More on the Four Year EMS Degree

So, I’m thinking more about the push for an EMS degree. In theory, I think it’s a great idea. But here’s a couple of observations.
The “other countries have it” argument. Those other countries also have a national healthcare system where EMS is integrated into healthcare. We don’t have that in the United States. Additionally, some of these other countries don’t have a tradition of mid-level practitioners that the United States does like advanced practice nurses and physician assistants, so in some of these cases, paramedic providers are stepping into roles that might be filled by other healthcare professionals here.
As a corollary to that, much of our EMS is provided by the fire service and by large private EMS companies. The fire service does EMS because it “has to” in order to maintain some justification for its existence. It has no interest in EMS save for staffing and budget. They’re not going to be advocates for EMS. As for the privates, they want low wages and lower educational standards, since they’ve got a long history of churning through employees and needing a steady inflow of new people.
Volunteers. Yeah, truthfully, it’s going to be hard to require a four year degree to volunteer on the ambulance. And unfortunately, there are parts of the USA where the local authorities have chosen not to fund an EMS system or there’s not sufficient people to do it. As the old adage goes, you get the EMS system you pay for.
Clinical outcomes. Everyone talks about evidence based medicine, including me, until they don’t like what it says. Is there any evidence that a more educated paramedic provider has better clinical outcomes. Australia and Canada both have college-educated providers and that’s become the norm there. Yet, these paramedics often have a more limited scope of practice than many locations in the United States.  Is there any evidence to indicate that American paramedics with a lower educational standard and (often) a broader scope of practice have worse clinical outcomes than their more educated foreign colleagues? As a further question, would a four year degree expand the current scope of practice for American paramedics?  As a liberal arts graduate myself, I believe the real value of a four year degree comes from the critical thinking and communications skills that a core liberal arts curriculum develops, but the majority of EMS degree advocates seem to believe that only a four year EMS specific degree is going to “save” EMS.

Actual logistics. Let’s assume that we do decide to put in a degree requirement for paramedics. Let’s further assume that it’s going to be a four year degree. How many degree programs exist? Are there sufficient faculty with an “appropriate” terminal degree in the field to satisfy the higher education accreditation authorities?  And on that note, what is an appropriate terminal degree for EMS?  Would we now end up inadvertently or intentionally creating a doctorate in EMS education?  Would current EMS educators be ineligible to continue what they’re already doing? The demand for nurses and nursing education has already created a shortage of nursing educators.  What would EMS education do to meet that demand on day one?

What would happen with an actual EMS degree requirement?  The skeptic and cynic in me says that most places wouldn’t have degree-educated paramedics.  Instead, the “powers that be” will do one of two things.  They will continue the current paramedic education and call it something else.  Or they will water that down even further and create another “paramedic light” certification. See also: Rhode Island’s EMT-Cardiac, New York’s Advanced EMT-Critical Care, NREMT Intermediate-99 (thankfully being phased out), Virginia’s EMT-Intermediate, or Iowa’s “paramedic” based on the NREMT I-99 standard (the actual “full” paramedic in Iowa was called a “paramedic specialist). And I will make you a bet that the majority of large EMS operations in this country will immediately default to providing service at this “paramedic light” level.


If we want degree educated paramedics and believe that’s for the best, we’re going to need to answer these questions.  And we’re also going to need find the funding for this. That probably means getting the primary payer of EMS services, the Federal government, to change Medicare/Medicaid so that EMS systems are paid for treatment and services rendered rather than just transport mileage.  But to do that means that we’re going to have to be more involved in the political process rather than the occasional appearance on a designated “lobby your politician” day where you wear a uniform that looks something like a third world dictator. The truth be told, increased EMS education and increased EMS reimbursement are like the chicken and the egg.  I don’t know which comes first.


I’d also point out something said by a former EMS director of mine.  He said he’s paying paramedics (and EMTs) what he can afford to pay them, not what he wants to pay them.  Again, until reimbursement changes, there’s no magic source of increased paramedic compensation, even with higher education.

Before you think I oppose an EMS degree, let me say that I don’t.  I believe that a four year degree is appropriate for a medical professional. I also don’t know that all of the advocates of an EMS degree have fully thought out the impact of such a requirement, even if gradually phased in.

I believe that our current America EMS system may be like Churchill’s definition of democracy. Churchill said that “Indeed it has been said that democracy is the worst form of Government except for all those other forms that have been tried from time to time.…”  I believe that we may find this to be equally true for American EMS if we suddenly change our educational paradigm without considering the consequences.

These concerns and this rant was brought to you by a mostly proud graduate of a certificate granting paramedic program who also had a bachelor’s degree in liberal arts followed by a graduate and a professional degree. Higher education taught me to think. Paramedic education taught me to do. And coming into a paramedic program with a college degree taught me to think and consider what I do as a paramedic.


  1. These are arguments I’ve made for and against a degree program in paramedicine. And some of your points are better refined.

  2. John Donohoe says:

    Until we change reimbursements to reflect “care provided” this is going to be very difficult. This requires a 3 prong approach.. higher education requirements, reimbursements based on care, professional license requirements… mtf

  3. Andy Perris says:

    Read this from the UK where we have moved to a degree for all paramedics since introducing national registration in 2000. The are advantages and disadvantages of degree paramedics – most of the disadvantages tend to be economic rather than clinical.

    Your system does seem to be fragmented and inconsistent, however is this not a consequence of having private healthcare?

    • Scott Lancaster says:

      Maybe on the fringes. The majority of healthcare in the US is actually paid for by government entities already (Centers for Medicare and Medicaid Services, VA Health Care, State / county / local health departments, etc.).

      The biggest payer tends to be CMS, and they pay for EMS in a fee-for-transport model. Basically, that means they are paying for the ride and not the care given. They do have 3 levels of emergency care (ALS1, ALS2, and BLS) for Medicare which does help make up some of the costs of advanced care, but at the mean they pay less than the cost of providing the care. They do not pay the cost of care because, again, they are paying for transport; CMS doesn’t view EMS as a clinical practice and one reason for that is the technician-based history of EMS here, and that will never change without education changes. Private insurance providers tend to reimburse EMS agencies more than CMS, especially Medicaid.

      One of the issues we also have is that far too many communities see EMS as a profit-center in their budgets. They attempt to run it with minimal to no impact on the tax-base, which suppresses both wages and innovation.

      Of course, this is a short and just at the surface description of some of the issues.

    • John Riggs says:

      Not so much a result of the private health care we enjoy (or at least use and can afford), but the result of health and human services licencing and regulation tends to be maintained at state level. Thus we have a 51 component EMS system that only mirror each other in various minimal ways.

      A paramedic is not even a protected title in Mississippi (anyone can call themselves one). EMT on the other hand, is. Thus I am (always) and EMT-Paramedic which means nothing to anyone outside of healthcare (and Mississippi).

      The NHS has an advantage of controlling the system at the national level but please remember your population exceeds any one state but California alone is twice the size and about 2/3 the population. Mississippi (where I’m from is about the same size as England itself, with a population of about 3 million. It’s way more space with way fewer people concentrated together and that leads to 51 various ways to deal with EMS (the 50 states plus the District of Columbia).

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