.8,9 Following the implementation of the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project10 and duty hour limitations,11 program directors' responsibilities have become increasingly complex, leading to a recognized need for advanced training.12–14 Responding to this need, the Association for Program Directors in Internal Medicine and the Association of Subspecialty Professors published a textbook for internal medicine education programs,15 and offer accreditation workshops.16 

Aside from the potentially daunting scope of their responsibilities, program directors face multiple other challenges. First, like many academic physicians, they feel pressure from inadequate time for the multiple professional responsibilities, and they may lack formal training in adult learning theory and education administration.9 Moreover, at the institutional level program directors may feel isolated from each other and from their graduate medical education office.12 Mentoring, which contributes to socialization within a profession,17 might ameliorate this sense of isolation, particularly for new program directors. Averaged over the past 8 academic years, 12.5% of nephrology fellowship programs appointed a new program director in each year. This is at the 12.6% ± 2.0% average rate for new program director appointments for internal medicine subspecialties (the range is 7.8% for pulmonary disease programs to 16.1% for hematology programs).18 

To address the lack of information about the mentoring of program directors, we conducted an electronic needs assessment survey via the American Society of Nephrology (ASN) Training Program Director (TPD) listserv to assess perceptions of preparedness for the program director role and recall of prior mentoring experiences, to determine areas in which mentoring might benefit, and to explore interest in mentoring relationships.

A needs assessment survey was created using Survey Monkey (Portland, OR) software19 to evaluate program director mentoring and preparation of their role and to collect demographic information. The survey was distributed via the ASN listserv and a reminder e-mail was sent 8 days later to those who had not yet responded. The listserv is the primary means of communication for the organized group of TPDs of accredited nephrology fellowship programs and reached approximately 95% of nephrology program directors. Statistical analysis was performed using the chi-square test or the 2-tailed Fisher exact test, depending upon sample size. The Mayo Clinic Institutional Review Board screened and approved this study and determined it to be exempt under 45 CFR 46.101 items 4 (IRB No. 08-002650).

Fifty-eight of 139 (42%) TPDs responded to the survey. tablelists the respondent characteristics. Overall, 58% of respondents (34 program directors) did not feel adequately prepared when beginning in that role, and only 32% (19 respondents) reported formal or informal mentoring for the role. One third of respondents had previously served as associate program directors and were more likely to report mentoring (58%) than those who had not served in an associate role (24%; P  =  .019). However, serving as associate director was not associated with feeling prepared for the responsibilities for program director. Gender, academic rank, program size or setting, and length of program director's appointment were also not associated with being mentored. Mentors included the internal medicine core program director (50%), the preceding nephrology program director (46%), an associate dean (23%), another subspecialty program director at their institution (19%), and a nephrology program director from another institution (19%). Eighty percent of respondents reported that mentoring from another nephrology program director would have been beneficial during their first several years. Useful topics for mentoring mentioned by respondents were the ACGME competencies (87%), accreditation requirements (85%), site visit preparation (79%), difficult fellow issues (63%), and curriculum development (59%). Twenty percent of respondents thought they would currently benefit from mentoring by a nephrology program director, and 76% reported willingness to serve as a mentor.

Based on the results of our survey, the ASN TPD Executive Committee recognized the need to provide opportunities for mentoring of new nephrology directors and formed the New Training Program Director Training and Mentoring Work Group in May 2009 and charged it with developing a course for new program directors and exploring approaches to enhance program director mentoring and training. The work group cochairs (S.M.N. and L.P.K.) created the Course for New Training Program Directors (box), which was attended by 21 program directors and associate program directors.

1. Identify new nephrology program directors using ACGME website information.18 Because it is mandatory to report program director changes to the ACGME, the list of new nephrology program directors on the ACGME website is the most reliable source for this information. An introductory e-mail from the American Society of Nephrology will ask new program directors to join the ASN listserv and highlight other resources such as the ASN website.

2. Compile a list of program directors willing to serve as potential mentors for posting on the ASN website. Finding a mentor willing to invest time in a mentoring relationship, particularly one using a traditional dyadic model, is seen as a barrier to mentoring.2,5 To obviate this, the work group recommended posting a list of individuals willing to serve as mentors to be available to new program directors. Short-term, intermittent mentorship by different people rather than enduring mentor-mentee dyads has been reported to be a primary means of mentoring for physician-leaders.5 Other nontraditional mentoring models such as co-mentoring and long distance mentoring have also been described as being effective.17,20 

3. Offer an expanded version of the course for new TPDs regularly, during the annual ASN Renal Week and/or at future program director retreats. According to data from the ACGME, on average, 16 new nephrology program directors were appointed annually since 2001 (figure).18 There is general agreement that the course for new program directors held in 2009 should be repeated and that, in the future, more interactive techniques such as case discussions and workshops should be included in the course.

4. Develop a timeline of recurring annual activities for nephrology TPDs to post on the ASN TPD website. Guidance for residency program directors has focused on cyclical events over the course of the academic year.21 A general guideline for the timing of important events for subspecialty programs may assist new program directors who have not yet experienced several academic year cycles. The ASN has posted a timeline on its website (http://www.asn-online.org/training/ASN-TPD_GMETimeline-Per-DK_120309_V1.pdf.). Ideally, future versions of this timeline will be downloadable as a modifiable document to which programs could add recurring local events.

5. Encourage succession planning for program directors and mentoring of associate program directors. It has been proposed that in contrast to internal medicine core program directors, subspecialty programs may not be well prepared for accreditation site visits and may be unaware of the details of training program requirements.9 Our survey did not find that having served as associate program director was associated with feeling better prepared for the program director role. The specific outcome of preparedness at the start of one's appointment as TPD is difficult to define and evaluate. Further research is needed to assess the benefits of succession planning and mentoring to prepare associate program directors to transition to full responsibility for the program.

This study has several limitations. First, the survey response rate was 42%, and response bias may be present. Our response rate is comparable to highly variable e-mail survey response rates reported elsewhere (19%–72%)22 and to other electronic surveys of nephrology program directors (30%–63%; S. E. Owens, BA, Sr. Policy Coordinator, ASN, written communication, January 2010). Information about characteristics of nonresponders to this anonymous survey is not available, and it is not clear how presence or absence of mentoring experiences might have affected response rate. Recall bias may be a factor due to the retrospective nature of the questions. Also, “mentoring” has been defined in many ways;5 thus respondents may have perceived the concept of mentoring differently, and 83% of respondents directed university-based programs, where mentoring might be more common. Finally, the total sample size was small, possibly affecting the overall validity of the study.

Mentoring of TPDs is a previously unexplored concept, and this appears to be the first study to examine mentoring of TPDs for their role. Despite its limitations, the study findings offer new insight into the subjective lack of preparedness of nephrology TPDs upon being appointed, and it highlights the potential unmet need for mentoring new TPDs. Although the subjects of this study were nephrology TPDs, the results may be generalizable to new TPDs in other specialties. As a result of this survey, several initiatives to address mentoring of new nephrology TPDs have been outlined, and the outcomes of these efforts should be evaluated. In addition, the need for mentoring TPDs in other specialties needs further exploration.