Going Global: PAs, NPs Practicing Internationally

For most of their 40+ years, physician assistants and nurse practitioners have been a uniquely American phenomenon. But now, clinicians are starting to transport their ideas and expertise to all parts of the globe.

Training programs have already been established in parts of Europe and Australia. Now, as countries in the Middle East, Asia, Africa, and Latin America struggle with physician shortages in rural areas, they, too, are eager to bring these highly trained professionals within their borders.

Through international conferences, groups like the International Council of Nursing (ICN) in Geneva (which has NP or APN programs in 78 countries) and the International Academy of Physician Associate Educators (IAPAE) are connecting willing professionals to countries in need.

For clinicians with a sense of adventure, practicing overseas is a wonderful opportunity to delve into a new culture and share ideas and skills. Herein, we profile several PAs and NPs who are already living the international life. Read on, and be inspired!

Saudi Arabia: Welcoming PAs to the Middle East
As an established PA who had worked in emergency medicine for years and who serves on the faculty of the PA program at George Washington University (GWU), Amy Keim, MS, PA-C, is used to having a lot of freedom in her practice. Keim, who is the director of GWU’s International Physician Assistant Development program for the Department of Emergency Medicine, is also no stranger to working overseas.

So when Saudi Arabian government officials approached her department about designing a curriculum for the first PA program in the Middle East, she was thrilled and a little nervous. She wondered how she would be received, both as a PA and as a woman.

“I have worked in Beirut and Abu Dhabi, but Saudi Arabia had this more intimidating feel to it,” Keim says. “We think of it as this romanticized, really exotic locale. People don’t go on vacation to Saudi Arabia, let’s put it that way.”

Keim says she was pleasantly surprised during her first visit, when her Saudi hosts invited her for a wonderful fireside picnic out in the desert. “There was delicious food and music, and the people were very warm and welcoming,” she says. “They were so hospitable, it changed my impression overnight.”

Keim and GWU Program Coordinator Megan Williams both wanted to be sensitive to cultural expectations for women in Saudi Arabia. They learned, sometimes through trial and error, when it was acceptable to wear Western clothes and when they needed to cover their heads or don an abaya (a full-length black robe). Keim and Williams discovered, for example, that when they were shopping in a more westernized mall, they could wear their usual outfits. But if they were invited to an official military ceremony, they would wear an abaya out of respect for the culture.

“I haven’t run into any real difficulties because I’m a woman,” Keim adds. “They have been extremely open to the [program] model and to the leadership.”

The first 25 students started in the Saudi PA program in September. It will last 28 months and will be based on a military model, similar to that of the first PA programs in the United States and Canada. Only male military officers will have the chance to become PAs.

The program will be administered through the Prince Sultan Military College of Health Sciences in the Eastern Province capital of Dhahran. When the students graduate, they will be called “Assistant Physicians,” mainly because the title translates better.

“These highly trained students will not only be the first physician assistants in the Middle East, but will be a critical component to improving access to quality health care in military and civilian communities throughout the country,” Keim says.

Keim feels the Saudi Arabian PA program will serve as a model for other countries with similar health care needs. “I think this trend reflects a general need for this type of provider, with this type of training, to really close some of the gaps,” she says. She has enjoyed having the opportunity to help bring better care to Saudi Arabia, and to learn more about its culture.

Surprisingly, it was on US soil that an accidental cultural misunderstanding occurred, when one of the Saudi Arabian officials visited Washington, DC. Keim was driving him to an event, but needed to stop by the vet first to pick up her beloved Jack Russell terrier. When her colleague started to look uncomfortable in the passenger seat, she asked why. He told her almost no one in Saudi Arabia has a dog, because the Islamic religion considers the animal unclean. Her colleague “toughed it out” for the duration of the trip, but Keim wishes she had recognized the potential problem sooner.

In the end, this new program has been a learning experience for everyone—in more ways than one. It’s those kinds of exchanges with other cultures that make working overseas a joy and a challenge, Keim says: “I reflect back and think this has been a phenomenal career, because it has taken me down paths I never imagined.”

Honduras: Clean Water and Compassion
When Thad Wilson, PhD, RN, FNP-BC, graduated with a BSN from the University of Iowa nursing school, he happened to attend a career fair. One of the booths, way over in a corner, was advertising a primary care nursing position at a clinic in a rural area of Honduras. Wilson, who had been considering the Peace Corps anyway, jumped at the chance for an adventure. “I was going to be the only primary care provider for 5,000 people,” says Wilson (who was 22 and unmarried at the time).

During his first few weeks at La Buena Fe Clinic in a small village by Lake Yajoa, Wilson says he “got really good” at suturing. That’s because so many of his clients came in with machete wounds. One man even had a machete stuck in the back of his neck. Another patient still thanks Wilson every time he sees him, for sewing his thumb back on after he accidentally cut it off while working with a machete.

“This was a great clinic, in the middle of nowhere,” Wilson recalls. “I had no electricity and no running water. I delivered babies by candlelight and boiled water to sterilize my instruments.”

Just about every patient who came to La Buena Fe had gastrointestinal problems. The area was replete with tropical diseases. “I saw every kind of amoeba and worm you could think of,” Wilson says. “Those were my biggest nemesis.”

Upset by seeing toddlers dying of diarrhea, Wilson consulted with some local nonprofit agencies. Eventually, they built a well so the community could have clean water to drink. “Now, we don’t see the number of cases in that area with gastrointestinal problems,” he adds.

Without the fancy diagnostic tools most US nurses take for granted, Wilson says he honed his skills in taking histories and doing physical assessments. “The greatest technology we have is between our eyes and our ears,” he says. When he needed help, he turned on his ham radio and tapped into the expertise of several doctors thousands of miles away, back in the US. Talk about trial by fire… Wilson, who is now Associate Dean of the University of Missouri School of Nursing in Kansas City, recalls those days with fondness.

Thirty years later, Wilson (the Immediate Past President of the American College of Nurse Practitioners) still goes to Honduras on a regular basis. These days, he visits with 12 nursing and pharmacy students from the University of Missouri. He wants them to capture the magic and the intense hands-on experience that he had in his earlier years as a nurse.

The 15-day program gives students a chance to work in rural clinics as well as city hospitals. Part of the goal is to get students thinking about quality of care under different health care systems. For example, in Honduras, patients must make a down payment before they can have surgery in a hospital. “There are people who will die on that bed, waiting for $50,” Wilson says, “whereas in the US, we would do the surgery first and ask for money later.”

Compassion and cultural sensitivity are other byproducts of Wilson’s overseas class. For example, the students begin to understand the importance of family in Latin American culture. Back home, when an entire extended family crowds into their exam room for one family member’s appointment, they won’t mind so much.

Stoicism is another trait they learn about. “In Central America, they come from a culture where pain is just a way of life,” Wilson says. “They are able to improvise and do whatever it takes to survive.” So students realize patients from these areas may not complain much, and it might take a little coaxing to find out what’s wrong.

Wilson is grateful for his time in Honduras. It has offered a life-changing experience—both for him and for his students.

Australia: Digging in Down Under
Al Forde, PA-C, originally from Wyoming, admits he has always had a love affair with Australia. “I’ve always kept an ear to the ground as to how I could get there someday,” he says.

So he felt incredibly lucky to be hired at James Cook University in 2006, when the college decided to launch a pilot PA program. At the time, Forde was teaching in the PA program at the University of Utah in Salt Lake City. Luckily, his wife and 12-year-old daughter were up for the adventure of moving to Queensland.

“The pace of life is much slower here,” Forde says. “I enjoy living in the tropics, with the warm weather, and living near the coast.”

The James Cook PA program is up and running, Forde explains, but graduates can have a hard time finding jobs. That’s because the PA role has not completely caught on yet in Australia.

With such vast rural territory, Australia would seem to be perfectly suited to the skills and expertise PAs could offer. Forde and his colleagues have learned, however, that they must be patient and slowly encourage change within the current health care system. “It’s a matter of persistence,” he adds.

Australia’s health care system, Forde says, has a medical philosophy similar to the British system’s. The government pays for most health care in Australia, so market forces are not shaping the need for PAs the way they did in the US during the 1980s.

Doctors, for example, do only primary care, emergency care, and obstetrics. Specialists are called physicians. “They have different education and different roles,” Forde says.

It’s still unclear where PAs might fit into that system. One thing that is clear is the shortage of providers, particularly in remote and indigenous areas. “The state health departments, especially in the rural areas, are desperate for backup and help and manpower,” Forde says.

Some clinics in Australia are privately run, Forde says, and the doctors who staff them are interested in seeing whether employing PAs can be cost-­effective.

Forde, who now has permanent resident status, is willing to wait and keep promoting the value of PAs. Other than occasional pangs for good Mexican food, he would not want to be living anywhere else.

England: X-rays and Expressions
Physician Assistant Kristen Gipson has worked in emergency medicine for most of her 21-year career. She did her original training at Emory University.

Gipson was glad to be chosen as part of the first pilot group of 12 PAs to travel to the United Kingdom in 2004. She currently works in an emergency room (called Accident and Emergency) in Birmingham, England.

During her first year in the UK, Gipson ran into some unexpected bureaucracy. For example, each time she went to order an x-ray for a patient, she hit roadblocks. In the UK, Gipson explains, a radiographer can refuse to do an x-ray if he or she doesn’t feel it’s justified.

“Initially, we weren’t allowed to order them, but then the PAs in the hospital managed to attend a radiation safety course, which allowed us to request an x-ray,” Gipson explains. Now, most hospital PAs have the right to order x-rays, but PAs providing primary care in other parts of England still cannot order these basic tests.

In Accident and Emergency, Gipson’s daily routine is pretty similar to that in an emergency department in the US. “I see medical trauma, mental health, children, obstetrics, and gynecology,” she says. “I evaluate, diagnose, request tests, and make referrals.” She can discharge and admit patients and arranges for community care. Gipson also is involved in teaching and training medical students.

While four universities currently offer training programs in England, “physician assistant” is not yet an official role in the UK, Gipson says. To be able to officially practice medicine and prescribe, she had to find a physician willing to “delegate” care or treatment to her, under a specific clause in the British Medical Council’s laws. The employer also usually covers the cost of malpractice coverage.

After six years in England, Gipson says she feels pretty well acclimated to British culture. Even though British and American citizens all speak English, subtle language differences can sneak up on you and perhaps put someone’s knickers in a twist. “Both the medical and everyday expressions can be drastically different,” she adds. “Certain words are very differently used and could cause some embarrassment until you learn not to use them in their American context—for example, fanny and pants.”

Scotland: Of Tea Breaks and Trust
Sometimes, while doing rounds as a PA at the Edinburgh Cancer Center in Scotland, Juanita Gardner must stop and wait for her patients to partake in a bit of tea and crumpets. “Tea breaks are a vital part of the workday,” Gardner says. “The oncology wards have a person who will often come around with a cart containing tea, biscuits, and coffee for every patient at no charge.”

Right away, Gardner noticed the pace was different for workers in the Scottish medical system. They have more holidays and time off to be with their families. Unlike many American health care workers, her Scottish counterparts “work to live,” instead of the other way around.

Gardner came to Scotland from the US in 2006, when the National Health Service (NHS) of Scotland launched a pilot PA program. Gardner was among the initial group of 12 American PAs involved. Her assignment was to set up diabetes and COPD clinics at a local primary care health center in Edinburgh.

As in England, the PA profession is not fully recognized in Scotland. PAs do not yet have prescribing privileges. The UK PA association is working on this, but Gardner says she is still in the process of applying for registration. “As you can imagine, there is much red tape and politics involved in such a process,” she says. “Things here move rather slowly.”

Gardner describes her first year in Scotland as “extremely challenging.” For example, the clinic staff refused to give her access to computer programs and medical records that she needed. “I had two wonderful supervising physicians who used their influence to remove all barriers and obstacles in my path,” Gardner says.

Despite their kindness, Gardner sensed a general lack of trust from the medical community there. “Many seem to feel PAs will take away jobs; others are resistant to change and new ideas,” she says. “Some feel the NHS nurses are equally skilled and trained, so why hire a PA?” In the end, it’s probably a matter of people not understanding the diversity of the PA role and the level of education required, Gardner adds.

When the pilot study ended, Gardner’s employers asked her to stay. Her role blossomed into providing education about the PA role for the NHS. She also helped train nurses and prepare them for clinical exams. Later, she was hired for her current position in the Edinburgh Cancer Center.

It has been an interesting educational experience to work in a socialized medicine system, after having been trained in the US, Gardner says. In some respects, it makes her appreciate what we have in America.

“In Scotland, this system provides patients with limited to no choices in the types of treatment they receive and what doctor they will see,” she says. “They often do not have access to the newest treatments, medications, or facilities, and technology lags.”

Gardner has been surprised by the lack of preventive medicine and patient education programs, despite a nationwide problem with heavy drinking and smoking. “The majority of patients continue to practice unhealthy behaviors, even though they are being treated for cancer,” Gardner says.

Despite these issues, Gardner loves being where she is and feels hopeful that with large enough numbers, PAs will succeed in Scotland.

“The country of Scotland is extremely beautiful and the Scottish people are very friendly, kind, genuine, and humble,” she says. “The PA can be someone who will take the time to listen, show compassion, and go an extra mile for a patient. If used correctly, and enabled to function within his/her full scope of practice, PAs can definitely be cost-effective for the NHS.”

For most of their 40+ years, physician assistants and nurse practitioners have been a uniquely American phenomenon. But now, clinicians are starting to transport their ideas and expertise to all parts of the globe.

Training programs have already been established in parts of Europe and Australia. Now, as countries in the Middle East, Asia, Africa, and Latin America struggle with physician shortages in rural areas, they, too, are eager to bring these highly trained professionals within their borders.

Through international conferences, groups like the International Council of Nursing (ICN) in Geneva (which has NP or APN programs in 78 countries) and the International Academy of Physician Associate Educators (IAPAE) are connecting willing professionals to countries in need.

For clinicians with a sense of adventure, practicing overseas is a wonderful opportunity to delve into a new culture and share ideas and skills. Herein, we profile several PAs and NPs who are already living the international life. Read on, and be inspired!

Saudi Arabia: Welcoming PAs to the Middle East
As an established PA who had worked in emergency medicine for years and who serves on the faculty of the PA program at George Washington University (GWU), Amy Keim, MS, PA-C, is used to having a lot of freedom in her practice. Keim, who is the director of GWU’s International Physician Assistant Development program for the Department of Emergency Medicine, is also no stranger to working overseas.

So when Saudi Arabian government officials approached her department about designing a curriculum for the first PA program in the Middle East, she was thrilled and a little nervous. She wondered how she would be received, both as a PA and as a woman.

“I have worked in Beirut and Abu Dhabi, but Saudi Arabia had this more intimidating feel to it,” Keim says. “We think of it as this romanticized, really exotic locale. People don’t go on vacation to Saudi Arabia, let’s put it that way.”

Keim says she was pleasantly surprised during her first visit, when her Saudi hosts invited her for a wonderful fireside picnic out in the desert. “There was delicious food and music, and the people were very warm and welcoming,” she says. “They were so hospitable, it changed my impression overnight.”

Keim and GWU Program Coordinator Megan Williams both wanted to be sensitive to cultural expectations for women in Saudi Arabia. They learned, sometimes through trial and error, when it was acceptable to wear Western clothes and when they needed to cover their heads or don an abaya (a full-length black robe). Keim and Williams discovered, for example, that when they were shopping in a more westernized mall, they could wear their usual outfits. But if they were invited to an official military ceremony, they would wear an abaya out of respect for the culture.

“I haven’t run into any real difficulties because I’m a woman,” Keim adds. “They have been extremely open to the [program] model and to the leadership.”

The first 25 students started in the Saudi PA program in September. It will last 28 months and will be based on a military model, similar to that of the first PA programs in the United States and Canada. Only male military officers will have the chance to become PAs.

The program will be administered through the Prince Sultan Military College of Health Sciences in the Eastern Province capital of Dhahran. When the students graduate, they will be called “Assistant Physicians,” mainly because the title translates better.

“These highly trained students will not only be the first physician assistants in the Middle East, but will be a critical component to improving access to quality health care in military and civilian communities throughout the country,” Keim says.

Keim feels the Saudi Arabian PA program will serve as a model for other countries with similar health care needs. “I think this trend reflects a general need for this type of provider, with this type of training, to really close some of the gaps,” she says. She has enjoyed having the opportunity to help bring better care to Saudi Arabia, and to learn more about its culture.

Surprisingly, it was on US soil that an accidental cultural misunderstanding occurred, when one of the Saudi Arabian officials visited Washington, DC. Keim was driving him to an event, but needed to stop by the vet first to pick up her beloved Jack Russell terrier. When her colleague started to look uncomfortable in the passenger seat, she asked why. He told her almost no one in Saudi Arabia has a dog, because the Islamic religion considers the animal unclean. Her colleague “toughed it out” for the duration of the trip, but Keim wishes she had recognized the potential problem sooner.

In the end, this new program has been a learning experience for everyone—in more ways than one. It’s those kinds of exchanges with other cultures that make working overseas a joy and a challenge, Keim says: “I reflect back and think this has been a phenomenal career, because it has taken me down paths I never imagined.”

Honduras: Clean Water and Compassion
When Thad Wilson, PhD, RN, FNP-BC, graduated with a BSN from the University of Iowa nursing school, he happened to attend a career fair. One of the booths, way over in a corner, was advertising a primary care nursing position at a clinic in a rural area of Honduras. Wilson, who had been considering the Peace Corps anyway, jumped at the chance for an adventure. “I was going to be the only primary care provider for 5,000 people,” says Wilson (who was 22 and unmarried at the time).

During his first few weeks at La Buena Fe Clinic in a small village by Lake Yajoa, Wilson says he “got really good” at suturing. That’s because so many of his clients came in with machete wounds. One man even had a machete stuck in the back of his neck. Another patient still thanks Wilson every time he sees him, for sewing his thumb back on after he accidentally cut it off while working with a machete.

“This was a great clinic, in the middle of nowhere,” Wilson recalls. “I had no electricity and no running water. I delivered babies by candlelight and boiled water to sterilize my instruments.”

Just about every patient who came to La Buena Fe had gastrointestinal problems. The area was replete with tropical diseases. “I saw every kind of amoeba and worm you could think of,” Wilson says. “Those were my biggest nemesis.”

Upset by seeing toddlers dying of diarrhea, Wilson consulted with some local nonprofit agencies. Eventually, they built a well so the community could have clean water to drink. “Now, we don’t see the number of cases in that area with gastrointestinal problems,” he adds.

Without the fancy diagnostic tools most US nurses take for granted, Wilson says he honed his skills in taking histories and doing physical assessments. “The greatest technology we have is between our eyes and our ears,” he says. When he needed help, he turned on his ham radio and tapped into the expertise of several doctors thousands of miles away, back in the US. Talk about trial by fire… Wilson, who is now Associate Dean of the University of Missouri School of Nursing in Kansas City, recalls those days with fondness.

Thirty years later, Wilson (the Immediate Past President of the American College of Nurse Practitioners) still goes to Honduras on a regular basis. These days, he visits with 12 nursing and pharmacy students from the University of Missouri. He wants them to capture the magic and the intense hands-on experience that he had in his earlier years as a nurse.

The 15-day program gives students a chance to work in rural clinics as well as city hospitals. Part of the goal is to get students thinking about quality of care under different health care systems. For example, in Honduras, patients must make a down payment before they can have surgery in a hospital. “There are people who will die on that bed, waiting for $50,” Wilson says, “whereas in the US, we would do the surgery first and ask for money later.”

Compassion and cultural sensitivity are other byproducts of Wilson’s overseas class. For example, the students begin to understand the importance of family in Latin American culture. Back home, when an entire extended family crowds into their exam room for one family member’s appointment, they won’t mind so much.

Stoicism is another trait they learn about. “In Central America, they come from a culture where pain is just a way of life,” Wilson says. “They are able to improvise and do whatever it takes to survive.” So students realize patients from these areas may not complain much, and it might take a little coaxing to find out what’s wrong.

Wilson is grateful for his time in Honduras. It has offered a life-changing experience—both for him and for his students.

Australia: Digging in Down Under
Al Forde, PA-C, originally from Wyoming, admits he has always had a love affair with Australia. “I’ve always kept an ear to the ground as to how I could get there someday,” he says.

So he felt incredibly lucky to be hired at James Cook University in 2006, when the college decided to launch a pilot PA program. At the time, Forde was teaching in the PA program at the University of Utah in Salt Lake City. Luckily, his wife and 12-year-old daughter were up for the adventure of moving to Queensland.

“The pace of life is much slower here,” Forde says. “I enjoy living in the tropics, with the warm weather, and living near the coast.”

The James Cook PA program is up and running, Forde explains, but graduates can have a hard time finding jobs. That’s because the PA role has not completely caught on yet in Australia.

With such vast rural territory, Australia would seem to be perfectly suited to the skills and expertise PAs could offer. Forde and his colleagues have learned, however, that they must be patient and slowly encourage change within the current health care system. “It’s a matter of persistence,” he adds.

Australia’s health care system, Forde says, has a medical philosophy similar to the British system’s. The government pays for most health care in Australia, so market forces are not shaping the need for PAs the way they did in the US during the 1980s.

Doctors, for example, do only primary care, emergency care, and obstetrics. Specialists are called physicians. “They have different education and different roles,” Forde says.

It’s still unclear where PAs might fit into that system. One thing that is clear is the shortage of providers, particularly in remote and indigenous areas. “The state health departments, especially in the rural areas, are desperate for backup and help and manpower,” Forde says.

Some clinics in Australia are privately run, Forde says, and the doctors who staff them are interested in seeing whether employing PAs can be cost-­effective.

Forde, who now has permanent resident status, is willing to wait and keep promoting the value of PAs. Other than occasional pangs for good Mexican food, he would not want to be living anywhere else.

England: X-rays and Expressions
Physician Assistant Kristen Gipson has worked in emergency medicine for most of her 21-year career. She did her original training at Emory University.

Gipson was glad to be chosen as part of the first pilot group of 12 PAs to travel to the United Kingdom in 2004. She currently works in an emergency room (called Accident and Emergency) in Birmingham, England.

During her first year in the UK, Gipson ran into some unexpected bureaucracy. For example, each time she went to order an x-ray for a patient, she hit roadblocks. In the UK, Gipson explains, a radiographer can refuse to do an x-ray if he or she doesn’t feel it’s justified.

“Initially, we weren’t allowed to order them, but then the PAs in the hospital managed to attend a radiation safety course, which allowed us to request an x-ray,” Gipson explains. Now, most hospital PAs have the right to order x-rays, but PAs providing primary care in other parts of England still cannot order these basic tests.

In Accident and Emergency, Gipson’s daily routine is pretty similar to that in an emergency department in the US. “I see medical trauma, mental health, children, obstetrics, and gynecology,” she says. “I evaluate, diagnose, request tests, and make referrals.” She can discharge and admit patients and arranges for community care. Gipson also is involved in teaching and training medical students.

While four universities currently offer training programs in England, “physician assistant” is not yet an official role in the UK, Gipson says. To be able to officially practice medicine and prescribe, she had to find a physician willing to “delegate” care or treatment to her, under a specific clause in the British Medical Council’s laws. The employer also usually covers the cost of malpractice coverage.

After six years in England, Gipson says she feels pretty well acclimated to British culture. Even though British and American citizens all speak English, subtle language differences can sneak up on you and perhaps put someone’s knickers in a twist. “Both the medical and everyday expressions can be drastically different,” she adds. “Certain words are very differently used and could cause some embarrassment until you learn not to use them in their American context—for example, fanny and pants.”

Scotland: Of Tea Breaks and Trust
Sometimes, while doing rounds as a PA at the Edinburgh Cancer Center in Scotland, Juanita Gardner must stop and wait for her patients to partake in a bit of tea and crumpets. “Tea breaks are a vital part of the workday,” Gardner says. “The oncology wards have a person who will often come around with a cart containing tea, biscuits, and coffee for every patient at no charge.”

Right away, Gardner noticed the pace was different for workers in the Scottish medical system. They have more holidays and time off to be with their families. Unlike many American health care workers, her Scottish counterparts “work to live,” instead of the other way around.

Gardner came to Scotland from the US in 2006, when the National Health Service (NHS) of Scotland launched a pilot PA program. Gardner was among the initial group of 12 American PAs involved. Her assignment was to set up diabetes and COPD clinics at a local primary care health center in Edinburgh.

As in England, the PA profession is not fully recognized in Scotland. PAs do not yet have prescribing privileges. The UK PA association is working on this, but Gardner says she is still in the process of applying for registration. “As you can imagine, there is much red tape and politics involved in such a process,” she says. “Things here move rather slowly.”

Gardner describes her first year in Scotland as “extremely challenging.” For example, the clinic staff refused to give her access to computer programs and medical records that she needed. “I had two wonderful supervising physicians who used their influence to remove all barriers and obstacles in my path,” Gardner says.

Despite their kindness, Gardner sensed a general lack of trust from the medical community there. “Many seem to feel PAs will take away jobs; others are resistant to change and new ideas,” she says. “Some feel the NHS nurses are equally skilled and trained, so why hire a PA?” In the end, it’s probably a matter of people not understanding the diversity of the PA role and the level of education required, Gardner adds.

When the pilot study ended, Gardner’s employers asked her to stay. Her role blossomed into providing education about the PA role for the NHS. She also helped train nurses and prepare them for clinical exams. Later, she was hired for her current position in the Edinburgh Cancer Center.

It has been an interesting educational experience to work in a socialized medicine system, after having been trained in the US, Gardner says. In some respects, it makes her appreciate what we have in America.

“In Scotland, this system provides patients with limited to no choices in the types of treatment they receive and what doctor they will see,” she says. “They often do not have access to the newest treatments, medications, or facilities, and technology lags.”

Gardner has been surprised by the lack of preventive medicine and patient education programs, despite a nationwide problem with heavy drinking and smoking. “The majority of patients continue to practice unhealthy behaviors, even though they are being treated for cancer,” Gardner says.

Despite these issues, Gardner loves being where she is and feels hopeful that with large enough numbers, PAs will succeed in Scotland.

“The country of Scotland is extremely beautiful and the Scottish people are very friendly, kind, genuine, and humble,” she says. “The PA can be someone who will take the time to listen, show compassion, and go an extra mile for a patient. If used correctly, and enabled to function within his/her full scope of practice, PAs can definitely be cost-effective for the NHS.”

For most of their 40+ years, physician assistants and nurse practitioners have been a uniquely American phenomenon. But now, clinicians are starting to transport their ideas and expertise to all parts of the globe.

Training programs have already been established in parts of Europe and Australia. Now, as countries in the Middle East, Asia, Africa, and Latin America struggle with physician shortages in rural areas, they, too, are eager to bring these highly trained professionals within their borders.

Through international conferences, groups like the International Council of Nursing (ICN) in Geneva (which has NP or APN programs in 78 countries) and the International Academy of Physician Associate Educators (IAPAE) are connecting willing professionals to countries in need.

For clinicians with a sense of adventure, practicing overseas is a wonderful opportunity to delve into a new culture and share ideas and skills. Herein, we profile several PAs and NPs who are already living the international life. Read on, and be inspired!

Saudi Arabia: Welcoming PAs to the Middle East
As an established PA who had worked in emergency medicine for years and who serves on the faculty of the PA program at George Washington University (GWU), Amy Keim, MS, PA-C, is used to having a lot of freedom in her practice. Keim, who is the director of GWU’s International Physician Assistant Development program for the Department of Emergency Medicine, is also no stranger to working overseas.

So when Saudi Arabian government officials approached her department about designing a curriculum for the first PA program in the Middle East, she was thrilled and a little nervous. She wondered how she would be received, both as a PA and as a woman.

“I have worked in Beirut and Abu Dhabi, but Saudi Arabia had this more intimidating feel to it,” Keim says. “We think of it as this romanticized, really exotic locale. People don’t go on vacation to Saudi Arabia, let’s put it that way.”

Keim says she was pleasantly surprised during her first visit, when her Saudi hosts invited her for a wonderful fireside picnic out in the desert. “There was delicious food and music, and the people were very warm and welcoming,” she says. “They were so hospitable, it changed my impression overnight.”

Keim and GWU Program Coordinator Megan Williams both wanted to be sensitive to cultural expectations for women in Saudi Arabia. They learned, sometimes through trial and error, when it was acceptable to wear Western clothes and when they needed to cover their heads or don an abaya (a full-length black robe). Keim and Williams discovered, for example, that when they were shopping in a more westernized mall, they could wear their usual outfits. But if they were invited to an official military ceremony, they would wear an abaya out of respect for the culture.

“I haven’t run into any real difficulties because I’m a woman,” Keim adds. “They have been extremely open to the [program] model and to the leadership.”

The first 25 students started in the Saudi PA program in September. It will last 28 months and will be based on a military model, similar to that of the first PA programs in the United States and Canada. Only male military officers will have the chance to become PAs.

The program will be administered through the Prince Sultan Military College of Health Sciences in the Eastern Province capital of Dhahran. When the students graduate, they will be called “Assistant Physicians,” mainly because the title translates better.

“These highly trained students will not only be the first physician assistants in the Middle East, but will be a critical component to improving access to quality health care in military and civilian communities throughout the country,” Keim says.

Keim feels the Saudi Arabian PA program will serve as a model for other countries with similar health care needs. “I think this trend reflects a general need for this type of provider, with this type of training, to really close some of the gaps,” she says. She has enjoyed having the opportunity to help bring better care to Saudi Arabia, and to learn more about its culture.

Surprisingly, it was on US soil that an accidental cultural misunderstanding occurred, when one of the Saudi Arabian officials visited Washington, DC. Keim was driving him to an event, but needed to stop by the vet first to pick up her beloved Jack Russell terrier. When her colleague started to look uncomfortable in the passenger seat, she asked why. He told her almost no one in Saudi Arabia has a dog, because the Islamic religion considers the animal unclean. Her colleague “toughed it out” for the duration of the trip, but Keim wishes she had recognized the potential problem sooner.

In the end, this new program has been a learning experience for everyone—in more ways than one. It’s those kinds of exchanges with other cultures that make working overseas a joy and a challenge, Keim says: “I reflect back and think this has been a phenomenal career, because it has taken me down paths I never imagined.”

Honduras: Clean Water and Compassion
When Thad Wilson, PhD, RN, FNP-BC, graduated with a BSN from the University of Iowa nursing school, he happened to attend a career fair. One of the booths, way over in a corner, was advertising a primary care nursing position at a clinic in a rural area of Honduras. Wilson, who had been considering the Peace Corps anyway, jumped at the chance for an adventure. “I was going to be the only primary care provider for 5,000 people,” says Wilson (who was 22 and unmarried at the time).

During his first few weeks at La Buena Fe Clinic in a small village by Lake Yajoa, Wilson says he “got really good” at suturing. That’s because so many of his clients came in with machete wounds. One man even had a machete stuck in the back of his neck. Another patient still thanks Wilson every time he sees him, for sewing his thumb back on after he accidentally cut it off while working with a machete.

“This was a great clinic, in the middle of nowhere,” Wilson recalls. “I had no electricity and no running water. I delivered babies by candlelight and boiled water to sterilize my instruments.”

Just about every patient who came to La Buena Fe had gastrointestinal problems. The area was replete with tropical diseases. “I saw every kind of amoeba and worm you could think of,” Wilson says. “Those were my biggest nemesis.”

Upset by seeing toddlers dying of diarrhea, Wilson consulted with some local nonprofit agencies. Eventually, they built a well so the community could have clean water to drink. “Now, we don’t see the number of cases in that area with gastrointestinal problems,” he adds.

Without the fancy diagnostic tools most US nurses take for granted, Wilson says he honed his skills in taking histories and doing physical assessments. “The greatest technology we have is between our eyes and our ears,” he says. When he needed help, he turned on his ham radio and tapped into the expertise of several doctors thousands of miles away, back in the US. Talk about trial by fire… Wilson, who is now Associate Dean of the University of Missouri School of Nursing in Kansas City, recalls those days with fondness.

Thirty years later, Wilson (the Immediate Past President of the American College of Nurse Practitioners) still goes to Honduras on a regular basis. These days, he visits with 12 nursing and pharmacy students from the University of Missouri. He wants them to capture the magic and the intense hands-on experience that he had in his earlier years as a nurse.

The 15-day program gives students a chance to work in rural clinics as well as city hospitals. Part of the goal is to get students thinking about quality of care under different health care systems. For example, in Honduras, patients must make a down payment before they can have surgery in a hospital. “There are people who will die on that bed, waiting for $50,” Wilson says, “whereas in the US, we would do the surgery first and ask for money later.”

Compassion and cultural sensitivity are other byproducts of Wilson’s overseas class. For example, the students begin to understand the importance of family in Latin American culture. Back home, when an entire extended family crowds into their exam room for one family member’s appointment, they won’t mind so much.

Stoicism is another trait they learn about. “In Central America, they come from a culture where pain is just a way of life,” Wilson says. “They are able to improvise and do whatever it takes to survive.” So students realize patients from these areas may not complain much, and it might take a little coaxing to find out what’s wrong.

Wilson is grateful for his time in Honduras. It has offered a life-changing experience—both for him and for his students.

Australia: Digging in Down Under
Al Forde, PA-C, originally from Wyoming, admits he has always had a love affair with Australia. “I’ve always kept an ear to the ground as to how I could get there someday,” he says.

So he felt incredibly lucky to be hired at James Cook University in 2006, when the college decided to launch a pilot PA program. At the time, Forde was teaching in the PA program at the University of Utah in Salt Lake City. Luckily, his wife and 12-year-old daughter were up for the adventure of moving to Queensland.

“The pace of life is much slower here,” Forde says. “I enjoy living in the tropics, with the warm weather, and living near the coast.”

The James Cook PA program is up and running, Forde explains, but graduates can have a hard time finding jobs. That’s because the PA role has not completely caught on yet in Australia.

With such vast rural territory, Australia would seem to be perfectly suited to the skills and expertise PAs could offer. Forde and his colleagues have learned, however, that they must be patient and slowly encourage change within the current health care system. “It’s a matter of persistence,” he adds.

Australia’s health care system, Forde says, has a medical philosophy similar to the British system’s. The government pays for most health care in Australia, so market forces are not shaping the need for PAs the way they did in the US during the 1980s.

Doctors, for example, do only primary care, emergency care, and obstetrics. Specialists are called physicians. “They have different education and different roles,” Forde says.

It’s still unclear where PAs might fit into that system. One thing that is clear is the shortage of providers, particularly in remote and indigenous areas. “The state health departments, especially in the rural areas, are desperate for backup and help and manpower,” Forde says.

Some clinics in Australia are privately run, Forde says, and the doctors who staff them are interested in seeing whether employing PAs can be cost-­effective.

Forde, who now has permanent resident status, is willing to wait and keep promoting the value of PAs. Other than occasional pangs for good Mexican food, he would not want to be living anywhere else.

England: X-rays and Expressions
Physician Assistant Kristen Gipson has worked in emergency medicine for most of her 21-year career. She did her original training at Emory University.

Gipson was glad to be chosen as part of the first pilot group of 12 PAs to travel to the United Kingdom in 2004. She currently works in an emergency room (called Accident and Emergency) in Birmingham, England.

During her first year in the UK, Gipson ran into some unexpected bureaucracy. For example, each time she went to order an x-ray for a patient, she hit roadblocks. In the UK, Gipson explains, a radiographer can refuse to do an x-ray if he or she doesn’t feel it’s justified.

“Initially, we weren’t allowed to order them, but then the PAs in the hospital managed to attend a radiation safety course, which allowed us to request an x-ray,” Gipson explains. Now, most hospital PAs have the right to order x-rays, but PAs providing primary care in other parts of England still cannot order these basic tests.

In Accident and Emergency, Gipson’s daily routine is pretty similar to that in an emergency department in the US. “I see medical trauma, mental health, children, obstetrics, and gynecology,” she says. “I evaluate, diagnose, request tests, and make referrals.” She can discharge and admit patients and arranges for community care. Gipson also is involved in teaching and training medical students.

While four universities currently offer training programs in England, “physician assistant” is not yet an official role in the UK, Gipson says. To be able to officially practice medicine and prescribe, she had to find a physician willing to “delegate” care or treatment to her, under a specific clause in the British Medical Council’s laws. The employer also usually covers the cost of malpractice coverage.

After six years in England, Gipson says she feels pretty well acclimated to British culture. Even though British and American citizens all speak English, subtle language differences can sneak up on you and perhaps put someone’s knickers in a twist. “Both the medical and everyday expressions can be drastically different,” she adds. “Certain words are very differently used and could cause some embarrassment until you learn not to use them in their American context—for example, fanny and pants.”

Scotland: Of Tea Breaks and Trust
Sometimes, while doing rounds as a PA at the Edinburgh Cancer Center in Scotland, Juanita Gardner must stop and wait for her patients to partake in a bit of tea and crumpets. “Tea breaks are a vital part of the workday,” Gardner says. “The oncology wards have a person who will often come around with a cart containing tea, biscuits, and coffee for every patient at no charge.”

Right away, Gardner noticed the pace was different for workers in the Scottish medical system. They have more holidays and time off to be with their families. Unlike many American health care workers, her Scottish counterparts “work to live,” instead of the other way around.

Gardner came to Scotland from the US in 2006, when the National Health Service (NHS) of Scotland launched a pilot PA program. Gardner was among the initial group of 12 American PAs involved. Her assignment was to set up diabetes and COPD clinics at a local primary care health center in Edinburgh.

As in England, the PA profession is not fully recognized in Scotland. PAs do not yet have prescribing privileges. The UK PA association is working on this, but Gardner says she is still in the process of applying for registration. “As you can imagine, there is much red tape and politics involved in such a process,” she says. “Things here move rather slowly.”

Gardner describes her first year in Scotland as “extremely challenging.” For example, the clinic staff refused to give her access to computer programs and medical records that she needed. “I had two wonderful supervising physicians who used their influence to remove all barriers and obstacles in my path,” Gardner says.

Despite their kindness, Gardner sensed a general lack of trust from the medical community there. “Many seem to feel PAs will take away jobs; others are resistant to change and new ideas,” she says. “Some feel the NHS nurses are equally skilled and trained, so why hire a PA?” In the end, it’s probably a matter of people not understanding the diversity of the PA role and the level of education required, Gardner adds.

When the pilot study ended, Gardner’s employers asked her to stay. Her role blossomed into providing education about the PA role for the NHS. She also helped train nurses and prepare them for clinical exams. Later, she was hired for her current position in the Edinburgh Cancer Center.

It has been an interesting educational experience to work in a socialized medicine system, after having been trained in the US, Gardner says. In some respects, it makes her appreciate what we have in America.

“In Scotland, this system provides patients with limited to no choices in the types of treatment they receive and what doctor they will see,” she says. “They often do not have access to the newest treatments, medications, or facilities, and technology lags.”

Gardner has been surprised by the lack of preventive medicine and patient education programs, despite a nationwide problem with heavy drinking and smoking. “The majority of patients continue to practice unhealthy behaviors, even though they are being treated for cancer,” Gardner says.

Despite these issues, Gardner loves being where she is and feels hopeful that with large enough numbers, PAs will succeed in Scotland.

“The country of Scotland is extremely beautiful and the Scottish people are very friendly, kind, genuine, and humble,” she says. “The PA can be someone who will take the time to listen, show compassion, and go an extra mile for a patient. If used correctly, and enabled to function within his/her full scope of practice, PAs can definitely be cost-effective for the NHS.”