An article by Dr Ambreen Usmani published by the Asian Human Rights Commission
PAKISTAN: Ethical implications in mentoring medical students
Introduction: Formal mentoring programs are essential for medical colleges since medical students face a busy and stressful life style. The medical curricula are very vast, making the students socially isolated. In order to cut down the stress and over burden of studies Bahria University Medical and Dental College has implemented a structured mentoring program for the students. This mentor-mentee relationship has many benefits, but along with its success there are some ethical issues which need to be recognized and identified.
Objective: To identify ethical implications of mentoring medical students.
Methodology: A questionnaire based survey was conducted. All the mentors were recruited which were 22 in number and there was 100% response. The questionnaire which was distributed among the faculty members consisted of close-ended and open-ended questions. The answers which needed elaboration were asked in open-ended questions.
Conclusion: The structured mentoring program has been proved to be very successful, however it has been seen that at certain times there is violation of the close interpersonal relationship among mentor and mentee. Some mentors have shown lack of interest in mentoring due to which they do not give proper time to their mentee. Breach in confidentiality and privacy of the mentee has also been noticed. A very common issue is the paternalistic approach of the mentors towards their mentee and this attitude may pose to be harmful. Mentor is one who has strong belief in autonomy and helps in developing his or her mentees’ personality.
Key words: mentor, mentee, ethical implications, interpersonal relation, confidentiality, privacy, paternalism
When an individual voluntarily gives time to support and encourage another individual in a non judgmental, one to one manner it is known as mentoring. Although there is no definite definition of mentoring it is usually expected that a mentor is a person who is more experienced then the mentee whereas a mentee is someone who is mentored and is usually less experienced. The mentor-mentee relationship typically develops at a time of transition in the mentees’ life and lasts for a significant and sustained period of time. 1, 2
Mentoring is an ancient notion; the original mentor from whom this word has been derived was one who Odysseus entrusted in charge while he went for travelling, it was Athena who became the guardian the true mentor of Odysseus’s son Telemachus. Medical students encounter a busy curricula and this leaves them hardly any time to concentrate upon and groom their personality. This demanding and stressful life style of medical students makes them socially isolated, with limited faculty-learner relationship. The study course and isolation leads medical students to burnout and sometimes become depressed. In order to combat this some academic centers have implemented learning curricula in which increased interaction between students and faculty members are facilitated. These faculty members will function as faculty advisors to a certain number of students. Formal mentoring programs are still lacking in many countries especially for medical students. Many benefits of such programs are stated for example at Zurich University, mentoring program was established in which their aim was to provide career counseling, help increase in research interest which is a source of support in their personal growth. Therefore aiming at a personal mentor – mentee relationship which is an important aspect as it helps them to bring an overall academic and personal improvement within themselves. 3, 4
Nowadays mentoring is widely used in institutes for both undergraduate and graduate students. It is done to nurture the students’ academic and personal well being. Students of medicine have to face a lot of stress and are overburdened with work load of studying and passing exams, this burden on students result in many different consequences especially when they are unable to share their burden and tension with anyone.4, 5 In order to reduce this burden in this competing world Bahria University Medical and Dental College has established a rigorous mentoring program which caters to the students’ academic and personal problems within a certain boundary. This program is formally structured and faculty has been trained via workshops to mentor students, the mentoring program has been running for 2 years. In order to evaluate the program the faculty who are mentors and students are interviewed time to time. This is done to ensure the successful running of the program. Ten mentees have been assigned to one mentor and weekly scheduled meeting between mentor and mentee are held where the mentees can personally meet their mentors and discuss different issues. This close interpersonal relationship sometimes allows mentors and mentees to unknowingly violate the set boundaries and it has been reported that many times ethical dilemmas arise due to these close relationship. 5, 6
The objective of this study is;
To identify ethical implications of mentoring medical students
A questionnaire was distributed among the faculty members who were also mentors. At present we have 22 mentors; all of whom responded to the questionnaire which was to remain anonymous. There were 5 close-ended (table) and 3 open-ended questions related to ethical issues. The answers which needed elaboration were asked in open-ended type questions, so that the mentors could express themselves.
This was a qualitative research in which the questionnaire was filled by all mentors. The response rate of mentors was 100%, there are a total of 200 MBBS students of both 1st and 2nd year thus the approximate mentor – mentee ratio is 1:10.
The 5 close ended questions were noted in an ordinal manner and a table was constructed mentioning result of close-ended questions (table). Answers to the close ended questions show clearly that most of the mentors are very protective towards their mentee. They pose a friendly attitude towards them and are also ready to violate boundaries to some extend. The mentors predict that they may also cover up for their mentees’ unethical issues related to their personal or academic life, whereas the open-ended questions that were asked were:
i)If your mentee puts his/her trust in you and discloses his/her secret to you and asks you not to disclose it further, what will you do?
ii) Apart from being your student, how do you relate yourself to your mentee?
iii) Do you discuss your mentee’s problems with other colleagues?
In response to the open-ended type questions, for the 1st question, 18 mentors wrote that they will keep the trust of the mentee and never disclose the secret. However 2 mentors mentioned that if the secret will cause harm to the mentee they will disclose it to the concerned person. Another mentioned that s/he will definitely disclose the secret to the institute since her/his duty to the institute comes first. One mentor wrote that s/he will advise the mentee to disclose the secret and discuss it so that a solution may be sought.
In response to the 2nd question, 12 mentors said that the mentees were just like their own children, 4 mentors wrote that mentees were just like their younger sister or brother, 2 wrote that they could only relate to them as students and nothing else whereas the rest that is 4 did not respond to this question.
Very interesting responses were received of the third question, some of which are:
“yes, sometimes we do discuss various problems regarding mentees although I know we should not” “we do not have special rooms for mentoring so others tend to over hear the discussions then obviously the rumors spread”
“it is important to discuss their (mentees) problems so that others who are more experienced can guide us to solve their issues”
“no never, I make sure that my mentee trusts me and we always sit in my office with the door closed so that all that s/he tells me stays with me”
In response to this question, 10 mentors thought it were alright to discuss mentoring issues with their colleague, 12 mentors said it was unethical and a wrong practice to discuss any issue regarding their mentee with anyone.
A healthy mentor-mentee relationship is important for mentoring to be successful. Mentoring has been explored in many disciplines and at many different educational levels. Mostly this relationship has a good, positive impact but sometimes it may have a negative impact.
Several authors especially in the field of psychology have documented and confirmed that the relationship of mentorship benefits both mentor and mentee. In contrast there is also a dark side of this relationship which mainly consists of ethical risks. Johnson and Nelson have clearly mentioned that these risks are usually intrinsic to the mentoring relationship which maybe due to the close personal and professional nature of this relationship. This may make the mentee vulnerable to the exploitation. Johnson and Nelson also pointed out that this relationship results in both mentor and mentee playing multiple roles.6 These situations have been specifically counseled against by the American Psychological Association’s Ethical Principles and code of conduct. This ethics code provides a guide and it is an obligation of all mentors to avoid engaging in multiple relationships because this may result in impairment of their ability to perform their jobs properly and ethically, also it may cause harm or exploit the mentee. It has been stated in certain studies that some mentors have power over their mentee and can use this power to exploit or otherwise harm them. 7 With its many benefits, this relationship may encounter certain potential problems. Simpler problems may occur when mentors lack the requisite skill or may not take the role very seriously. Sometimes mentors do not give enough time to their mentees. Some very serious problems occur when mentors become very possessive about their mentees and show undue favoritism at many forums. At times when a mentee has a good and nurturing relationship with a mentor who is in a powerful position, the mentee may become a subject of envy and thus people will target him resentfully. This behavior leads to jealousy among peers. Another area of ethical concern due to strong mentor-mentee bond which deepens could be the potential risk of boundaries being blurred or crossed causing the relationship being converted into an unethical and objectionable one. When the mentee leaves the institute or when the mentee is ready to be independent termination of this relationship is planned and this may result in adverse effects especially when the mentor has a paternalistic approach towards the mentee. 8, 9
In our setup however, a paternalistic approach of the mentors has been observed and the students tend to become emotionally attached to their mentors and vise versa. It has been observed that mentors will go to great trouble in helping their mentee and will continue to advice and nurture them in a paternalistic manner which the students seem to expect and appreciate. This sometimes becomes unethical in the sense that undue favors are showered upon students. The mentors will be ready to take up any risk on the part of their mentee leading to too much dependency. 10, 11
Confidentiality and Privacy of the mentee’s issues is also a key issue in mentoring. This is an important aspect which may be overlooked since it has been experienced that many faculty members discuss their mentees and their problems with their colleagues and this leads to breaching ones confidentiality and sometimes also privacy. Respecting privacy and to safeguard ones confidentiality are hence of utmost importance in order to maintain integrity of the process of mentoring and this must under all circumstances be observed all the time. 12,13 Therefore it is important that refresher courses on mentoring should be conducted so as to remind the mentors of their roles as mentors and keep ethical implications at the lowest. In all profession the primary ethical directive is first do no harm, we must be sensitive and aware of the harm that we may do to our mentees. Therefore mentoring with all its positive outcomes is very fruitful for the growth of the mentee but we must identify the dangers that mentoring can sometimes pose. 14, 15
Mentoring program for undergraduate medical students has proved to be a very successful program in our set up. However it has been observed that close interpersonal mentor – mentee relationship may lead to violation of boundaries resulting in undue favors towards mentees. Some of the mentors also exhibit lack of interest in mentorship, due to which they do not give appropriate time and guidance to their mentees. Breach in confidentiality and privacy of mentees has been noticed which must be safeguarded and respected. A very paternalistic attitude of mentors towards their mentee has also been reported in majority of the cases but mentees expect and appreciate this attitude which may pose to be harmful. Mentor is one who has strong belief in autonomy and helps in developing his or her mentees’ personality. These few lofty aims are attainable by mentors who respect the ethics of mentoring as true caring.
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||Do you report unethical issues regarding your mentee, even if it may harm your mentee?
||Are you in contact with your mentee’s parents?
||Will you prefer it, if your mentee was of the same sex as yours?
||Both sexes= 22
||How is your relation with your mentee?
||How are you going to react if your mentee violates boundaries?
||Take him/her to the supervisor=2
||Ask for mentee to be replaced=none
Table: close-ended questions
The views shared in this article do not necessarily reflect those of the AHRC, and the AHRC takes no responsibility for them.
About the authors: Dr Ambreen Usmani Assistant Prof of Anatomy, Professor Syed Tipu Sultan, Principal, Dr Quratulain Omaeer, Bahria University Medical and Dental College- Karachi