The opportunity to work abroad in a clinical setting, whether updating the skills and knowledge of local providers for a couple of weeks or a longer term commitment of months providing essential health care to displaced populations suffering from the ravages of war, will likely have long-term effects for the physician assistant (PA) who rises to such a challenge. For many PAs, 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 world the needs are great and the resources scarce. Regardless of the motive, such service as a PA will likely be a life-altering event.
Physician assistants have actively participated in the delivery of international health care since the inception of the PA profession. PAs work with many international organizations, both private and governmental. PAs have served, and continue to serve, with international relief organizations in Cambodia, Brazil, Tonga, Peru, Guatemala, Nicaragua, Syria, South Sudan, and Somalia, to name but a few. Other PAs are employed by private multinational corporations, supporting the oil-drilling and diamond mine crews above the Arctic Circle or providing primary care to expatriates and their families living in China and Saudi Arabia. Many more PAs serve with U.S. Armed Forces throughout the world in a variety of environments where they are often tasked to provide medical care to the indigenous populations. Still other PAs work in other branches of the U.S. government. Some PAs serve as Peace Corps workers, although more experienced PAs serve as Peace Corps Medical Officers (PCMOs). As PCMOs, PAs provide the medical support for Peace Corps volunteers in a given country. PAs are employed by the U.S. Foreign Service and are also recruited for service with the Central Intelligence Agency. In addition, they will find opportunities through private corporations for deployment overseas in “hardship” environments such as Iraq and Afghanistan. In a much less volatile setting, American PAs have been working in the United Kingdom’s National Health Service for the past 15 years. There they have served as both clinicians and role models for the recently qualified U.K.-trained PAs.
Physician assistants who want to practice internationally now have many more options than they did even just a few years ago. Nonetheless, the overall number of PAs who work internationally remains relatively small.
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.
Physician assistants who choose to work in an international environment have many options. These options largely depend on the PAs themselves. First they must determine whether they will seek formal paid employment with financial compensation of salary and benefits or serve on a volunteer basis. PAs then need to identify the target population (expatriates or indigenous) they are interested in serving. After they have decided where, how, and with whom they want to work, PAs can begin an often lengthy application process. Passports, visa application forms, references, security clearances and background checks, screening health examinations, necessary vaccines, language skills and other pertinent training, and formal interviews are just some of the many steps that are likely to be required.
Working for the U.S. government, either in the capacity of the military PA or with other governmental organizations (e.g., Foreign Service), 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 and supplies, although perhaps rudimentary, are likely to be familiar to even inexperienced providers. Advanced care may sometimes only be available by transporting the patient back to the continental United States by air ambulance.
At the other end of the health care spectrum is work in developing countries. Providing health care to indigenous populations through nongovernmental organizations (NGOs) can offer PAs 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 in the United States cannot, and for a variety of reasons must not , apply to the delivery of health care in a developing country. PAs may 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 an oxygen delivery system. Frequently, they will find that the medical and diagnostic equipment, if and when available, is rudimentary. Laboratory studies might be limited to determination of a hemoglobin value and microscopic examinations of urine and blood (for cell count and differential, as well as thick and thin prep slides for malaria) and stool for ova and parasites. Unless they are fluent in the local language, common tasks such as diagnostic studies and hands-on physical evaluations frequently have to be done through local interpreters, thus increasing the time required for even a simple patient encounter. The organizations listed in Box 47.1 can provide additional information.
A PA who chooses to work with an indigenous population will have to decide if he or she wants shorter terms (e.g., 3–6 months doing emergency relief where conditions are likely to be stressful). The generally safer alternative is to work in developmental projects for longer terms (e.g., 9–12 months). These developmental projects typically have more infrastructure and are therefore likely to be in more stable countries.
A PA serving indigenous populations will likely confront many other hurdles beyond simple language differences. There may 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.
The experience of many internationally experienced PAs demonstrates the need for a well-conceived plan. PAs who hope to practice internationally would be well advised to research all aspects of such a commitment. This section addresses a number of major hurdles that PAs have encountered. Although the following list of topics is comprehensive, it is by no means complete.
Box 47.2 presents a set of guidelines for PAs considering international work, which were adopted by the American Academy of Physician Assistants (AAPA) in 2015.
Physician assistants (PAs) should establish and maintain the appropriate physician–PA team.
PAs should accurately represent their skills, training, professional credentials, identity, or service both directly and indirectly.
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.
PAs should respect the culture, values, beliefs, and expectations of the patients, local health care providers, and the local health care systems.
PAs should be aware of the role of the traditional healer and support a patient’s decision to use such care.
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.
When applicable, PAs should identify and train local personnel who can assume the role of providing care and continuing the education process.
PA students require the same supervision abroad as they do domestically.
PAs should provide the best standards of care and strive to maintain quality abroad.
All PAs working internationally need to adhere to these guidelines, as well as to the AAPA’s Guidelines for Ethical Conduct for the Physician Assistant Profession.
Licensure and Registration
There is no universal means by which PAs are permitted to work in a foreign country. In some cases whereby 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 by which they can perform the tasks and deliver the level of care for which they are trained. One such groundbreaker, Donald Prater, worked in Nanjing, China, for a U.S.-based company, providing health care to hundreds of expatriates and their families who live in that region. Even though he was not providing medical services to the local residents, Chinese authorities required that he take the Chinese medical examination (in English) so that he could see his expatriate patients on a fee-for-service basis.
More commonly, governmental approval is awarded to the agency with which the PA is working (e.g., American Refugee Committee). Thus, the PA is allowed to work under the umbrella of that organization. Consequently, the agency typically requires that credentials and letters of recommendation be submitted as the first step in going “to the field.” Experience indicates that PAs, as fully licensed, certified, and registered providers in the United States, can usually practice their clinical skills to the full scope of their training. However, the actual scope of practice for the international PA can, and often does, vary widely. It is important to remember that other international agencies such as Doctors Without Borders do not routinely recruit PAs because the majority of the countries where they work do not recognize the PA profession.
Physician–Physician Assistant Relationship
The physician–PA relationship in international settings can be informal or tightly structured. The supervising physician can be in immediate proximity, working alongside the PA in a refugee camp, or in the capital city of the country, accessible by radio or cell phone, while the PA is working remotely in the field. Another possibility is that the supervising physician may be based in the United States but available by satellite communications or another electronic format, a model that many private multinational companies follow. It is important to remember that because 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), practice standards for PAs in international settings unfortunately remain vague and ill defined.
Although the myriad aspects of U.S.-based medical practice differ from those of international practice, and malpractice is not usually an issue in international practice, PAs must always provide the same high level of care for which they have trained, regardless of where in the world they find themselves. PAs should check with their malpractice insurance carriers before departing because insurance carriers rarely provide coverage outside the United States.
Physician assistants must never represent themselves as physicians, either 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 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 that adequate documentation be provided for any extended absences, including formal verification from the international employer or the organization.
Continuing medical education (CME), although not usually an issue for the other countries in which the PA may work, is nonetheless a requirement for maintaining licensure and certification. Maintaining certification by the National Commission on Certification of Physician Assistants (NCCPA) becomes an issue only if the PA is outside of the United States for 1 year or longer. From a practical perspective, Category 1 CME credits are best obtained either by “stockpiling” before leaving the United States or accessing web-based formats. Technologic developments can allow the globetrotting PA to access various Category 1 CME programs online from Internet cafes around the world.
From PAs who work for a small NGO who may have to pay for all of their own travel and lodging expenses to the few lucky PAs who are fully employed by a multinational corporation that may compensate them generously, PAs working in the international arena will find that the range of salaries and benefits will be as varied as the types of positions that they may encounter.
The ability to work with limited or improvised resources is an essential skill. Of particular value is a reliance on a basic hands-on approach to medicine. To highlight this issue, Cameron McCauley, an experienced international PA, tells of a time during his PA training when he was learning to evaluate heart murmurs. Similar to many of his peers, he scoffed at the need for physical assessment skills when technology such as echocardiograms would confirm the diagnosis. Cameron was humbled many years later, when he found himself working in a remote village without any hope of accessing such technology. Instead, he used those basic physical diagnostic skills he had learned years before to determine that a young patient had a ventricular septal defect. The child was then referred to the distant capital city, where his diagnosis was confirmed and the defect was surgically corrected.
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, or even the basics of plain radiography. As an example of the paucity of resources that can be faced, when I worked in Kabul, Afghanistan, there was only one working electrocardiogram machine in the entire country. Often the nearest x-ray unit is hours away and can be reached only by driving over rough roads, with the patient bouncing along in the back of a beat-up Land Rover.
Patients in developing countries typically do not have the same causes of morbidity and mortality as those in the United States. Instead of cancers and cardiovascular diseases, patients in developing 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 the leading causes of death. Treatment is usually simple if the patient can access the proper medication in time. Clinicians can spend years learning to specialize in infectious tropical disease; however, there are several short courses in American universities that can provide excellent training over a couple of weeks to a few months.
Public Health and Epidemiology
Because infectious diseases are so commonplace, especially in developing countries, a strong emphasis must be placed on prevention of these problems. Therefore, it is essential that PAs, especially those working in medical infrastructure development and public health capacity building, develop an understanding of the basic principles of public health. Many accredited schools of public health are available in the United States, but only a relative few offer specialty training in international health, and fewer still focus on refugee health and humanitarian emergencies.
Human Resource Management and Teaching 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).
Speaking a second language (e.g., French, Spanish, Portuguese, Arabic) can open many doors and allow for an 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 can sometimes act as a screen, perhaps keeping details vague or even misleading the clinician.