International health care

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.

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