Global physician assistant (PA) development is moving rapidly in terms of education and clinical practice startups in new countries and settings. However, once the decision is made by a country, healthcare system, or institution to adopt and/or adapt the PA profession, the hard work has only just begun. The path to successful integration is always challenging and often littered with discouraging moments.
PAs in the United States—especially those new to the profession—may think that our own PA profession developed seamlessly. This is absolutely not true. In fact, I have witnessed firsthand, and at times impatiently, how long it has taken to solidify PA integration into US healthcare. To illustrate this point, the first PAs were graduated in the late 1960s but it was 2000 when the final state (New Jersey) recognized and authorized PAs.
Why did integration of PA practice take so long? Aside from the expected initial opposition from some other more traditional and well-established healthcare professions, the main barriers to PA practice, at least in the United States, were at the state level. As a federated country with 50 states, we leave licensing authority and decisions to each state, district, or territory. This preserves the right to make state-specific decisions based on unique features and trends for each state. Not surprisingly, the states with the first PA laws were typically those that had PA programs. Other states followed at varying speeds. Similarly, upgrades for the PA role have been quick in some states and very slow in others. On the global scene, we learned a lot from PA development in the Netherlands, where, in 2001, a relatively small country and a single government provided an optimal environment to create PAs (Figure 1). The efficiency of effectiveness of the Netherlands' top-down needs assessment, decision making, funding, and implementation process was impressive. The government realized that they had done such a good job of taking care of Dutch people's health that life expectancy had significantly increased; this led the government to decide that it needed more people to provide medical care. Creating PAs and NPs was the chosen strategy. The Netherlands' development also was successful because it took advantage of existing infrastructure, including teaching hospitals and the selection and ongoing financial support of people already employed in these systems. In exchange for partial salary support, these new PAs and NPs agreed to ongoing employment (in their new roles) in these same hospitals.
Based on the rapid progress in the Netherlands, those of us working on PA global development naively hoped and expected that it would be as easy everywhere. Wrong!
Despite the lengthy struggle experienced by US PAs, based on federated countries' highly variable state-specific rather than national licensing, leaders in PA global development efforts still wanted to believe that a single national legislative document could suddenly let PAs practice throughout an entire country. Some painful battles have occurred. Despite the strong support of physicians in Australia's rural and remote communities, physicians in large urban centers saw no need for PAs in their “over-doctored” communities. Their support for rural physicians took the form of a sudden doubling of training slots in Australia's medical schools, based on their assumption that many of these new physicians could be enticed into rural practice, there would be no need for PAs. Although the government of the large state of Queensland, in Northeast Australia, has been supportive of PAs, none of the other states or territories have yet taken the same steps.
Similarly, Canada seemed like an “easy sell” for the development of PAs. In a role pioneered first by the Canadian Armed Forces, military PAs are respected and highly regarded. A large pilot project in Ontario, using PAs and international medical graduates, made more enemies than friends. As a result, PA practice in the province of Ontario continues under delegation by a physician, but without regulation or prescribing practice. Fortunately, the rural provinces of Manitoba, New Brunswick, and Alberta saw the need for PAs and passed legislation for PAs. The Canadian Academy of Physician Assistants is emphasizing advocacy for licensure in British Columbia, a province in which PAs and other advocates have been working to achieve recognition for more than 30 years.
India is another country with growing recognition of the value of the PA role but with no regulation in place. A strategy for recognizing PA practice must include individual plans for 29 states and 7 union territories there.
For almost every country, there is a dramatic story. Sub-Saharan countries in Africa, many of which have had PA-like clinicians since the 1970s, are upgrading their formerly unchanged curricula, developing new models of training, integrating new skill sets, and increasing their involvement in the International Academy of Physician Associate Educators. Some of these PA projects are connected to physician residency education initiatives established by European and US medical schools.
Although some educators have a goal of uniting PAs (“assistants” and “associates”), clinical associates, and medical licentiates under one name or category, there is less interest in this at the country-specific level, where the name often fits within the history and cultural context of that country. This argument is reminiscent of times when PAs and NPs in the United States were called nonphysician clinicians or midlevel providers by various regulators and insurers.
Ultimately, the national professional societies articulated an expectation that the professions be “called by what we are and not by what they are not.” In other words, we are physician assistants/associates (PAs) or NPs in the United States.
Although PAs in the United States may practice or provide aid in Central and South America, there is as yet no formal PA development in those countries. I think we can expect to see some early work done by the PA programs and faculty members that send PA students to Central America for rotations or cultural immersion experiences.
Similarly, PAs who have led and participated in humanitarian relief work in Asia, Indonesia, and Liberia continue those connections for themselves, their colleagues, and their students.
As global PA development began, there was initially concern among some PAs—and even the American Academy of PAs—that PAs trained overseas would come to the United States and compete for our jobs. That issue is now of less concern as the complexities of reciprocity become apparent. Overall there is a greater appreciation of how the PA role is most effective when it is adapted from current models, rather than adopted as a single nonnegotiable model. After all, PA practice in the United States has now significantly evolved from its original model.
Much work remains to be done. As it was in '70s and '80s, networking and building working and sharing relationships between programs is especially helpful (Figure 2). Some international programs have twinning relationships with US programs or other parallel programs developing internationally. Originally developed by the US State Department as a strategy for AIDS/HIV prevention, the twinning model received US government funding for supportive work with three clinical associate programs in South Africa and the PA programs at Emory University in Atlanta, Ga., the University of Colorado, and Arcadia University in Glenside, Pa.
Less formal twinning models with countries and institutions have involved Drexel University in Philadelphia, Yale University, the University of Utah, the University of Southern California, Duke University, and MEDEX Northwest at the University of Washington. Taking twinning a step further, it is interesting to consider whether state chapters of the AAPA might twin with emerging PA professional organizations in countries where the PA equivalent is still new. Assistance, mentorship, and observational exchanges could be offered on features of PA leadership, organizational structure, role development, and advocacy. Similarly, our specialty organizations might offer exemplars and exchanges demonstrating PA role models and medical supervision.
My personal observation is that many of these supportive international interactions often begin with one-on-one relationships between PAs, PA educators, and/or physicians. These relationships grow and recruit new advocates because they are based on shared values relating to improved healthcare access and garner the support of governmental agencies, policy makers, and even patients.
What is the role of the four US PA organizations (AAPA, Physician Assistant Education Association [PAEA], National Commission on Certification of Physician Assistants [NCCPA], and the Accreditation Review Commission on Education for the Physician Assistant [ARC-PA]) in interacting with international PA development activities? After initially assigning staff to assist with and coordinate global PA activities within their organizations, both AAPA and PAEA stepped back, feeling that resources should be primarily directed to domestic activities. Stating strongly that they would never engage in any international accreditation activities, ARC-PA distanced itself from any international discussions. Stepping down as a commissioner for the NCCPA, I was assigned to provide technical assistance, primarily on regulatory matters as the director of international affairs. With almost 15 years in that role, my most visible and notable success has been through networking and connecting individuals, PA programs, governmental agencies, medical regulatory agencies, and healthcare delivery systems between and across countries to talk about what works and what does not.
Although PA leaders in some countries believe that it is time to create a structured international organization composed of designated representatives from each country's PA organization, I do not think we are ready for that yet. Instead, open international meetings and networks with shared, rotating, but not necessarily formally elected leadership seem to be most useful in helping everyone move forward. In early meetings of countries, PA representatives visiting the United States wanted to know our history and “what worked,” but they were even more interested in knowing what we would do differently if we had it to do over again. As one visitor said, “With that information, hopefully we'd be able to accomplish in 10 years what it took you 40 to do!”