International medical graduates (IMGs) are physicians who attended medical school outside the United States. The physician assistant (PA) profession's interactions with IMGs have been contentious at times, particularly when some IMGs sought licensure as PAs through nontraditional pathways. In the 1980s and 1990s, some state legislatures attempted to allow IMGs to obtain licenses as PAs without further training or examination, which resulted in PA leaders lobbying against such efforts. States had hoped to address physician shortages; however, legislatures had not thought through the public health and safety consequences of letting physicians who lacked U.S. credentials simply sign on as PAs.1-3 Projects to train IMGs as PAs in accelerated programs and to let IMGs test out of PA school met with mixed results, as many IMG-PA hopefuls performed below expectations.4,5 The American Academy of Physician Assistants (AAPA) issued a statement in 1993 affirming its position that a person seeking PA licensure must graduate from an accredited PA program and pass the national certifying examination.1
Debates on IMGs as PAs grew controversial as some in the PA establishment were accused of discrimination and some IMGs were accused of attempting to bypass procedures that had been established to assure clinical competency and patient safety.1-3 Even as PA licensure laws were strengthened, several PA programs chose to maintain their distance from IMGs, and some still decline applications from IMGs. This exclusion fails to acknowledge that some IMGs might be successful PAs.3,6
One concept that arose in the 1990s was that IMGs have the potential to contribute to the primary care workforce, as well as specialty practice, if PA programs are willing to screen appropriately. The MEDEX Northwest PA program at the University of Washington has worked with IMGs since the early 1990s, screening applicants and educating and graduating new PAs. This descriptive study will outline characteristics of IMGs who have become PAs through the MEDEX program, review IMG-PA outcomes, and discuss why the program's strategy may have succeeded where others failed.
APPLICATION AND EDUCATION PROGRAM
The MEDEX program's goals include graduating PAs who will work in primary care, medically underserved areas, and rural locations. The PA program requires that all applicants have a minimum 4,000 hours of clinical experience. The application process includes an additional personal statement for all those trained at the doctoral level (including IMGs, chiropractors, and naturopaths) to explain how they will embrace collaborative, team-based practice and the PA profession. Faculty members with experience training IMGs in the program screen the applications. The program also requires that all students participate in the full curriculum. With few exceptions (such as the pharmacology course for concurrent PA-doctor of pharmacy students), students are not allowed to waive or test out of coursework. Similar to all PA programs, the MEDEX curriculum orients students to the PA profession and collaborative practice.
METHODS
All IMGs who completed the program through 2013 were included in the study. The program's graduate database documents current practice location and specialty. Practice specialty was classified as primary care if it was family medicine, general internal medicine, or general pediatrics. Underserved practice status also is included in the database and is identified positively if it meets federal, state, or local definitions. Graduate files document country of origin and identify whether the IMG had practiced in primary care before entering the United States. Historical program data were used to compare rates of attrition, deceleration, and first-time pass rate on the Physician Assistant National Certifying Examination (PANCE) between the IMG group and the overall graduating class.
Analysis excluded two graduates who were not working at the time and one IMG who obtained American credentials as a physician subsequent to PA school. Graduation year was collapsed into two categories (1991-2005, n=18; and 2006-2013, n=18) to facilitate statistical comparisons. Descriptive statistics summarize outcomes in terms of practice specialty, geographic location, and whether the practice provides access to medically underserved populations. Comparisons review characteristics within the IMG-PA group using chi-square analysis or Fisher exact test where appropriate. Statistical analyses used SPSS version 19.
The University of Washington institutional review board determined that this report did not require its oversight.
RESULTS
Thirty-nine IMG-PAs were graduated from 1991 to 2013 (2.5% of 1,537 total graduates during these years). In terms of geographic origin, 48.7% came to the United States from central or eastern Europe, and 33.3% from Asia. Of the 39 IMG-PA graduates, 36 are working as PAs (92.3%). Although women account for about half of the MEDEX program's graduates, they accounted for 69.2% of the IMGs (72.2% of those working as PAs, Table 1). Almost all IMG-PAs (91.7%) practice in metropolitan settings (Table 2). The majority (55.6%) are in primary care, and 30.6% work in medically underserved areas. The program's northwest service region—Washington, Wyoming, Alaska, Montana, and Idaho—is home to 75% of these IMG-PAs.7
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Table 1: MEDEX IMG graduate demographics (n=39)
Table 2: Practice characteristics of those working as PAs (n=36)
In terms of who entered primary care practice in the United States, no significant difference was found when IMG-PAs with a history of primary care practice in their home countries were compared with specialist colleagues (P=0.37). Among the IMG-PAs, no significant difference was found between primary care practice and either graduation era (P=0.74) or sex (P=0.29). No significant difference was found between practice in medically underserved areas and graduation era (P=0.47) or sex (P=0.22). IMG-PAs practicing in rural areas (n=3) were not compared with their urban counterparts due to the low number. IMG-PAs in primary care were more likely than those in specialty practice to practice in an underserved area (P=0.009, Table 3).
TABLE 3: IMG-PAs serving in primary care and underserved areas
Between 1991 and 2013 the MEDEX program enrolled 1,613 students, of whom 1,565 graduated (97%). During this same time frame, 40 IMGs enrolled and 39 graduated (97.5%). Forty-eight students in the general student population decelerated (repeated part of the program); none of the IMG did. The overall first-time pass rate on the PANCE across the study years averaged 86.2%; the IMGs averaged 97.4%. Due to low numbers in the IMG population (n=1 for attrition, n=0 for deceleration, and n=1 for first-time PANCE failure), statistical comparisons of these three outcomes were not conducted.
DISCUSSION
The MEDEX program encourages PAs to practice in primary care, medically underserved areas, and rural areas within its five-state service region. As part of this goal, MEDEX has educated carefully selected IMGs over more than 20 years with results that appear to justify the effort. These PAs are practicing in a range of specialties and settings. They contribute to the mission to practice in primary care (55.6%) and medically underserved areas (30.6%). Most (75%) have remained in the northwest service region. Although this study did not include a direct comparison with all other MEDEX graduates, these numbers appear to be equivalent from the perspective of a recent all-graduate survey that showed 43.2% in primary care, 34.5% in self-reported underserved areas, and 74.1% in the MEDEX service region.8 The rate of practice in primary care compares favorably to current national data available from AAPA, with only 31.7% of recent survey respondents indicating primary care practice (using federal definitions).9
The IMGs who were accepted into the program performed well academically. In contrast to some of the earlier experiments that truncated the PA curriculum, this program ensured that all IMGs followed the same educational plan as the rest of the PA class. The lack of need for deceleration and the minimal attrition may be results of the applicant screening process, the requirement to complete the full curriculum, or both. The requirement that all applicants have clinical experience may reduce potential IMG expectations that they could waive portions of the curriculum because their classmates also have been involved in patient care. The MEDEX program and its institution have faculty resources to support students with English as a second language, which also may contribute to the success of these IMG-PAs during their education.
Some of the IMG MEDEX graduates increase healthcare access in urban underserved areas for immigrant populations with origins similar to their own. These patients appreciate being able to see a provider who shares their cultural and linguistic background. The evaluation of underserved practice area for these PAs was based on verifiable designations, in contrast to the all-graduate survey in which respondents self-reported their practice classification. In this context, the program believes that its IMG graduates are equivalent to their peers in their ability to meet the MEDEX mission.
Very few of this program's IMG-PA graduates are in nonmetropolitan settings, which may be due to issues of acculturation, not just to a new healthcare system, but also to small-town America. This can be set in the context of a 2009 study showing that IMG physician practice in rural areas can be quite variable across states and regions.10 Acceptance of an IMG by residents in a rural area can sometimes pose a challenge and retention is problematic. Including IMGs practicing as rural PAs would expand this discussion.
The fact that one IMG-PA subsequently obtained US physician licensure may speak to a concern that programs cannot always know whether an IMG will remain in the PA profession. The MEDEX program reviewed this issue and now asks questions in the application process designed to define the applicant's long-term expectations. Such questions cannot guarantee future actions, but can be one component of an effective admissions screening. On the other hand, all PAs have the right to expand their careers into other fields such as education or administration.
LIMITATIONS
The main limitations of this study are the shortcomings of all case reports: the absence of external validity and lack of generalizability to other PA programs. This study reviewed IMG-PA graduates from a single program in the northwest United States. However, new information about the rich experience of successfully integrating IMGs as PA students has been presented and can be adapted elsewhere as appropriate. Further examination of the broad range of PA applicant backgrounds might illuminate the potential effect of applicant backgrounds on subsequent PA practice characteristics.
The limited nature of this study, focusing on IMG-PA graduates only and lacking a direct comparison with their colleagues, does not address the question of whether IMG-PAs are more likely than other PAs to demonstrate specific workforce outcomes. A follow-up study would conduct such a comparison.
CONCLUSION
The MEDEX program has found that IMGs can be graduated as PAs who possess the clinical and professional skills to contribute to healthcare delivery in the program's service region. One possible reason for this success is that as they progress through the full PA curriculum, the IMGs are socialized into the PA profession along with their classmates and adopt appropriate roles on the healthcare team. By adapting this approach to fit other PA programs, the PA educational community may find that carefully selected IMGs can broaden perspectives in their classrooms and contribute to increased diversity in the PA workforce. This PA program can serve as a case study of a successful model to train IMGs as PAs.
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