I recently posted the question, “How much medical direction do we need?” to an EMS physician listserv. The result? It turns out the old saying about EMS services applies: If you’ve seen one EMS medical direction system, you’ve seen one EMS medical direction system. There are wildly different models across and within states.
I’m often faced with questions from new EMS fellowship graduates who’ve been approached by systems regarding what they should charge for their service as a medical director. My first response is always the same: “How much of your time do they need?” This is a difficult question to answer for many EMS organizations. The default answer is to go with the same amount of time the last medical director spent. Others use calculations based on various factors in the service such as call volume, number of ambulances, number of ALS providers, etc., to create an oversight ratio.
If we look at “span of control” models to help guide us in the search for a magic oversight ratio, we should start with the military. The ratio for command and control is 6:1, which creates 222 separate relationship possibilities when you consider the complexity of the task. If the ratio changes to just 8:1, the relationship monitoring of the supervisor changes to 1,080 relationships. In the EMS world, however, in regards to the medical director, we aren’t talking about supervision of workplace relationships and if they show up on time for duty; we’re strictly monitoring their individual clinical performance as well as system-based metrics. This, combined with electronic medical records, may lend itself to larger ratios.
In addition to the number of personnel EMS physicians are providing oversight for, we also must consider the number of patient encounters. The very brief and limited survey results on my recent listserv query revealed a ratio among the six or so counties and cities with call volumes over 30,000 that responded with specific information that the ratio of physician full-time employees (FTE) to call volume was from 0.2—1.0 FTE per 30,000 calls.
Major metropolitan areas tend to have the most advanced structure regarding medical direction, which usually includes lower-cost EMS fellows. These services on average had physician-to-call ratios of 1:27,000. We must advocate for more comprehensive salary and effort surveys for medical directors so that we have a more educated approach to determining the effort needed.
The truth is that there’s no golden ratio we can refer to when determining the amount of medical direction needed. If we look again to the closest comparison of the oversight of physician assistants by supervising physicians, we see more specific guidance in many states. For instance, in Texas the limit is seven, in Florida eight, but in California and New Jersey it’s four.
While there are exceptions to specified ratios (Massachusetts removed its ratio law in 2012), the general consensus seems to be that there’s a limit in the ability to effectively supervise people who are practicing under one’s medical license.
Medical directors and EMS services together need to renew this dialogue about appropriate levels of oversight in this new age of EMS. We’ve pushed new technology in the field, we’ve added complexities such as paramedic-initiated non-transport of patients and community paramedicine. We can’t continue to advance the field of paramedicine to make paramedics more like physician’s assistants without expecting the oversight requirements to become more rigorous.
Where Do We Go from Here?
I’ve been asked by many EMS services how to get their medical director more engaged. My first response is to ask how much they’re paying their medical director, and how much time they expect them to be around. The reality is that the average emergency medicine physician is making $150—200 per hour, which is less than an EMS service pays per hour for a decent contract attorney. I know that some EMS services are offering medical directors $75—100 per hour. What are the chances you’re going to find a good attorney for $75 per hour? How interested would your paramedics be in coming to work if you paid them half of what they could make working as a medic in the ED?
The flip side of this argument is that if an EMS service is paying the medical director’s regular clinical rate, in effect “buying down” their other responsibilities, they should be giving you the amount of time that you buy, period! Some medical directors want EMS services to pay for using their medical license and accepting the liability without providing the in-person service necessary to ensure the quality of care delivered by every credentialed paramedic meets the highest standard.
Physicians are an essential part of an EMS service and it’s time both of our expectations align so we can all answer the question of how much medical direction we need.