Administration and Leadership, Columns

EMS Subspecialty Creates an Opportunity to Change the Role of the Paramedic

Issue 1 and Volume 40.

Since the inception of modern EMS with the Highway Safety Act of 1966 and the EMS Services Development Act of 1973, the provision of prehospital medical services has been developed as an emergency medical service. Similar to the police and fire service, this model has been perpetuated, modified and updated over the past 40 years.

We’ve seen remarkable developments and striking improvements in the outcomes of patients in multiple areas of care—particularly in the management of trauma, cardiac arrest, myocardial infarction and stroke. There have been tens of thousands of scientific publications focusing on the care provided before the patient arrives at the hospital and resulting improvements in systems of care.

Transition to a Physician Subspecialty

As a result of this herculean effort, the American Board of Medical Specialties (ABMS) voted in 2011 to create a new physician subspecialty called “emergency medical services.” Similar to cardiology, neurology and trauma surgery, this governing entity decided what we do in EMS has a distinct body of research and is a significantly different clinical field. The American Board of Emergency Medicine was named the parent board for this subspecialty and held its first board certification exam in 2013.

Some may ask, “So what? What difference does that make to the paramedic on the street?”

The development of EMS as a physician subspecialty changes everything. In the moment the ABMS made this decision, we took an evolutionary leap forward by transitioning from “technician” to “physician extender.”

A physician extender is how we refer collectively to nurse practitioners (NPs) and physician assistants (PAs). These are the paramedics of other specialties and subspecialties. The other physician extenders may take exception to grouping paramedics with them—and they should! They aren’t the same, so let’s look at the differences.

NPs and PAs have bachelor’s degrees, plus master’s-level postgraduate training. Additionally, they’re required to complete a minimum of 500 hours of clinical training with the option of fellowship training to gain additional experience in an area of specialty such as emergency medicine, which can total 6–7 years of education and training after high school.

Once complete, the average emergency medicine PA or NP will earn around $100,000 annually and is generally assigned to cover the lower acuity areas of the ED. They’re provided with direct oversight and immediate availability of the physician staff if needed.

In contrast, paramedics have as little as 12 months of post-high school education and training, with around 500 hours of clinical education. At the end of their training they may go straight to work or have an internship process with their employer. On average they’ll earn around $40,000 annually and will be assigned to work with one other person in austere conditions, taking care of the most critical patients with little direct physician oversight.

Bridging the Gap

As the newest physician extenders, paramedics have to work harder to bridge the chasm of disparities between their in-hospital counterparts. For leadership in this area, we should turn to Australia and the U.K. They began this battle more than a decade ago and are now seeing the fruits of their labor.
To become a paramedic in South Australia, for instance, you must have a bachelor’s degree in ambulance studies. After completion, you can apply for an internship that lasts 12 months and is structured for further development of knowledge, skills and critical decision-making. After successful completion of the internship, the paramedic is offered a permanent position—at which time they can be further trained in special operations, intensive care or extended care. Salaries for intensive care paramedics and extended care paramedics also increase up to $105,000 annually for nonadministrative positions.

The presence of the EMS subspecialty in the United States must place a much heavier focus on the critical need for bachelor’s and master’s degree-based programs for our EMS physician extenders. We must abandon the “technician” days and reinvent our paramedics to be clinicians with the knowledge and decision-making skills to finally banish the word “protocol” from our EMS vocabulary.

The future paramedic practitioner will be much more dependent on the medical director as the manager of what’s now a medical practice. This will increase the medical director’s involvement in quality review, direct oversight, and continuing medical education. What has historically been a peripheral position in many EMS services must become a central part of the day-to-day management of the service.