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Licensure Eligibility for Foreign Trained Physician Assistants
Foreign-trained PAs in the U.S.
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Physicians around the world have sought and received help from many types of health care workers. Until recently, however, physician assistants (PAs) have been a uniquely American phenomenon. Now, educational programs for physician assistants exist in several countries. Some of these programs have been independently developed; others have been assisted by American PA educators. The early graduates of these programs will be the pioneers who seek recognition and acceptance of PA practice in their own countries. However, it is inevitable that some graduates will immigrate to the United States, where they will qualify for visas as physician assistants under the Immigration and Nationality Act if their education is perceived to be comparable to that obtained by their U.S. counterparts. (See Appendix 1 for background on immigration requirements.)

The granting of a visa as a physician assistant will not entitle these individuals to practice in this country. A state license is still required. Currently, state PA licensure laws contain two standard requirements related to education and examination. The education requirement is graduation from a PA program accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) or its predecessors. The examination requirement is passage of the Physician Assistant National Certification Examination (PANCE) administered by the National Commission on Certification of Physician Assistants (NCCPA).

As things stand now, PAs trained abroad will not be able to meet either of these two state requirements for licensure. At this time, there are no ARC-PA accredited programs outside the borders of the United States. International accreditation is a very difficult and expensive proposition and the ARC-PA has no plans to extend the scope of its activities beyond North America. (Recognition of PA programs in Canada, similar to U.S. recognition of Canadian medical schools, is a possibility.) Moreover, eligibility for the PANCE depends upon graduation from an ARC-PA accredited PA program.

Without changes to state laws, foreign trained PAs will be unable to qualify for licensure. One can easily imagine, however, the political pressure that could be put on the NCCPA to change its eligibility criteria and on legislatures and state licensing boards to change laws and regulations from groups of individuals who have entered the U.S. with federal validation of their training, i.e., visas as physician assistants.

To avoid the problems that could result from this situation, the PA profession must be prepared with recommendations for government policymakers. These recommendations should have as their goal, first and foremost, the protection of the public health and safety. They should reflect the PA profession's tradition of inclusiveness and its ethical principles of fairness and non-discrimination. Any policy proposed by the Academy should not seek to limit competition and should recognize the diversity of culture in the United States and the important role played by immigrants from all corners of the world in founding and shaping this nation.

Licensure Requirements for Foreign Trained PAs

The American Academy of Physician Assistants believes that the following represents a framework for foreign trained PAs who wish to become licensed in the United States.

A visa screening or credentialing organization, such as the Commission on Graduates of Foreign Nursing Schools or other recognized entity, should verify the physician assistant education, physician assistant licensure, experience, and English proficiency of individual PAs trained abroad, as is currently required by federal law for international health care workers, entering the United States.


A national, standardized qualifying or pre-admission examination should be developed by an independent organization and administered to these foreign-trained physician assistants. This examination should cover basic medical sciences, such as anatomy, physiology, microbiology, and pharmacology. It should also include a clinical medicine component. It should test the individual's foundation of knowledge and provide an objective and standardized result for use by accredited PA programs as part of their admissions processes.


Entry-level (not postgraduate) PA programs that choose to offer advanced standing to foreign-trained PAs would establish their own admission criteria, but should require a passing grade on the qualifying exam as a prerequisite. Programs would maintain their right to accept only qualified students who meet their admission criteria.


The education for foreign-trained PAs in U.S. physician assistant programs is envisioned to include four components:
Credit for some of the coursework done in their own country;
Didactic coursework in those areas for which they did not receive advanced standing;
Mandatory didactic coursework about physician-PA role and team practice and standards of care in the United States;
Clinical rotations.


Only those programs with the interest and resources necessary to handle this complement of students should do so. Those that lack the faculty or clinical rotations or that would face state or institutional barriers would not have to offer this educational experience.
In summary, foreign-trained PAs wishing to enter the U.S. for the purposes of working as physician assistants would have their education, experience, license, and English proficiency verified by CGFNS or another approved visa screening organization. They would submit their certification with their visa applications. If granted visas, they would come to the U.S., where they would apply to take the national qualifying examination administered by an independent organization. Those who pass the qualifying exam would apply for admission to an accredited PA program that offers advanced standing for foreign-trained PAs. Programs that choose to accept these students can establish their own admission criteria, but would require a passing grade on the qualifying examination as a prerequisite. After admission and graduation from an accredited PA program, these individuals would be eligible to sit for the PANCE. Passage of the PANCE would make them eligible for state licensure. Those individuals who fail the qualifying exam would be free to apply to an accredited PA program for acceptance as a regular student.

This system is similar to the one that exists for physicians (see Appendix 2). It involves one set of requirements for PAs trained abroad who wish to practice in the United States – an examination of basic science and clinical knowledge, passage of which is required for entry to additional supervised education in the U.S. Completion of this education would be followed by a requirement to take the same NCCPA examination that is given to U.S. graduates prior to licensure.

Implementation of these policy recommendations would require, among other things, some changes in state laws and regulations. These changes are necessary to establish a single consistent pathway to licensure for PAs who have been trained abroad and to alert foreign-trained PAs to the steps required for practice in this country. The AAPA recognizes that these recommendations cannot – and need not – be implemented overnight. The flow of foreign-trained PAs into the United States will determine the point at which this system should be put in place.

The proposal described above does not require every foreign-trained PA to repeat his or her entire education after arriving in this country. The AAPA believes it is unnecessary and unfair to impose this requirement on every individual who has received PA education outside the U.S. Such an approach implies that only American educational programs are good enough to train PAs, even if programs in other countries follow the U.S. model or deliver a superior education. "One size fits all" is not necessarily applicable when considering the quality of education received abroad. It would also be an economic hardship for most foreign PAs to repeat the entire two-year program. Depending on the willingness of American PA programs to accept such applicants, this requirement could be perceived as discriminatory or designed to limit competition.

The AAPA acknowledges that there are cultural and educational differences among the countries of the world, and that the knowledge needed to practice according to the standards of care of each country can vary substantially. That is why the Academy recommends that foreign-trained PAs seeking licensure be required to complete a supervised clinical component at an accredited entry-level PA program and be taught more about the PA role as part of physician-led teams in the U.S. health care system. Using a national qualifying examination for foreign-trained PAs as part of the admissions process will assure that only individuals with the appropriate scientific and clinical foundation for practice will be accepted into accredited PA programs.

The Academy hopes, with the adoption of this document, that other countries will adopt similar practice requirements for American PAs who wish to work abroad. While American PAs may have much to contribute, it is essential to respect cultural differences and values and to be knowledgeable about health system norms, allocation of resources, and treatment of conditions common to the population before working in another country.

APPENDIX 1. IMMIGRATION PROCEDURES FOR FOREIGN HEALTH CARE WORKERS

Immigration law requires that individuals wishing to enter the United States on either a temporary or permanent basis must apply to the U.S. State Department for a visa. There are two major categories of visas: non-immigrant and immigrant. Non-immigrant visas are given to individuals who wish to come to the U.S. on a temporary basis and for a specific purpose. There are approximately 60 different non-immigrant visa classifications, in areas such as business, education, pleasure, and temporary work. Immigrant visas are given to individuals who intend to live and work permanently in the U.S. These visas are either family- or employment-based.

The law specifies the documentation that must accompany visa applications. For example, individuals applying for H-1B visas (temporary work in a specialty occupation such as law or engineering) must submit evidence regarding education or experience and qualifications. In some cases, a permanent or temporary state license to practice must be obtained prior to approval of the visa application.

There are specific provisions in the law regarding foreign physicians and nurses. In 1996, Congress amended the Immigration and Nationality Act to add, among other things, provisions related to other foreign health care workers. The 1996 amendments require all immigrants and non-immigrants coming to the U.S. as health care workers to be screened and certified by the Commission on Graduates of Foreign Nursing Schools (CGFNS) or an equivalent independent credentialing organization approved by the U.S. Attorney General. Health care workers are defined as physical and occupational therapists, medical technicians and clinical laboratory scientists, speech language pathologists and audiologists, and physician assistants.

The screening organization must verify that the alien's education, training, license, and experience are comparable to those required for an American health care worker of the same type; that they are authentic, and, in the case of a license, unencumbered. The foreign health care worker must also have an appropriate level of proficiency in written and spoken English. If the majority of states licensing the profession in which the alien intends to work recognize a test that predicts an applicant's success on the profession's licensing or certification examination, then the alien must have passed that test.

Anyone who meets these criteria is given a certificate that becomes part of his or her visa application.

CGFNS

Based on its capabilities and established track record, as well as the specific reference to the organization in the law, CGFNS has been authorized by the Department of Homeland Security (DHS) to review the qualifications of all the types of foreign health care workers mentioned above.

CGFNS uses committees composed of members of each particular profession to establish the standards against which they assess the comparability of foreign education. All the members of the CGFNS Physician Assistant Professional Standards Committee have expertise in PA education and accreditation and are familiar with the issues surrounding foreign medical graduates.

The PA Professional Standards Committee began its work in May 2001. Using the American accreditation standards for PA educational programs as a basis for its work, the group has developed a document that describes, in detail, the curriculum content that they consider essential, including education on the special relationship between physicians and physician assistants. The document is more specific than the ARC-PA accreditation standards, particularly in the areas of pharmacotherapeutics, clinical skills, and diagnostic testing and imaging as they are practiced in the United States. The committee is confident that the standards will prevent unqualified individuals from gaining visas as physician assistants.

Other Visa Screening Agencies

To gain recognition as a visa screening and certifying agency from the Department of Homeland Security, which now houses the agencies concerned with immigration issues, an organization must meet fairly stringent criteria. It must have the ability to evaluate credentials and English competency. It must maintain comprehensive and current information on foreign educational institutions and it must have no conflict of interest regarding whether an alien receives a visa. The organization's ability to conduct examinations outside the United States is also considered before it is recognized by DHS.

The Department of Homeland Security has recognized, in addition to CGFNS, the Foreign Credentialing Commission on Physical Therapy and the National Board on Certification of Occupational Therapists as screening agencies for PTs and OTs, respectively. DHS does not limit the number of organizations it will recognize to perform the visa screening function for any given health care profession, nor does it review the educational equivalency standard used by each organization.

APPENDIX 2 - REQUIREMENTS FOR GRADUATES OF FOREIGN MEDICAL SCHOOLS

Graduates of foreign medical schools who apply for visas to enter the United States as members of the medical profession or to receive graduate medical education (GME) must be certified by the Educational Commission for Foreign Medical Graduates (ECFMG).

ECFMG certification is necessary before foreign medical school graduates or foreign-trained physicians can enter an accredited residency program, take Step 3 of the U.S. Medical Licensing Examination (USMLE), or, in most states, obtain a license to practice medicine.

ECFMG certification is obtained by

passing Steps 1 and 2 of the USMLE. Step 1 has approximately 350 multiple-choice test items, divided into seven 60-minute blocks, focused on the understanding and application of basic science concepts. Step 2 includes test questions in clinical subjects and requires the development of a diagnosis and prognosis, as well as identification of disease mechanisms and treatments. It has approximately 400 multiple-choice questions divided into eight 60-minute blocks.


passing the Test of English as a Foreign Language (TOEFL).


successfully completing a day-long Clinical Skills Assessment that evaluates the ability to gather and interpret clinical patient data by obtaining a relevant medical history, performing a focused physical exam, and composing a written record of the patient encounter. Proficiency in spoken English and appropriate interpersonal skills are also evaluated by standardized patients at 11 testing stations.


verifying completion of four credit years at a medical school listed in the International Medical Education Directory, maintained by the Foundation for Advancement of International Medical Education and Research, a non-profit foundation of ECFMG. (Some diplomas, such as those for Licensed Medical Practitioner or Assistant Medical Practitioner, and some licenses, such as those for stomatology, ayurvedic or homeopathic medicine, are not acceptable.)
ECFMG certification is necessary in order to take Step 3 of the USMLE, which has approximately 500 multiple-choice test items administered over two days. Step 3 content reflects a data-based model of generalist medical practice in the United States and includes computer-based case simulations.

To obtain a license to practice, graduates of foreign medical schools are required to pass the USMLE (all three steps within a certain time period). There is frequently a limit on the number of attempts allowed to pass each step. Applicants must also complete at least one year of graduate medical education in an accredited residency program. More than half the states require foreign medical school graduates to complete three years of GME. Licensure requirements for foreign medical school graduates are more stringent than for graduates of accredited U.S. medical schools.

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