Should international medical graduates work as physician assistants?

FigureIn response to the research article on IMGs as PAs by Keren H. Wick, PhD (see page 43), I asked myself, What is a physician assistant (PA)? We all know the credentials, the scope of practice, and the mission statement of the profession; I ask what makes us something more than just initials after our name? Do we have some special quality to separate us from other healthcare providers? Given that we perform similar tasks, whether assessment or procedural, that can be accomplished by physicians or nurse practitioners, what is it that makes us unique? Do we believe there is something in our raison d'etre and approach to clinical practice that signifies “that's a PA”? We must identify why PAs are unique or else others will replace us in our jobs. In some Canadian provinces (Alberta, Manitoba, Ontario, and Nova Scotia) and in some US states (Missouri), medical school graduates who were unable to get into a residency program have been proposed as assistant physicians or clinical assistants. Canadian provinces are using IMGs in traditional PA roles, calling them clinical assistants to avoid title issues. However, I do not believe being a PA is just medical education; it is also a calling and an assimilated professional culture. In Canada, the expansion of the PA profession is in competition with the hiring of international medical graduates (IMGs). Saskatchewan has refused to consider PAs as an alternate solution to physician shortages and actively recruits physicians from India (a country with a documented physician shortage) at three times the cost of potential PAs.1 Provincial governments have been slow to embrace PAs as a solution to Canadian health workforce issues, although economic resources are stretched to the breaking point and patients are waiting longer for some treatments and even to see physicians. In the United States, Missouri is using medical school graduates without residency education in traditional PA roles.2 As demonstrated in Florida, California, and now Ontario, accepting IMGs or medical school graduates and assuming they can or perhaps want to function as PAs without the full PA education process is a misaligned assumption and a poor use of resources.3 In 2007, the provincial government of Ontario fast-tracked IMGs not accepted into a Canadian medical residency program into a 4-month PA-role program called the IMG-PA Stream.4 Outlined as an orientation to the responsibilities and role of PAs, the program gave these IMG-PAs a brief introduction to the PA profession's duties and placed them in supervised practices. The program leaders assumed that these clinicians knew medicine and could function efficiently as supervised practitioners. The Physician Assistant Certification Council of Canada (PACCC) and the College of Family Physicians of Canada (CFPC), which track continuing professional development for Canadian PAs and family physicians, indicate that of the 51 IMGs who participated in the Ontario IMG-PA Stream project from 2007 to 2009, only eight remain in practice as PAs as of 2014 (Personal communication with PACCC, December 10, 2014). The other 43 who completed the selection process (from the original 800 invited applicants) are no longer PAs. Despite hours of evaluations, interviews, and 4 months of focused training, the program failed to teach or instill PA culture and identity. Apparently, the role was not acceptable to the majority of program participants, who used the province's resources as a steppingstone to other careers, some as medical residents, and some away from medicine completely. The primary purpose of the program was to use graduate physicians in a PA role to address urgent healthcare needs in Ontario. But the 15.6% retention rate failed to prove anything other than that most IMGs want to be physicians and that spending money on short-term solutions for a long-term health workforce problem is a very poor investment. The opportunities provided to these pseudo-PA roles of clinical assistant or assistant physician need to be placed in context. In the United States, more than one-quarter of physicians and surgeons (27%) are foreign-born, as are more than one out of every five (22%) persons working in healthcare support (nursing, psychiatric, and home health aides).5 The Association of Faculties of Medicine of Canada reported that of the 72,368 physicians in Canada in 2012, 24.1% (17,407) earned their medical degree in non-Canadian programs.6 And 13,440 IMGs who passed the Medical Council of Canada evaluating examinations between 2005 and 2010 are not practicing, many due to a lack of residency positions. The findings of St. Michael's Hospital in Toronto in 2011 reported 1,800 applicants competed for 191 Ontario residency spots designated for foreign-trained physicians. The success rate that year was about 20% for Canadians who had gone abroad for their medical training, compared with 6% for immigrant IMGs.7 In the United States, the National Resident Match Program for 2014 had 26,678 positions, 412 short of the number of American medical school graduates.8 The situation is expected to worsen because in the Balanced Budget Act of 1997, Congress imposed a payment cap on Medicare funding of advanced training.9 Obviously, high numbers of IMGs are seeking employment as physicians and will use the system as best they can to make better use of their education in many different healthcare roles.10 These medical professionals often are skilled and intelligent and simply seeking the opportunity to be a licensed and practicing physician. Not all IMGs are born outside North America; Canadians who studied medicine abroad in Ireland, Australia, European, or Caribbean schools account for 35.4% of those 13,000 IMGs who meet initial licensing requirements. But should they use our PA profession as a steppingstone? Dr. Wick's research confirmed that IMGs can be successful as PAs if accepted into a formal program. Taking students through a rigorous education program has proven successful at producing PAs for half a century, according to Dr. Wick. The potential of physicians trained abroad being used as PAs is commendable, in the same manner paramedics, nurses, and military medics are trained to become PAs. The formal accredited program pathway is the best solution to educating PAs who stay PAs. Formal and structured education programs are needed to teach the philosophy, culture, and role of PAs, and appear to be the proven strategy that will produce good long-term PAs. Respected, dedicated PAs are possible by selecting from the qualified and highly motivated people who apply for our PA programs. Regardless of healthcare experience or social background, intelligent people learn from a solid curriculum. A PA curriculum that includes bioscience, clinical assessment, medical foundations, and the social determinants of health best serves society. Students placed in a tight-net community under pressure to learn quickly will learn teamwork, communication skills, PA-style medical practice, and how to establish priorities. They learn the perhaps not-so-hidden curriculum of what defines a PA. The hidden curriculum consists of the unspoken academic, social, and cultural messages that are learned by students while they are in school. I believe that our PA programs' hidden curriculum produces highly skilled and valued generalists who learn to work as essential members of physician-directed teams. PA graduates learn not just medicine but team medicine. Using IMGs as PAs is incredibly expensive and inefficient with a 15% retention rate. Putting IMGs directly into the role of PAs without cultural adaptation, professional development, and substantial quality control is poorly supported and destined to fail. Teams are not made by bringing in outsiders to practice individually but by forging relationships with common goals and commonly shared values. The use of IMGs as PAs without formal PA education wastes time, energy, and our valuable resources. If you want PAs, train PAs.

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