The Future of Paramedicine

[SpecialK]

As far as who should determine standards, it should be EMS providers - I think - in a self-regulatory body like the UK has.

So here is the part I am confused about. We are told, in the Australasian move towards registration and "formal' self-regulation recognised in legislation, that Paramedics in the US are already a registered and self-regulated profession? You have a body you are accountable to for performance and conduct and said body sets standards and is able to censure you for bad performance or conduct and they also hear complaints against you if bought to them?

For example, I looked up California (because this is where you get off the plane direct from downunder!) and they have an agency which registers and licenses paramedics, they set standards of conduct and can hear complaints and presumably censure bad conduct - be it clinical or otherwise you know, like bad professional conduct. This sounds exactly like what the HCPC in the UK does, and what AHPRA in Australia does, and will soon do for Paramedics, same with the "responsible authorities" in New Zealand. So how is this not self-regulation?

if I was treated very clinically poorly by a Paramedic in California (or presumably any other state) or they did something really bad like in terms of conduct with a patient or a coworker; could I not make a complaint to the appropriate agency described above? Presumably they would investigate it and there would be a disciplinary process with evidence and whatnot and they would make a determination to suspend or alter or cancel this persons registration or make them do something to be able to continue being registered; for example attend more clinical training or something in an area they were deficient in?

 

[EpiEMS]

Paramedics in the US are already a registered and self-regulated profession? You have a body you are accountable to for performance and conduct and said body sets standards and is able to censure you for bad performance or conduct and they also hear complaints against you if bought to them?

Yes and no. So, for most EMS providers, we are licensed by a state and authorized to practice by a medical director. This is not exactly portable, and is not consistent across the country. However, on the other hand, most (I believe) of us are certified (at least, initially) under the auspices of the National Registry of Emergency Medical Technicians (NREMT), which is an independent certifying body.

So, broadly speaking, we've got a couple of things going on:
- State licensure (possibly also weird things like county-level authorization, like in CA)
- NREMT certification
- Medical direction authorizing you to practice in a system (and, obviously, the employer's authorization to do basic things like drive the ambulance, etc.)

Keep in mind, of course, that certification by the NREMT confers no legal right to practice - it is merely a certification by this independent body saying that you are (entry-level) competent to practice.

So, to bury the lede a little bit...Are we self-regulated? I would say, emphatically, no. If I mess up, I don't necessarily answer (ultimately) to an EMS provider (or body of EMS providers) - I answer to several groups that may or may not include EMS providers: The state EMS office (which, may or may not be EMS provider run - it could be physicians, nurses, or just state bureaucrats), the state medical board (physicians), my own medical director, as well as my EMS service (so, here, I'm probably dealing with another EMS provider), and, depending on where I am, a county EMS office.

Are, for example, physicians self-regulated? Absolutely - they answer to their own, pretty much exclusively (other than, perhaps, a hospital administrator). Yes, they have state licenses, but they answer to the state medical board (physicians), their own national bodies (like the ABMS),etc. So, what's the difference? They answer to their own.

What does it mean to you that paramedics/EMS providers are "registered"? Do you mean that we have an authorization through a license (within a state) that lets us practice more or less with whatever employer in that state will hire us?

 

[SpecialK]

Oh, that's quite interesting that you speak of a regulatory body (state office) which might be run by nurses for example, why on earth would nurses want anything to do with regulating ambulance personnel? That'd be like a bunch of physiotherapists running the regulatory authority for dentists ...

"Registration" refers to the fact you must have your name on a register to be allowed to call yourself by a specific title and practice what that entails, for example doctors must be registered to practice medicine, dentists must be registered to practice dentistry etc. This registration is invariably required by some law (for example the AHPRA National Law in Australia, the Health Professions Order in the UK, or the HPCA Act in New Zealand). Without your name on this register, you cannot be employed.

Regulation determines registration; i.e. you must meet certain regulations (standards) to be registered. Very common examples are an education of a specific standard (for example bachelor degree or higher), meet various criminal background checks, maintain on-going professional development, apply for re-registration every year or two years or whatever. The "other side" this is you are held to various standards in terms of your conduct both clinically and otherwise; if you read the HCPC disciplinary reports from the UK they have altered and cancelled registration of people who have performed very clinically poorly but also poorly in non-clinical areas such as being sexually harassing towards coworkers etc.

A "self-regulating" profession is exactly that, one which regulates itself. For example, the Medical Board of Australia regulates doctors. The Board is made up entirely of Doctors, except for some community representatives. The HCPC in the UK is a bit different, on its disciplinary panels it is made up of members of the HCPC who may be of other professions (for example an arts therapist might make up part of the panel disciplining an audiologist) but IIRC they always have a minimum of two of the same profession on the panel as well. This is a bit unique because the HCPC is a "merged" single regulatory authority covering all the professions regulated by it. This is not the case in Australasia, although the AHPRA Agency in Australia has a merged overarching body with distinct professional Boards. Regardless, it is the profession which determines its own standard of conduct and "fitness" for registration via the regulations it promulgates via the regulating authority.

Sounds to me like you pretty much have self-regulation as far as determining what standards are applicable for registration (such as education being the main one) with some variation in how your regulatory authorities are made up, so a bit like the HCPC in the UK. In Australasia by comparison, there is complete self-regulation but no registration, and that is what is changing.

Sounds like you blokes need to make some moves towards a single national cross-jurisdictional regulatory body akin to AHPRA or the HCPC, even if it's just for ambulance personnel. And truth be known, I think Canada is doing something like that .... don't quote me though.

 

[EpiEMS]

@SpecialK unfortunately I doubt we could have anything cross jurisdictional as far as regulation goes. Each state controls professional licensure, at least in my understanding, so I'd be surprised to see anything for EMS personnel when even nurses, say, don't have too much going on there.

as to why nurses (for example) would want to be on an EMS regulatory body, I would say that the answer is largely turf protection - other fields have a vested interest in limiting EMS providers from "usurping" their roles (e.g. in some states, nurses have successfully prevented paramedics from being providers in the ER under their paramedic license).


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[SpecialK]

@SpecialK unfortunately I doubt we could have anything cross jurisdictional as far as regulation goes. Each state controls professional licensure, at least in my understanding, so I'd be surprised to see anything for EMS personnel when even nurses, say, don't have too much going on there.

Interesting. I'm surprised it hasn't become the topic of some health agenda by a political party; particularly one on the more conservative end of things. They usually bash on about maximising gains of money spent and such, and it's not exactly a new idea; it's done already in Australia and the UK, and something about it is being done in Canada. It also makes common sense too, you know, if you move from X state to Y state within the same country why should you have to go through all that again with another regulatory agency ... hence the portability of the AHPRA National Law in Australia.

as to why nurses (for example) would want to be on an EMS regulatory body, I would say that the answer is largely turf protection - other fields have a vested interest in limiting EMS providers from "usurping" their roles (e.g. in some states, nurses have successfully prevented paramedics from being providers in the ER under their paramedic license).

Also interesting ... never seen any of this myself. Nurses, docs, ambos, all get on great down here, except when the nurses want to do daft things without realising it.

So what do you blokes think "the future" looks like within the next say, five to ten years? Where do you see the big "wins on the board" being? Broadly in Australasia, it is in the expansion of hear-and-refer and see-and-refer pathways which will be greatly enhanced by a single national electronic health record and formalised pathways such as falls, stroke, COPD etc. Registration is also key but this won't change "day-to-day" stuff much. I can also see perhaps a post-graduate pathway developed for more specialised primary care work in exactly the same way you need a postgraduate qualification to be an Intensive Care Paramedic. Is there anything you think the US is doing the rest of the world could learn from?

 

[E tank]

Is there anything you think the US is doing the rest of the world could learn from?

This is what the rest of the world just can't get it's head around in terms of the United States. We are the most heterogeneous, far flung nation in the history of the world. Our territories span from the US Virgin Islands in the Caribbean Sea to Guam and American Samoa in the South Pacific. We have more ethnic diversity in our citizenry than any other nation on the planet in all of recorded history. This heterogeneity makes standardization of agency based services in neighboring states impractical, let alone half way across the globe. Our historical philosophy here (since 1776, anyway) for the most part is that folks on the ground where they are make the assessments and determine the need, for better or worse. Chicago is not LA is not New York is not Oakland is not Laramie is not Cheyenne is not Boise is not Lahaina. And will never be.

Comparisons are interesting, but at the end of the day are apples to oranges as far as other national systems are concerned. Forgive me my giggles when non-Americans criticize our systems. I'd love to see them give it a try.

 

[SpecialK]

Yeah all right mate.... I didn't ask if everything should be identical, I asked if you guys did anything you thought we could learn off of?

Where do you see "the future" being in 5 or 10 years perhaps?

 

[Medico]

I think this is great!

The nursing profession advanced and has been unstoppable ever since requiring an associates to be an RN. The possibilities for nursing In magnet facilities where it is required that nurses have or earn a B.S. in nursing is even greater.

For paramedicibe to advance we must require more education and unify it on a notional lever.

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[Summit]

An associates is not required to be a RN.

You can be an RN with after attending a diploma program (non-degree program), but diploma schools are still 2.5-3 years of schooling and clinicals. These schools have been in decline and only still found in the North East.

 

[E tank]

Yeah all right mate.... I didn't ask if everything should be identical, I asked if you guys did anything you thought we could learn off of?

I guess that was my back hand way of saying, to the degree possible, leave operational decision making and medical control at the local level. That may be the model in a lot of other places already...just throwing it out there.

 

[Summit]

I guess that was my back hand way of saying, to the degree possible, leave operational decision making and medical control at the local level. That may be the model in a lot of other places already...just throwing it out there.

In other words, when considering span of control, most other first world nations are smaller in population and/or area than many American states?

@SpecialK is asking for more good ideas than that realization. But I am unsure what the US has to teach other first world nations in EMS in terms of systemic ideas or operational conceptions...

 

[SpecialK]

@SpecialK is asking for more good ideas than that realization. But I am unsure what the US has to teach other first world nations in EMS in terms of systemic ideas or operational conceptions...

Most of what we're doing is pretty much what everybody else is doing anyway, for example, clinical advice and pathways are nothing new, registration is "new" but certainly the norm elsewhere. When I said we might get a Postgraduate level specialist qualification for the more primary care stuff well that was first done in England in about 2000, so 17 years ago now. Hardly anything new.

You'll often hear "oh that's done by so and so this way in Canada / Australia / NZ / the UK ... but they do it like ...." or whatever. I've never heard anybody say "oh we saw this great idea in the US, and they're doing .... and we could do it too, but maybe like this ..." or something.

There must be something you blokes do you reckon is a good idea?

 

[Summit]

There must be something you blokes do you reckon is a good idea?

Hmmmmmmmmmmmmmmmmmmmmmmm............
Uhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh...................

We have some cool integration opportunities between ambulance services and SAR teams where ambulance paramedics undergo some SAR training and utilized by the SAR teams to offer Paramedic ALS to appropriate SAR patients. This works well in the US where most almost all SAR is volunteer BLS.

We have some cool integration programs where SAR and Ski Patrol train with HEMS to utilize the HEMS helicopter to deploy rescuers rapidly to time sensitive patients particularly in avalanche rescue. It works well for an American style system, but if you want to see a better way to do it as a system, look at Austria or Switzerland or France.