Summary
Over the past 2 decades, interest and involvement in global surgery as an evolving discipline have increased among practitioners and trainees. A demand for formal evaluation of global surgery projects has also increased with demands for outcomes and impact. However, there has been little or no encouragement or requirement for participants to formally assess their personal contribution either to a project or to the discipline itself owing to the volunteer-based nature of those involved. Though participant contribution cannot be easily measured, the experience can be used to foster professional development. We propose that this neglected opportunity be addressed and suggest a framework of intentional reflection and mentorship that can be applied as an integral part of the global surgery experience, from participant selection through debriefing after the experience.
For more than a century, surgeons with long-term or lifetime commitment to global surgery were the only ones involved in this activity. Over the past 2 decades this picture has changed dramatically. Interest and direct involvement have sharply increased, particularly among trainees.1 Similarly, the number of surgical care projects has risen exponentially.
Increasingly, sponsors of global health projects are demanding an accounting of outcomes and impact, usually tied to a cost analysis. Project evaluation is important, but assessment of individual contribution is often overlooked. How do individuals who participate in this work, many on a volunteer basis, assess their contribution to global surgery projects?
Why assess personal contribution?
Global surgery activities involve personal contributions and provide personal benefits. Literature examining benefits from participation in global health activities is limited, and focuses on the medical student or resident level. Benefits identified for trainees include an increased likelihood that they will care for underserved populations, have increased interest in humanitarianism and remain more generalist in clinical practice.1
Benefits to practising surgeons are more speculative, but mesh with self-awareness and professional development. Professionalism is a core competency and reflective learning is at the heart of professional development.2 This is true at undergraduate, postgraduate and continuing education levels.3
Intentional reflection is the process of analyzing and reframing experiences for the purpose of deeper learning and meaning (reflective learning) and a process through which personal experience informs and improves practice (reflective practice).2 Reflective learning can improve professionalism, and reflective practice can contribute to better management of patients and health systems.3 Repeating the same activity without reflection is simply repeating the same experience over and over again.
Enhancement of behaviours and practice through reflection is rooted in the opportunity to have assumptions challenged.4 Effective reflection requires time, effort and a willingness to question actions and underlying beliefs and values and to solicit different viewpoints. It is not a solitary activity. Surgeons can gain insight into their personal contribution within global surgery through intentional reflection upon their experience and discussion with others.
Framework for personal contribution assessment
Many methods, including journaling, field notes, blogs, portfolios, reflective narratives or storytelling, audio recordings or group discussion, can encourage reflection. There are no data to suggest the superiority or inferiority of any approach.3 Methods for reflection must be individualized.
Reflection creates a better understanding of ourselves and our global work so that future actions can be informed by this understanding. It is an essential part of professional development, but process is critical.4 Authors agree that reflection is iterative, but not intuitive.3,4 Reflection needs fostering. Many frameworks for reflection are described in the literature. Although somewhat different in content, each framework identifies questions that serve as prompts for reflection. Table 1 summarizes 2 models (Borton and Gibbs) for reflection with specific questions to promote reflective thinking.4–7
However, self-assessment is often inaccurate; shared reflection is better than individual reflection.8 Others typically see things the reflector cannot see. When done well, feedback provides multiple perspectives, supports integration of emotions and cognitive experience, and discourages uncritical acceptance of the experience.3 Colleagues with experience in reflection can help foster skills for reflection.
Timing of personal contribution assessment
Recognizing the iterative nature of reflection and the responsibility of global surgery to encourage maturation of individuals involved, reflection should be applied throughout the experience. The focus of reflection and the persons involved in the reflective process will differ among the project phases.
Selection and preparation phase
Self-selection is the primary selection mode in global surgery, because the work is primarily volunteer-based. Obviously, when the work involves an actual contract and salary, competency benchmarks and key field performance indicators are more clearly articulated.
At the trainee level, predeparture training is mandated or encouraged.1 It begs the question why such standards are not established for practitioners. All too often there is little or no formal selection or preparation process.
It is a joint responsibility of interested individuals and those directing global projects to encourage such reflection. What information is or should be available to would-be recruits or volunteers? How much effort is put into orientation or predeparture discussions to establish expectations and provide information about the host community?
Integration and performance appraisal phase
Reflection is an iterative process and is most successful when we incorporate insights from others. Reflection should involve other expatriate team members and the host community.
Global projects need regular team meetings among expatriate participants to air concerns. Dialogue with host colleagues is equally essential. Feedback from both greatly facilitates integration and reduces tension and confusion.
Even though formal performance appraisals are standard throughout the workforce, they are frequently absent in global surgical care activity because of the volunteer nature of much of this work. Such appraisals are best conducted as a combination of self-assessment, project leader assessment and host assessment with an ensuing open discussion. These assessments should have a defined format and relate to specific tasks and behaviours that are specified in project goals and known to all participants. The final appraisal may be verbal but ideally ought to be written and available to both the individual and the evaluator. This exercise helps to close loose ends or dissipate unsubstantiated impressions.
Debriefing phase
Once a project has finished and individuals have returned home they should participate in broader reflection or debriefing of their experience. Debriefing encourages individuals to articulate both positive (satisfaction) and negative emotions (tension) to an experienced listener to gain a broader perspective. This period can occur weeks or months later as an individual reflects on the personal meaning of the experience. One may ask him or herself, “Did this experience whet my appetite for future global surgery involvement?” “Have I become an advocate for global surgery, or have I lost interest in it?”
This is an important phase of the reflection process. There is usually an informal aspect to this phase as individuals relive and share common experiences. Seldom, however, is there a formal debriefing session with an experienced mentor. This is unfortunate because opportunities are missed to consolidate learning experiences and to correct misconceptions. It brings personal closure to the project, informs future involvement in global surgery and raises insights into how a participant may behave or do things differently in the future.
Who should participate in personal contribution assessment?
Persons involved or considering involvement in global surgery are encouraged to reflect in each phase of their experience and involve others as much as possible in seeking a more robust and realistic perspective. Mentors can be critical in the process. Three types of mentorship are described.9 One type of mentor answers questions and gives advice. In this model, knowledge transfer is the focus, with the mentor controlling much of the meeting content and the mentee having a more passive role as listener and spectator. Another type of mentorship model involves the mentor sharing experiences. This is a more reciprocal relationship. The third type of mentorship focuses on listening and stimulating reflection. In this type, the mentee is the focus of attention and the mentor is the listener. The mentor seeks to understand the mentee’s situation and experience and attempts to widen perspective by promoting reflective learning. The mentor seeks to be an “authentic voice.”2 We would suggest that, in the context of assessing personal contribution in global surgery by encouraging reflection, the third type of mentor is the most applicable.
The realities of mentorship are such that it is generally a scarce commodity in global surgery. It can be time consuming and it requires commitment and genuine interest.10 But, as we have described, mentoring and role-modelling are critical components toward improving reflective capacity, and improving reflective capacity enhances professional development in global surgery.
The individual participant needs to play the key role in reflection in each phase of his/her involvement. Other participants may vary depending upon the phase (Table 2).
Conclusion
Assessing personal contribution in global surgery projects is an important but largely neglected area. Many surgeons consider themselves experts and, as such, even if they have not done previous work in global surgery, consider their expertise and skill set sufficient to do effective global work. They wrongly assume that as a professional and medical expert, they will automatically have a positive impact as a participant in global surgery.
Assessing one’s contribution is complex, and no consistent metric can be applied — just like professionalism cannot be easily defined or measured. Teaching reflective principles and applying mentorship models are increasingly being applied at the trainee level as the model for encouraging professional competency. This may also be the best model within the discipline of global surgery for both trainees and surgical practitioners.
We encourage participants in global surgery to intentionally reflect in all phases of their involvement, from their decision to participate through to the debriefing phase after completing a project. Reflection is also something that project leaders should encourage by setting expectations and defining roles and, in conjunction with host colleagues, by providing meaningful feedback during and after a project. Those who are very active in global surgery should also reflect on what it means to be a mentor to new participants and work toward being better equipped to meet this role.
Footnotes
Elements of this article were presented at the Canadian Surgery Forum, International Surgery Symposium in Calgary, Alta, in 2012.
Competing interests: None declared.
Contributors: Both authors contributed substantially to writing and/or revising and to the conception and design of the manuscript and approved the final version for publication.
- Accepted April 13, 2015.