In the 1984 box-office hit The Karate Kid, we are introduced to an iconic mentor, Mr. Miyagi. Recognized for his mastery of karate, Mr. Miyagi is approached by young Daniel LaRusso, who eagerly wants to learn the martial art himself. Although Mr. Miyagi initially refuses, he eventually promises to teach Daniel, but only if Daniel obeys Mr. Miyagi's orders without question. After agreeing to the terms, Daniel is then assigned to wash and wax several old cars. "Wax on, right hand. Wax off, left hand. Wax on, wax off!" is the only explanation Mr. Miyagi provides as Daniel labors. After 4 days of back-breaking work, Daniel finally learns why he was asked to perform those menial tasks. Washing and waxing cars enabled Daniel to build the muscle memory needed to perform defensive karate maneuvers. All along, Mr. Miyagi had carefully chosen tasks that would establish Daniel's foundation for karate.1 Although a fictional illustration, the Miyagi model of mentorship provides an excellent example of a traditional apprenticeship style of learning. According to Fuller and Unwin, an apprenticeship model is a more prolonged and formal relationship than an instructional 1-on-1 relationship, such as tutoring.2 The object of a master-apprentice relationship is to impart the knowledge, skill, and judgment of a master to an apprentice through a contractual agreement. Through task participation, the apprentice progressively embodies the talents and characteristics of the master.2 As one of the oldest forms of tutelage, this model of training is prevalent in many disciplines, particularly the trades and arts. It was through this model of training that Ghirlandaio taught Michelangelo how to paint frescoes, which endowed him with the foundational skills needed to paint the Sistine Chapel.3 Transforming unprocessed wood into a cello seems magical to the untrained eye. To a master luthier, this process is answerable through knowledge of how to organize material, skillful use of one's tools and hands, and following principles of construction. Similarly, plastic surgeons are faced with the challenge of healing traumas, congenital differences, and diseases through concerted knowledge, skill, and wisdom. This partially explains why surgical training has followed an apprenticeship model since as early as the eighteenth century.4 Rather than simply memorizing anatomy and learning how to sew tissues, the purpose of residency is to teach young doctors how to become master surgeons. Instrument handling, knowledge of anatomy and techniques, economy of motion, and creativity all play into why the apprenticeship model was used historically and why elements of this model persist.5,6 Surgical training has always required more purposeful instruction than the adage, "see 1, do 1, teach 1." WHY THE MIYAGI MODEL FAILS RISING GENERATIONS If the Miyagi model of training worked for Dr. Sterling Bunnell and Dr. Raymond Curtis, iconic teachers in hand surgery, why are rising generations of plastic surgery trainees deviating from this approach? The explanation is more complex than simply pointing to generational differences in communication or work ethic. Plastic surgery is becoming more diverse in terms of operations performed, patient populations served, trainee backgrounds and interests, and trainee career trajectories. No longer does "1 size fit all."7 Personalized mentoring is increasingly valued (Fig. 1).Fig. 1.: Shortcomings of the Miyagi model of mentoring and what future generations want.According to a 2021 study, mentees are looking for mentors who are successful both within their careers and outside the workplace.7 This echoes findings of burnout and overall job and life satisfaction impacting medical student and trainee career decisions.8 Consequently, many among the rising generations are seeking mentors who share elements in appearance, background, or personality. Finding mentors with similar characteristics is linked to mentees experiencing greater cross-identity and lower imposter syndrome.9 This is especially important for minority individuals who rarely see themselves mirrored in plastic surgery leadership, which is a contributing factor to career attrition and burnout. Another critique of the Miyagi model is that it often stifles a mentee's innate genius by encouraging him or her to problem-solve through adherence to rote memorization or to embark on the same career path forged by the mentor.10 Rather than having a mentor-boss, rising generations want a mentor-partner. As illustrated in The Karate Kid, the mentee, Daniel, expressed frustration after being assigned seemingly pointless busywork. Had Mr. Miyagi explained why the tasks were important and how they were contributing to Daniel's goals, the initial friction between Daniel and Mr. Miyagi would have been avoided. Creating a mentor-mentee partnership in which communication and expectations are clear will lead to a more productive relationship. Career success also no longer solely hinges on one's knowledge or technical expertise. Embodying a multitude of soft skills is increasingly important. Soft skills, or a scope of interpersonal skills needed to lead and collaborate effectively, are increasingly valued in plastic surgery. Many of these soft skills include business acumen, emotional intelligence, and effective communication.7,11,12 Within academic and private practice plastic surgery, it often implies leading and collaborating within teams, expressing oneself in person and in writing effectively, developing creative solutions to systems-based issues, and brand marketing. Rather than placing total responsibility on 1 person to impart these skills, having a community of mentors is thought to be more effective. MENTORING INSIGHTS FROM BUSINESS TRAINING As in many industries, mentoring in business has critical advantages for rising entrepreneurs and leaders. According to the Harvard Business Review, chief executive officers who were mentored received greater compensation, were more likely to receive early promotions, and reported higher levels of work satisfaction.13,14 However, business education and mentoring varies compared with surgical training. Whereas surgical trainees are instructed to memorize dogma and perform standardized technical skills, business mentees are trained to problem-solve through experimentation. With the attitude that many solutions are acceptable, there is more freedom to innovate and express individuality. It is not uncommon for business mentors to seek input from their mentees. With the inherent fluidity of business, it is also standard for young entrepreneurs to adopt multiple mentors. These foundational differences in mentoring provide learning points to those invested in improving surgical training.15 Contrary to the Miyagi model of mentoring where trust is assumed based on reputation and experience, those in business establish trust through forging relationships.16 If personal chemistry is lacking, mentees are encouraged to seek other mentors.16,17 Chemistry, or the feeling of connection between a mentor and mentee, is established in many ways. Establishing early, regular meetings to communicate shared values, hobbies, and interests is a great way to relate to one another. Examining personality types and learning where one derives energy and how he or she makes decisions is another way to increase understanding. Above all, the mentor and mentee should share their goals and learn what similarities exist between them. Having a clear path of what they would like to accomplish together sets a valuable tone for the relationship. Unsurprisingly, mentors and mentees who establish a positive relationship report higher levels of satisfaction and continue mentoring others.13 This indicates that although mutual respect is essential to the mentor-mentee relationship, it alone is insufficient to spark mentee interest in propagating the mentoring lineage. This has lasting implications for plastic surgery, as our field is closely knit. Positive relationships often beget a wider spanning network and will expand career opportunities for those established within the field and for those new to the specialty. Business mentors are also encouraged to guide rather than direct.16 Contrary to the Miyagi training model, mentees should work with their mentors to set terms and expectations for the mentee-mentor relationship and goals they aspire to accomplish. With the mentee steering the direction, there will likely be more buy-in from the mentee to follow through on tasks. Guiding, rather than ordering, also prevents mentors from living vicariously through a mentee or insisting that their way is the only way to success. However, one of the challenges in applying this principle of training in surgery is that the knowledge and experience of an attending surgeon far exceeds that of a resident and medical student. This makes it tempting for an attending surgeon to dictate step-by-step instructions on how tasks should be performed. It requires more effort to ask the mentee for his or her ideas and solutions, especially because many of the mentee's initial contributions will not be practical. However, regular collaboration will promote the mentee's problem-solving capabilities and preserve enthusiasm for goal completion. Regular collaboration also serves as a route for attending surgeons to assess how their mentees are progressing and how to tailor their feedback. With an emphasis on maintaining strong relationships, business mentors intuitively customize their feedback (Fig. 2). Before providing feedback, a mentor should reflect on how his or her mentee will likely respond. A reactionary mentee often needs to be reminded of the positive work he or she provides before emphasizing an area needing improvement. When feedback is given to this type of mentee, starting the discussion with a question provides a nonthreatening space to reflect before responding. For example, if a reactionary mentee is failing to meet deadlines, the mentor should start by stating, "I noticed that you've missed a few deadlines recently. Is there a reason for this change?" Ending feedback-oriented conversations with open-ended questions (eg, "What do you think is the solution?") will provide these mentees opportunities to create their own solutions without feeling judged or reprimanded. Alternatively, an assertive and confident mentee is better served with direct communication. In these cases, providing specific examples, facts, and details behind the feedback will likely be better received than passive communication. For example, "In yesterday's meeting you interrupted several colleagues. When you communicate in this way, your team members state it makes them feel uncomfortable." However, even when providing clear examples and details, the mentor should avoid accusatory or judgmental statements, such as, "You are a rude person." Rather, try statements that remind the mentee of his or her goal. For example, "I would like to see you listen and wait before responding, so that your team members feel comfortable sharing their opinions and ideas with you. This will help you be a more effective group leader." Ultimately, communication significantly affects the quality of a relationship. Mentors and mentees should be cognizant of how they express themselves.Fig. 2.: Customizing feedback.MODERN SURGICAL MENTORING: THE SHERPA MODEL Notwithstanding the advantages from the business approach to mentoring, plastic surgery training requires learning craft specifics and mastering technical skills. The hierarchy in surgery also needs to be preserved for patient safety and team unity. A new mentoring style that encompasses characteristics from the Miyagi model and the business approach is better identified as the Sherpa model of mentoring. Sherpas, or mountain guides to Earth's most extreme climbs, are known for their ability to withstand high altitudes, knowledge of multiple paths, how to maximize safety, and discernment when encountering technical challenges or facing harsh environments.18 For their skill, knowledge, and leadership, Sherpas are often praised as the ultimate guides.19 Thus, Sherpas are not entirely different from mentors in plastic surgery who take on the roles of guides, coaches, and sponsors for their mentees. How do we define the Sherpa model of mentoring? Sherpa mentors are those who are committed to guiding their mentees to goal attainment by actively and enthusiastically serving as a coach and partner. The object of the Sherpa model of mentoring is to create technically proficient, well-rounded surgeons who maintain positive, long-lasting relationships with their mentors. We recommend the following 3 steps to create such a relationship (Fig. 3).Fig. 3.: Sherpa model of mentoring.Spend Time at Base Camp Just as Sherpas and trekkers spend time at Mount Everest's base camp, mentors and mentees should take the time to acclimate to one another. In the Miyagi model of training, respect was superficially reciprocated based on reputation and perceived skill or experience. Although near blind faith in one another suffices temporarily, the relationship will inevitably encounter strains while traversing difficult terrains that result in critical errors. Many hazards and communication missteps will be avoided if trust and mutual understanding are established early. Multiple methods are available to facilitate this aim.20–22 As in the business approach to mentoring, mentors and mentees should review common interests, review relevant life experiences, and discuss shared goals to establish trust. This is especially important when a long-term mentor-mentee relationship is commencing. Mentors should prioritize knowing the mentee holistically rather than viewing him or her as a unidimensional, task-accomplishing individual. When possible, mentors should learn of their mentees' inherent strengths and weaknesses. Starting these conversations is frequently taxing for mentors who have limited time, and it is intimidating for mentees. In these instances, short, informal meetings create a relaxed environment and improve efficiency. Meeting between cases, while waiting for anesthesia induction or when walking to and from other required meetings, such as grand rounds, also improves efficiency. Alternatively, mentors can also choose to meet with multiple mentees in a team setting to increase efficiency and improve peer camaraderie. Both parties should discuss their communication preferences. In the era of technology, e-mail, texting, telephone calls, Zoom meetings, and other virtual platforms are available to improve communication. Mentors should establish which avenues of communication they use, and mentees should accommodate their mentor's preferences. Clarifying these points will minimize miscommunications. While establishing these lines of communication, mentees should take the initiative to propose when and how often to meet while respecting the time constraints of their mentors. Mentees should also be attentive to their mentor's communications and respond in a timely fashion. Mentors and mentees should start with the end in mind. Mentees should reflect on their goals and have a clear vision of what they aim to accomplish before meeting with the mentor. This is especially important for rising generations who value individualism and wish to forge a unique career trajectory. A mentee who effectively articulates what he or she wants will enable a prospective mentor to create a plan that will help the mentee. Alternatively, the mentor should also refer the mentee to another faculty member or associate if it is apparent that the mentee's long-term goals better align with another's. Just as the mentee should take time to introspect, the mentor should consider his or her expectations of the mentee. Although in this model of mentoring, mentees hold the responsibility for creating the end vision, mentors are expected to use their experience, connections, and knowledge to ensure the mentees will reach their goal in a realistic manner. Like Sherpas, mentors should explain prior career failures or course corrections. Mentors, with their invaluable experience, should preemptively educate their mentees of potential pitfalls to prevent the mentees from making the same mistakes. For example, if a mentee is writing a grant, showing examples of successful and rejected grants is useful. This avenue is more productive than simply assigning step-by-step instructions and will teach the mentee how to discern quality proposals for themselves. Mentees report that being led by example and having a mentor serve as a guide leads to more effective mentoring and success.22 Just as teams of Sherpas guide groups of hikers, mentors and mentees should recognize that a mentee will likely need many mentors along the way. Mentors should not feel solely responsible for preparing the mentee in every technical, academic, or professional situation. It is also important for mentors to recognize when another is better suited to help their mentee with a particular short-term goal. In this way, the mentor will also act as a sponsor and improve his or her mentee's network of support. Communicate Clearly and Regularly Similar to summiting Mount Everest, striving toward a lofty goal will be fraught with roadblocks, delays, and detours. Sherpas are responsible for providing real-time, quick instructions to maintain safety and take the lead in providing open-ended conversations at the end of each day. Correspondingly, there will be multiple instances when feedback and specific coaching from mentor to mentee is required in plastic surgery. Examples of this could be providing precise feedback on technical performance in the operating room, helping the mentee overcome a repeated soft-skill error, or redirecting a trainee from unsatisfactory performance. As with the Miyagi model, instructions should be clear. However, instructions should also be accompanied by explanations and, ultimately, be beneficial to the mentee's progress. Before giving feedback, mentors should check the atmosphere; knowing when and where to provide feedback is as important as the message itself. While in the operating room, mentors should focus on task-specific feedback. Examples include instructing a trainee how to hold an instrument or change how a critical step of the operation should be performed (eg, "Hold your Adson forceps in a pencil grip, not a palm grip"). Open-ended dialogue about performance should ideally take place in a private and relaxed environment, outside the operating room, and away from others.23 Ideally, these conversations should be held in person to prevent any miscommunication that will occur through incomplete assessments of body language or tone. Feedback should target behavior, not the person. Personal and nonspecific feedback, such as, "You never meet deadlines," will likely be taken as a personal attack, regardless of a mentee's personality or maturity. Instead, mentors should tailor their feedback and consider using some of the business approaches to providing critiques. Knowing an individual's communication style will influence how to deliver feedback.24 Critiquing the action, not the person, is more useful to a mentee, as behavior is more readily modifiable compared with inherent personality traits.24,25 Climb Together Perhaps the most valuable aspect of collaborating with Sherpas is that they actively climb the summit with their trekkers rather than passively providing a map and sending warm wishes from afar. It is a partnership from the beginning. Although some view this as disproportionate service from the Sherpa, there are bidirectional benefits. Each time a Sherpa assists a climber to the summit, the Sherpa likewise gets to appreciate the beautiful view and enjoy the exhilarating feeling of reaching a major milestone and ascending to a new height. Like Sherpas, mentors are familiar with the journey and have mechanistic habits. Mentors who recognize that stamina, skill, and resiliency take time to strengthen are more likely to empathize with their mentees. For mentors who struggle to show patience, reflecting on their own training and recognizing their current deficiencies will provide perspective and compassion. Even if a mentor did not receive effective mentoring during his or her training, they should strive to be the mentor they never had for themselves. Mentors who offer consistent support, are generous with their time, and show patience to their mentees have been shown to enhance their own interpersonal skills.26 Mentors who maintain a growth mindset are more likely to create a positive long-term relationship with their mentees.13,16,20 Aside from a sense of fulfillment and giving back, those who mentor are more likely to analyze their behavior, methods, and systems, which improves their efficiency and influence. Mentoring is often associated with network expansion, as mentors frequently train future leaders within the field. Other benefits to the mentor include personal development, improved career satisfaction, improved performance, expansion of knowledge, and academic promotion and tenure.27,28 Creating a partnership and seeking insights from each other is educational for both the mentee and mentor. Although mentors have experience and provide guidance as to which proposals are realistic, mentees often provide fresh ideas and new perspectives on how to improve. As the mentee gains experience, his or her input will be increasingly useful. Mentors should encourage early participation and collaboration from their mentees to better hone these skills. Mentees should also practice dedication and follow through on assigned tasks, even if their motivation is low. It is through early collaboration that the field advances with new techniques and innovations. CONCLUSIONS In many ways, the training of a plastic surgeon parallels that of an extreme sport, such as mountaineering. Even prepared and resilient trainees will need the assistance of mentors. Historically, surgical mentoring followed a formal master-apprentice model. In recent years, plastic surgery has expanded and diversified, necessitating the need to adapt this approach to a Sherpa model of mentoring. To maximize the mentor-mentee experience, we recommend 3 steps: (1) spending time at basecamp; (2) engaging in regular, purposeful communication; and (3) climbing together. Spending time at basecamp means mentors and mentees should invest time up front to learn of each other's goals, skillsets, personalities, and communication styles to build trust and rapport. Laying this foundational work is important to the long-term success of the mentor-mentee partnership, especially as the short-term goals increase in complexity. While working together, regular, purposeful communication should be given to help the mentee progress. Feedback should be given regularly in the right setting, under the appropriate context, and be focused on modifying behavior. Climbing together implies that both the mentor and mentee are open to how the relationship will change them. Even though the mentor has more experience, bidirectional benefits are gained from the relationship. Mentors should view their mentees as junior partners and seek their input to advance the field and train the mentees to develop practical, novel innovations. Ultimately, sojourning with a Sherpa mentor makes the climb toward one's goals possible and enjoyable. DISCLOSURE Dr. Chung receives funding from the National Institutes of Health and book royalties from Wolters Kluwer and Elsevier, and has received research funding from Sonex to study carpal tunnel surgery outcomes. The other authors have no financial interests to declare. No funding was received for this work. ACKNOWLEDGMENT The authors appreciate the peer review and edits from Mike Stokes, staff vice president of communications at the American Society of Plastic Surgeons.
Graham et al. (Wed,) studied this question.
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