Community Paramedicine, The next step?

[ExpatMedic0]

It looks like you guys are on the right track Wolfman, good to hear.

By the way here is a couple interesting websites to check out

http://www.ircp.info/

http://www.communityparamedic.org/

 

[Carlos Danger]

In brainstorming for the future of the profession, I would keep in mind a few things:

1. Simply admiring the Canadian, Australian, and European models of EMS will do nothing to change things in the US. We need to actually DO something. We have an entirely different model of healthcare and reimbursement than they have over there; their system will not automatically replicate itself here.
   
   
2. Like it or not, it is an absolute joke to even being to discuss "advanced practice" issues when most paramedic programs are still 2-semester vocational programs which utilize textbooks written at a 10th grade reading level and whose only pre-requisites are a GED and a 90-hour EMT course.
   
   Seriously...you can barely do the pre-reqs a for 2 year nursing program in the amount of time it takes to become a paramedic, and you can graduate paramedic school with fewer clinical hours than an AAS program nursing student does in 1 semester. Whereas NP's and CRNA's with doctorates and hundreds of hours of clinical experience are having to fight in court for the right to do the types of things that paramedics are wanting to do.
   
   
3. In the US, paramedics are generally looked upon by many (if not most) physicians as barely educated technicians, rather than as professional clinicians.
   
   
4. With the current model of paramedicine in the US being 100% dependent on physicians for approval in everything that we do, we can accomplish nothing - no sweeping changes at all - without the approval of physicians.
   
   
5. These models and initiative we are discussing (community paramedicine, acvanced-practice paramedicine) will never garner widespread support from physicians, because there is no money in it for them, and nothing to allay their liability.
   
   
6. Physicians will not willingly cede control of what goes on in the prehospital arena. They may appear uninterested now, but as soon as someone else starts making money in EMS, believe me, the doctors will assert their authority. Just ask the CRNA's.
   
   
7. Corollary to number 6: Even those professionals who are indisputably classified as clinicians constantly battle with physician groups over issues related to autonomy, scope of practice, and billing. Generally this relates to advanced-practiced nurses (NP's, CRNA's, CNM's), as PA's, RA's, and AA's are inherently physician-dependent models of practice. Just ask the CRNA's.
   
   
8. If you are really willing to work to advance the paramedic profession, it is probably much easier and more effective to effect change as a PA or NP who has earned the respect of their physician colleagues and learned the ins-and-outs of healthcare politics than it is to do so as a paramedic. Because unfortunately, no matter how well educated and experienced a paramedic you are, you are still "just a paramedic".
   

I don't mean to be all doom-and-gloom. EMS is full of very smart, motivated clinicians who really want to effect positive change. And that is perhaps the most important factor.

We just have to be realistic about what we are up against: market forces and physician interests.

For anyone who really wants to effect change in EMS, my suggestions are these:

1. Become an ED PA or NP. Maintain your state EMT-P card, and keep some active involvement with EMS. (alternatively, earn a BS degree at a minimum - a MS or PhD is better - and be active in education, professional organizations, and lobbying)
   
   
2. Don't be afraid to piss off the physicians. This is a little easier to get away with as an NP than as a PA.
   
   
3. Learn how to lobby at the state level.
   
   
4. We have to learn how to do research, or at least how to interpret and "exploit" (for lack of a better term) research that supports our vision.
   
   
5. Push for much higher educational standards for paramedics in your state.

 

[VFlutter]

[*] Physicians will not willingly cede control of what goes on in the prehospital arena. They may appear uninterested now, but as soon as someone else starts making money in EMS, believe me, the doctors will assert their authority. Just ask the CRNA's.


[*] Corollary to number 6: Even those professionals who are indisputably classified as clinicians constantly battle with physician groups over issues related to autonomy, scope of practice, and billing. Generally this relates to advanced-practiced nurses (NP's, CRNA's, CNM's), as PA's, RA's, and AA's are inherently physician-dependent models of practice. Just ask the CRNA's.

Great points. EMS as a whole could learn a lot about professional advancement from CRNAs who have been fighting a similar battle for years.

I once heard a MD say that CRNAs are the Paramedics of nursing. Undereducated providers trying to perform advanced procedures and then arguing that they are superior to everyone else.

Although there are distinct differences I think there are some similarities in how they both will be viewed by Physicians and their respective struggles.

I am guessing some Emergency Physicians will try to set up something similar to the ACT model and utilize community paramedics to substantially increase their billable patient loads.

 

[Carlos Danger]

Yeah, I don't think there is much parallel at all between paramedics and CRNA's in terms of education, or in comparison to their MD counterparts as far as scope of practice or demonstrated outcomes....

But I don't doubt at all that some doctor said it, and I definitely agree there's a lot that paramedicine can learn from advanced-practiced nursing in general, and nurse anesthesia in particular.

 

[medicsb]

In brainstorming for the future of the profession, I would keep in mind a few things:

1. Simply admiring the Canadian, Australian, and European models of EMS will do nothing to change things in the US. We need to actually DO something. We have an entirely different model of healthcare and reimbursement than they have over there; their system will not automatically replicate itself here.
   
   
2. 
   Seriously...you can barely do the pre-reqs a for 2 year nursing program in the amount of time it takes to become a paramedic, and you can graduate paramedic school with fewer clinical hours than an AAS program nursing student does in 1 semester. Whereas NP's and CRNA's with doctorates and hundreds of hours of clinical experience are having to fight in court for the right to do the types of things that paramedics are wanting to do.

1. 
   
   Lets not get ahead of ourselves here. These nursing doctorate programs, short of a PhD, are a joke. In terms of medicine, they're even more of a joke. BSN to DNP requires a little more than 1000 hours of clinical time, which is about what a 3rd year med student does in 6 months.
   
   

   [*]In the US, paramedics are generally looked upon by many (if not most) physicians as barely educated technicians, rather than as professional clinicians.

   
   By and large, paramedics/EMS has not quite reached "professional" status nor "clinician" status. Be that as it may, the physicians who know what a paramedic does do tend have respect for them. But most physicians, particularly those not in EM know almost nothing about EMS or paramedics.
   
   
   

   [*] Physicians will not willingly cede control of what goes on in the prehospital arena. They may appear uninterested now, but as soon as someone else starts making money in EMS, believe me, the doctors will assert their authority. Just ask the CRNA's.
   
   [*] Corollary to number 6: Even those professionals who are indisputably classified as clinicians constantly battle with physician groups over issues related to autonomy, scope of practice, and billing. Generally this relates to advanced-practiced nurses (NP's, CRNA's, CNM's), as PA's, RA's, and AA's are inherently physician-dependent models of practice. Just ask the CRNA's.

   
   
   
   NPs are nowhere near the level of training and education that is obtained by a physician and are a lower level of care and are fought as they should be. They should have no autonomy - they haven't earned it and do not deserve it. Though CRNAs have a much more rigorous training program, they are nonetheless inferior in training and education and should not be allowed to touch a single patient with complete autonomy.
   
   Regardless, I think it is totally fair for any profession to put a stake in the ground and declare a territory as their own. I only think it appropriate for others to come in when there is an undisputed need. I don't care to see paramedics in EDs or ICUs functioning as nurses. That job is for nurses. I don't care to see NPs or PAs trying to play doctor, when that is the job of a doctor. I similarly don't care to see PAs or NPs trying to be paramedics. The goal of APP or community health medics is, in my mind, to deal with patients related to EMS, in terms of prevention (i.e. proactive vs. reactive).
   
   
   
   

   I once heard a MD say that CRNAs are the Paramedics of nursing. Undereducated providers trying to perform advanced procedures and then arguing that they are superior to everyone else.

   
   Actually, the MDs assessment doesn't sound to far-fetched. Maybe almost spot-on in some cases.
   
   

   I am guessing some Emergency Physicians will try to set up something similar to the ACT model and utilize community paramedics to substantially increase their billable patient loads.

   
   EPs won't see much benefit from community medics. It will be hospitalists and specialties whose future reimbursement will depend upon "quality metrics" such as hospitalization, rehospitalization, medication compliance, etc. of their patients.

 

[Carlos Danger]

NPs are nowhere near the level of training and education that is obtained by a physician and are a lower level of care and are fought as they should be.

You are completely missing the point.

Regardless of how you feel that an NP's training compares to a physicians, the point is that they have far more training than paramedics, yet still have problems gaining autonomy.

They should have no autonomy - they haven't earned it and do not deserve it. Though CRNAs have a much more rigorous training program, they are nonetheless inferior in training and education and should not be allowed to touch a single patient with complete autonomy.

These are highly subjective and emotional statements with no basis in fact. Rather than continuing to spew ignorance, I would suggest that you review the history of APN's, as well as the literature concerning outcomes between FNP's vs. Family Practice MD's and also between CRNA's and MD's.

By and large, paramedics/EMS has not quite reached "professional" status nor "clinician" status. Be that as it may, the physicians who know what a paramedic does do tend have respect for them.

They show you respect because it doesn't cost them anything. But try to get them to support you doing something that they could potentially bill for.....and see how much "respect" they have for paramedics then.



This thread is about the advancement about paramedicine, and how the field can learn from others that have gone before it.

You sound like just another paramedic who is disgruntled at nurses because they make more money than and have more career opportunities than he does.

If you just want to bash nurses, or debate the educational models of the different types of providers, that's fine..... but start a different discussion.

 

[Carlos Danger]

NPs are nowhere near the level of training and education that is obtained by a physician and are a lower level of care and are fought as they should be. They should have no autonomy - they haven't earned it and do not deserve it. Though CRNAs have a much more rigorous training program, they are nonetheless inferior in training and education and should not be allowed to touch a single patient with complete autonomy.

Ahhh, I see.....a medical student

That explains the objectivity, lol.

I guess I'd be cranky too, if I knew I were investing lots of time and money into entering a profession whose model is cost-innefective, at a time when reimbursement dollars are becoming more and more scarce.

 

[VFlutter]

NPs are nowhere near the level of training and education that is obtained by a physician and are a lower level of care and are fought as they should be. They should have no autonomy - they haven't earned it and do not deserve it. Though CRNAs have a much more rigorous training program, they are nonetheless inferior in training and education and should not be allowed to touch a single patient with complete autonomy.

I am not going to try to argue that NPs should have total autonomy because for the most part I think it is a bad idea and we both know neither of our opinions will change since we both have professional stakes. However, the required physician involvement for many NP and even some PA is so non existent it is laughable.

An example of what I think old school is referring to: ACNPs have at least 6 years of education requiring 2 years of ICU experience. Up until recently Intubation was outside their scope of practice in many states and had to fight tooth and nail for it compared to a skill that is automatically granted to paramedics.

 

[Tigger]

Let's keep things civil and on topic here please.

 

[VFlutter]

Ok, Back on topic.

It sounds like a great idea if it can be done the right way. I think we can all agree that is going to take more than a 200 hour course like some places are pushing for. I think a PA program with specialty in paramedicine may be a better more feasible alternative.

 

[JPINFV]

[*]In the US, paramedics are generally looked upon by many (if not most) physicians as barely educated technicians, rather than as professional clinicians.

That's because the large number of <1 year certificate paramedics makes the average paramedic look like a barely educated technician. Don't mistake current location with ideal location. Also you shouldn't care what a pathologist or pediatrician thinks of EMS.

[*]With the current model of paramedicine in the US being 100% dependent on physicians for approval in everything that we do, we can accomplish nothing - no sweeping changes at all - without the approval of physicians.

...and with the growth of EMS specialized EM physicians, the number of EMS friendly physicians are going to grow. It's not necessarily an antagonistic situation.

[*]These models and initiative we are discussing (community paramedicine, acvanced-practice paramedicine) will never garner widespread support from physicians, because there is no money in it for them, and nothing to allay their liability.

The prior point and this one are at odds with each other. As is the assumption that all physicians are greedy businessmen just looking to earn an extra buck. Sure, we're not going to spend a decade of our lives and half a million dollars in debt to make 50k/year, but most of us aren't Gordon Gekko (Reference: movie: Wall Street. Quote: "Greed is good") either.

[*] Physicians will not willingly cede control of what goes on in the prehospital arena. They may appear uninterested now, but as soon as someone else starts making money in EMS, believe me, the doctors will assert their authority. Just ask the CRNA's.

So if intermediates all of a sudden say that they're just like paramedics and should be able to do everything a paramedic does with significantly less education, you'd be fine with it?

[*] Corollary to number 6: Even those professionals who are indisputably classified as clinicians constantly battle with physician groups over issues related to autonomy, scope of practice, and billing. Generally this relates to advanced-practiced nurses (NP's, CRNA's, CNM's), as PA's, RA's, and AA's are inherently physician-dependent models of practice. Just ask the CRNA's.

You mean midlevel providers who want only the easy patients, punt anything hard to physicians, and want the same pay, respect, and privilege as physicians? ...and physicians should just roll over and accept it? If I was mean, I'd say that we should set up two systems of healthcare. One ran by physicians (and physician supervised midlevels) and one by autonomous midlevels (who can subsequently pay their own malpractice). When a midlevel poops the bed (and all providers end up pooping the bed, but want to compare a 2 year educated noctor in IM (internal nursing? After all, nursing isn't medicine... according to nurses) practicing independently to a physician who has 4 years of med school and 3 years of IM residency?), they should only be allowed to refer to another midlevel.

The problem with the militant midlevels is that they want all the benefits of being a physician without the struggles or risks (i.e. malpractice) of being a physician. Being a patient advocate also means knowing one's own limitations. The midlevels who want in essence an unrestricted license to practice medicine do not know their own limitations.

For anyone who really wants to effect change in EMS, my suggestions are these:

1. Become an ED PA or NP. Maintain your state EMT-P card, and keep some active involvement with EMS. (alternatively, earn a BS degree at a minimum - a MS or PhD is better - and be active in education, professional organizations, and lobbying)

Why not go to med school if you want to play with the big dogs?

 

[JPINFV]

You are completely missing the point.

Regardless of how you feel that an NP's training compares to a physicians, the point is that they have far more training than paramedics, yet still have problems gaining autonomy.

Because autonomy should be handed out like toys from a Crackerjack box?

These are highly subjective and emotional statements with no basis in fact. Rather than continuing to spew ignorance, I would suggest that you review the history of APN's, as well as the literature concerning outcomes between FNP's vs. Family Practice MD's and also between CRNA's and MD's.

You mean ones like this abortion of statistics?
http://www.ncbi.nlm.nih.gov/pubmed/10632281

17 physicians to 7 NPs? Hardly a powerful study, painfully short study period (6 months and 1 year?) and relying on simple statistical significance as a crutch. Where's the relative risk ratio? What about medical signficiance? Oh, look, a 3 point drop in diastolic BP? Heck, that's not even out of the normal margin of error for most blood pressure cuffs (+/-3 mmHg). Can we discuss the the validity of a study which is mostly a survey when it comes to saying that primary care physicians and NPs are equal?

They show you respect because it doesn't cost them anything. But try to get them to support you doing something that they could potentially bill for.....and see how much "respect" they have for paramedics then.

By gosh, by golly, how the heck are there even community paramedic programs to begin with! [/sarcasm]

This thread is about the advancement about paramedicine, and how the field can learn from others that have gone before it.

You sound like just another paramedic who is disgruntled at nurses because they make more money than and have more career opportunities than he does.

If you just want to bash nurses, or debate the educational models of the different types of providers, that's fine..... but start a different discussion.

What I heard you say here was, "How dare someone disagree with me and not think that mid levels are the best thing since sliced bread."

 

[JPINFV]

Ahhh, I see.....a medical student

...and what's your background?

I guess I'd be cranky too, if I knew I were investing lots of time and money into entering a profession whose model is cost-innefective, at a time when reimbursement dollars are becoming more and more scarce.

Cost-inneffectiveness? Physician pay is about 20% of US healthcare costs in 2010. Now there's a catch here. Physicians don't make 20% of healthcare costs in take home pay. That includes overhead and insurance and supplies and staff. Unless midlevels can fart out malpractice insurance, clinic space, supplies, and support staff (including nursing staff) for their clinics, then they're going to have the same overhead costs as physicians. That makes the amount of the pie representing take home pay significantly less.

 

[medicsb]

You are completely missing the point.

Regardless of how you feel that an NP's training compares to a physicians, the point is that they have far more training than paramedics, yet still have problems gaining autonomy.

I don't think I missed any point, but, I'll clarify mine: short of an MD or DO - no one should be allowed complete autonomy to practice medicine - nurse, paramedic, or PA. I do not think it unreasonable to grant a certain degree of autonomy, but within medicine, the physician is the ultimate authority and should have ultimate control.

These are highly subjective and emotional statements with no basis in fact. Rather than continuing to spew ignorance, I would suggest that you review the history of APN's, as well as the literature concerning outcomes between FNP's vs. Family Practice MD's and also between CRNA's and MD's.

I'm familiar with the various studies of dubious quality that the nursing lobby tout. There vast differences in training quality and quantity is undeniable. Moving on...

They show you respect because it doesn't cost them anything. But try to get them to support you doing something that they could potentially bill for.....and see how much "respect" they have for paramedics then.

EMS has long been able to bill for medical care, which hasn't caused physicians to oppose paramedics, especially since paramedics initiate care that could otherwise be initiated by a doc at a hospital for which they'd be able to bill. I don't think physicians are threatened by "community paramedics", particularly since most of these (all?) of these programs have been initiated by physicians or with strong physician support. Even in NJ, community paramedics are being considered. The only folks there I've heard raising objections are nurses.

And as mentioned previously, there are A LOT of physicians who got their start in EMS. I do not foresee physicians opposing these programs as currently envisioned.

 

[usalsfyre]

Regardless, I think it is totally fair for any profession to put a stake in the ground and declare a territory as their own.

The vast majority of my complaints about nursing relate to this exactly. Micturate in your own sand box.....

 

[Carlos Danger]

see what I mean? you just proved my point for me.

I'm familiar with the various studies of dubious quality that the nursing lobby tout.

Studies of such "dubious quality" that they have been accepted by CMS, the Institute of Medicine, and many if not most state hospital associations, all which have issued statements or directives arguing for expanded use of APN's "to their fullest potential".

Here's something to chew on: The salaries that anesthesiologists demand are in most cases significantly higher than the revenue that they generate. This means that the large hospitals lose money on every anesthesiologist that they employ.

CRNA's, on the other hand, can bill for the same amount as MD's, yet are perfectly happy working for HALF what an anesthesiologist requires......now how do you think that's gonna wash out when the Affordable Care Act takes full effect and hospitals get so tight for dollars that they have no choice but to start making really tough decisions about cutting services and looking at who and what is really cost effective?

And if CRNA's are unsafe providers, then explain why their malpractice rates have fallen steadily for the past several decades, which is the opposite of the overall trend in healthcare......right now, a CRNA who practices independently (as about 25% do) pays less in malpractice premiums, on average, than does one in an ACT practice. How does that work, if they are a risk?

Be as dismissive as you want, but CRNA's and NP's are steadily gaining autonomy and a larger role in healthcare, whether you like it or not.

of an MD or DO - no one should be allowed complete autonomy to practice medicine

Under what authority does the medical lobby proclaim to have the only right to provide healthcare? Just because "that's how it's always been"?

That paradigm is over, brother. That ship has sailed and given the current state of healthcare, with the ultra-demand for value and cost control, it is never coming back.

The medical lobby pretty much shot itself in the foot when for decades they artificially inflated demand for their services (and thus their income) by intentionally maintaining shortages in certain specialties. They essentially created a vacuum that the market decided to fill with other providers.


All of this may seem off-topic, but it's actually not....the reality is that these are issues that may affect paramedics as they push for a greater autonomy and a wider scope of practice.

 

[Shishkabob]

Also you shouldn't care what a pathologist or pediatrician thinks of EMS.

Had an ER physician call me an ambulance driver last night when a patient said they wanted to speak with me.

While looking at the physician, but directing the verbal response to the patient, I said "Sorry (patients name), I didn't go to school for 2 years to be called an ambulance driver"


It's one thing if a GP said that, another completely when a physician at a level 1 trauma center that works daily alongside my medical control says that.

 

[JPINFV]

Studies of such "dubious quality" that they have been accepted by CMS, the Institute of Medicine, and many if not most state hospital associations, all which have issued statements or directives arguing for expanded use of APN's "to their fullest potential".

You mean a bunch of agencies who care more about cost than quality want the cheaper option? Color me shocked.

Here's something to chew on: The salaries that anesthesiologists demand are in most cases significantly higher than the revenue that they generate. This means that the large hospitals lose money on every anesthesiologist that they employ.

CRNA's, on the other hand, can bill for the same amount as MD's, yet are perfectly happy working for HALF what an anesthesiologist requires......now how do you think that's gonna wash out when the Affordable Care Act takes full effect and hospitals get so tight for dollars that they have no choice but to start making really tough decisions about cutting services and looking at who and what is really cost effective?

You think that hospitals employ physicians? Cute. The anesthesiologist's group is contracted through the hospital and is going to bill independently.

And if CRNA's are unsafe providers, then explain why their malpractice rates have fallen steadily for the past several decades, which is the opposite of the overall trend in healthcare......right now, a CRNA who practices independently (as about 25% do) pays less in malpractice premiums, on average, than does one in an ACT practice. How does that work, if they are a risk?

You mean providers who take the least risky cases have lower malpractice costs? Fun fact, university hospitals tend to have higher mortality rates. Residents aren't always the reason. Another is that those hospitals are more likely to accept the cases that no one else will touch. Likewise, anesthesiologists are more likely to touch high risk cases that CRNAs won't... and shouldn't... touch. However I guess we should deny those people health care because it's just to risky?

Under what authority does the medical lobby proclaim to have the only right to provide healthcare? Just because "that's how it's always been"?

Under what authority do NPs and PAs have to claim the right to practice medicine?

The medical lobby pretty much shot itself in the foot when for decades they artificially inflated demand for their services (and thus their income) by intentionally maintaining shortages in certain specialties. They essentially created a vacuum that the market decided to fill with other providers.

...because residencies can be funded and opened on a dime... right?



Also... we still don't know what your conflict of interest is here. Are you a noctor student?

 

[Chris07]

That paradigm is over, brother.

Out of curiosity...then why do we need doctors? If I can see a fully autonomous NP for half price why on earth would I want to see a physician?

If the paradigm is over why are we not phasing out physicians and replacing them with autonomous mid-level providers, since we've already established that they are more cost effective?

I'm sorry but something has to seperate a physician from a mid-level besides the kind of school they go to and the letters before/after their name. I believe full autonomy should be that element of separation. I mean if I can be autonomous as an NP/PA...why the heck should I go to med school?

 

[Aidey]

Back on topic. Now. The next person that posts about RNs vs MDs vs Anyone is going to be the object of my complete and undivided attention.