Alumni spotlight: Diana Culbertson, MMSc, MPA, PA-C

What do you think PAs can bring to international work?

Their flexibility. PAs are taught the nuts and bolts of medicine—the history, the physical exam, and a crash course in nearly every specialty. PAs are trained to be versatile, and versatility is critical to success in international work. I came here with a background in nutrition and pediatric endocrinology. When I first arrived, I observed a team completing rounds in the pediatric ward and thought that I would never be able to do that. Now, that’s a huge part of my day, along with diabetes consults, family medicine, preventive medicine, and supply chain logistics. I have even been able to get involved with policy-level work. If you keep an open mind and don’t confine yourself to one area of medicine, you’ll have a lot to offer as a PA working internationally.

Compare being a PA in Liberia vs. the U.S.

In the U.S., we rely on technology to make accurate diagnoses. My examination skills have improved while working in Liberia because we can’t rely on technology here. An exhaustive search for a diagnosis is often futile and sadly, even with the best diagnostics, many treatment options don’t exist here.

What inspired you to work internationally?

Doing some work abroad and seeing such abject poverty, especially working with children who were dying of acute malnutrition often complicated by HIV. You see that kind of poverty and the lack of access to basic things, and you feel compelled to try to help. You don’t feel like you’re working, you are just living your passion.

What continues to inspire me to work in global health are my local colleagues.

The Liberian community health workers and clinicians whom I practice alongside have faced the brutality of civil war in which many have lost their entire family. They come to work with their own burdens, often going unpaid for months at a time. Many of them use their own resources to support our patients. They practice medicine with huge patient loads, complex diseases with late presentations, insufficient training and continued lack of supplies and medicines, and yet they show up every day. It’s easy to come here for some finite time and work hard, knowing you can leave and practice anywhere you want, knowing that you can take time off and go on vacation.

What was it like being part of a temporary response team vs. having this long-term foreign placement as your life?

In terms of my day-to-day activities, my role is different now. When I was working with the response team, we planned and implemented community outreach programs that focused on Ebola prevention. We worked a lot in schools, developing rules about handwashing and hygiene. We would take motorbikes into the bush, sometimes for hours, and seek out villages that were disconnected from the outside world except via radio. They were very happy to receive the education and resources we provided. Working with Partners in Health, I am more stationary and my responsibilities vary. My job title includes the noncommunicable disease lead and the malnutrition lead. My responsibilities include or have included making pediatric ward rounds, developing a chronic disease management clinic that provides mentors for local PAs and nurses, managing the outpatient and inpatient malnutrition programs, and working with children with type 1 diabetes and insulin-dependent adults. When I came here, I was a little overwhelmed by the amount of need. Now that I’ve been here a while, I am learning to prioritize and realize that change doesn’t happen overnight. Capacity building takes patience, faith, and grit on both the ministry side and the side of the NGO. Western medicine customs and local customs are sometimes similar but often vary dramatically. Our patients have strong beliefs that witchcraft and curses cause disease, often going to churchyards for healing. Learning to embrace my patients’ own ideas of their disease while treating them with evidence-based Western medicine is a skill I’m still perfecting, but I love the challenge. It is poetry when the two can be woven together for the good of the patient.

How is your life different from when you worked in the United States?

The food! Since I’m living and working among a mostly Liberian team, we are eating rice nearly every meal. After a while, you start to miss food from back home, especially chocolate and good wine. We live in communal housing, which has its perks, but as an introvert, I find it can be draining sometimes. There is really no such thing here as work-life balance. It’s funny though because it doesn’t feel like work, it feels like your work seamlessly blends into the rest of your life. It’s just what you do. My mornings start around 6 or 7 a.m., answering e-mails and phone calls and other administrative duties. Then I will start rounds with the hospital staff, see patients, and discuss cases with my coworkers. We are usually going home around or after dark. Some nights, you get calls from the hospital or patients and are pulled back into the hospital. There really isn’t much downtime, but I can’t complain. I live on the beach with an amazing view and great people. We do find some time for weekend hikes and I even learned to surf! Tell me about a favorite moment at work. The other day I was working with an adolescent girl whom I feel like I’ve known forever. She is a type-1 diabetes pediatric and reminds me of my patients in St. Louis. I was asking her about her blood sugars because she had recorded all normal results in her logbook. When I reviewed her insulin meter, many of the numbers were quite high. I knew she was not being truthful, but I understood this as I had seen this with my teen patients in St. Louis. I laughed to myself, teenagers the world over trying to negotiate the line between autonomy and dependence. The teen, her parent, and I came to an arrangement that allowed the teen to feel “normal” and the parent to feel “in the know.” The similarities of these kids to the ones I worked with back in St. Louis just brought me home for a moment. They’re just kids dealing with a chronic disease.

How did you get approval to work as a PA internationally?

The first time I worked internationally as a PA, I enrolled with the U.S. Agency for International Development registration list for health care workers to assist with the Ebola outbreak. After that, I was hired by the American Refugee Committee. I simply faxed them my license and resume, and they handled everything else. I was placed in a village that was on the verge of being declared Ebola-free, so my role was to provide community education and outreach. The same process took place when I joined Partners in Health. n