Clinical officer

Clinical officer (CO)
Occupation
Names
  • Assistant Medical Officer (AMO)
  • Medical Licentiate (ML)
Occupation type
 Specialty
Activity sectors
Description
Education required
  • Diploma in Clinical Medicine and Surgery
  • Advanced/Higher diploma in Clinical Medicine and Surgery
  • Bachelor of Clinical Medicine and Surgery
  • Master of Clinical Medicine and Surgery

A clinical officer (CO) is a mid-level practitioner of medicine in East Africa and parts of Southern Africa who is qualified and licensed to perform general medical duties such as diagnosis and treatment of disease and injury, ordering and interpreting medical tests, performing routine medical and surgical procedures, and referring patients to other practitioners.

A clinical officer is an independent practitioner who, like physicians, is trained in the medical model and is licensed to practice the full scope of medicine and provide routine care in general medicine or within a medical specialty such as anesthesia and carry out treatment that is outside the nurses' scope. A clinical officer oversees a health center or a district hospital and is part of the medical team in bigger hospitals where one may head a department or work under a senior clinical officer or a physician.[1][2][3]

Overview

To practice medicine as a clinical officer one requires at least four years of full-time medical training, supervised clinical practice and internship at an accredited medical training institution and hospitals and registration with the relevant medical board in their country. One may then upgrade their qualification to a bachelor's degree at the university or, after three years of general medical practice, specialize in a field such as pediatrics, surgery, psychiatry and anesthesia - or get an advanced general qualification in medicine and surgery - by completing an additional one or two years of residency training. There are no pathways (post-basic or post-graduate entry-level conversion programs) for nurses and other health workers hence it takes at least eight years of specialised medical training and experience for a clinical officer to graduate with a post-basic qualification. It should be noted, however, that "clinical officer" in some countries such as Tanzania and Zambia refers to a different cadre of health workers, comparable to "medical assistants" in Malawi, who have less than three years of training but may upgrade to a similar level by becoming Assistant Medical Officers (AMOs) or Medical Licentiates (MLs).

No significant difference has been demonstrated in studies comparing treatment decisions, patient outcomes, quality of care provided and level of knowledge about diseases between a clinical officer and a medical officer (a non-specialist physician) except in countries where nurses were mistakenly assessed as clinical officers. However, because of the nature of practice, populations served and resources at ones disposal, a clinical officer is less likely to administer expensive treatment, prescribe expensive (but not necessarily better) drugs or engage in futile care.[4]

The success of HIV/AIDS prevention and treatment initiatives in Africa is mostly attributed to use of clinical officers to diagnose the disease and provide comprehensive medical care. Access to emergency obstetric care through greater deployment of the clinical officer is one way of attaining the Millennium Development Goals 4 (reducing child mortality) and 5 (improving maternal health).[5]

Worldwide, patients are seen by many other practitioners other than the traditional doctor such as:

Physician Assistants in the United States, United Kingdom, Liberia and Ghana

Scope of practice

A clinical officer takes the Hippocratic oath and, depending on jurisdiction, may be registered by the same statutory board as physicians (in the southern countries such as Zambia and Malawi) or a separate board (in the eastern countries such as Kenya and Uganda). The broad nature of medical training prepares one to work at all levels of the health care system. Most work in primary care health centres and clinics, and casualty departments in hospitals where one will diagnose and treat all common diseases, including serious and life-threatening ones, in all age groups; and stabilise then admit, discharge or refer emergency cases. In smaller hospitals one may work as a hospitalist and one who has specialized in a clinical field provides advanced medical and surgical care and treatment such as administering anesthesia, performing general or specialised surgery, supervising other health workers and other administrative duties.

A clinical officer's scope of practice depends on one's training and experience, jurisdiction and workplace policies. In Malawi, for instance, a clinical officer performs all routine surgical and obstetric operations such as laparatomy and Caesarean section whereas in Kenya, Tanzania and Mozambique one must undergo further specialized training in order to perform such major operations safely.

In rural and small urban health facilities, a clinical officer may be the highest medical care provider and works with minimal resources relying on the traditional medical history and physical examination, often with little or no laboratory facilities, to make a diagnosis and provide treatment. In bigger and better equipped facilities a clinical officer generally acquires superior knowledge, experience and skills and provides high quality and a wider range of services in district, provincial and national hospitals, universities and colleges, research institutions and private medical facilities.

A clinical officer is usually the basic medical cadre in the medical hierarchy but in some countries, with years of experience or training, one can rise to the same or a higher grade than a physician. In most countries, however, wages are usually low compared to training and responsibilities and career progression is usually restricted by awarding terminal degrees and diplomas, training students who have not attained the minimum university entry grade and, in some countries, not awarding any degree or recognition for advanced training. In such countries, this usually results in a demotivated and low quality workforce and resulting poor health indicators.

The United States' Centers for Disease Control and Prevention and other international health and research institutions make extensive use of COs in their projects in Africa.

A clinical officer has a broad and comprehensive training and knowledge in medicine. Unlike nurses and other health professionals who can learn to treat a specific disease (or group of diseases) and perform specific tasks and procedures, a clinical officer provides the broad range of routine medical care that you would get from a physician in general medical or specialty settings.

Countries train and utilise COs in different ways depending on their needs and resources.[1] Against a backdrop of an acute shortage of physicians, Tanzania, Malawi and Zambia train complete physician substitutes who have advanced skills in all medical and surgical specialties including performing major surgery. They are utilised interchangeably with medical doctors.

Elsewhere, COs are more medical-oriented (like in Kenya where physicians perform most major emergency surgery and COs can only perform major surgery within a specialty e.g. cataract surgery, orthopedics and reproductive health); or more surgical-oriented (like surgical technologists in Mozambique who perform major and emergency surgery across specialties). Some countries like Burkina Faso and Ghana train nurses to practice like COs.

Research done by the University of Birmingham and published in the British Medical Journal concluded that the effectiveness and safety of caeserian sections carried out by clinical officers did not differ significantly compared with doctors.[5][11] Better health outcomes including lower maternal mortality rates were observed where COs had completed further specialised training particularly in anaesthesia.

In the multi-country study, poor outcomes were observed in Burkina Faso and Zaire - the only countries where the procedure was performed by trained nurses. Higher rates of wound infection and Wound dehiscence in these countries was thought to be due to the nurses' poor surgical technique and need for enhanced training.

Kenya

Kenya has a comprehensive framework of parallel laws and regulations that govern the medical practice of doctors and clinical officers. The supreme health policy and medical authorities in the republic are the cabinet secretary of health and the director of medical services who oversee the registration and licensing of medical institutions and the training, registration and licensing of medical practitioners through the Medical Practitioners and Dentists Board and the Clinical Officers Council.

As a British colony in 1928, Kenya started training a select group of natives to practice medicine and care for the local population who were increasingly accepting and seeking western medicine. After independence from Britain in 1963, medical training in Kenya initially adopted the four-year medical school system used in the US rather than the six-year UK model. This was heavily influenced by The Kennedy Airlifts[12] which followed initial funding by the African-American Students Foundation (AASF) in 1959 and led to hundreds of young Kenyan students getting scholarships to study in American institutions: These students came back to Kenya after their studies and joined the civil service in the early post-independence Kenya. It was also around this time that the first DOs were accepted as medical officers by the US civil service and by 1967 the structure and duration of medical training in Kenya was similar to the US MD training. When the University of Nairobi split from the University of East Africa and became the first university in Kenya in 1970, it continued to teach the six-year British degree and, because clinical officers were independent practitioners rather than physicians' assistants, this led to the creation of two statutory bodies: the Kenya Medical Practitioners and Dentists Board in 1978 which had jurisdiction over medical officers and physicians, and the Clinical Officers Council in 1989 which had jurisdiction over clinical officers. Instead of residency for the clinical officer, the higher diploma in paediatrics, ophthalmology and other specializations was introduced in the late 1970s as a post-basic course for those who had worked for three or more years and, after ten years of service, one became a Senior Clinical Officer and qualified for a license to practice under his own name as a private medical practitioner. The Bachelor of Clinical Medicine and Community Health degree was later introduced in 2006 for those who wish to get a bachelor's degree.

Clinical officers play a central role in Kenya's medical sector today. There were 8,600 clinical officers on the register in 2010 compared to 7,100 medical officers.[13] They are trained by the universities, the Kenya Medical Training College (KMTC),[14] St. Mary's School of Clinical Medicine and other private institutions. The Ministry of Health, through the Clinical Officers Council (COC)[15] regulates their training and practice, accredits training institutions, and approves the syllabi of the universities and colleges. The Kenya Medical Training College (KMTC), also under the Ministry of Health, has campuses in regional teaching hospitals and trains the majority of clinical officers. St. Mary's School of Clinical Medicine and St. Mary's Mission Hospital in Mumias, owned by the Roman Catholic diocese of Kakamega, was the first private institution to train clinical officers. It admits students who got the minimum university entry grade in high school and have passed a written examination and oral interview. The students sit the same examination as their counterparts at the KMTC and are examined by consultants from the public service.

Legal status

Kenyan courts uphold that, for legal purposes, a clinical officer is a medical officer as defined by Section 2 of the Anatomy Act by virtue of having a recognized medical qualification and training, being eligible for registration under Section 11(1) of the Medical Practitioners and Dentists Act, and being authorized to render medical and dental services by Section 7(4) of the Clinical Officers Act.

A medical officer is defined by the Anatomy Act as any public officer who is entitled to be registered as a medical practitioner under any law in the country. Section 14(1) of the Medical Practitioners and Dentists Act and Section 7(4) of the Clinical Officers Act are the two laws that authorize one to practice medicine and render medical and dental services as employees if they hold a registration certificate or as private practitioners if they hold a license. The Public Health Act further defines a medical officer of health as a government official who is responsible for a prescribed geographical area such as a county or sub-county.

A clinical officer is therefore legally authorized to see, examine and treat patients and, in accordance with Section 77 of the Evidence Act, to sign legal documents such as medical certificates, death certificates and P3 legal forms, and to submit medical evidence in a court of law in cases of rape, assault etc.

The Clinical Officers (Training, Registration and Licensing) Act Cap 260

The Clinical Officers (Training, Registration and Licensing) Act Cap 260 of 1988 of the laws of Kenya is the legal basis for the practice of a clinical Officer.[16] It establishes the Clinical Officers Council whose functions are:

Before this act there were many sub-cadres within the profession such as registered clinical officer (RCO), certified clinical officer (CCO), medical assistant, etc., who had different kinds and levels of education. All these were abolished by the act in 1989, in favor of a uniform Clinical Officer (CO) cadre. However, the title Registered Clinical Officer (RCO), who were the creme of the profession at one time, has persisted even in official publications.

Training

Although training programmes existed as early as 1928, the first university to train clinical officers was Egerton University[17] in 1999. Programs also exist at Jomo Kenyatta University of Agriculture and Technology,[18] Kenya Methodist University (KEMU)[19] and Mt Kenya University.[20] The diploma in Clinical Medicine and Surgery is completed in nine 15-week trimesters over three calendar years (or 135 weeks which, notably, exceeds the minimum 130 weeks of instruction required to complete US MD programs).[21][22] The Bachelor of Clinical Medicine and Community Health is completed over 4 years.

Students study the biomedical and clinical sciences such as anatomy, physiology and pathology in the first year followed by the clinical subjects (medicine, surgery, pediatrics, obstetrics and gynecology) in the second year. The third and fourth year involves supervised clinical practice and internship in teaching hospitals where they rotate in all the departments, receive beside lectures, attend consultants' ward rounds, clerk patients and present medical histories, perform deliveries and first-assist in major surgery. They also attend clinical meetings and write prescriptions which at this stage must be counter-signed by a supervising clinician.

There is special emphasis on primary care with modules on community health taught throughout the course. Before starting their internship after the third year, clinical officers spend at least one month in a Provincial Rural Health Training Centre where they immunize children, examine pregnant women and offer family planning services in mother and child health clinics. They also treat in-patients and out-patients under the guidance of qualified Clinical officers and organise outreach services where they venture into remote rural villages, seeing patients and immunising children. During this time they complete a project in community diagnosis.

They also learn Health Service Management which prepares them for their management and leadership roles in health centers and other institutions.

Internship and registration

All clinical officers must work as full-time interns for one year at an approved public or mission hospital before getting a license to practice medicine. On passing the final qualifying examination, they take the hippocratic oath then apply for provisional registration by the Clinical Officers Council,[15] the statutory body that regulates the practice of clinical officers in the country. The internship involves supervised rotations in the major clinical departments namely casualty, medicine, paediatrics, surgery, obstetrics and gynecology. They are supervised by consultants in the respective fields. The consultants ensure that they can practice clinical medicine safely before signing them off for registration. An internship booklet signed by the consultants is required for registration. After registration one is required to apply for a license from the COC which allows them to practice medicine, surgery and dentistry legally in the country. This license is renewable every two years. Renewal requires evidence of having attained 60 Continuous Professional Development (CPD) points in the CPD diary by further training, research and publications, attending conferences and Continuing Medical Education (CME) sessions or major ward rounds and outreach activities.

Advancement

A clinical officer can upgrade their qualification to a bachelors or a higher degree in clinical medicine at the university, or enroll for specialised Higher Diploma programs at the Kenya Medical Training College. These last twelve to eighteen months leading to a specialised Higher Diploma qualification in paediatrics, reproductive health, anaesthesia, ENT, ophthalmology and cataract surgery, orthopaedics skin and chest diseases, epidemiology and Community health. They are then able to provide advanced medical and surgical care including invasive procedures in their specialisation such as caeserian section, cataract surgery, tonsillectomy and administering anaesthesia.

Many COs hold advanced degrees and diplomas in Biochemistry, Microbiology, Counselling psychology, Management, Statistics, Sociology, Public Health, etc. A good number go on to medical school.

Malawi

Medical care is generally provided by medical assistants whereas clinical officers provide surgical care. The College of Surgeons of East, Central and Southern Africa (COSECSA) is involved in the Clinical Officers Surgical Training (COST) programme which aims to increase the surgical capacity of clinical officers who perform most general and obstetric surgery, including 80 percent of caeserian sections, in rural Malawi and Zambia.[1]

Medical assistants can enrol for an 18 month upgrading course to become specialised clinical officers in ophthalmology, psychiatry and anaesthesia etc. The upgrading course takes place at Malamulo and Malawi College of Health Sciences.[23]

Sudan

Southern Sudan separated from the Arab North (Sudan) in July 2011 after years of civil war that left much of the southern part in ruins. The healthcare system is almost non-existent. AMREF started training clinical officers by setting up the Maridi National Health Training Institute.[2]

The graduates supplement the efforts of COs trained in neighboring countries, e.g. Kenya, Uganda and Tanzania, most of who work for international humanitarian agencies.

Tanzania

In Tanzania, training is under the Ministry of Health. There are numerous clinical officer training schools and programs last three years. Internship is not required for registration.[1]

Experienced clinical officers may enrol for an advanced diploma in clinical medicine which takes two years to complete. This qualification is regarded as equivalent to a first degree in medicine by universities and the Ministry of Health in the country. The graduates are known as Assistant Medical Officers. A further two years training leads to a specialist qualification in anaesthesia, medicine, surgery and radiology etc.

Kampala International University has opened a campus in Dar es Salaam where it is now offering its Bachelor of Clinical Medicine and Community Health.

Uganda

By 1918, Uganda was training clinical officers who were called medical assistants at the time. The training is under the Ministry of Education and takes place in clinical officer training schools.[24] Postsecondary programs last three years, focusing on medicine and hospice care, followed by a two-year internship.[1]

Kampala International University offers a Bachelor of Clinical Medicine and Community Health.[25] High school graduates take four-and-a-half years to complete this degree while practicing clinical officers take three years.

Zambia

In Zambia, clinical officers who complete a two-year advanced diploma course are called medical licentiates. Medical licentiates have advanced skills in medicine and surgery and may be deployed interchangeably with physicians. Medical licentiates outnumber general physicians (with university degree) across all regions, with the ratio ranging from 3.8 COs per physician in Lusaka to 19.3 in the Northwestern provinces.[26] They perform routine surgical and obstetric operations as well as providing clinical care in hospitals. The College of Surgeons of East, Central and Southern Africa (COSECSA) is involved in their training to increase their surgical skills through the Clinical Officers Surgical Training (COST) programme.

Burkina Faso

In Burkina Faso, as elsewhere in sub-Saharan Africa, the use of non-physician clinicians began as a temporary measure while more doctors were trained, but has become a permanent strategy in the face of a crisis in health human resources. Different training alternatives have been used. Two-year advanced training programs in surgery were developed for registered nurses. Clinical officers (known as attachés de santé en chirurgie) were district medical officers trained with an additional six-month curriculum in emergency surgery.[27]

Many studies show that trained COs provide quality medical and surgical care with outcomes similar to physicians' providing similar care in the same setting. However, nurses re-trained to become COs have been associated with more adverse outcomes as shown in a study using 2004-2005 hospital data from six regions of Burkina Faso, which associated them with higher maternal and neonatal mortality when they performed caeserian sections.[27] The observed higher fatality rate pointed to a need for refresher courses and closer supervision of the nurses.

Ethiopia

The first medical school in Ethiopia was initially a "health officer" training institution. The training of health officers started at Gonder University in 1954 due to the shortage of physicians.[3] Health officers hold bachelor's degrees and undergo a three-year training program plus one-year internship. Those who complete the master's degree provide advanced care (e.g. emergency surgery).[1]

Ghana

In Ghana, Medical Assistants (MAs) have traditionally been experienced nurses who have undergone a one-year post-basic course to become MAs. High school graduates can now attend a three-year diploma course to become MAs.[28]

Liberia

In Liberia, the Tubman National Institute of Medical Arts (TNIMA) was established in 1945. In 1965, the physician assistant (PA) programme was established as a joint venture between the Liberian government, WHO and UNICEF. Initially it was a one-year course, but currently it is a three-year diploma course accredited by the Liberia National Physician Assistant Association (LINPAA) and the Liberia Medical and Dental Association Board. In order to legally practice medicine as a PA one must sit and pass a state exam administered by the medical board.[29]

Mozambique

In Mozambique, tecnicos de cirurgia, or surgical technologists, are experienced Clinical Officers who undergo further residential training in surgery under the supervision of senior surgeons lasting two years at Maputo Central Hospital, and a one-year internship at a provincial hospital. They are trained to carry out emergency surgery, obstetrics and traumatology and are deployed to the district hospitals where they are usually the sole surgical care providers.[30]

South Africa

South Africa trains clinical associates for three years and awards them the Bachelor of Clinical Medical Practice degree. The first program was launched by the late Health Minister Tshabalala Msimang on 18 August 2008 at the Walter Sisulu University in Mthatha. The first class graduated in December 2010.[31] Programs also exist at the University of Pretoria and the University of the Witwatersrand.

International

The specialised nature of medical training in the developed world has created a shortage of general practitioners and runaway expenditure on healthcare by governments. primary care is increasingly being provided by non-physician providers such as physician assistants.

United States

Main article: Physician assistant

Physician assistants in the United States train for at least two years at the postsecondary level and can hold an associate, bachelors or master's degree. Most PAs have earned a master's degree. Some institutions offer a Doctor of Science degree in the same. According to Money magazine, this is currently one of the best careers in the US.[32] The profession is represented by the American Academy of Physician Assistants.

United Kingdom

The United Kingdom has in recent years employed physician assistants from the United States on a trial basis as it plans to introduce this cadre into their health care system. Several UK universities are already offering a post-graduate diploma in Physician Assistant studies. The PAs of the UK are represented by the Association of UK PAs.

Australia

The University of Queensland offers a one-and-a-half-year Master of Physician Assistant Studies to those with a bachelor's degree. Those with a post-secondary healthcare qualification such as registered nurses and paramedics can access the programme via a Graduate Certificate in Physician Assistant Studies; as long as they have at least five years full-time working experience.[33] It has been announced that PAs will be allowed to work in Queensland as fully licensed practitioners in 2014.

China

China has about 880,000 Rural Doctors and 110,000 assistant doctors who provide primary care to rural populations where they are also known as barefoot doctors. They typically have about one year of training; those who sit and pass government examinations qualify to be rural doctors. Those who fail become community health workers. However, there is a government move to have all rural doctors complete three years training.

Fiji

Africa and the rest of the world are perhaps following a well trode path. In 1879, a group of Indians arrived in Fiji by ship having survived cholera and smallpox en route. During a period of crew quarantine, a small group was trained in vaccination. The experience was considered so successful that a few years later, in 1885, a group of young Fijian men started a three-year training program at the Suva Medical School, now known as the Fiji School of Medicine.[34] The title given to the professional practice has had many names over the years, including Native Medical Practitioner, Assistant Medical Practitioner, Assistant Medical Officer, and Primary Care Practitioner (PCP). By 1987, the PCPs were training for three years before going back to their communities to serve one-year internship, followed by another two years of study after which they were awarded a MBBS degree.

India

Under British rule, India trained licenciate doctors for three years. They were then registered with the General Medical Council of Britain. Most of them worked among the rural population providing medical care.

After independence, and on the recommendation of the bhore committee in 1946, the training of licentiate doctors was stopped and their qualifications converted to MBBS degrees. They were then grandfathered into the Medical Council of India.

The plan was to train enough doctors who would serve the whole country. However, the plan has not borne fruit and doctors generally leave their rural posts after their internship for more lucrative and glamorous careers in the big cities.

As of 2009, the Indian government plans to introduce a three-and-a-half-year Bachelor of Rural Medicine and Surgery (BRMS) degree to train doctors who will work in remote Indian villages. On graduation they will undergo a one year internship period at a regional hospital before being licensed. Those with five years' experience will qualify for post-graduate studies on equal standing with their MBBS counterparts.[35]

In India, the Madras Medical Mission in Chennai, collaborating with Birla Institute of Technology and Frontier Lifeline has since 1992 offered a bachelor of science degree in Physician Assistant studies. The program duration is four years, comprising three years classroom and laboratory coursework then one year compulsory internship. Several other universities offer similar courses in partnership with US universities. PAs in India can pursue masters and doctor of science degrees.[36][37][38]

Malaysia

Malaysia started training Medical Assistant in the early 1900s after independence from Britain. Also known as Assistant Medical Officers, they are trained for three and a half year in an undergraduate academic program recognized by the Malaysian Qualifications Agency in order to practice. They are mainly deployed in public hospitals, parastatal institutions (e.g. military, prisons), rural health centres, aged care centres, or private specialist hospitals.[39]

See also

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Mullan F, Frehywot S. Non-physician clinicians in 47 sub-Saharan African countries. Lancet; 2007, 370: 2158–63.
  2. ↑ 2.0 2.1 AMREF. Clinical Officers. Accessed 6 April 2011.
  3. ↑ 3.0 3.1 Kruk ME et al. Human Resource and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective Cross-Sectional Survey. PLoS Medicine; 2010 http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000242
  4. ↑ http://www.biomedcentral.com/1471-2334/8/162. Missing or empty |title= (help)
  5. ↑ 5.0 5.1 University of Birmingham. Major analysis shows value of non-physician clinicians for maternal health in sub-Saharan Africa. Posted on 20 May 2011.
  6. ↑
  7. ↑
  8. ↑
  9. ↑
  10. ↑ World Health Organization. Classifying health workers. Geneva, WHO, 2010.
  11. ↑ Wilson A et al. "A comparison of clinical officers with medical doctors on outcomes of caesarean section in the developing world: meta-analysis of controlled studies." BMJ 2011; 342 doi:10.1136/bmj.d2600 (Published 13 May 2011)
  12. ↑
  13. ↑
  14. ↑ Kenya Medical Training College
  15. ↑ 15.0 15.1 Kenya Clinical Officers Council
  16. ↑ Clinical Officers Council. The Clinical Officers (Training, Registration and Licensing) Act Cap 260. Accessed 6 April 2011.
  17. ↑ Egerton University, Kenya
  18. ↑ Jomo Kenyatta University of Agriculture and Technology, Kenya
  19. ↑ Kenya Methodist University
  20. ↑ Mt. Kenya University
  21. ↑
  22. ↑
  23. ↑ Malawi College of Health Sciences
  24. ↑ Health Training Institutions in Uganda Information Portal. Accessed 6 April 2011.
  25. ↑ Kampala International University, Uganda
  26. ↑ Ferrinho P et al. "The human resource for health situation in Zambia: deficit and maldistribution." Human Resources for Health 2011, 9:30 (19 December 2011)
  27. ↑ 27.0 27.1 Hounton SH et al. "A cost-effectiveness study of caesarean-section deliveries by clinical officers, general practitioners and obstetricians in Burkina Faso". Human Resources for Health 2009 (7): 34. doi:10.1186/1478-4491-7-34.
  28. ↑ Narhbita College. The Medical Assistant Course.
  29. ↑ Tubman National Institute of Medical Arts, Liberia
  30. ↑ Cumbi A et al. (2007). "Major surgery delegation to mid-level health practitioners in Mozambique: health professionals' perceptions". Hum Resour Health 5: 27. PMC 2235883.
  31. ↑ Walter Sisulu University. First South African Clinical Associates take their pledge at WSU.
  32. ↑ CNNMoney.com. Best Jobs in America: #2. Physician Assistant
  33. ↑ University of Queensland, Australia
  34. ↑ Fiji School of Medicine. History. Accessed 6 April 2011.
  35. ↑ ABClive.in
  36. ↑ PRlog.org
  37. ↑ Bits-pilani.ac.in
  38. ↑ IAPAonline.org
  39. ↑ Management and Science University, Malaysia

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