Facilitatory mentoring in general practiceBMJ 1996; 313 doi: http://dx.doi.org/10.1136/bmj.313.7060.2 (Published 28 September 1996) Cite this as: BMJ 1996;313:S2-7060
Continuing medical education will increasingly be based on methods which promote active personal development rather than passive knowledge acquisition. Here, East Anglian GP Robert Alliott discusses mentoring
The original mentor was Mentor, wise counsellor to Telemachus, son of Odysseus; his contemporaries provide one to one guidance on personal development for general practitioners in several regions. This development is part of a trend away from knowledge based education, which traditionally takes the form of a consultant based lecture, to other methods of education.
Many such schemes are developing along individual lines with little coordination and no universally recognised job description or formal training. At the Anglia postgraduate deanery we are developing a method of facilitatory mentoring, defined as “dialogue between two autonomous practitioners on a voluntary basis.”
Mentors meet with “mentees” to talk through any impediments or problems which are obstructing personal and professional development. For their part, mentees are encouraged to speak up about any obstacles and explore potential remedial action with the mentor, facilitating constructive reflection. The mentee sets the agenda, on which both pastoral and educational issues may be discussed.
Where a mentor has been appointed, letters are sent to general practitioners advising them of the service. Responding general practitioners arrange a meeting with the mentor, usually at their own surgery or home. Confidential and personal issues often arise during the course of the sessions, making public venues unsuitable. Meetings usually last between 60 and 90 minutes, though a preliminary meeting may be necessary to explain the scheme.
Box 1: Issues raised during mentoring from analysis of taped inetrviews with general practitioners in Anglia deanery
We usually start by asking “How are things going?” This allows the mentee to set the agenda and often a current topic or problem is raised. By being given space to talk and by sensitive questioning, mentees are encouraged to articulate and reflect on their experiences and problems. We have found opening topics frequently involve issues such as living with uncertainty, unresolved complaints, feelings of inadequacy, or loss of control of working lives. An important part of any meeting is the development of a caring and trusting relationship. A friendly manner, observing all the social graces, and a little deference towards the mentee all help the discussion.
Having established a relationship and started on a topic of discussion, the mentee is encouraged to explore any problems or obstructions to development, and to seek their causes, before moving on to consider options for constructive action. The issues most commonly raised are shown in Box 1. This list can be used to change the direction of the meeting when one issue has been fully discussed; introducing a new thought may highlight serious problems which lead to further discussion.
Anglia mentors have found the use of anecdotes and the sharing of mistakes and common vulnerabilities helpful in gaining trust, reassuring the mentees and encouraging further disclosures.
Repeated visits to mentors are an important part of mentoring. Less time is spent at subsequent meetings on fact finding and unimportant details, and the ongoing relationship increases trust and shared knowledge. As another meeting approaches, the mentee reflects on the previous meeting, and has a stimulus to implement some of the plans that were previously discussed.
Serious problems may be revealed at mentoring sessions, and mentors should be careful not to leave their mentees disturbed or without a safety net. Addressing problems is challenging and sometimes ways forward can be unsettling. We offer a crisis service which offers the mentee an urgent meeting should a new problem develop.
Dealing with mentees' personal issues can be stressful. We have found our support group of mentors extremely important in helping us cope with these emotions. This group is also important for sharing educational ideas and acts as a powerful means for disseminating useful ideas and problem solving skills horizontally throughout the region.
Mentoring the stressed doctor
Stress is now a major problem in general practice. Many practitioners do not consult their own doctors or even recognise they have a problem themselves until it is too late. Mentoring is a means of reaching general practitioners in an acceptable non-threatening way, allowing them to discuss problems without losing face. A recent study of mentoring and co-tutoring in Anglia has shown a reduction in stress in both groups.
Mentoring as a career
Facilitatory mentors should be practising general practitioners; mentees are more likely to trust their mentors if they are colleagues and find in them someone who has empathy with their problems. Mentors spend about half or one day a week seeing mentees and need such attributes as an understanding, caring nature, enthusiasm, and an ability to encourage reflection and constructive action. Experience both of success and failure is also important, as are up to date knowledge and clinical skills. One mentor thought his mentee was clinically depressed recently, and with the mentee's agreement approached the mentee's GP, who arranged an urgent appointment and initiated treatment.
A mentor must be non-judgmental and offer a complete and confidential service. Mentors must be well versed in general practice education, administration, and politics to provide the infrastructure for advising on continuing development and need initiative to cope with the varied situations that develop. Counselling should be non-directional, looking at what happens when various options are tried rather than suggesting a specific route. Mentors need compassion, so they can show caring for mentees in their predicament, tact, in order that they do not make the situation worse; and honesty, so that trust can develop. Counselling skills such as listening, eye contact, feedback, use of open questions and appreciation of non-verbal cues are essential to establish and maintain the relationship. Mentors need to have a degree of self awareness, of their own strengths, weaknesses, and personal characteristics, and guard against imposing against their own attitudes and agenda upon mentees.
Although the mentees' agenda predominates, mentors gain from the meeting. Mentors earn a small session fee and some travel expenses (around £100 per session, including travel) but the main gains are of knowledge, skills, and status, offset to a degree by coping with the frustration, strains, and conflicts which can occur in any caring relationship. With only one mentor in any district, it is possible to see more than one doctor from the same practice, but this can lead to confidentiality conflicts as well as difficulties of interpretation when facts are presented in different ways. We have found our mentor support group invaluable in giving support and guidance when these problems occur.
Box 2: Key points
Mentoring in general practice facilitates personal/professional development looking at both educational and pastoral issues as a mentee's agenda dictates
Mentoring necessitates the development of a caring and trusting relationship
Mentoring helps mentees understand their true thoughts and needs
Mentoring encourages constructive reflection before exploring alternative courses of action
Mentoring in general practice is voluntary between autonomous principals
The future of mentoring
It is difficult to expect general practitioners to look after patients properly if they have major educational needs or disturbing personal problems. We see mentoring as a means of establishing a culture where sensitive issues and vulnerabilities can be openly raised to reflective constructive discussion. Practitioners with no obvious difficulties also seem to benefit from the mentoring experience by reflecting on their practice and future planning. Because we come in an educational as well as a pastoral role, mentors do not engender the feeling of failure that using help lines or counsellors seems to produce. It is better to prevent stress and burnout than to treat a developed problem, and we would like to develop a service in which every practitioner has access to a trained mentor, seeing them once or twice a year, or more as necessary. A training programme and job description should be set up, and in Anglia this is happening under the supervision of the regional adviser in general practice. Each mentor will need to see more than one mentee to offer such a service, but this will allow the development of skills and the sharing of knowledge. A caseload of 20 mentees for each mentor would allow twice yearly visits with some spare weeks for holidays, mentor support groups, and training.
With the growth of mentoring and the need for standard setting, a supervisory base is necessary to cover appointments, training, and continued supervision. It seems sensible for this to come under the regional adviser for general practice because of the large educational input. Mentors will, however, have considerable personal and private knowledge about their mentees which may be shared in a confidential form during mentor support group meetings. This knowledge is based on what general practitioners on the ground are saying and is more likely to reflect current feelings on such issues as morale, complaints, and night visiting. It is possible that this information could be fed up to local medical committees or the General Medical Services Committee, but the problems of confidentiality, mentor bias, and appearing to be agents of the government will have to be examined extremely carefully. Mentors are in a position of considerable power because of their knowledge base, analogous to that which general practitioners have over their patients. Safeguards of confidentiality and the standards set by the General Medical Council backed by a pragmatic need to maintain trust with mentees should ensure that this power base is not abused.
Facilitatory mentoring works well in the Anglia deanery and we commend it as a foundation upon which to build mentoring throughout the regions.
Thanks to Norfolk and Suffolk Health Authorities and to NHS Executive Oxford and Anglia Region for sponsoring the mentors. Thanks also to the members of the Anglia Support Group, Dr G Brown, Dr A Hibble, and Dr P Sackin.
Dr Arthur Hibble, Deputy Director of Postgraduate General Practice and mentor supervisor. NHS Executive, Anglia and Oxford Region, PO Box 650, Central Block, Fulbourn Hospital, Cambridge, CB1 5RB.