Mentorship is an invaluable facet of medical education that has continued to garner attention in medical student education in the recent years.1–4 Despite this recognition and push for more mentors, many barriers prevent successful mentorship including time limitations and ability of mentors to provide valuable, personalized advice.5 In the field of surgery and orthopaedic surgery in particular, Oladeji et al6 found that over 95% of trainees thought that mentorship was vital to achieving success as orthopaedic surgeons. With the recent increasing complexity of the current residency application and matching service, it is evident that mentorship plays a more important role than ever for students applying to the field of orthopaedic surgery.7

Various perspectives on the mentor-mentee relationship have been explored previously, particularly regarding faculty and residents. It has been shown that, in general, faculty had higher overall satisfaction with their mentoring relationships with residents in orthopaedic surgery as compared with residents with faculty, and they valued active participation and openness to feedback as key qualities in a mentee. Residents, meanwhile, reported more favorable results when their mentor was a role model of work-life balance.8 In addition, a previous study surveying orthopaedic surgery residents found that mentoring experiences are less prevalent in medical school and female medical students lack accessibility to mentoring opportunities.9 This is an especially important finding, given the established role mentorship plays in the recruitment and support of women and underrepresented minorities (URM) in the field.10

Although many studies have sought to determine the value of mentorship and identify how to deliver it effectively, we are not aware of any studies that have investigated the medical student's perspective in the field of orthopaedic surgery. As such, the purpose of this study was to evaluate the role of mentorship from the medical student perspective and identify the current trends in advising and mentorship for students pursuing the field of orthopaedic surgery.

Methods

This was a cross-sectional study based on an 18-question survey. After obtaining institutional review board (IRB) approval (IRB #00329294), an anonymous electronic survey was distributed through e-mail to 115 program directors' whose contact information was available on the Fellowship and Residency Electronic Interactive Database. In these e-mails, a request was made to pass this survey along to the interested students at their home institutions. In addition, this survey was posted on Instagram to recruit additional interested students. Participants were given 1 month to complete the survey with a reminder shared on social media at the 2-week mark. Before deidentification, e-mail addresses were used to ensure and remove duplicate or impartial entries. After this was completed, all e-mail addresses were removed and data were fully deidentified before analysis.

The survey began with demographic questions, followed by questions regarding mentorship that was evaluated in multiple facets as described further. Participants were asked about their current mentorship and asked to rate their satisfaction from very dissatisfied to very satisfied. In the next section, seven sources for mentorship and advising, including residency program leadership, departmental chair/leadership, home faculty, student interest groups, peers, outside faculty, and social media, were assessed. Within these six groups, participants rated the accessibility, quality, personalization, and consistency of the advice they may or may not have received using a 10-point Likert-type scale. No free response questions were added to improve standardization and comparability of responses. All statistics were analyzed using Statistical Package in Social Sciences (IBM Corp. Released 2021. IBM SPSS Statistics for Windows, Version 28.0). Basic demographic data were analyzed for trends in responses, and similar analyses were run to assess responses to the mentorship questions. Mean scores and standard deviations were tabulated for the final ranking section that used a Likert-type scale. Chi square analyses were run to compare categorical variables while an analysis of variance with post hoc Tukey test was used to compared mentorship scoring.

Results Demographics

Two hundred fifteen students completed the survey with 6%, 33%, 20%, and 29% being first, second, third, and fourth-year medical students, respectively. Postgraduate students and students currently on gap years completing research fellowship positions represented 5% and 7%, respectively. Participants were mostly Medical Doctor (MD) students (82%) with 13% Doctors of Osteopathic Medicine (DO) and 6% of students representing other degree programs. Most respondents were in the Southeast or Northeast (30% and 29%, respectively). Responses regarding school ranking according to the US World News Reports showed that most students who completed this survey came from ranked schools (66%), with less than 30% of respondents coming from top 30 medical schools; additional delineation of demographic data is presented in Table 1.

Table 1 - Demographic Data Number (%) Age  20-25 99 (46%)  26-30 103 (48%)  31-35 7 (3%)  36-40 2 (1%) Sex  Cis man 126 (59%)  Cis woman 86 (40%)  Nonbinary 1 (<1%)  Transgender male 1 (<1%) Transgender female  No answer 1 (<1%) Hispanic/Latino?  Yes 31 (14%)  No 184 (86%) Ethnicity  White 129 (60%)  Asian 30 (14%)  Black 24 (11%)  Native Hawaiian/Pacific Islander 2 (1%)  Other 30 (14%) Degree type  MD 176 (82%)  DO 27 (13%)  MBBS 8 (4%)  Other 4 (2%) Year in school  MS1 13 (6%)  MS2 71 (33%)  MS3 42 (20%)  MS4 62 (29%)  Postgraduate 11 (5%)  Research year 16 (7%) School rank (USWNR)  1-10 6 (3%)  11-30 22 (10%)  31-50 35 (16%)  51-75 37 (17%)  76-100 21 (10%)  101-200 13 (6%)  >200 11 (5%)  Unranked 70 (33%) Region  Northeast 63 (29%)  Midwest 20 (9%)  Southeast 64 (30%)  South Central 11 (5%)  Southwest 27 (13%)  Northwest 10 (5%)  International 20 (9%)

DO = Doctor of Osteopathic Medicine, MBBS = Bachelor of Medicine, Bachelor of Surgery, MD = Medical Doctor, USWNR = US World News Reports

Evaluating Mentorship

Over 50% of participants reported currently having someone who they consider to be a mentor in orthopaedic surgery while 34% were actively seeking one. Most students found mentors through research opportunities (25%), with cold e-mails being a close second (20%). Other popular methods included word of mouth (18%) or interest group events (18%). In students with mentors, common hurdles faced by participants were primarily perceived lack of access (38%) while time was also a limiting factor (30%). A portion of students also found it difficult to find mentors who they identified with based on sex/race/values (21%). Most students described their ideal mentor as one who acts as an advocate for students (22%), serves as a role model (21%) or advisor (21%), and provides opportunities for professional advancement (21%). Overall, most students were somewhat satisfied (33%) or very satisfied (41%) with their mentors. Less than 5% of students were very dissatisfied with their mentorship experience. Additional details regarding mentorship are provided in Table 2. No significant difference was found in students’ access to mentorship (has a mentor, does not have a mentor, and in search of a mentor) based on sex, race, or degree type (P = 0.926, P = 0.197, P = 0.053, respectively) (Table 3). No significant difference was found in their evaluation of mentors based on sex, race, or degree type (P = 0.413, P = 0.313, P = 0.635, respectively) (Table 4).

Table 2 - Evaluating Mentorship Number (%) Do you have a mentor?  Yes 110 (51%)  No 27 (13%)  In search of mentor 73 (34%) Method of finding mentor  Clinic opportunities 81 (14%)  Cold e-mail 116 (20%)  Interest group events 103 (18%)  Other 28 (6%)  Research opportunities 146 (25%)  Word of mouth 102 (18%) Hurdles to mentorship  Access to mentors 150 (38%)  Lack of mentors with whom you identify (sex/race/value) 82 (21%)  N/A 15 (4%)  Perceived value of mentor 29 (7%)  Time with which to engage a mentor 118 (30%) Characters of an ideal mentor  Acts as your advocate and champion at your institution and beyond 178 (22%)  Other 7 (1%)  Provides educational/emotional/or social support 121 (15%)  Provides opportunities in research/shadowing/or professional advancement 170 (21%)  Serves as a role model 170 (21%)  Serves as an advisor 175 (21%) Current satisfaction with mentor  Neither satisfied nor dissatisfied 19 (13%)  Somewhat dissatisfied 12 (8%)  Somewhat satisfied 47 (33%)  Very dissatisfied 6 (4%)  Very satisfied 58 (41%)
Table 3 - Demographics Versus Mentorship n = 208 Yes No In search of one P Race 0.926 White 65 16 45 Asian 13 5 11 Black 14 2 7 Other 17 4 9 Sex 0.197 Cis Woman 46 10 26 Cis man 64 16 45 Other 0 0 1 Prefer not to answer 0 1 0 Transgender man 0 0 1 Degree 0.053 MD 97 21 53 DO 10 3 14 MBBS 1 3 4 Other 2 0 2

DO = Doctor of Osteopathic Medicine, MBBS = Bachelor of Medicine, Bachelor of Surgery, MD = Medical Doctor

Table 4 - Demographics Versus Mentorship Rating N = 215 Very Dissatisfied Somewhat Dissatisfied Neither satisfied no dissatisfied Somewhat Satisfied Very Satisfied P Race 0.413  White 1 3 9 23 19  Asian 5 9 9 24 39  Black 0 0 1 0 0  Other 0 0 0 0 0 Sex  Cis Woman 31 1 3 9 23 0.313  Cis man 40 5 9 9 24  Other 0 0 0 1 0  Prefer not to answer 1 0 0 0 0  Transgender man 1 0 0 0 0  Degree 0.635  MD 55 5 9 16 38  DO 12 1 3 1 5  MBBS 4 0 0 1 3  Other 2 0 0 1 1

DO = Doctor of Osteopathic Medicine, MBBS = Bachelor of Medicine, Bachelor of Surgery, MD = Medical Doctor

The Mentee Perspective

Looking at seven common sources of mentorship including home program director, home department chair, home faculty, student interest groups, peers/older students, outside faculty, and social media, peers and older students had higher mean satisfaction scores in five of six domains compared with other sources of mentorship (Table 5). For example, peers on average scored 7.3/10 for ‘quality of advice’ while home program directors scored 5.4/10 on average. Comparing mean scores between these seven groups, there was a significant difference between groups (P < 0.001). Post hoc analysis revealed that peers and outside faculty had significantly higher mean scores compared with the home program director (peers mean score was 1.95 points higher than home program director while outside faculty score was 1.87 points higher) (P < 0.001, P < 0.001, respectively). Additional information is provided in Table 5. The only domain in which peers were not as helpful was in their ability to facilitate matching. Participants also ascribed higher mean scores to outside faculty in comparison with their home faculty. Social media was also found to have high mean scores in most domains. The lowest scoring group on average was the home departmental chair, especially when it came to ease of communication. When it came to the ability to facilitate matching, students felt that outside faculty rather than home faculty provided a better mentorship experience within this domain. Additional delineations are presented in Table 5.

Table 5 - Cross Tabulation of Mentorship Evaluation by Source Source (n = 215) Accessibility as a mentor Quality of advice/mentorship provided Personalization of guidance Communication Comfort in reaching out to mentor Ability to facilitate matching into orthopaedic surgery residency P < 0.001a Mean Difference (PD - source)b P (post hoc)b Home PD 5 5.4 4.7 4.9 5.1 5.1 — — — Home chair 4.2 4.9 4.3 4.1 4.2 4.8 — 0.62 0.46 Home faculty 6.2 6.2 5.6 5.7 6.3 5.5 — −0.83 0.104 Interest group 5.5 5.4 5.2 5.3 5.8 4.8 — −0.3 0.961 Peers 7.4 7.3 7 7.4 7.6 5.2 — −1.95 <0.001a Outside faculty 6.8 7.2 7 6.8 7.1 6.5 — −1.87 <0.001a Social media 6.2 5.9 4.1 5.2 5.2 4 — −0.067 1

aP values < 0.05 were considered significant.

bResults of a Tukey post hoc test.

PD = program director

Discussion

Orthopaedic surgery has long been regarded as the least diverse medical specialty.10,11 Women and URM comprise only 5.8% and 4.5% of the American Academy of Orthopaedic Surgeons membership, respectively, according to the 2018 census of members.12 Among orthopaedic surgery residents, the proportion of women increased from 10.9% in 2006 to only 14.4% in 2015. In addition, the share of minority residents decreased over the same period from 33.3% to 22.5%, representing the greatest decrease in any specialty.7,13,14 Although our survey captures a small sample of the greater applicant population, this stands in contrast to our survey respondents. Approximately 40% of respondents were women; 26% were Black, Native Hawaiian/Pacific Islander, or other; and 14% were Hispanic/Latino. This may highlight changes in the overall demographics, but may also highlight potential selection bias among the survey respondents. Regarding respondents' demographics, we would like to highlight the distribution of students across class years. Although there was limited participation from MS1 students (6%), who may be less sure of their specialty, the rest of the respondents were evenly distributed across the remaining class years (33%, 20%, and 29%). Postgraduates and those on research years made up 12% of respondents. Looking at school rankings according to the US World News Reports, most of our respondents were largely from middle-ranked programs and a large number unranked, with DO respondents representing a small share of total respondents (13%).

Notably, only 51% of medical students reported having someone whom they identify as a mentor at the time of the survey. Although those who did have a mentor identified a wide variety of ways of connecting with a mentor, there were clearly barriers to mentorship that many students experience. The most common reported reason for lack of mentorship was perceived lack of access to mentors and limited time with which to engage a mentor, the latter likely due to the busy schedules of physicians and medical students making it difficult to find time to interact. In this context, it is understandable that most students with mentors engaged by finding common ground such as research projects or clinical experiences at the intersection where work and mentorship meet. As mentioned previously, finding a mentor who the student identifies with also posed a challenge. Thus, access to mentors from a wide variety of backgrounds will be a key area of growth for programs looking to foster medical student interest and mentorship within their field. Despite this, however, it is important to note that even with barriers for URM students, there was no notable difference in the availability of mentors or the evaluation of mentors as a function of sex or race. Similarly, despite hurdles faced by DO and international graduate applicants, we also found no differences in their access to or evaluation of mentors either.14,15 In addition, it is key to acknowledge that medical students in our study who do have mentors are either somewhat (33%) or very (41%) satisfied with their mentors, with few reporting dissatisfactions. Thus, our results indicate that resources to improve medical student mentorship in orthopaedic surgery would be best focused on fostering connections between mentors and mentees as we generally found that medical student mentees were satisfied with their mentor relationship when present.

Knowing the hurdles to find mentorship, it is important to assess sources of mentorship for medical students. There has been a large proliferation of mentorship avenues in recent times with increased use of social media and student interest groups in orthopaedic surgery.16 There has also been an increasing demand for mentorship from peers at every stage of training, an important part of medical and graduate medical education. When examining different sources of mentorship in our study, a few key patterns emerge which underline our general results.17 On average, peers and older students scored significantly higher across the six mentorship categories (access, quality, personalization, communication, comfort, and facilitating matching) in comparison with home program directors and department chairs who scored lower (Table 5). This, in some respects, reflects the issue of access: It is easier for students to connect with other students for mentorship but can be difficult to connect with a busy program director or department chair. In addition, mentees likely find it easier to communicate with and gather personalized advice for their stage of training from peers a few years above them.

Outside faculty members also scored highly on our questionnaire. Seemingly, outside faculty could pose more difficulty in access compared with home program directors, department chairs, and faculty. Perhaps this might reflect that students who form connections with outside faculty did so on their own volition and were able to research and find faculty who shared similar interests and values. By contrast, home faculty and mentors provide less variety and options for trainees, leading to lower satisfaction scores. Seeing this also emphasizes the commitment to mentorship within the field of orthopaedic surgery, with outside faculty demonstrating their willingness to help students who take the initiative to reach out. Interestingly, social media also scored highly, particularly in accessibility, perhaps pointing to why outside faculty might have been highly regarded: Social media may provide students access to faculty anywhere in the country. Current literature shows the dramatic increase in social media accounts for orthopaedic surgery faculty as well as residency programs, and this has only been accelerated in the post-COVID era where so much is done remotely.16,18–20 Abbas et al. showed that both Instagram and Twitter usage by residency programs has grown exponentially with a R2 of 0.99 and 0.95, respectively.19 Our results point to an important takeaway: Student mentorship networks in orthopaedic surgery are strong, and students appear to be taking an active role in finding and establishing their mentorship relationships. When evaluating the current residency selection process, it is evident that mentorship plays a pivotal role in the matching process as well, highlighting the importance of mentorship in career development for medical students.20

This study is not without limitations. The most notable limitation was the difficulty of assessing the response rate given that this survey was sent out through numerous avenues including social media where it is not possible to judge the response rate. Given our sample size of 215 respondents and distribution of respondents from various backgrounds, the results of this study are a valuable representation of medical students interested in orthopaedic surgery, although the lack of a response rate may diminish our results. It is important to keep in mind that this is a common hurdle for cross-sectional studies.21 Other limitations include that this study used a survey which may result in inherent biases in structure and response options; however, care was taken to minimize these by using a structure that was similar to other studies on mentorship and using appropriate labels/options as needed. Finally, as with most surveys, this study is limited by selection bias as students could choose to or not to participate in this study. Therefore, it is difficult to ascertain the value of the reported demographic data.

Conclusion

Overall, this study demonstrates that medical students across the nation rely on mentorship to guide them on their path to becoming an orthopaedic surgeon. Most students with mentors felt satisfied with their experience but did feel it was difficult to find time for and access to mentors. We found equality in reported access to mentorship in orthopaedic surgery based on race, sex, and degree type.

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