SPECIAL TOPIC The Medical Mission and Modern Core Competency Training: A 10-Year Follow-Up of Resident Experiences in Global Plastic Surgery Caroline A. Yao, M.D., M.S. Background: The emphasis on cultural competency for physicians and sur- Jordan Swanson, M.D. geons is increasingly important, as communication with both patients and Meghan McCullough, M.D. other providers significantly affects individual and system-wide outcomes. Trisa B. Taro, M.S., M.P.H. International surgical training has been shown to improve leadership skills, Ricardo Gutierrez cultural competency, and technical proficiency of participants in short-term Allison Bradshaw follow-up. This study explores the long-term impact of international surgical Alex Campbell, M.D. mission experiences on developing participants’ core competencies, profes- William P. Magee, Jr., M.D., sional outcomes, and commitment to global health. D.D.S. Methods: All 208 plastic and reconstructive surgeons who completed the Op- William P. Magee III, M.D., eration Smile Regan/Stryker fellowship programs between 2006 and 2015 were D.D.S. surveyed electronically. Los Angeles, Calif.; and Norfolk, Va. Results: One hundred sixty-five surveys were returned, for an overall response rate of 79.3 percent. The majority of participants reported that the fellowship positively impacted all six Accreditation Council for Graduate Medical Educa- tion core competencies. Most participants who were attending physicians at the time of the survey were practicing general plastic surgery, with 42 percent in an academic/teaching environment, 32 percent in assistant/associate professor positions, and 6 percent in either a program director or department chairman position. The majority currently volunteer on local or international missions, and all respondents would consider volunteering again. Conclusions: Carefully structured and rigorously proctored programs such as the Regan/Stryker Fellowship offer plastic surgery residents the opportunity to gain valuable professional and personal experiences that benefit them long after their service experience. Programs of this nature can not only effectively improve cultural competency of physicians, but also positively influence their attitudes toward leadership and direct that potential to meet the growing need for surgical care in low- and middle-income countries. (Plast. Reconstr. Surg. 138: 531e, 2016.) ross-cultural experiences have become and understanding resource allocation and an integral part of surgical education, in system-based medicine are critical in today’s Cpart because of the increasing diversity of global health landscape, as an estimated 2 billion patients in the United States and the growing bur- people worldwide lack access to adequate den of surgical care in low- and middle-income surgical care.2 countries.1 Strengthening cultural competency Surveys report that a significant number of North American residents and medical students From the Division of Plastic and Reconstructive Surgery and are interested in having international educational the University of Southern California Institute of Global experiences and select medical education pro- Health, Keck School of Medicine of the University of South- grams based on the availability of these opportu- ern California; the Department of Plastic and Reconstruc- nities.3–6 In response to this interest, there are now tive Surgery, Shriners Hospital for Children; the Division of more than 50 global health institutes seated within Plastic and Reconstructive Surgery, Children’s Hospital Los major academic health centers in North America. Angeles; and Operation Smile International. Received for publication October 30, 2015; accepted April 20, 2016. Disclosure: The authors have no financial interest Copyright © 2016 by the American Society of Plastic Surgeons to declare in relation to the content of this article. DOI: 10.1097/PRS.0000000000002484 www.PRSJournal.com 531e Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Plastic and Reconstructive Surgery • September 2016 However, less than one-third of these institutions such as questions regarding the degree to which cater to surgical residency programs.6 the fellowship affected Accreditation Council for A 2011 study from our group in this Journal Graduate Medical Education core competencies. reported that plastic surgery resident participa- Questions were structured to be fact-based and tion in medical missions and short-term interna- objective whenever possible (e.g., demographics, tional experiences advanced educational growth career status, and quantification of the number of in Accreditation Council for Graduate Medical the people the individual had helped on a volun- Education core competencies.7 This report builds teer basis). Demographics reported were from the on our previous work and examines the long-term time of the survey. There were no financial incen- impact of a global surgical experience on the tives for completing the survey. careers of participants and the populations they serve, and the potential impact on global surgery RESULTS capacity. One hundred sixty-five surveys were returned, for an overall response rate of 79.3 percent. Fel- METHODS lows were from 42 different countries; 47 percent The Operation Smile Regan Fellowship and were from North America and 44 percent were Stryker International Fellows Program are edu- from low- and middle-income countries. Fellows cational initiatives that offer plastic surgeons in participated in missions in 34 different countries training (plastic surgery residents) from both in Africa, Asia, South America, Central America, developed countries and low- and middle-income and the Middle East. Table 1 lists demograph- countries surgical experience in the treatment ics of past fellowship participants and current of cleft lip and palate. The programs consist of a career pursuits. Mean and median age of respon- 2-week experience that includes a surgical mission dents was 34 years, with a range of 26 to 45 years. with a follow-up debriefing meeting. Each fellow Respondents were an average of 3 years out from serves as a member of a multidisciplinary cleft care the fellowship experience (range, 1 to 14 years). team on an Operation Smile mission—involving The majority of participants are currently living in 2 days of preoperative screening, 4 to 5 days of North America, between 30 and 40 years of age, surgery, and 1 to 2 days of postoperative—under and in their fellowship or attending years. mentorship of senior attending surgeons. In a Thirty-eight percent of fellowship participants rigorously proctored environment, fellows partici- pursued a fellowship in craniofacial surgery. Of pate in the delivery of multidisciplinary surgical respondents who were attending physicians at care in resource-limited, multicultural settings the time of the survey, a majority were practicing and explore the socioeconomic factors that affect general plastic surgery, with 42 percent in an aca- local and national surgical capacity. All fellows demic/teaching environment, 32 percent in assis- reconvene at an annual follow-up meeting to tant/associate professor positions, and 6 percent debrief with peer and mentor groups in a prac- in a program director or department chairman tice-based learning environment. position. In 2015, a cross-sectional survey was conducted Figure 1 shows the reported impact of the of all 208 Operation Smile Regan/Stryker fellows Reagan/Stryker Fellowship on participants’ who completed the program between 2006 and Accreditation Council for Graduate Medical 2015. Operation Smile, an international not-for- Education core competencies, leadership, and profit organization that specializes in treatment of career development. Table 2 defines and exem- patients with cleft lip and/or cleft palate, provides plifies the type of survey question used for each millions of patient evaluations and hundreds of of the categories for growth and development thousands of gratis operations for children in presented in Figure 1. The vast majority of par- low- and middle-income countries. Online surveys ticipants reported that the fellowship positively were distributed by means of e-mail; they consisted impacted their core competencies in patient care, of 60 simple free response and three-level Lik- medical knowledge, practice-based learning and ert scale questions designed to maximize clarity. improvement, interpersonal and communication Questions focused on the fellowship’s impact on skills, professionalism, and systems-based prac- Accreditation Council for Graduate Medical Edu- tice. Participants reported being able to develop cation core competencies, career motivations and their technical skills through intensive training trajectory, populations served, and global health in the operating room and diverse mentorship capacity. Certain questions were more subjective, from leading surgeons in the field. A significant 532e Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Volume 138, Number 3 • Core Competencies on Medical Missions Table 1. Respondent Demographics and Attending Table 1. Continued Leadership Positions Characteristic No. (%) Characteristic No. (%) Volunteerism Age Would volunteer again 164 (100) <30 yr 24 (15) Currently volunteer on medical missions 91 (55) 31–35 yr 72 (46) Currently perform nonmedical volunteerism 45 (27) 36–40 yr 51 (33) Currently an active mentor 75 (46) >40 yr 8 (5)