Introduction
The opportunity to work abroad, whether that means updating the skills and knowledge of local providers for a couple of weeks or committing to a longer-term stay of months to years and providing essential health care to displaced populations suffering from the ravages of war or natural disasters, is attractive to many physician assistants (PAs). For some, it is simply a heightened sense of adventure that makes such service appealing. For others, it is the heartfelt sense of moral obligation to help wherever in the world the needs are greatest and the resources scarcest. Regardless of the motive, such service can be a life-altering event.
PAs have participated in the delivery of international health care since the inception of the profession. PAs work with many international organizations, both private and governmental. Other PAs are employed by private multinational corporations, providing primary care to expatriates and their families living in Egypt and Saudi Arabia. Many more PAs serve with the U.S. Armed Forces throughout the world in a variety of environments where they are often also tasked to provide medical care to the indigenous populations. Still other PAs work throughout the many branches of the U.S. government. Some serve as Peace Corps volunteers, and more experienced PAs may serve as Peace Corps Medical Officers (PCMOs). As PCMOs, PAs provide medical support for Peace Corps volunteers in a given country. PAs are employed by the U.S. State Department for Embassy assignments and are also recruited for service with the Central Intelligence Agency. In addition, they may find opportunities through private corporations for deployment overseas into “hardship” environments such as Iraq and Afghanistan. In a much less volatile setting, American PAs have been working with the United Kingdom’s National Health Service for almost 20 years. There, they have served in both clinical and academic posts, as well as role models for the recently qualified U.K.-trained PAs.
The actual clinical roles and responsibilities of international PAs are as varied and diverse as the many countries and cultures in which they work. Thus, for the same reasons that it is difficult to describe the role of a “typical” PA practicing anywhere in the United States, it is equally difficult to identify the “typical” PA role in foreign countries.
PAs who choose to work in an international environment have many options. They must first determine whether they will seek formal paid employment with financial compensation of salary and benefits or serve on a purely volunteer basis. PAs then need to identify the target population (expatriates or indigenous) for whom they are interested in providing care. After they have decided where, how, and with whom they want to work, PAs will then begin an often-lengthy application process. Passports, visa applications, references, security clearances, background checks, screening health examinations, necessary vaccines, language training, and other relevant instruction are just some of the many steps that are likely to be encountered.
Working for the U.S. government, either in one of the military branches or with other governmental organizations (e.g., the State Department), usually entails providing care to a generally young and otherwise healthy expatriate staff. The “standards of care” are expected to be similar to treatment for the same problem in a typical medical facility in the United States. Diagnostic equipment, medications, and supplies are likely to be familiar. Advanced care, however, may sometimes only be available by transporting the patient back to the United States.
The other end of the international health care spectrum involves work in low-resourced countries. Providing health care to indigenous populations through nongovernmental organizations (NGOs) can offer a far greater challenge on many levels. Novice PAs (in terms of international experience) will likely face a rather unsettling experience when they come to realize that many of their preconceptions about what constitutes a “norm” in medical standards of care at home cannot, and for a variety of reasons, must not apply to the delivery of health care in a low-resourced country. Those PAs will likely face medical conditions that they never imagined; disease states of which they know little or nothing; and an overwhelming lack of resources, such as hospitals without running water or even an oxygen delivery system. Frequently, they will find that the medical and diagnostic equipment, if and when available, is rudimentary. Unless they are fluent in the local language, common tasks such as obtaining a history and performing physical evaluations frequently necessitate the help of local interpreters, increasing the time required for even a simple patient encounter. The organizations listed in Box 53.1 can provide additional information.
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Physician Assistants for Global Health: https://www.pasforglobalhealth.com/
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Fellowship of Christian Physician Assistants: https://cmda.org/specialty-sections/fellowship-of-christian-physician-assistants/
A PA who chooses to work with an indigenous population will have to decide if he or she wants to have shorter terms of stay (e.g., 3-6 months doing emergency relief where conditions are likely to be stressful) or longer terms (e.g., 9-12 months). The generally safer alternative is to work in developmental projects for longer terms. These developmental projects typically have more infrastructure and are therefore likely to be located in more stable countries.
A PA serving indigenous populations will likely confront many other hurdles beyond simple language differences. There may also be significant cultural, societal, and religious issues to address. Despite these factors, and perhaps because of them, the rewards of investing oneself in such a venture are often immeasurable.
Practical considerations
General issues
PAs planning to practice internationally would be well advised to research all aspects of such a commitment. This section addresses several major hurdles that PAs have encountered. Box 53.2 presents a set of essential guidelines for PAs considering international work, first adopted in 2001 and since revised, by the American Academy of Physician Assistants (AAPA).
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Physician assistants (PAs) should establish and maintain the appropriate physician–PA team.
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PAs should accurately represent their skills, training, professional credentials, identity, or service both directly and indirectly.
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PAs should provide only services for which they are qualified via their education or experiences and in accordance with all pertinent legal and regulatory processes.
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PAs should respect the culture, values, beliefs, and expectations of the patients, local health care providers, and the local health care systems.
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PAs should be aware of the role of the traditional healer and support a patient’s decision to use such care.
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PAs should take responsibility for being familiar with and adhering to the customs, laws, and regulations of the country where they will be providing services.
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When applicable, PAs should identify and train local personnel who can assume the role of providing care and continuing the education process.
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PA students require the same supervision abroad as they do domestically.
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PAs should provide the best standards of care and strive to maintain quality abroad.
Licensure and registration
There are no universal means by which PAs are permitted to work in a foreign country. In some cases, in which PAs are serving an expatriate patient population, official approval from foreign governments may be obtained through a series of clinical competency examinations. More often, PAs may be breaking new ground as they explore the ways that they can perform the tasks and deliver the level of care for which they are trained.
More commonly, local governmental approval is awarded to an “umbrella” agency with which the PA is working. Consequently, agencies typically require that credentials and letters of recommendation be submitted as the first step in going “to the field.” Experience indicates that, although fully licensed, certified, and registered providers in the United States, PAs usually practice their clinical skills to the limitations of their license. Nonetheless, the scope of practice for the international PA varies widely.
Physician–physician assistant relationship
The physician–PA relationship in international settings can be informal or tightly structured. The collaborating physician may be in immediate proximity, as a local doctor working alongside the PA in a refugee camp, or may perhaps be located in the capital city of the country, accessible only by radio or cell phone, while the PA works remotely. Another possibility is that the collaborating physician could be based in the United States but available by satellite communications, a model that many private multinational companies follow. There are no distinct or universal rules that govern international PA practice (except those constraints of the state wherein the PA is duly licensed or registered). As a result, practice standards for PAs in international settings unfortunately remain vague and ill-defined.
Medical liability
Although U.S.-based medical practice differs significantly from international practice and medical liability is not usually a substantial issue in international practice, PAs are still expected to provide the same level of care for which they have been trained, regardless of where in the world they find themselves. PAs should check with their malpractice insurance carriers before departing as they typically do not provide coverage outside of the United States.
PAs must never represent themselves as doctors, whether at home or abroad. The problems that could occur as a result of such misrepresentation may be devastating for an individual PA and may even have long-reaching effects on the further development and acceptance of the PA profession.
When a PA is working overseas, it remains his or her responsibility to account for absences from clinical practice at home. This may require documentation to be provided for any extended absences, including formal verification from the international employer or the organization.
Continuing education
Continuing medical education (CME) is an ongoing requirement for the maintenance of licensure and certification. Maintaining certification becomes an issue only if the PA is outside of the United States for 1 year or longer. CME credits are best obtained either by “stockpiling” before leaving the United States or accessing web-based formats, when feasible.
Qualifications
Core medical skills
The ability to work with limited or improvised resources is an essential skill. Of particular value is a reliance on basic, hands-on physical exam skills. It is important to remember that there are usually few advanced resources available. The PA will seldom find advanced diagnostic options, such as ultrasonography or computed tomography. Some resources are hours away and can only be reached by driving over rough roads, with the patient bouncing along in the back of a beat-up Land Rover.
Tropical medicine
Patients in underresourced countries typically do not have the same causes of morbidity and mortality as patients in the United States. Instead of cancers and cardiovascular diseases, patients in underresourced countries typically succumb to the ravages of infectious diseases. Even such relatively straightforward illnesses as gastroenteritis; acute respiratory infections, such as pneumonia; and measles are leading causes of death. Treatment is usually simple if the patient can access the proper medications in time. Several short courses in tropical medicine are available at American and European universities that can provide excellent training over a couple of weeks to a few months.
Language skills
Proficiency in a second language (e.g., French, Spanish, Portuguese, Arabic) will open many doors and allow for ease of communication with patients and professional counterparts. The alternative—total reliance on interpreters—can result in frustration for all parties involved. As a result, nuances in conversation during the medical history or examination process can be missed, and the interpreter may sometimes act as a screen, perhaps keeping details vague or even misleading the clinician.
Human resource management and clinical expertise
Frequently, PAs are sought not just as clinical providers but also as trainers or managers of local operations. In Jalalabad, Afghanistan, I served as the project medical coordinator for New Hadda, an emergency refugee camp of more than 80,000 people who, in the mid-1990s, had fled the fighting in Kabul, the capital, but were then unable to escape to neighboring Pakistan. Health care provided in the camp was the responsibility of the international humanitarian aid agency Doctors Without Borders, which provided primary care through a series of clinics staffed by Afghan doctors and nurses. As the project medical coordinator, I was responsible for the overall delivery of medical care in the camp clinics, some limited clinical practice, and clinical teaching, as well as all aspects of public health in the camp. To accomplish this, I regularly collaborated with representatives from other local and international NGOs, the local Ministry of Health, the United Nations International Children’s Emergency Fund (UNICEF), and the World Health Organization (WHO).
Other considerations
Stress
It is a well-known fact that living in harsh environments can be stressful. Accommodations are typically Spartan. Insects and vermin can plague your living space. The sound of gunfire may fill the night air. The days are often long and physically, and sometimes emotionally, demanding. Adequate rest becomes a precious commodity. Working and living in close proximity to the same group of people, day in and day out, contributes additional challenges. It is common for expatriates working in the emergency setting of large refugee camp environments to work 7 days a week, 12 or more hours each day. Workers often experience a feeling that there is so much work that needs to be done and so little time in which to do it. There must be some opportunity for rest and recuperation to avoid what many see as inevitable burnout. Therefore many NGOs insist that workers take time away, to the extent that this can be done without affecting the operations of the project.
Medications and standards of treatment
Medications will sometimes be antiquated, or even inappropriate, by Western standards. Typically, the latest multigenerational antibiotics are unavailable, not just because of the cost but more often because resistance has not yet become a significant issue in the area. As a result, inexpensive but effective drugs such as chloramphenicol or penicillin G are still used extensively.
Traditional health care
Maintaining an open mind is important when one is confronted with traditional and folk medicines. These methods, although usually unfamiliar to U.S.-born PAs, often play a significant role for patients and should not be invalidated. An awareness of how a community relies on traditional healers is important if one is to understand what that community expects of the PA. We must remember that after the PA and other international expatriate staff members leave, especially in emergency relief settings, the responsibility for ongoing health care usually falls back onto the traditional health care worker.
Personal health and safety
Although working in war-ravaged and underresourced countries presents many challenges, typically the greatest risk to expatriates occurs while they are traveling by car or truck. Injuries from motor vehicle accidents remain the primary reason why expatriates return from the field for medical reasons. Other common maladies can range from the nuisance of common traveler’s diarrhea to life-threatening cerebral malaria.
Expatriate PAs can sometimes find themselves in volatile environments. As a result, field workers have been robbed, held hostage, and worse. Although the economic motivation for these acts seems clear, perhaps less obvious are the political overtones commonly encountered in some countries.
Reentry
Returning home from an overseas experience often proves difficult, and returnees should not count on a smooth transition. Family members, other loved ones, and coworkers can seldom understand fully what the returned PA has experienced. Common stress reactions have been identified among returning relief workers. A classic example of such an experience is the “supermarket event,” which is the shock felt upon entering a well-stocked supermarket at home after having cared for starving people just a few days before.
More serious symptoms of posttraumatic stress disorder, as well as severe depression and suicide, can also result. It is therefore important to provide a mechanism for adequate debriefing on return and a means to follow up with mental health care in a timely manner.
Topics for preparation
When a PA is considering taking the time to work overseas, it is important that he or she learns about all the possible aspects of such a commitment. The following list includes a selection of topics to be researched:
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What is the overall mission of the organization?
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Will you be part of a self-sufficient unit, functioning outside the established health care system, or will you work alongside local counterparts in existing health support structures?
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Who will pay the necessary expenses of your travel, room, and board?
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Is there a training program available, or will you be expected to go directly to the field?
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What will happen to the job that you will be leaving behind? Is there any chance that the job, as well as any promises regarding the security of that job, will not be maintained? If so, what is your fallback plan?
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Case 53.1 , written from my personal experience, illustrates the challenges and satisfactions of work in international health care.
