While the United States is still one of the few countries where physician assistants (PA) play an active role on health care teams, a significant number of Yale School of Medicine (YSM) Physician Associate Program students have participated in clinical rotations outside of the U.S. Since 2007, students have completed rotations in countries including Argentina, China, Costa Rica, Mexico, Peru, Rwanda, Spain, and Uganda, even though PAs are not an established profession in any of these countries. Currently, approximately 20 per cent of Yale PA Program students participate in an international rotation for several weeks at some point during the last six months of the 28-month program.
Tracy Rabin, MD, SM, assistant professor of medicine, who co-directs the Makerere University-Yale University (MUYU) medical education capacity building collaboration, based in Kampala, Uganda, explained that while there are no physician assistants in the Ugandan health care system, PA students act in the same capacity as medical students on the ward teams, like they do in clinics and on the wards in New Haven. Rabin is excited to have PAs participate in the MUYU program because it provides her colleagues in Uganda an opportunity to learn about the PA profession and PA students the chance to gain clinical experience. It also results in opportunities for improved patient care in both places.
On December 6, 2018, just a few days before graduating, seven members of the Yale PA Program Class of 2018 presented on their international clinical rotations. The following students reported on experiences in the following locations:
Andrew Cook and Jose Arciniega: Córdoba, Argentina
Matthew Drause and Clayton Schutz: Iquitos, Peru
Yukari Suzuki: La Merced, Peru
Kara Becker: Kampala, Uganda
Rebecca McCurdy: Butare, Rwanda
The audience was comprised predominantly of members of the Class of 2019, many of whom are considering pursuing an international clinical experience. The PA Program encourages students to take advantage of this opportunity. PA Program Director Alexandria Garino, PhD, PA-C, explains “we feel very fortunate to be able to offer international clinical experiences to our students. The experience of other cultures and health delivery systems broadens our students’ perspectives and deepens their understanding of our own healthcare culture. Our students see first-hand the importance of the physical exam. They understand the need to be creative and resourceful when resources are limited. They experience the resilience of the human spirit. Our students come back better clinicians because of the experience.” Rabin notes that some PA students are drawn to the Yale program because of its extensive global clinical opportunities.
At the December 6 session, Rosana Gonzalez-Colaso, PharmD, MPH, assistant professor in the Yale PA Program, expressed gratitude to the preceptors and staff abroad who have made these international clinical rotations possible. She also noted that the preceptors consistently are "very impressed with the preparation of our Yale PA students, which allows us to grow our program with long time partnerships."
While each presenter’s international experience was different, all reported having a positive experience. The topics discussed ranged from the geographic locations where they were based, to clinical issues, the composition of health care teams, health insurance and access to care, and the role of language.
A majority of the students were in urban settings. Cook described Córdoba, which has a population of around 1.5 million people, as the “second city” of Argentina, with the feel of a college town as home to the second largest university in the country. Kampala is the capital of Uganda. McCurdy described Butare, like Córdoba, as a university-town, which was green and beautiful. Suzuki explained that the La Merced is a town within the province of Chanchamayo; the province has a population of about 142,000, about half of whom live in La Merced.
Drause and Schutz were in a very different setting, based out of Iquitos, Peru. As Drause described, they traveled to isolated locations that only could be reached by river or air to create pop-up clinics. Drause said that one of the community clinics was on the boat itself, because the river level was too low for the boat to reach the community on land.
Drause and Schutz described the “army,” organized through Amazon Promise, which comprised their traveling medical team including three doctors, two nurses, one PA, one dentist, one lab specialist, one pharmacy director, a sexual health educator, two PA students, four translators, and several individuals who helped with transport, cooking, and other logistics.
Cook’s daily routine was very different from that of Drause and Schutz. Cook described rotations with a nephrology team in both a private hospital and a public teaching hospital, where he had two preceptors. He also had opportunities to rotate in cardiology, ob-gyn, and general surgery.
Suzuki said her daily schedule typically started with rounds at 7:30 am, followed by work at an outpatient hospital clinic beginning at 10 am. On occasion, she also went to the outpatient private practice clinic at 5:00 pm.
Becker, whose experience was coordinated through the MUYU Program, was able to choose different areas of medicine to rotate through. One area she chose was palliative care, where she spent time with Hospice Africa Uganda. Because tests and chemotherapy were prohibitively expensive, the medical team’s main role was to provide patients with morphine. Moreover, she said that the role of nurses essentially was limited to administering medication, resulting in an expectation that family and friends would be at the hospital to care for the patients.
Several of the students discussed the cost and accessibility of health care. Suzuki explained that Seguro Integral de Salud (SIS) was begun in Peru in 2001, combining the health insurance for pregnant women and children. However over 60 percent of the population still had no health insurance, so around 10 years ago, SIS was expanded to cover low income individuals. According to Becker, in Uganda, once a patient has a terminal diagnosis, access to hospice care is essentially free. McCurdy said that only about 75 percent of people in Butare have health insurance because many cannot afford it, and she explained that people with insurance still must pay 10 percent of medical bills, which often is beyond their means, leading some not to seek care until years after a problem first develops. This resulted in McCurdy seeing “very advanced diseases, unfortunately.”
Beyond affordability, McCurdy reported on access problems; for example, it was a three-hour drive to get a CT scan. Drause similarly described how many patients did not want to travel long distances for diagnostic tests and instead just wanted to treat symptoms.
Related to this, Drause says “the most significant thing that I learned during my rotation was creativity and resiliency. When you have limited amounts and variety of treatments you need to be creative and thoughtful in your patient management. Access to references outside of the brilliant clinicians we were with and some limited texts was minimal. The medications we had might not be the first line. It became important to know what the goal of treatment is, understanding and thinking through a pathology to think of a way to manage it utilizing the supplies we did have. It helped me to gain perspective in my own future practice, as I will be more conscience of purpose in my patient management.”
Several of the students reported on the typical problems with which patients presented. For Suzuki in La Merced, these included asthma, diarrhea, and malnourishment. McCurdy reported that infectious diseases, such as malaria and hepatitis, were common, and that she also saw lots of patients with cancer, congestive heart failure, and hypertension. She noted that traffic injuries are a major cause of death in Butare, though she did not personally see those cases since she was in internal medicine. McCurdy added that life expectancy is short: 63 years for men and 66 years for women.
Drause compared the rainforest in Iquitos to New Haven, Connecticut, and was more struck by the similarities than the differences. “In both places a population remains without access to care. And when access is made available, the problems many people face are similar, so that many of the things we treated in the communities of the Pacaya-Samaria were things we would see at a clinic in New Haven, including muscle aches after a lifetime of physical work, upper respiratory tract infections, or urinary tract infections. This experience strengthened my resolve to contribute to improving not only global access to care, but domestically as well.”
Drause added that the number one diagnosis he experienced was blurry vision; they handed out lots of reading glasses, because it was a four-hour boat ride for many people to get glasses. Schutz added that anemia was another common problem, likely because the local diet was mostly fruit, with few leafy greens.
Several students spoke about the role of language. For example, Becker said while there are over 40 languages spoken in Uganda, English and Swahili are the official languages, and translators were also available. Drause found that the language barrier was one of the biggest challenges for him in Peru, because even though translators were available, “developing a rapport through a translator can be difficult.”
These experiences can impact career paths, as Drause states “I would like to continue to work with Amazon Promise in the future, and hope to incorporate international medicine into my career.”