Administration and Leadership, Columns

Reflections on the EMS Lexicon

Issue 6 and Volume 42.

Three things often appear in conversations and articles about EMS that are worth reflection: 1) we are all providers; 2) a principal focus for all of us should be on customer satisfaction; and 3) we all work in the EMS industry.

It’s all seemingly pretty straightforward stuff, and most of us would probably never blink an eye seeing any of these familiar expressions in print. But what if these words also spoke to some unhealthy ideas deeply rooted in our collective EMS consciousness?

Since language often has a way of shaping thoughts and perceptions, if not reality itself, what if these concepts also had the unintended but potentially negative effect of degrading the value that we and others place in ourselves and in our work?

‘Providers’ of What?

On the surface, “patient care provider” sounds pretty good. Yet, we don’t refer to police officers as criminal justice providers, nor do we call firefighters providers of suppression.

If you do a little amateur sleuthing, you can follow at least some of the breadcrumbs to the Center for Medicare and Medicaid Services (CMS), the federal agency that sets policy and billing requirements for EMS-and for almost everyone and everything else that crosses our patients’ paths.

According to CMS, a provider is someone contractually obligated to provide healthcare to Medicare or Medicaid beneficiaries. No big deal, perhaps, except that it has the subtle effect of reducing what we do to a commodity.

Our education and training, special skill sets and whatever sustains us in our work becomes more about insurance and the administrative functions required for government-regulated reimbursement.

The net effect is that we’re effectively reduced to providers whose job is to make stuff available to our patients. The focus is no longer on the clinician-patient relationship, which is essential to establishing trust, taking a good history and initiating an effective and safe therapeutic intervention.

Instead, we become moving parts in a consumer-driven business transaction, not unique and essential members of a team managing the patient’s entire continuum of care.

‘Customer Satisfaction’

It’s not entirely clear either who came up with the expression, primum non nocere or “first, do no harm.” It’s a good bet, though, that it wouldn’t be so catchy today if it read instead something like “first, do not disappoint.”1

If nothing else, we would all probably agree that it’s at least reasonable to encourage courtesy, dignity and respect in all of our interactions with patients, families, bystanders and other healthcare professionals.

But what if a crew is a little inattentive or even brusque with family while busy hanging fluids and vasopressors, as their septic patient’s blood pressure nosedives enroute to the hospital?

Patient satisfaction can be useful for identifying problems or rewarding outstanding interpersonal skills. But the average patient or family member doesn’t typically have the knowledge, insight or understanding to really understand what’s going on, either on scene or in the back of the truck.

Focusing on patient satisfaction doesn’t make up for inadequate training and mentoring, superficial credentialing processes and a lack of measurement tools and quality assurance processes either.

The ‘Industry’

When it comes to EMS, the compelling focus for politicians, the media and the public is still on operational performance and efficiency and the financial health and sustainability of the business or industry.

It’s all actually pretty important stuff, but it’s also sort of like starting your workday opening your email, and then finding yourself getting to almost nothing else. The clinical care becomes an afterthought in a large industry driven by budgets, staffing, scheduling, collective bargaining, public perception and politics.

As we begin the shift to mobile integrated healthcare and community paramedicine, we now have a unique opportunity to reshape the entire industry.

Sometimes, though, it looks a little like an instant replay of the early development of EMS, with its strong focus on process measures. Instead of response times, we now measure things like readmission avoidance and anticipated cost savings.

We’re getting a reasonable handle on the first two components of the triple aim, improving the patient experience and reducing the per capita cost of healthcare, but the third element, improving the health of populations, maybe not so much, at least not yet.

Make It a Double

The triple aim has a nice ring to it, but if we focus only on the compelling economic and industry challenges that lay before us, and if we continue to utilize only customer satisfaction and limited financial efficiency tools for measurement, then we might just have to settle for a double.


1. Horana LS. The oath is ‘first, do no harm’ (not first, do not disappoint). Emergency Medicine News. 2013;35(9A).