Is EMS Headed for a Crisis of Competency?

Doug Wolfberg
Doug Wolfberg

The COVID-19 pandemic wreaked havoc on EMS systems nationwide. Call volumes for many agencies plummeted, creating financial sustainability issues. Hospital capacity became an issue, stranding ambulances in emergency departments for hours on end. Many EMS practitioners became sick. Some died. The recruitment and retention of EMS clinicians became – and still is – an existential problem for EMS in the United States.

The Pandemic Learning Gap – A Coming Crisis for EMS?

But a more latent crisis is lurking in the wings, waiting to take center stage as the coming generation of EMS professionals enters our workforce: the pandemic learning gap. Learning losses during the pandemic lockdowns among elementary, middle and high school students are coming into sharp focus in study after study measuring the effects of remote learning on school students. This learning gap may well pose another pandemic-related challenge to EMS – in education, operations and clinical care – in the near term. 

There’s certainly evidence that deficiencies in student success were mounting even in the pre-pandemic era. But now, EMS needs to gear up before it faces what could become a true crisis of competency among our next generation of professionals.

The National Center for Educational Statistics, in its most recent National Assessment of Educational Progress, estimates that nine-year-old children lost the equivalent of two-decades worth of progress in math and reading. Sharp decreases in learning among eighth graders were also documented in this recent study. Particularly troublesome is emerging data that point toward even larger learning gaps among poor and minority students.1

Mounting evidence suggests that remote instruction played a key role in the deterioration of student achievement during the pandemic. Research in Ohio, for instance, found that schools which stayed fully remote in the 2021-22 school year experienced learning gaps that were up to three times greater than schools that returned to in-person instruction during the same school year.2

The evidence is becoming clear. Primary, intermediate and secondary education in the United States was hit with an earthquake during the pandemic. Now, EMS needs to be prepared for the aftershocks.

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Students who come out of our public schools with gaps in math, reading and other essential disciplines will carry those deficiencies into their postsecondary education, and without necessary interventions, into the workplace. EMS education programs and EMS employers should start developing and implementing strategies now to stave off this coming crisis.

Student Learning Has Decreased – But EMS Standards Haven’t

The knowledge and skills needed to be a competent EMS clinician are relatively fixed. Of course, clinical standards change as evidence-based practices dictate, but the baseline of knowledge, skills, reasoning and logic necessary to be a competent EMS clinician is essentially a fixed requirement. EMS standards of care set the bar, but the reality is that not all students coming into EMS will be prepared to clear it.

A STEMI or stroke behave, for the most part, in physiologically predictable ways. There are minimum necessary assessment and diagnostic skills to be able to detect these conditions. And, once detected, these conditions require evidence-based regimens of care and clinical decision-making necessary to optimize patient outcomes. The patient’s ischemic blood vessels simply don’t care whether the clinician attending to that patient is smart enough to handle them. These conditions are going to do what they’re going to do. But the competency of the EMS clinician – from the detection of the condition to the administration of the appropriate care to the determination of the most appropriate destination – is what gives the patient the best chance to survive these episodes and to optimize their outcomes. 

Simply put, patient care demands a baseline of clinical competence. And clinical competence requires learning and mastery of knowledge and skills. And some of our incoming students will be behind the curve.

As a lawyer, I also can’t help but think of the gap between student achievement and standards of care from a tort liability perspective. If a patient suffers a bad outcome and brings a medical malpractice case against the EMS clinicians, I don’t foresee a judge allowing the use of an “educational deficiency” theory in their defense. We cannot expect judges and juries to cut us some slack because we were handed a generation of pandemic-era students with learning gaps. EMS education will need to close those gaps, because although learning may have dropped off, the standard of care expected of our practitioners has not.

EMS Strategies

While we may not have foreseen the COVID-19 pandemic, we can certainly foresee some of its aftereffects, and plan accordingly. It is vitally important that EMS systems establish methods to deliver EMS education in ways that will close learning gaps.

EMS educational programs need to recognize that student success in EMT and paramedic courses and the resulting certification/licensure examinations will require extra resources. Students may require tutoring, one-on-one remediation and additional time to achieve required learning objectives. Studies demonstrate that “high-dosage tutoring” (three times a week, 50 hours per semester) is shown to be 20 times more effective in math and 15 times more effective in reading than low-dosage tutoring.3 Some of these lessons may translate into EMS learning as well.

EMS educators will need to assure that they are staying current, both in terms of clinical practice and educational methods. The “Death by PowerPoint” lecture model may not be the best way to serve the needs of students.

EMS learning will also need to be highly adaptive, that is, specific to the needs and the level of knowledge and learning of each student. One-size-fits-all EMS education may not cut it when the pandemic generation enters our classrooms.4

EMS educational programs should consider whether their physical facilities are prepared to handle in-person learning during another pandemic. Presuming the evidence shows that in-person learning better enables students to meet learning objectives, physical facilities will need to have the necessary ventilation, capacity for distancing and other safety capabilities necessary to accommodate in-person learning during a pandemic.

Partnerships in the EMS educational process may be another vital key to student success. Beyond merely establishing agreements with clinical precepting sites for student experience, EMS educational programs can leverage those partnerships to help make experiential learning a key component of student success. Precepting can be more than simply punching a ticket for the required number of student clinical hours. The precepting experience can be a more effective adjunct toward the mastery of EMS educational learning objectives. And by the way, if busy EMS agencies push back against the idea of spending more time with EMS students, they should remember that today’s students are the employees they will be hiring into their workforce tomorrow. 

Speaking of employers, learning doesn’t stop when our students graduate and get jobs. EMS requires continuing education for a reason. But again, instead of simply checking the boxes for the required number of hours in medical, trauma, etc., EMS continuing education can play a role in addressing learning gaps that may not have been fully closed in the clinician’s initial EMT, advanced EMT or paramedic programs. 

EMS employers also need to play a continuing role in practitioner competency through effective continuous quality improvement programs. Measuring and monitoring key indicators of high-quality clinical care will never be more important than when students from the pandemic generation come into the workforce with these chasms in their learning and academic achievement. The obligation of EMS employers to assure the competency of their clinicians is a continuing and ever-present obligation, and agencies will need to carefully document and maintain records of doing this on a regular basis.

Finally, EMS education – and EMS agencies – must recognize that the pandemic learning gaps are more pronounced among poor and minority populations. Studies show that workforce diversity is also a key in reducing disparities in clinical care among underserved populations. If proper attention is not paid and proper resources not devoted to the particular needs of minority students in the post-pandemic era, the EMS educational system will not be able to play the role we need it to play when it comes to producing well-prepared and qualified practitioners from historically underrepresented populations. In addition to the strategies discussed above, EMS education will be well-served to intensify efforts to recognize and reduce implicit bias through training that becomes an integral part of EMS education programs. 

These challenges will require resources. In some cases, program tuition may need to be increased to cover these costs. That, of course, can compound these problems, necessitating more financial assistance for poorer students to be able to enroll in EMS educational programs. State EMS agencies and legislatures can play a role in assuring that EMS educational programs – so vital to our profession and to the public health – are affordable and have the resources to meet the learning challenges that students face when the time comes to mold them into new EMTs and paramedics.

Conclusion

The devastating effects of the COVID-19 pandemic won’t end once the public health emergency is finally declared over. The learning gaps that arose during the pandemic will require a reckoning in EMS education and practice to assure that our profession continues to produce competent caregivers who can effectively meet the needs of patients, employers and EMS systems in the United States. That reckoning will require resources – and EMS education needs to be prepared to respond so that our profession does not face a crisis of competency in the coming years.  

Doug Wolfberg is an EMS attorney and founding partner of Page, Wolfberg & Wirth. He has also been involved in EMS education for decades as an instructor and course designer, and he teaches as an adjunct professor at the University of Pittsburgh and Commonwealth Law School. He is also integrally involved in higher education as a member of the Board of Trustees of Widener University.

The author would like to thank Dr. Walt Stoy, Donnie Woodyard and Rob Walker for their review and suggestions. 

References

1. National Center for Educational Statistics, National Assessment of Educational Progress, nces.ed.gov/nationsreportcard).

2. Mervosh, S., Pandemic Learning Loss, The New York Times, November 28, 2022.

3. Best Practices for Learning Loss Recovery, Hanover Research, December 2022. https://wvde.us/wp-content/uploads/2021/02/Learning-Loss-Recovery-Best-Practices.pdf.

4. Hadley, E and Ortiz, E., How to Avoid a Lost Generation: Three Strategies to Combat Pandemic Learning Loss, Inter-American Development Bank, September 8, 2022. https://blogs.iadb.org/educacion/en/combat-pandemic-learning-loss/#:~:text=Implement%20specific%20programs%20to%20close,time%20during%20the%20school%20breaks.

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