It's tough to know whether you're in a midlife crisis. A professional friend of mine, a well-respected local ED doc, told me he was feeling tired. Too many early mornings, too many late nights spent trying to practice perfection in an intensely imperfect art. He knew he didn't want this for the next 15 years, but didn't know what was next. He doesn't think he's in a midlife crisis because he hasn't divorced his wife, jetted to Tahiti, bought a Maserati or grafted a silicone bimbo to his right hip (personally, the last three don't sound too bad). But his quandary reminded me of e-mails I've received from readers about the glass ceiling of EMS. Where does a field medic go?
It's an intriguing question one that I think all people in all professions really have to answer. I'm no exception to the rule. Believe it or not, even medicine has its own set of deadends. You get out of residency, establish a practice or join a group, and work. If you stay put, you eventually gain some seniority in your group and a larger piece of the pie, but for most physicians that's about as far as it goes. If you go into academics, you teach the same basic lessons to a rotating cast of residents while you wait for your department chair to move on so you can assume the role. (My tenure in academics has convinced me that a major reason for the explosion of medical journals and learned societies is the need for academics to feel like they're doing something other than spinning in place.)
The sense of inertia can be very limiting, and I'm certainly not immune to this feeling. In the mid 1990s, I left a secure position at the University of Florida and moved abroad simply because I thought I had done all I could there, and it was time to move on. The problem was that I really had nothing to move on to. I was a doctor, with doctor skills. I was not also a manager, a businessman or a legal eagle. While my bookshelf was eclectic, I wasn't exactly a Renaissance man.
Friends in EMS have the same issues, and I sympathize with them more than they know, as a result of my own career moves (or mismoves I now look back on them as short-term career suicide). I've tried to find answers to their quandary: Short of vacancies opening up for an immediate supervisor, what kind of career advancement is there for the street paramedic?
I think there are two ways to advance one's career in EMS, one structural and one professional. Structural advancement occurs when one "moves up the chain" in an organization and is intimately linked with rank, pay and increasing degrees of autonomy and self-direction. Advancement in this fashion should be (and most often is) based on qualifications, experience and achievement, matching the qualities of the individual to the needs of the organization. Unfortunately, in some scenarios, this kind of advancement may be a result of seniority or internal politics. The qualifications for advancement are often key as well. In an agency that performs EMS as a secondary or mandated mission, rather than as a primary or preferred goal, advancement may have very little to do with commitment to, understanding of or proficiency in prehospital medical care.
Professional advancement is more difficult to define but closer to the ideals of an EMS career. I view this kind of promotion in terms of expanded roles for paramedics in patient care and community service. These changes are driven not only by internal motivators to serve, but also by external factors. The economics of prehospital care will prompt underutilized units to be out in the community, either to directly generate revenue or to raise community awareness (and therefore taxpayer support) of EMS needs. These functions will require paramedics to adopt an expanded scope of care. I think prehospital providers can play a key role in bringing basic primary health services to those unable to leave their homes or who have no other access to care. It's easy to envision paramedics providing home health services, such as chronic wound care, administration of IV antibiotics and medication checks. Paramedics may also play a role in health screening activities, or in identifying persons at risk for health or social problems amenable to community intervention. Just a few minutes' thought rapidly identifies many more community roles for the previously restricted paramedic. Other means for professional advancement include participating in teaching programs, serving with community groups sharing EMS interests, or conducting an EMS research project.
However, while additional skill sets enhance our knowledge base and self-esteem and offer new opportunities to serve, they are often not recognized as "advancement" in the profession. For better or worse, society links advancement to external changes in status, such as money or rank. In an ideal world, you would hope that the recognition of your peers and your community would be all the reward you need (as in the epic Beowulf, where the hero was "most eager for fame"), but in our culture esteem is a secondary reward at best. EMS agencies that wish to retain the best employee-clinicians must recognize the varied ways in which paramedics serve the community (both inside and outside the agency) and develop an advancement track offering tangible benefits. These benefits need not be salary-related. They may include flexible work hours, choice of shifts or partners, time off for professional meetings and training, or funds for further education. (For what it's worth, I do think that when an agency pays for advanced academic training, it's reasonable for the agency to expect a "time served" payback for the investment.)
The bottom line in both advancement tracks is education, and this is true whether one wishes to advance in rank or in knowledge. One simply cannot be an effective thinker (which, after all, should be the minimal requirement for promotion) with no more formal education than a technical certificate. While I recognize that there are time and economic incentives to compress EMS training to the minimal required time, I truly believe that we would all benefit if ALS providers were required to attain at least a two-year associate degree before taking to the streets.
I hold this view because the practice of prehospital care is more than a technical discipline. It requires judgment and character, verbal and written communication skills, an open mind toward different races and cultures and the ability to place individual issues within the larger framework of life. Effective patient care requires familiarity with the scientific method and literature, and developing patterns of critical thinking. The qualities cannot be learned in a technical program emphasizing protocol and routine, but only through a varied program of study that opens the mind and produces a well-rounded person. And if the need to develop a better paramedic is not enough motivation to pursue a degree, than perhaps the desire to advance is. Employers of all kinds look for recognized degrees because they suggest the individual holding the title is committed, flexible, and motivated.
I would be remiss if I did not recognize that there are many "certificate" medics who do an excellent job of prehospital care. But I would bet that many of these elite providers recognize their own need for further education. They would tell you that the secret to their success is to spend time in study, review, and professional development, and to continually move ahead with their educational and career goals.
If one chooses to leave the field in the course of a career, a background in EMS coupled with further education opens up many opportunities. Many paramedics study nursing in "bridge" programs, advancing their role in emergency care in the ICU or ED. An educational degree can lead to a teaching position in an EMS training program, and business coursework can lead to a position as an equipment representative or distributor or as a billing specialist. Computer training may mesh with roles in communications. And these suggestions are only within the EMS industry. The same background with some additional learning can lead to opportunities in public health, environmental monitoring and disaster planning. Jobs in public relations or with local service organizations may benefit from the knowledge of the community "on the ground" obtained through a career in EMS. And it goes without saying that the more education one is willing to pursue, the higher one can rise. (I'm reminded of an Instructor I knew at the University of South Florida who, over a 20-year career in the fire service, managed to get a doctorate degree on his days off on the department's money. He retires with full benefits and moved immediately into an academic career. Not too bad a deal.)
I know that some people find the call to education intimidating, coming as it does from a doctor who already has his degree. But I will tell you that everyone can achieve an education to the highest degree. All that's required is the will. It's true some people can catch on to things quicker than others and that some people are just good at taking test; that's just the way we are all "wired." But given the will, everyone can achieve (remember that half the doctors in this country graduated in the lower half of their class). I think it was Albert Einstein who said that genius was 1% inspiration and 99% perspiration. Personally, I've always liked the comment that most of life is just showing up. You get the drift.
Two last notes. First, I would encourage anyone who leaves EMS to still keep a hand in the field, even if it means taking a day off to ride as a volunteer. It never hurts to know where you came from. You may find that your new career skills positively influence your patient care or that the realities of the street allow you to synthesize the theories you've learned.
My final point is that while we all want to advance, change simply for the sake of change is rarely good. If you're disgusted with your current job, you need to consider if the answer is a just a change in scenery or a profound and permanent change in career. There's a reason we all got into EMS: to serve the public. Leaving the field simply to satisfy a short-term frustration is bound to provoke feelings of anxiety and loss, and lower your confidence and self-esteem. If you need to make a change, do so, but remember not to stray too far from your roots.
I started out by telling you that I know the feeling of being caught in a career trap. I'll end by telling you that I've taken my own advice. In 2001, I completed a Master of Public Health (MPH) program at the University of South Florida. Knowing myself, I recognized that the ennui bug would eventually hit, and I needed to position myself to look at other opportunities.The time and effort spent in search of the degree has finally paid off. In October I started as the Director of the Volusia County (Fla.) Health Department. This position is a real challenge. The VCHD serves more than 430,000 year-round residents (and a lot more during our special events, such as Bike Week, Speed Weeks, Spring Break and Black College Reunion) with more than 300 employees and a multi-million dollar budget. Part of me is quite confident in my abilities to handle the job, and part of me is scared silly (which part is 51% and which is 49% varies with the day). So I hope you'll understand if some of my future works start to spin toward public health. Enjoy my latest transition, while you prepare for yours.