I arrived to my shift early, nervous about caring for critically ill patients as a first-year fellow. I sat in the workroom alone, paralyzed, not sure how to preround despite being months into fellowship. The senior fellow appeared minutes before sign-out; fresh, knowledgeable, and calm, despite her busy night and lack of sleep. She asked me how I was doing. With tears in my eyes, my emotions poured out. I explained that I felt lost, unsure of myself, my place, and my knowledge. For the first time, I confessed out loud, “I don’t think I’m supposed to be here. I have no idea what I’m doing.” I could trust her in a way I couldn’t trust others. She was like me: othered by her identity, minoritized by society. Though different from my own, her identity allowed her to understand my own experiences. We were different from one another and we were also the same. Unlike the senior faculty, it was safe to talk to her. And, unlike my other cofellows, there was a kinship between us in our otherness. She looked at me, closed the door, and shared words of strength that I needed to hear. I belonged. I was more than enough. She shared that the pressure I was experiencing was common among systematically minoritized individuals; she too had felt it before. Sitting with her, I was finally seen, supported, and comforted. As a peer mentor from a minoritized background, she provided a sense of security and belonging that had not been provided in my training and was distinct from the support of senior faculty.
While most efforts to increase diversity in medicine focus on the underrepresented in medicine (URiM) pipeline into medicine by recruiting individuals URiM, creating an inclusive and supportive environment to enhance retention is essential to plug the leaky pipeline of URiM physician advancement in medicine. Furthermore, it can foster a sense of true belonging among URiM physicians that then allows individuals to thrive and contribute. Mentorship of early career URiM physicians, specifically by senior faculty with shared backgrounds, has been promoted as a strategy to improve health care workforce diversity1,2 However, the critical role of the minoritized peer and proximal mentor has been overlooked and undersupported.
Peer and proximal mentors are individuals at the same or near-same career stage as mentees. Peer mentoring models for physicians include matched career-stage or identity-based programs. Existing models include formal national programs, subspecialty specific programs, social media-enabled national informal programs, and local formal and informal programs.3,4 Although the efficacy of such programs remains to be completely understood, some evidence suggests that facilitated peer mentorship for women faculty can result in increased self-reported skills involving professional development and scholarship, as well as increased publications and promotion rates.5,6
Peer mentorship is often posited as a potential solution to the problem of a dearth of available mentors. In pediatrics, the proportion of URiM trainees has not increased since 2007, and in some subspecialties has even decreased.7 As such, URiM physicians face unique hurdles identifying mentorship with similar backgrounds and lived experiences.
This Features piece focuses specifically on the unique role of peer and proximal mentors from minoritized backgrounds at the early stages of their career, specifically senior residents, fellows, and junior faculty, and the important role they serve in promoting and maintaining diversity in medicine.
URiM senior faculty are trailblazers; they achieved success in an implicitly and explicitly biased and racist system. Although established senior faculty are invaluable mentors, their lack of proximity to the current medical training landscape and the steep power differential can make it difficult for early career mentees to access and relate to senior faculty. Additionally, today’s trainees and early career physicians must navigate a differently nuanced terrain, where the “hidden curriculum” of racism, colorism, sexism, homophobia, and ableism persist despite explicit calls for equity in medicine.8 Although URiM senior faculty continue to experience discrimination in their current positions, their experiences vary significantly from URiM trainees and early career physicians who lack power, influence, and stature.
Peer and proximal mentors bring their recent lived experiences as physicians from minoritized communities to the mentoring relationship. Their unique proximal position to the mentee and minoritized identity are instrumental in identifying antiracist mentorship, normalizing and combating imposter syndrome, and providing safe and brave spaces to debrief in community. Because of this, they are well positioned to plug some of the persistent, and often overlooked, leaks in the diversity pipeline.
To begin, peer and proximal mentors can help mentees identify antiracist senior mentors and sponsors within institutions. Antiracist mentors acknowledge their position of privilege, critically and humbly examine systemic and institutional racism in medicine, and use their position of power to uplift URiM individuals.9 Because early career physicians have recently identified their own mentorship teams, early career peer and proximal mentors are well positioned to leverage their own dynamic and young mentor networks to help mentees identify mentors. They also can share their newly acquired institutional knowledge to benefit mentees as they navigate similar challenges in new settings.
Peer and proximal mentors are poised to help mentees acknowledge and mitigate imposter syndrome in a way that senior mentors cannot. These feelings of self-doubt can be heightened in minoritized trainees and early career physicians who often feel isolated and discriminated against in clinical and academic environments.10 Imposter syndrome can be challenging to discuss with senior faculty who have the dual role of mentor and promoter. Additionally, because of the potential influence of senior mentors over their career, URiM trainees and early career physicians may not be comfortable discussing imposter syndrome and discussions may even exacerbate feelings of insecurity. Alternatively, peer mentors can provide real-life strategies to mitigate imposter syndrome, normalize the phenomenon, and remind us of our value and deserved place in medicine.
URiM physicians experience discrimination at all levels, but the peer and proximal mentor is uniquely positioned to serve as a source of support and guidance. Having recently experienced these challenges at similar stages of their career, peer and proximal mentors can provide a safe space to debrief micro- and macro-discrimination, as well as overt racism, colorism, sexism, homophobia, and ableism that may be difficult to discuss with senior mentors who completed the early stages of their career in a vastly different academic climate. Furthermore, peer and proximal mentors can support disenfranchised and disempowered URiM trainees in reporting acts of discrimination and identifying senior advocates.
Finally, classic mentorship from senior faculty can help trainees and junior faculty reach their higher goals through sponsorship and positive role-modeling, but peer and proximal mentors can provide examples of more proximal and attainable goals. In other words, although senior mentors provide the goals and resources for career attainment at the peak of the academic ladder, peer and proximal mentors can provide the safe footing to ascend to the next rung of the academic ladder.
Despite the importance of peer and proximal mentorship, this role is often overlooked and unrewarded, adding additional burden to URiM early career physicians. Trainees and junior faculty should be seen not just as mentees, but also as valued mentors who make meaningful contributions and are critical to the integrity of the pipeline. Efforts to amplify diversity in medicine should include an infrastructure to acknowledge, encourage, and reward peer and proximal mentorship along the pipeline. Although there are many models for implementation of peer and proximal mentorship,11 one potential approach can be to pair early trainees from minoritized backgrounds with senior trainees, fellows, and junior faculty. In this way, peer and proximal mentorship can grow to create a chain of mentorship that expands from early career into established faculty over time. Additionally, graduate medical education programs can partner with hospital- and medical school-based diversity, equity, and inclusion offices to assist with identifying peer and proximal mentors.
However, to ensure peer and proximal mentorship models are sustainable, institutions should dismantle structural barriers to providing peer and proximal mentorship. In particular, institutions should focus on the lack of career advancement of URiM trainees and faculty who bear the “tax” of peer and proximal mentorship for other URiM physicians. This can be achieved by offering protected time to junior faculty, and formal positions, acknowledgment, and awards to residents who serve as peer and proximal mentors. This could be achieved by creating awards and honors dedicated to the URiM peer and proximal mentor role and/or by adding value to the applications of those who have served as peer or proximal mentors in hiring and promotion decisions. Also, institutions should invest in peer and proximal mentorship by coaching early career physicians and trainees on the fundamentals of effective mentorship. This would bolster existing efforts and provide the necessary resources to continue to be a successful mentor. This is fundamental to developing and retaining high-quality URiM mentors along the entire pipeline. Together, we believe that these incentives have the power to help remove the tax on diverse and URiM peer mentors and justly reward them for this work in a way that will advance their academic careers and also benefit the medical community as a whole.
Peer and proximal mentors are integral to the success of URiM physicians and the ultimate diversification of the medical workforce. Without peer and proximal mentorship, efforts to diversify the health care workforce and academic medicine at large will continue to be leaky by failing to address some of the persistent and systemic barriers to URiM physician retention and success. Of course, additional concerted efforts must be made to ensure that water continues to flow into the pipeline; that is, that we continue efforts to diversify the workforce. Even with the leaks filled, an empty pipeline will be unable to deliver. In our personal experience as early and mid-career physicians of varied racial and ethnic backgrounds, we have found that the quiet conversations in stairwells, over coffee, and while sitting in house staff lounges with our peer and proximal mentors have best equipped us with the day-to-day tools needed to navigate the complexities of the medical ivory tower. These are the relationships that have bolstered us as we have faced acts of overt and covert racism, colorism, sexism, and homophobia and helped us to take important steps in each of our academic journeys. This work should be recognized and rewarded, because without it, the pipeline will never be fixed.
We thank the proximal and peer mentors who have supported our personal, professional, and academic development.
Dr Fraiman and Peña conceptualized and jointly drafted the initial manuscript; Drs Montoya-Williams, Ellis, Fadel, and Bonachea reviewed and critically revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: Dr Fraiman was supported by the Agency for Healthcare Research and Quality (T32HS000063) as part of the Harvard-wide Pediatric Health Services Research Fellowship Program. Dr Peña was supported by the National Institutes of Health (T32HL098054-11 Training in Critical Care Health Policy Research). Dr Montoya-Williams is supported by the National Institute of Child Health and Human Development (K23HD102526A).
CONFLICT OF INTEREST DISCLAIMER: The authors have indicated they have no conflicts of interest relevant to this article to disclose.