Photo by A.J. Heightman.
Photo of the inside of an ambulance.
Nothing, of late, has stirred more debate than the issue of mandatory college degrees for EMS personnel. The arguments have been passionate—but they have not always been informed. Let’s look at this issue from a rational perspective. Before we can answer questions about mandatory degrees, we must first reach some conclusions about EMS in general. EMS has been said to consist of three domains: public safety, health care, and public health. Granted, public health is a minor EMS domain leaving public safety and health care as the principal EMS domains.
Generally speaking, public safety can be defined as the protection of the general public. In the United States, public safety almost always consists of at least police protection and fire protection and animal control. These are generally seen as governmental responsibilities. Although some may be volunteer, most fixed-costs are funded or provided by governmental entities. It is uncommon to encounter private or for-profit police and fire departments in the United States, although they may exist. EMS and ambulance services came to the public safety system late in the game (e.g., 1960s to 1970s). Before that, they were operated by funeral homes, hospitals, first aid squads, and, in some instances, by police and fire departments. They were never, for the most part, funded by the governments.
With the development of the modern EMS system, planners opted to integrate EMS into the public safety system instead of the health care system. Oversight of EMS at the federal level was assigned to the National Highway Traffic Safety Administration (NHTSA) which is an arm of the United States Department of Transportation (USDOT). Many pushed for EMS to be under what was then the Department of Health, Education, and Welfare (USHEW). However, it was assigned to the USDOT, where it remains today. Thus, in the United States, EMS seems to have aligned itself with public safety instead of health care. It is forced to receive funding in competition with the two major public safety entities—police and fire. But, since the majority of what EMS does is health care, there is really no significant funding of the system. Thus, the proliferation of volunteer agencies, hospital-based operations (that operate EMS as loss leaders) and for-profit companies has occurred.
So, is EMS health care or public safety? Certainly, there will always be a component of both. But what is the major role? This has a direct bearing on the degree issue. If you look at public safety (police, fire), college degrees are rarely required except when one moves into management or very specialized areas. Certification of firefighters and police officers is typically overseen by state agencies and a college degree, although recommended, is usually not required. Firefighters and police officers become certified by the respective oversight agencies. When a degree is required, the minimum standard is often an Associate’s degree. So, if EMS is public safety, the prevailing standard is certification and not a degree (although a few states require an Associate’s degree for paramedics).
In healthcare, college degrees are a standard for most personnel who come into contact with patients. Some of the Allied Health professions only hold Associate’s degree (e.g., respiratory therapy, x-ray technicians). Most healthcare providers who contact patients hold Bachelor’s degrees or higher (e.g., nursing, pharmacy, physical therapy). Physicians are required to hold doctoral degrees and have post-medical school training (residency), and specialty board certification.
Thus, if EMS is deemed to be primarily healthcare (which it appears to be), then college degrees will be required to have a seat at the table in the House of Medicine. If you look at many of the Commonwealth countries (e.g., Australia, United Kingdom), EMS is a part of their healthcare system and funded in that fashion. Degrees are expected, although in some countries a Bachelor’s degree may take three years instead of the four years we have in the United States, and you see that most of the EMS providers hold some type of degree.
When I got into EMS (quite by accident) in 1974, I was attracted to the medical side of EMS. I liked the patient care and loved learning the science behind it. I knew that I wanted a career in healthcare but I did not see a good future for me and my family in EMS of the 1970s. I stayed in college throughout my EMS career because I knew that only a college degree would allow me a respectable career in healthcare. I ultimately attended a state medical school. Thus, a college education gave me a great career and my family a good life. But, that’s not for everybody and that’s OK.
So, back to the original question: Is EMS primarily healthcare or is it primarily public safety? Whether we want to admit or not, most of what EMS does is to provide medical treatment to individuals and transport them to a healthcare facility. Certainly, we help in disasters, traffic control, rescue, and similar endeavors that are in the domain of public safety. But the bread and butter of EMS is healthcare. Until we embrace healthcare as the principal EMS role or domain, the idea of requiring a college degree is putting the cart before the horse. Current EMS salaries, for the most part (based on the public safety model), are inadequate to justify the requirement of a college degree. What does a college degree bring to EMS in its current form (pseudo public safety/pseudo healthcare)? It has to be more than lip service.
Many years ago, my home state of Texas decided to recognize paramedics who had a college degree. It was done with good intent. They decided to create a second paramedic level referred to as a “Licensed Paramedic” as opposed to a regular or registered paramedic. Now, it didn’t matter what the degree was in (music, Greek literature, Spanish, biochemistry, etc.). If you had a degree you could become a “Licensed Paramedic” although that level of certification had the identical scope of practice to the garden-variety Texas paramedic. We can’t let the current discussion of degrees in EMS become a mental masturbation exercise like occurred in Texas.
So, do I support a college degree requirement for EMS providers? I do. But only when the time is right, and now the time is not right. If EMS is destined to remain a third public safety service funded by a bastardized system of ad valorem taxes, user fees, and donations, then the salaries will never justify the costs and time required for a college degree. I know many paramedics who stayed in school and received their degree. Few stayed in EMS because their degree made them more desirable to occupations that appreciated the benefit of the education. But, if we embrace EMS as a healthcare profession with EMS providers paid well akin to other equally -qualified healthcare providers, then I’m all for college degrees. Your mileage may differ. I guess time will tell.