A World of NPs and PAs
Respecting Differences
American clinicians who want to share their experience and accumulated wisdom with countries seeking guidance need to bear in mind that while the NP or PA model is a great idea, it may not work exactly the same way in another part of the world. The most well-intentioned efforts can be undermined if proper attention is not given to the cultural contexts of the country in question.
“You don’t just import something and say, ‘This model is going to work here,’” Ballweg says. “You actually go through a fairly detailed process to say, ‘What are our needs?’ Otherwise, you could end up with PAs and NPs in any of these countries working in the specialty hospitals, for the people who are fee-for-service and make a lot of money, and you wouldn’t have accomplished anything.”
Schober, who has worked with more than 20 different countries that are exploring the APN roles, notes, “All too often, countries are seduced by the concept but are unaware of the complexities and difficulties associated with developing and implementing the roles. ”
Issues of reciprocity between nations are already creeping up (however premature in most cases), bringing to the forefront a number of practical and ethical concerns. “There is this whole issue of whether there should be an international certifying exam for PAs,” Ballweg observes. “What needs more discussion is the ‘should we.’ Everybody is still working all this through, but I think I can safely say that we [the NCCPA] do not want to create an infrastructure that encourages brain drain. At the same time, we want to provide assistance to countries and regions that want to develop credentialing mechanisms.”
It would be unethical to prevent a clinician from taking advantage of better opportunities in another country. But at the same time, the goal of developing APN or PA roles in these nations is to better meet the needs of the people within that country. This is a complicated issue, Schober says, “with no easy nonpolitical answer.” One positive step that countries can take to offset the risk of a “brain drain” is to create incentives that will attract and retain homeland clinicians.
Differences in language and cultural norms, and even in the practice of medicine, may make a universal exam impractical, anyway. “That doesn’t mean that a credentialing process isn’t a good thing,” Ballweg says. “It just might look very different in Africa than it would in the United Kingdom or the European community, compared to the US and Canada.”
American clinicians who interact with their international counterparts must be prepared to be diplomats, in a way. In addition to being sensitive to cultural differences, it is essential to understand how the US fits into the world stage. “Become knowledgeable about the world in general” is Schober’s advice. “In working internationally, you are often expected not only to comment on the value of APNs to health care systems but also to provide your opinion on the US approach to foreign policy or to the economic downturn.”
Sharing information encourages learning on both sides and promotes mutual respect. It also provides an opportunity to prevent missteps that may have been made previously. “In many places, in the early days, PAs and NPs were pitted against each other,” Ballweg points out about the US, “and some people still view us as competitors.”
Ballweg shares the Clinician Reviews philosophy of NPs and PAs working together. Whenever people in other countries ask about the NP/PA relationship—and yes, the question does come up—she provides examples of how the professions can support each other.
“I try to make the point that if you just have individual training programs, then you just have training programs,” Ballweg says. “But if you have PAs and NPs working together and moving ahead on a policy front, then you have a movement.
“That’s really what we want—to create this movement that has to do with access to care and improving global health everywhere.”
