Right now, EMS is being asked to step up its game and take on more of a role in healthcare.  Even before we knew about COVID-19, EMS was being asked to do more in terms of reducing repeat patients and finding alternatives to the “you call, we haul” mentality that’s been the mantra of the American EMS system.  Of course, that’s in large part due to much of EMS reimbursement being based upon Medicare and Medicaid reimbursement models, which often get adopted by private insurance as well. And since CMS pays for transport, not treatment, EMS is going to focus on taking patients to the hospital.  And in large part, the EMS education framework focuses on immediate life-threatening conditions and the treatment thereof both in the field and in the hospital emergency department.

However, we’ve reached a point where it might be valuable to reexamine our educational framework — and maybe even make a few changes that might improve our long term prospects for EMS.  Because of COVID-19, we’ve got two new challenges.  First, we’re being asked to do more in the prehospital arena.  In many locales, paramedics and some EMTs are now able to refer or transport patients to alternative destinations.  While this change was already starting to occur, COVID-19 accelerated this.  It’s now almost semi-routine for EMS providers to tell non-acute patients that a quick ride to the emergency department is no longer the solution, whether because of the load on the EMS system or emergency department saturation. In fact, the Center for Medicare/Medicaid Services (CMS) had already rolled out a pilot program for select EMS organizations to “treat and release”prior to COVID-19.  And during the current pandemic, CMS is authorizing payment for transport to alternative destinations and some “treat and release” scenarios. And second, because of the pandemic, many of the traditional EMS clinical rotations have become unavailable for EMS students.

Rather than seeing these challenges as threats, maybe it’s time for EMS educators to reevaluate how we’re educating our future EMS providers and what we’re teaching. Anecdotally, my EMS experience has been that a lot of EMS providers have occasions where they end up transporting patients to hospitals unable to provide definitive care for the patient.  Sometimes, that’s a result of protocols or local politics. However, many EMS providers often have a remarkable lack of knowledge about medical care and capabilities outside of emergency care. This leads to two pitfalls.  One, EMS providers take the wrong patients to the wrong hospitals. Two, EMS providers have little knowledge to fall back upon beside “transport to the emergency department.”

It’s time to make two simple changes to EMS education.  First, let’s add some education, even a few hours, on the rest of the healthcare system running the gamut from acute to sub-acute, from inpatient to outpatient, from primary care to specialty care.  And let’s talk about what the different healthcare professionals and medical specialties do.  Giving us a bigger picture of where and how we fit into the world of healthcare and medicine can’t harm us.  And for those that say the EMS curriculum is already full and “there’s no room to add any more,” let’s take a look at what we’re currently teaching.  I’m pretty sure we can sacrifice some dated or low frequency topics like the Kendrick Extrication Device, seated spinal immobilization, or petroleum gauze.  Next, while clinical sites are limited, let’s look at getting EMS students into alternative clinical settings.  I’ve long believed that a rotation in urgent care, especially a pediatric urgent care facility, might provide students as much, if not more, skills and observational opportunities than many current rotations — and might have a better connection to reality.  Also, I’d suggest that EMS students might benefit from time in physician’s offices, especially specialist physicians.  The opportunity to interact with physicians AND see how chronically ill patients are managed outside the hospital would give EMS providers much needed perspective. On the same note, I’d like to see EMS students given the opportunity to follow physicians on the hospital floors.  Seeing patients only in the EMS and emergency department setting doesn’t always give perspective to the continuity of patient care. And finally, seeing as how EMS often has to deal with the failures of our healthcare system, especially for elder care, EMS students need to be exposed both to skilled nursing facilities and also to hospital discharge planning.

Addressing the education if EMS while we’re currently dealing with COVID-19 and the current financial and educational climate will put EMS in a position to both improve patient care and expand the scope of EMS for the future.

 

 

Time for me to bring up a semi-regular rant again. The Texas Bar requires 15 hours of continuing legal education a year, including 3 hours of ethics. Up to 3 hours can be self-study including 1 hour of ethics. And the Texas Bar specifically mentions participating in social media for attorneys as part of self-study.

We all know what our state and/or the National Registry require for continuing education for EMTs and paramedics. And that, at least for National Registry much of it has to be “live.”

Riddle me this, Batman. What’s more educational? Reading a #FOAM article shared by some of the EMS/emergency medicine opinion leaders on social media, discussing low titer whole blood with the actual author of many of studies- or sitting through DVDs of the American Heart Association’s resuscitation awareness schlock or listening to whatever a self-proclaimed “EMS Celebrity” has to say at an EMS conference? While there are certainly concerns about gaming the system, that’s already been a known issue with continuing education, whether it’s people signing off on attending classes they weren’t present for or exceptionally low educational value for certain presentations. (See also: certain EMS celebrities presenting on any topic, regardless of subject matter expertise.)

As Dr. Joe Lex says,

• If you want to know how we practiced medicine 5 years ago, read a textbook.
• If you want to know how we practiced medicine 2 years ago, read a journal.
• If you want to know how we practice medicine now, go to a conference.
• If you want to know how we will practice medicine in the future, listen in the hallways and use FOAM.

In summation, EMS continuing education needs to reflect current practice and actual continuing education as opposed to rehashes of the same dated material that is neither current nor advances medicine.  Neither card courses nor the usual cabal of celebrity EMS conference speakers reflect that.  FOAM and social media often do.  Yet, which gives you actual credit for recertification?

My good friend (and I daresay mentor) Dr. Bryan Bledose recently opined on the paramedic “shortage” in the United States.

The good doctor mentions several ideas worthy of consideration, including limiting the number of paramedics, improving the scope of basic and intermediate level providers, and allowing for transport to alternate destination.  And like many of the current discussions, he advocates a college degree for paramedic level providers, which is a cause that I can support, given the requisite forethought and groundwork prior to a requirement being instituted.

I really don’t know if the numbers support the assertion that there is a shortage — or that there isn’t.  What I do believe is that a degree requirement is going to exacerbate a shortage.  There’s all the usual arguments that the fire service won’t embrace a degree and that rural EMS will suffer from a lack of access to educational programs.  And the truth is that those are valid concerns.

 

But here’s my real concern. Most all of us know and agree that a college education creates a more well-rounded provider and provides a core curriculum in English and the humanities.  (I’d also note that said core curriculum is one of the least recognized benefits of a college education from many of the loudest EMS degree advocates on social media.)

 

We also know that many EMS organizations are poorly managed and have a toxic organizational culture. How many degree educated paramedics are going to stick around this average EMS workplace with the toxic culture and idiotic management? There’s a lot better places to work much of the time and a degree educated provider is typically educated enough to recognize this. College educated folks are a bit less likely to want to drive a truck around town for twelve hour shifts and eat and perform their bodily functions at the nearest 7-11, depending on the whims of dispatch.  And a college educated professional is unlikely to respond well to unwritten policies and upper management dictating policy through email rants.

If we want to fix EMS and address the paramedic shortage, we need to address working conditions first. And that starts with expecting EMS managers and leaders to actually be competent to run a functional organization.  EMS needs more education, but that education needs to extend well beyond a better way to read an EKG.

After a few minutes engaging this morning on the American Paramedic Association Facebook page, I’ve realized that many of those advocating higher education and a degree requirement for paramedics have little understanding of higher education or how higher education works.

There’s tons of people saying they need more science classes and advocating for specific EMS related courses. Meanwhile, there’s a lot of people also advocating against any humanities or liberal arts core curriculum coursework. I would submit to you that a course in research design and methodology like you see in many bachelor’s level social science curricula may be of much more long term benefit to EMS than a specific, technical course in the most recent innovation. Remember when backboards and rotating tourniquets were considered current EMS practice? However, a course in understanding research would enable the paramedic to have a lifetime knowledge base in evaluating EMS innovations and a healthy dose of skepticism, which is a virtual requirement for scientists and clinicians.

Many of these people arguing for an EMS degree don’t understand that college is designed to produce a well rounded education, even if the degree is in a specific field. There’s several people saying that the EMS associates degree needs to be a technical degree. What they don’t understand is that an Associate of Applied Science degree is often a terminal degree for a technical job. (Think ITT Tech or DeVry for those of us that remember the commercials on daytime TV.) And further, an AAS degree often doesn’t easily transition to a BS or BA degree in the future, even further limiting EMS career progression and upward mobility.

Bluntly, the more I see, the more I think an AAS degree will end up dooming EMS to remain a technical education with limited chance for upward mobility or further education. What I’m seeing is largely people engaging in either playing pretend at creating their dream college curriculum or wanting to turn card course curriculum into college hours.

I’m almost willing to come on board with requiring a degree for paramedic providers. However, I think we need to aim for the ideal and negotiate to what’s manageable. In my opinion, I believe that the role of a paramedic is actually that of an advanced practitioner with the ability (and likely the requirement) to exercise critical thinking and clinical decision-making. That critical thinking comes with an expanded knowledge base including the core liberal arts curriculum. And that level of education happens at the bachelor’s degree level.

The political process, which is ultimately how we’ll reach a decision on what education is required to be a paramedic, requires that we negotiate from an ideal solution to get to a realistic solution. The ideal is a paramedic with a bachelor’s degree, whether that’s a bachelor’s degree in paramedicine or a bachelor’s degree in another field, followed by a paramedic transition curriculum (see also the plethora of BSN transition programs for those with a BA/BS degree).

If we end up making the paramedic degree requirement an associate of applied science as many seem to be advocating, we’re dooming EMS to remain a technical field with limited upward mobility. An EMS degree, especially for the paramedic level, should not be in the same category as HVAC technicians or diesel mechanics. (Truth is, the average HVAC technician or diesel mechanic probably has a better salary than the average EMS provider — or even many so-called “white collar” jobs.)

As I’ve said before, we’ve got one chance to get the degree requirement right. Let’s not foul this up. And if we turn this into an echo chamber among ourselves and creating a curriculum that’s solely based on “cool new skills” for paramedics, we’re dooming ourselves with a degree requirement that ends up producing perishable skills that will be outdated within a few years of practice.

EMS is dependent on others to get what little we do.  Whether it’s getting physician involvement for clinical changes or convincing those with the money that a new ambulance is needed, we have to get others involved in our destiny.

If you listen to the current voices on EMS social media, you’ll hear the lamentations that EMS is broken.  The current consensus, promoted by all self-proclaimed EMS save those in the fire service, is that EMS degrees are what will surely fix EMS and make us respected.  Mind you, the EMS consensus has brought us some other sure-fire winners as system status management, declaring EMS an “essential service” (Hey, where did that go?), and community paramedicine.  We’re on EMS 3.0 or something now and we still haven’t mastered the basics of getting the right patients to the right hospital and treating people right, both as people and as patients.

I agree that more education is needed for EMS. But the last thing we need to do is follow the rest of the healthcare professions and have a solely clinically focused degree.

Too many people in EMS (and the rest of healthcare) think that all you have to understand is the medicine. If you don’t understand (or participate) in the policy and business aspects, others make those decisions for you. If you don’t believe me, look at our modern American healthcare system. For years, physicians refused to be involved in the business of medicine.  As a result, hospital and healthcare administrators developed to handle the business of medicine.  And ultimately, we have ended up where we are currently — where a lot of decisions about medical care are made by the business office rather than by those providing the actual care.

It often seems that there’s a belief in the world of healthcare that being involved in business or policy is somehow “unclean” or beneath the profession.  As a good friend of mine said, “Even if you aren’t interested in politics, politics is interested in you.”

So, in short, I’m not opposed to increasing EMS education.  But what an EMS degree should NOT be is a degree focused solely on the clinical practice of medicine.  Too many of the EMS degree advocates on social media would promote a degree that awards three hours of college credit for a course entitled “Latest Clinical Fads Capstone.”

EMS, like the rest of the healthcare world, does not exist solely in a clinical vacuum. For EMS to advance, we need to understand the business of healthcare.  That means an EMS degree needs to include coursework in the political and regulatory process, finance, personnel management, and the research process.

In other words, it needs to be a well rounded degree as opposed to a narrowly focused clinical pathway that will be doomed to irrelevance with every change in medical practice. But without this kind of education, an EMS degree is doomed to become an expensive addition to the current workplace.  If the current people pushing for a degree requirement better understood the non-clinical aspects of what we do, they’d see the potential pitfalls of an EMS degree such as a lack of buy-in from higher education and the availability of appropriately educated EMS faculty to teach in a college setting. By the way, the same shortage of faculty is partially responsible for the current nursing shortage. This is but one example of why healthcare education (including EMS) needs to understand business and policy. Take ultrasound.  It’s the current EMS clinical fad on social media.  Everyone wants it.  But has anyone developed a position as to how ultrasound saves money, improves care, or how EMS can get paid for ultrasound.  I’ll wait here for that answer.

And if you don’t believe that healthcare providers (including paramedics and EMTs) don’t need to understand the big picture of healthcare outside the actual provision of medicine to patients, then you’ve illustrated exactly why healthcare administrators often make even more money than the doctors do.