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by Mike Ward

EMT experience not needed for paramedic certification

Increasing gap between EMT and paramedic programs diminishes value of EMT street time in preparing for success as paramedic

By Mike Ward


It is a statement I have heard since my first EMT class: "You should spend at least a year as an EMT before starting paramedic school." Implementation of the 2009 Education Standards makes this assertion obsolete. Here are four reasons why:

1. CoAEMSP-accredited paramedic programs require more patient assessments and demonstration of clinical competency.

Education standards increased the breadth and depth of many paramedic-level topics. Program accreditation assures increased provider competency through documented patient assessments and demonstration of clinical competency.

For example, here is the August 2012 recommendation from the CoAEMSP task force on intubation:

"The paramedic student should have no fewer than 50 attempts at airway management across all age levels, with a 90% success rate utilizing endotracheal intubation models in their last 10 attempts. The paramedic student needs to be 100% successful in the management of their last 20 attempts at airway management."1

2. NSC programs had fewer patient encounters and clinical procedures.

Most National Standard Curriculum (NSC) paramedic training programs struggled to meet clinical competency recommendations. Salzman, Page, Kaye and Stetham shared the results of a 2001-2005 study of 1,817 paramedic students from 98 programs that were tracked with FISDAP™ record-keeping.

While all of the students graduated, their clinical experiences were not completely compliant with NSC recommendations:

·         15 medication administrations (92 percent)

·         25 successful IV accesses (88 percent)

·         30 geriatric assessments (63.7 percent)

·         Five live endotracheal intubations (63.5 percent)

·         50 adult assessments (63.2 percent)

"A majority of PS are completing less than 50% of the NCS-P recommendations for 20 ventilations on an un-intubated patient, 20 psychiatric patient assessments, 8 pediatric respiratory distress assessments, and 10 obstetric patient assessments," the study said5.

3. There is no relationship between paramedic student performance and time as an EMT.

It would be a mistaken assumption to think that more EMT field experience would result in a higher success rate.

Peralta, Fraga and Asensio conducted a retrospective survey comparing Mexico City paramedic students' passing rates on the certification exam with the time they spent as an EMT.

For exam year 2004-2005, there were 538 students. Exam year 2005-2006 had 132 students.

"More than 57% had > 5 years of PFE, but the experience level did not correlate significantly with higher passing rates for the registry evaluation," the survey said4.

The Mexico City study did not focus on the difference between students with zero experience versus one year. The smallest subsection included students with zero to four years of field experience.

4. The academic quality of EMT programs varies tremendously.

There has been significant effort in the past four years to improve resources and lead instructors' academic qualifications to prepare paramedic programs for CoAEMSP accreditation. Some EMT programs benefit from a trickle-down effect, but they are not required to be accredited.

In most states, a 2013 Education Standards EMT class will be taught by a lead instructor with a high school diploma and a state instructor credential.

The National Registry of Emergency Medical Technicians funded research to identify successful strategies of high-performance training programs:

  • Select students who are highly motivated to succeed.
  • Assure adequate institutional support.
  • Administer multiple assessments of student progress throughout the class.
  • Develop standardized lesson plans to be used when team teaching.
  • Establish a passing standard that is above the minimum competency level.
  • Hire qualified/certified instructors.
  • Maintain effective communication between didactic, practical and field instructors.
  • Assure instructional consistency.
  • Provide clearly defined objectives to students and instructors.
  • Provide immediate feedback for written, practical evaluations to students.
  • Require prerequisites prior to admission.
  • Teach test-taking skills in class.

The discussion on instructors included this:

"Focus group participants generally agreed that EMT instructor training/certification and meeting the state minimum standards alone was insufficient. Many programs required formal educational degrees (usually bachelors degree or above) for lead instructors as well as formal teaching experience (typically experience as a lab instructor and/or guest lecturer)."2

What I think

I have worked with a variety of EMT training organizations to meet the Education Standard. My experience is similar to this part of the National Registry discussion of paramedic educational programs:

"Create Your Own Examinations, Lesson Plans, Presentations, and Course Materials Using Multiple Current References

"This recommendation appeared to stem from the group's identification that many struggling programs rely heavily on commercially available instructional support materials and the National Standard Curriculum (NSC). High-performing programs recognized the paradox that as better materials are available (typically from publishers), instructors and programs tend to take less time and care in developing their own materials.

"In some cases, this leads to a lack of preparation for class ('Just giving instructors a PowerPoint file fosters lack of preparation'). One comment summarized the group opinion, 'It is no problem to start with commercially available resources, but it does not end there. '"3

I found experienced EMT instructors tethered to their vendor-provided PowerPoints and unwilling or unable to develop appropriate course material. The Virginia experience with 4,000 EMT instructors may provide a clue.

The Virginia Office of EMS is requiring incumbent instructors pass a 155-question multiple choice and five-question essay knowledge exam. The essay questions represent the type a student might ask, and the topics come from the new Education Standard areas. The minimum passing score is 85 percent.

Only 54 percent of the incumbent instrutors passed the exam on their first try. Of those who retook the exam, only 59 percent passed. The Office of EMS noted, "The low second time pass rate is somewhat concerning."6

The increasing gap between EMT and paramedic programs diminishes the value of EMT street time in preparing for success as a paramedic. The EMT graduate with the required 10 hours of clinical time and 10 patient assessments should start paramedic training right away.


Mike will discuss this article on Wednesday, Sept. 12, on EMSEdUCast.


1. CoAEMSP. CoAEMSP Defines Airway Competency. Aug. 2012.

2. Margolis, Gregg S., Jonathan R. Studnek, Antonio R. Fernandez, Joseph Mistovich. Strategies of High Performing EMT-Basic Educational Programs. Prehosp Emergency Care. 2008;12:206–211.

3. Margolis, Gregg S., Jonathan R. Studnek, Antonio R. Fernandez, Joseph Mistovich. Strategies of High Performing Paramedic Educational Programs. Prehosp Emergency Care. 2009;13:505–511.

4. Peralta, Luis M. Pinet, Juan M. Fraga, Enrique Asensio. (05/2008) Clinical experience and practical skills: results from Mexico City's paramedic registry. Prehospital and disaster medicine (1049-023X), 23 (3), 227.

5. Salzman, Joshua G., David I. Page, Koren Kaye, Nicole Stetham. Paramedic student adherence to the National Standard Curriculum recommendations. Prehospital Emergency Care. 2007 Oct.-Dec.;11(4):448-52.

6. Virginia Office of Emergency Medical Services. Quarterly Report to the State EMS Advisory Board. Aug. 2012.

About the author

Michael J. Ward, BS, MGA, MIFireE, NREMT-Basic, spent 12 years as an academic, ending as Assistant Professor of Emergency Medicine at George Washington University in 2012. He treated patients as an EMT (commercial, volunteer and seasonal) and paid firefighter/paramedic and, during a 25-year career with Fairfax County (Va.) Fire and Rescue, worked in every division of the department, retiring as the acting EMS division administrator. Ward is also a textbook author and conference presenter.
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John Longenecker John Longenecker Tuesday, July 09, 2013 7:04:43 AM I'm a believer in EMT-1 for two years before being eligible to apply to Paramedic School. This article speaks about credentialing and demonstrating skills, but one skill is missing: people person. A good EMT experience will develop people person skills, how an EMT handles stress, exhaustion, thinking on their feet, innovation, independence and good judgment. Two years is a good proving period to discover strengths and weaknesses, command and leadership potential, as well as developing skills into a model of a professional who is well prepared for a great leap in training. Whether the EMT really has the capacity for compassion, the ability to listen, or any essential attitude can be discovered only during real life care.
Skip Kirkwood Skip Kirkwood Friday, June 27, 2014 4:29:44 AM I agree with John Longnecker that people skills are important. However, I disagree that "....Whether the EMT really has the capacity for compassion, the ability to listen, or any essential attitude can be discovered only during real life care." There are a number of validated psychological testing instruments out there that can evaluate those areas, and several other affective domain characteristics. We just have to pick them, pay for them, and use them. "Experience" is not the end-all - the QUALITY and nature of the experience really matters. Two years at a negative, poor customer service ambulance company doing inter-facility transports probably won't improve the educational process for the future paramedic.
Michael Everhart Michael Everhart Friday, June 27, 2014 3:19:50 PM I disagree with this. While the education requirements may become more stringent. The experience received functioning at the EMT Level is critical to producing high quality Medics. In my experiences a good strong Medic was a good strong basic.
Dennis Mitchell Dennis Mitchell Monday, June 30, 2014 11:36:53 AM Perhaps we should begin by asking four questions. (1) Isn’t the value of experience contingent upon the quality of that experience? Just because they have been in the field does not necessarily mean it has been valuable in the sense that they are better prepared to understand and apply the knowledge associated with the paramedic curriculum. (2) What kind of experience adds educational value and is this what our incoming students are getting? If we could hand pick who our students gain their year (or two or three) of experience with the list would be very short indeed. We all know that paramedic mentors who are up to date, model life-long learning and exhibit the best of the profession are very rare. Few of our candidates will have this quality experience. Is it not also true that even great practitioners may fail to be great mentors resulting in sub-optimal learning experiences for our incoming students? If they deliver good patient care but never take the time to explain what they are doing and why or give the new EMT a chance to spread their wings (within their scope of practice) what good is that experience? Some of our candidates will have this experience. Then there are those paramedics who are walking examples of what is wrong with our profession that can ruin even the best and brightest candidate before they even get started. Who rates a green partner at your ambulance service? Is it your best and brightest or the person who can’t keep a partner and that no one else will work with? Far too many of our candidates will have this experience and it will hold them back or ruin them. (3) What are the repercussions to the student when their experience does not model or prepare them for up to date professional patient care? Think about the negatives of a sub-optimal experience and how it can place these incoming paramedic students at a very distinct disadvantage. We have to appreciate the bias that is the product of a poor experience resulting in a distorted, out of date, and myopic view of the profession. This sub-optimal experience hinders these students from the beginning and actually interferes with learning. In effect we set them up to fail. It is much more difficult to bring these students up to speed and overcome the resistance that their false perception has created. Sadly these students are often not able to make the transition and withdraw or fail. (4) When only marginal quality field experience and/or marginal mentor interaction is available couldn’t the student be better served by coming into the paramedic program without a poor field experience? Would it not be better for these candidates to begin with a clean slate and while their enthusiasm is high?
Dennis Mitchell Dennis Mitchell Monday, June 30, 2014 11:39:07 AM I agree that "good EMT experience" is valuable but it is the rarest of the rare for a green EMT to find today.
Dennis Mitchell Dennis Mitchell Monday, June 30, 2014 11:41:19 AM Skip, I think you are on target. It is the quality of their experience that matters to the paramedic candidate and those opportunities are diminishing by the day.

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