Environmental issues continue to occupy a good portion of the news and editorial thinking of contemporary society. No matter what we do, we are asked to think about the environmental impact of our actions. As we build, raze, and change the world around us, we worry about destruction of habitats, conservation of resources, and endangerment of species—and rightly so. In acknowledging the importance of that theme, I would like to discuss some of the factors that currently affect a different kind of environment—the one in which we work—which is facing real pressures from our current economic and political climate. Instead of the rain forest, I am alluding to our own ecosystem, the rather delicately balanced world of academic medicine, and to academic orthopaedics in particular.
I think the environmental analogy is reasonable. People already talk routinely about the health-care environment, the managed-care environment, and the medicolegal climate. Also, our academic world does resemble a rather complex and fragile ecosystem, with many interdependent parts and members. It is a system that has thrived for generations because of a favorable climate, and it has been able to support a diverse and vigorous "animal kingdom." But times have changed.
Extrinsic forces have developed that have stressed and challenged the health of our system and have begun to threaten the survival of some of our more exotic and valuable "species." Hurwitz and Buckwalter, in a recent editorial in the Journal of Orthopaedic Research, concisely and eloquently documented the decline and potential extinction of one of the most important members of our community—the orthopaedic scientist1. Any attempt made by me to paraphrase that position would serve no purpose; the case for concern was made clearly and convincingly. Instead, I would like to present my own candidate for our growing "endangered species" list—the orthopaedic mentor.
Just as factors in the natural environment threaten the health of the ecosystem, factors in our current economic environment threaten the diversity of our orthopaedic community, the individual "species" that inhabit our system, and the long-term health of our field.
Our reactions to changes in our environment may be as damaging as any threat that the outside world may pose. Take, for example, by way of analogy, our technological, corporate response to the expanding need for abundant and inexpensive food. Corporate farming has all but replaced the small, family-run farm in much of America. Commercial farming has improved efficiency, productivity, and profitability, but it has done so by converting more natural habitat to cropland, eliminating environmental diversity, and focusing energy on maintaining an inherently unstable ecosystem where all other species are sacrificed to optimize the growth of the one desired species—the crop.
Environmentalists warn that this process sets us up for great disaster in years to come. As vast expanses of our world are given over to growing a single plant from a single genetic line, we risk devastation should any new pathogen or parasite arise that can specifically target that crop. Our farmland, stripped of all other flora, lacks the diversity to respond to or compensate for such a plague. In the same way, if we as orthopaedists sacrifice our diversity in order to become "lean and mean," we will quickly lose our capacity to evolve and expand our field and we will become, in time, constrained technicians incapable of participating in the growth of the world around us.
We must also remember that loss of diversity means the loss from the system of certain key contributing individuals. As natural habitat is destroyed and converted to farmland, many beneficial species are inevitably displaced and eventually driven to extinction. We may not know for years the value of those species or individuals that we have lost in the struggle for productive efficiency.
Which brings me back to mentorship. The issue is not whether any one individual is a good mentor to the students and residents around him or her each day, nor is it about whether we all should work on some specific set of mentoring skills or techniques. It is far more important that we recognize that our current environment and our natural reaction to it put us at risk of losing mentorship from our environment altogether. A species is at risk.
Let us consider the mentor as a natural resource. Do we need to conserve and protect this invaluable and unique member of our community? And, if so, how do we do it? First, we must realize that true mentors are always in short supply. It is a population that is slow to build up and slow to recover from loss. For one thing, it is very difficult to "grow" good mentors: they are very sensitive to habitat destruction, they are easily injured during development, and it takes a long time for a mentor to reach "reproductive age."
Along the way to becoming a good mentor, the young orthopaedist must avoid many pitfalls, traps, and "predators," and there are more all the time. (Those little sea turtles that we always see hatching on the science channel have it easy by comparison! They just have to get to the water.) To become an effective mentor, the developing orthopaedist has to make many early career decisions that are counterintuitive, and our changing socioeconomic environment makes them more counterintuitive every day. The young clinician who might one day become a successful mentor—the proto-mentor, as we shall call him or her—has to select goals that are very long-term (providing delayed gratification, at best), not immediately self-serving (counter to most of popular culture), not necessarily revenue-generating (counter to most administrative/partner cultures), and not easily explained to family and friends (and getting harder to explain all the time). In addition, much as darker motivations may lure any young visionary from his or her noble path, internal struggles can easily derail a promising career and twist or obscure those early idealistic goals. The quest for knowledge may degenerate into a quest for funding, a desire to advance our science may deteriorate into the desire to advance our careers, a passion for research may become a hunger for fame and recognition, and, most often, fatigue may replace enthusiasm.
As this corruption progresses, we become cynical and skeptical. Our students and colleagues inevitably begin to view us with similar cynicism and skepticism, eroding our power to mentor effectively.
So, what can we do to protect our proto-mentors? In addition to supporting the general, rather vague, concept of mentorship as an all-around good thing, we must also be able to recognize a promising mentor when we see one. We must know more exactly what a successful mentor is.
First, I think a mentor is an individual who has at least a little gray hair, by which I mean a documented history—a track record—that allows younger physicians to envision long-term goals for their own careers, not just goals for the first few years of their practices. A good mentor provides a model for approaching life in its whole, as opposed to approaching just medical problems or a surgical specialty. A mentor provides patronage and teaches a philosophy of practice, not just a technique or a procedure.
Simply being productive does not necessarily make one a good mentor, but being unproductive probably hurts one's chances. Few people intentionally set out to emulate the ineffectual. Also, although being famous and recognized makes one famous and recognized, it does not necessarily make one either a good teacher or a good mentor. In fact, a good mentor may labor quietly for years in relative obscurity before his or her true impact and influence are recognized. It is possible, even probable, that any individual's success as a mentor will be recognized and appreciated only after his or her "kids are all grown."
I am not sure that one can simply decide to be a good mentor and go about being one. However, I am quite sure that one cannot simply assign the job to someone else and expect much to happen. Being a really good mentor is probably like being really good-looking or really likable; to a certain extent one either is or is not, either has an aptitude or does not. However, just as we can work on good grooming or learn to be more pleasant, we can work at being better mentors, if we want to.
More importantly, we can work at identifying and encouraging those around us who show a natural aptitude and inclination. It is particularly important for the senior members of our community to recognize their role here. Mentors cannot be created out of thin air, but they can be fostered and nurtured. Even more easily, they can be damaged and destroyed.
We must all recognize that our own behavior can have a negative impact on our colleagues' ability to effectively guide and teach the students and residents for whom we are all responsible. First, we work in a very demanding and challenging environment in which setbacks and complications are inevitable. We all tend to second-guess ourselves when things go badly in our practices. However, chronically critical or disparaging leaders undermine the credibility of all of those around them and limit their own ability to guide and advise those whom they are teaching.
Second, we all work hard and cannot help but measure ourselves in the light of the common currency. However, we must recognize, at least in an academic environment, that some contributions are measured in dollars and relative value units (RVUs) and some are not. Also, while we may pay lip service to the need for academic time, we must be sensitive to the fact that those whom we are teaching are keenly aware of whether we really value our partners' contributions or not.
Finally, we all have different perspectives and approaches to clinical practice. We may often disagree on how best to approach a specific disorder or clinical problem. In fact, in order to improve and advance our profession, we must disagree. However, disagreeing over an approach is greatly different from denigrating a partner's skills, perspective, or training. If we do not respect our colleagues and recognize their contributions, then our students and residents will not either.
At this point, I thought that it might be helpful to provide some examples of famous, or at least widely recognized, mentors, but I found it very difficult to cull out universally recognizable figures. That is because mentorship is, by definition, a very personal and individual thing. All of us have in our own minds the image of our individual mentors, those few individuals—or perhaps that solitary individual—who played a pivotal role in shaping the career that we have subsequently led. It would be unlikely that I could hold up to the audience any picture of my own that would have as much significance as the images they already have in their minds.
Nevertheless, I was fortunate enough to grow up in an orthopaedic "family" in which mentorship was long-established and highly valued. Not only did I have the opportunity to work with instructors and teachers who were invested in my success and who sought to motivate and guide me along my career path, but I had the chance to see where their influences, motivations, and guidance had come from. I learned that mentorship has a lineage, that it is a legacy. Perhaps this sense of indebtedness to our predecessors and this obligation to our students are what make mentorship different from instruction.
That lineage could not have been better illustrated than it was when, this morning, one of our graduating senior residents included in his research presentation a picture of his lab group from medical school. There, in the front, in the middle of the group, stood the grandfatherly figure of the man whom the resident wished to acknowledge as his mentor. This was a man whom my own classmates have widely claimed as one of their most important teachers and one whom my mentors and instructors have held up as their own guide and counselor. Three generations directly affected by one person—there are few operations that have lasted so well, so long.
I do not know whether that man ever consciously tried to be a good mentor or whether he was just naturally gifted in this way. His impact, however, is unmistakably reflected in the careers of those fortunate enough to have been his pupils, and it is echoed in the careers of their students as well. This is a contribution of immeasurable value, which cannot be calculated in RVUs or any other common currency.
Such figures are the tall trees of our landscape, the supreme canopy of our rain forest. They are immensely important to the health of our academic environment. Their influence is vital if academic orthopaedics is going to stay healthy and thrive, producing new generations of physicians, educators, and researchers. In addition, like the great trees of our natural world, they cannot be replaced overnight. If we lose them now, they will be gone for a long time.
We must resist the instinct to devour our resources now, in a time of stress. We must continue to manage our profession and our environment for the future. We need to recognize and honor our current generation of mentors and to encourage them to continue their work. However, we also need to identify, nurture, and protect our proto-mentors now, when they are young, to give them a chance to develop into fully mature leaders and educators. We must do this knowing that we ourselves may never see the outcome of our effort. We may never know which of our pupils was successful, who bore fruit.
We must each agree to foster those individuals who have an aptitude and an affinity for teaching and guidance, so as to ensure the diversity and vigor of our community beyond these times of economic stress and environmental hardship. Therefore, I urge that each of us make the effort to protect our young investigators, our junior faculty, our next generation of mentors. Let us strive not only to be the best teachers and counselors that we can be, but also to support and nurture those among us who have a natural talent for mentorship, so as to maintain the health and vitality of our profession into the coming millennium.
Robert F. McLain, M.D.
Department of Orthopaedic Surgery
The Cleveland Clinic Foundation
9500 Euclid Avenue, Desk A41
Cleveland, Ohio 44195
E-mail address: mclainr@cesmtp.ccf.org