To our mentors, Karl C. Podratz and William A. Cliby

INTRODUCTION
In surgical literature, the importance of role models for improving education of trainees is generally emphasized^1,3. A good organization is certainly very helpful in creating a good and effective teaching environment⁴. One of the most striking differences among the American and the European surgical educations consists in the organization of the different training programs. When medical students or residents graduate and decide which program to apply for their residency or fellowship training, they can request to know the number and types of surgery performed annually at the Institution where they are applying. Furthermore, they get to know how many surgical procedures have been done by the surgical residents or fellows during the immediate preceding few years. In this way, the applicants can figure out the volume and quality of surgery performed at a certain Institution, and at the same time the surgical exposure of the trainees. Future residents and fellows look for a good teaching system, in which they foresee the possibility of improving in their surgical and clinical skills. However, like in normal everyday life, during medical training it is very important to meet a mentor. The importance of a good mentorship is emphasized in medical literature⁴. In the present article the authors will show an example of the organization of a fellowship in Gynecologic Oncology in the United States (US), together with the personal experience in meeting a mentor.

Methods and results
The “matching” system
When residents in Obstetrics and Gynecology apply for a fellowship in Gynecologic Oncology in the United States (US), the candidates usually decide to do it at several different Institutions. Before the interview, the candidates send the appropriate documentation to different program directors, asking to be accepted to training programs. The program directors select a certain number of individuals that are considered good candidates (based on curriculum vitae and letters of recommendation) and invite them to come for an interview. In the American mentality, it is quite common that you move to another State (hundreds or thousands of miles far from home) for your training or for a job. After interviewing in different locations, candidates send a list of Institutions where they wish to go for their fellowship training, ranking their preferences in a computerized system, which consists in the Resident Matching Program in Washington DC (www.acgme.org). Similarly, the program directors send a list of preferences ranking the different candidates. After matching for preferences, an official list of Gynecologic Oncology fellows and their matching Institutions is issued.

Interviewing for fellowship: an example
The typical days of the interview for the Gynecologic Oncology Fellowship at Mayo Clinic may be organized as follows. The first day starts with a meeting with the program director who explains the program at Mayo Clinic, with particular emphasis on the objectives and the training method. After that, there is a presentation of research projects from the in-training fellows. At dinner time, thecandidates have the opportunity to spend some “informal” time with their fellow-peers. This is indeed a very good time to ask questions about their experience of working at Mayo Clinic and living in Rochester. The following day, the candidates have formal interviews with the different members of the Department of Gynecologic Oncology. They usually meet with the program director and other gynecologic surgeons as well as with a medical oncologist involved in the program, After that, they have a guided tour of Mayo Clinic accompanied by the fellows. During these days the candidates have the real opportunity to discover more about the program, but also to meet with the staff and the fellows and in this way get an idea about the working environment.

Gynecologic Oncology Fellowship at Mayo Clinic: an experience
The Gynecologic Oncology Fellowship at Mayo Clinic is mainly surgical oriented. Other programs in the US put more emphasis on research. The first year is spent in a laboratory working on basic science research (usually on biochemistry and molecular biology, but the preferences of the fellow are also a criteria for assignment to a specific laboratory). Then, the following 24 months are clinical. Most of them (20 months) consist of surgical experience: gynecologic oncology surgery (18 months), colorectal surgery (6 weeks), liver and pancreatic surgery (6 weeks). The remaining 4 months are medical rotations: Medical Oncology and Radiation Oncology (3 months), Intensive Care Unit (1 month) (Table 1).

Table 1 - Organization of the Gynecologic Oncology Fellowship at Mayo Clinic

Time	Rotation
12 months	Basic Science
18 months	Gynecologic Oncology Surgery
6 weeks	Colorectal Surgery
6 weeks	Liver and Pancreatic Surgery
4 weeks	Intensive Care Unit
3 months	Medical and Radiation Oncology

The surgical experience consists of the preoperative evaluation of the patients, performing the surgery in the operating room and taking care of the patients during the postoperative period. The fellow is usually assigned to one of the consultants (i.e. the staff person in the Gynecologic Oncology Department) for 6 week- to 3 month-rotations. During that time he or she works with the consultant side by side and learns how to perform surgery and manage patients during the pre and postoperative periods. Specifically, in the operating room the fellow is always scrubbed together with (or is under the supervision of) the staff doctor. If the trainee is still not skilled enough, he or she assists the consultant in the operation. However, when the fellow becomes adequately skilled during the training, he or she performs the entire operation, assisted by the consultant or by a specialized nurse, the surgical technician. The technician is often a very experienced individual. Therefore, being assisted by the technician in surgery is very useful in learning how to perform the proper operation. An interesting part of the American teaching system is its ability to help in developing the professional and teaching responsibility of the single trainee. In fact, residents and fellows are given a professional responsibility according to their maturity. This helps them in learning their job. As the clinical activity is largely performed by residents, the probability of clinical errors occurring in a teaching hospital is potentially higher than in a general community hospital. In the US, the whole system cooperates to try to minimize the mistakes of the trainees. Together with mentors, also a large number of paramedics supervise the residents’ and fellows’ work. Nurses, technicians and pharmacists are committed to control every single clinical order given by the trainees and they are allowed to criticize and help the young doctors. Everyone contributes to the good care of the patient, minimizing mistakes and helping the trainees to learn to take their responsibilities in patients’ care. The teaching responsibility of the single trainee is also developed through a system that makes every single resident or fellow responsible of his or her peers (for example, a fourth year resident is usually responsible of the professional conduct and the learning of all the other younger residents). In this way, the teaching attitude is stimulated and every trainee can learn from his or her older fellow-peers.

Meeting a mentor: a teacher and friend
Both the authors experienced a fellowship training at Mayo Clinic – Rochester and took advantage of the organized program and the surgical exposure to a large volume of cases. However, the most significant part of the educational experience has been the meeting with a teacher, friend and mentor. The mentors taught the authors how to do research, to take care of patients and to perform surgery. At the same time, mentors were instrumental in stimulating discussions about the best way to take care of patients and the meaning of work as part of the daily life. Moments at table for a good dinner and friendship were also frequent. The mentors helped the authors also in their decisions regarding job opportunities and career. This whole relationship is still ongoing as a continuous friendship, sharing life and work experiences. One of the mentors once said to the authors: “Mentorship is a lifelong experience, which will not finish at the end of your fellowship. It is not only medicine, but it involves the whole life”. And this is actually who we all in some way desire to meet in our professional life.

DISCUSSION
In the present manuscript, we describe an example of the teaching organization in US medicine. An organized system helps in developing a better quality of teaching and in creating more possibilities for learning, especially in the surgical specialties. However, a system that gives the chance to meet a mentor and that helps developing mentors is the most significant part of the teaching organization. The importance of mentoring and teaching in medicine has been widely described in the medical literature^5,13. The word “mentor” comes from the Greek literature, from the Odyssey, that describes the story of Odysseus, trying to come home from the Trojan War. His return to Ithaca was delayed for many years. In Odysseus’s absence from home, a trusted friend named Mentor assumed the responsibility of raising Odysseus’s son Telemachus¹⁴. Therefore, the word mentor indicates a “developer of talent, a teacher of skills and knowledge of the discipline, an assistant in defining goals, and one who shares social and professional values”⁵. The role of mentoring in academic career and advancement in satisfaction has been previously defined⁴. In a large national faculty survey, approximately half of respondents ranked lack of mentoring as one of the most important factors which impeded their progress in academic medical career¹⁵. It has been suggested that mentoring must be sustained as a professional activity of medical schools, with financial support. This would possibly enhance the quantity and quality of mentoring¹¹. Structured programs for better definition of mentors in medicine have been described⁴. It has been shown that the official institution of personal mentors for the students and residents permits them to have a “friend” to whom they can turn for questions and problems and to whom they can look at for learning. The residents enrolled in a mentorship program described it as helping them in having a role model, having increased visibility, feeling more supported and having an increase in self-confidence⁴. Institutionalization of mentoring, objective evaluation of the mentoring program, giving the ability to the residents to choose their mentor and assigning an award to the best mentor at the end of the year (together with the fact of penalizing those Institutions in which mentorship is not established) are all ways of improving mentorship^4,16. Moreover, the ability to establish protected time for mentors and mentee to stay together is also important¹⁶. In particular, 2 factors have been identified as being essential for a successful mentoring program: institutional commitment and institutional reward/recognition¹⁷. In the US, an attempt to create a system that will facilitate the meeting and collaboration between mentors and mentees is currently ongoing. In fact, Powell¹⁸ recently analyzed the problem of “not having a good mentor”. The author emphasized that a “growing number of universities are introducing policies that match trainees with mentors …”. For example, a MentorNet service, on the internet, can potentially help the trainee in deciding the site of future training, taking into account the personal characteristics of potential mentors that are working in the various Institutions. It should be stated, on the other hand, that in the mentor- mentee relationship there is always a component of  “chemistry”^8,15 or “character” that cannot be planned and organized beforehand. A good friendly and fruitful relationship will only happen as a meeting between two human beings. They will discover that learning, teaching and working together is part of the commitment of their lives. Confidentiality will enable to establish a mentor-mentee relationship that is not only professional, but more similar to friendship, or a father-son interaction¹⁶. The Mentor knows that “we must acknowledge that the most important, indeed, the only thing we have to offer our students is ourselves. Everything else they can read in a book”19. A very interesting description of a mentor-mentee relationship, that was similar to a relationship among father and son, or among friends, is the one between two very famous physicians: Sir William Osler and Harvey Cushing ²⁰. Also in the Hippocratic Oath, the gratitude of the young doctor for his or her teacher is described: “to hold the one who has taught me this art as equal to my parents and to live my life in partnership with him”²¹. Does the difference between the American and the European teaching systems lie only in the organization and in the mentorship programs? Another important issue is the conflict of interest. This is one of the most significant reasons why teaching is not popular in Italy, especially in surgery. In fact, conflict of interest has been recognized as an important problem for the lack of mentoring⁹. Too often experienced surgeons look at their skills as an instrument for power (economical, political and professional power), that need not to be shared with others. In this way, medicine is not seen as a way of serving patients in a specific need, but only as a tool for holding on their privileges. For a good teaching system, the presence of a central organ that is committed to control every single teaching program, objectively verifying that requirements for good mentoring and teaching are met is essential. Both the organization of medical and surgical teaching programs and the presence of good mentors are periodically controlled in the US by the Accreditation Council for Graduate Medical Education (ACGME) (www.acgme.org). “The ACGME is a private not for profit organization responsible for the accreditation of more than 7,800 US residency education programs. The Council accredits residency programs in 118 specialty and subspecialty areas of medicine, including all programs leading to primary certification by the 24 member boards of the American Board of Medical Specialties (ABMS). Completion of an accredited residency program is a prerequisite for primary board certification and for certification in the majority of subspecialty boards. Accreditation is a credential that signifies that an educational program substantially complies with the accreditation standards. To gain and maintain accreditation, residency programs are expected to comply substantially with the Program Requirements for their specialty, and the institutions sponsoring them are expected to comply with a set of Institutional Requirements. Compliance is measured through periodic review of all programs. Each year, nearly one-half of all accredited programs are reviewed. Approximately 2,000 of these reviews involve a formal on-site visit to the program; the remainder is based on documents the programs provide to the ACGME. On average, each accredited residency program is site visited every 3.7 years. Intervals between site visits range from one to five years” (www.acgme.org July 2006). The American teaching system is also characterized by paying attention to the desire of the single trainee. In fact, the Residents’ Matching Program (www.acgme.org) is only one example of the multiple attempts to help the single person to make his or her own professional choices. At Mayo Clinic, the importance of education and mentoring has always being emphasized. Education is an important part of the Mayo Mission (http://www.mayo.edu/ July 2006). In the description of the Mayo Clinic mission it is stated: “To provide the best care to every patient every day through integrated clinical practice, education and research”. Moreover, at Mayo Clinic there is the Mayo School for Continuing Medical Education (MSCME), whose mission is “… to serve the needs of the patient by providing continuing medical education for physicians and other health care professionals, consistent with the principles and goals of Mayo Foundation” (http://www.mayo.edu/ July 2006). Looking at this inspired vision of medicine and education, we realize that investing in the education of young doctors will in turn translate in a better care of patients and in a physician more satisfied with his/her job and more incline to teach.

CONCLUSIONS
The organization of a good teaching system is instrumental for improving the quality of education and the amount of surgical and medical experience for young physicians. A well organized educational system will help the single doctor to consider teaching as part of his/her professional life, and not only an optional and spontaneous decision of the isolated “well-intentioned” physician. It would be useful that teaching systems are compared with the US organization as a model for improving the quality of their education. In fact, both the US teaching program, that favors the development of the professional responsibility of the single person, and the culture that favors the birth of new relationships between mentors and mentees are fundamentals for the creation of good teaching systems in medicine. Moreover, the presence of a central organ (like ACGME) for impartial and objective control of teaching programs is instrumental for the good development and continuous improvement of mentoring and teaching. However, in spite of a well structured system being extremely helpful in creating good mentor-mentee relationships, the organization cannot completely substitute the presence of single individuals who are willing to give their time and experience to become mentors. In fact, the meeting with a mentor is something that cannot be completely planned beforehand. Such experiences should be favored as a real improvement in the education of the “in-training” doctors.

Riassunto – Scopo: descrivere l’importanza di sistemi educativi ben organizzati e di programmi di tutoraggio (mentorship) nell’iter formativo dei chirurghi negli Stati Uniti. Metodi e risultati: viene presentato, come esempio, il processo che porta il laureato all’ingresso in un programma di formazione specialistica in oncologia ginecologica. Descrivendo il programma di formazione in oncologia ginecologica, sottolineiamo l’importanza dell’assunzione di responsabilità cliniche e chirurgiche da parte del medico in formazione, sotto una adeguata supervisione. È auspicabile che i giovani medici in formazione trovino e seguano un buon mentore. Il tutoraggio può migliorare l’esperienza dell’apprendimento, facilitando la carriera accademica successiva e la soddisfazione professionale.

Conclusioni: un sistema di insegnamento ben organizzato, con un appropriato controllo di qualità esterno, è fondamentale per una educazione adeguata dei giovani medici e per lo sviluppo della relazione tra mentore e discepolo. Una buona organizzazione può facilitare ma non sostituire il rapporto con il mentore. L’incontro con un mentore rappresenta un’esperinza umana e professionale unica per il giovane medico.

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