Why EMS needs higher education
An increasing number of accredited paramedic education programs can lead to better care, career growth, and more respect within the health care industry
By Arthur Hsieh
Field medicine is evolving faster today than ever before.
External factors such as changes in an aging population, health care reimbursement, evidence-based medicine and a move toward preventive care are affecting the population EMS providers serve. Proactive EMS systems are rising to the challenges, adapting in innovative ways to not just survive, but also thrive in the new environment.
Training EMS providers to perform tasks such as discharge follow up, high-frequency caller reduction, and harm-reduction efforts may result in far more effective care, at a lower cost than the traditional EMS model of being highly reactionary and high cost.
While such efforts are laudable, they fall short of what is needed to sustain long-term growth in the profession. Systems will need to depend upon not only a well-trained workforce, but a well-educated EMS professional to provide increasingly sophisticated medical services in this dynamic environment.
In this regard, EMS education is at a crossroads.
Will it take the more difficult path of growth and change, or will it take the easier path of "if it ain't broke, don't fix it?" This decision has significant consequences for the industry's future.
The tail wagging the dog
In 1996, the National Highway Traffic Safety Administration's EMS section released EMS Agenda for the Future, a consensus document that provided a glimpse of what EMS might look like in the future. The Agenda advocated for continued development of "out of facility" care by focusing on various attributes of an EMS system.
Of particular note was the state of EMS education. The Agenda noted that there were no fewer than 40 types of EMS certification across the country, and that education was being provided in a wide variety of environments and circumstances. Little information regarding public health, management and research principles was offered in initial education programs.
Moreover, the nature of education in EMS was unusual in that it drove the development of the industry, rather than the other way around. Typically, new procedures, techniques, and processes in an industry are developed through innovation and research. Educators review the developments and incorporate the new content into the primary education process.
In early stages of EMS education, the industry adopted education content embedded in documents such as the National Standard Curriculum. In essence, it was a case of the tail wagging the dog, creating circumstances that were awkward and limiting to the practice of a local or regional system.
As a result of the discussions related to the Agenda, subsequent efforts of various EMS associations culminated in the release of the 2000 EMS Education Agenda for the Future: A System's Approach. The document outlined a process where the domain of practice was described (National EMS Core Content) and divided among various levels of field providers (National EMS Scope of Practice).
A set of National EMS Education Standards was then developed to provide guidance to educators who could develop curricula that was more specific to the practice of their region.
The Education Agenda also details the need for a consistent recognition process (National EMS certification) that would promote license portability across states, and a method to ensure that EMS education programs had the infrastructure to reliably and consistently train new providers (EMS Education Program Accreditation).
The Education Agenda suggested a 10-year timeline to implement the process. With the intent of bringing a level of consistency and quality to EMS education programs and their students, where does the Education Agenda stand today?
Where we are now
Since the release of the Education Agenda, the National EMS Core Content, Scope of Practice, and Education Standards have been completed and released. Many, if not most states have adopted the standards as the basis of education for EMTs and paramedics.
Educational institutions have been transitioning from the old standards since 2010. In March, NHTSA requested input from the national EMS community as to whether to update the Education Standards.
The general consensus was to only slightly modify the standards; most stakeholders felt that ongoing significant developments in EMS practice precluded a major update at this time.
Efforts continue to achieve national EMS program accreditation. There is no current requirement that EMS programs be accredited by a peer-driven, nongovernmental agency similar to all other allied health professions. The most evident trend has been the increasing number of accredited paramedic education programs.
The Commission on Accreditation of Allied Health Education Programs currently recognizes 389 paramedic programs across the United State; another 285 paramedic programs are currently under review for becoming accredited. It is not clear how many paramedic programs exist nationally.
There appears to be a trend toward national EMS certification, at least for EMTs and paramedics. Forty-six states currently require that EMS providers gain initial certification by the National Registry of Emergency Medical Technicians (NREMT) as a condition of state licensure. This may include EMT, paramedic, or both certifications. However, far fewer states require their providers to maintain NREMT certification.
In 2013, the NREMT required that paramedic candidates graduate from CAAHEP-accredited programs. This has accelerated the number of paramedic education programs that are accredited or under a letter of review.
There has been criticism leveled at the accreditation process, mostly by programs and states where accreditation is not mandatory. "It's mostly a case of the unknown," states Dr. George Hatch, Executive Director of the Committee on Accreditation of Educational Programs for the EMS Profession. "Once completing the process, nearly all programs report how positive and productive the accreditation process is in helping them better achieve positive student outcomes."
The value of a college degree
At this time, there is no effort to accredit programs that provide other levels of EMS education, such as EMT or advanced EMT. As many states require that paramedic students be certified as EMTs prior to, or during their program, the lack of consistent quality in EMT education programs may result in paramedic students who are underprepared to complete paramedic training.
The Education Agenda and its components do not address how formal higher education relates to EMS training, specifically when it comes to a college degree. While a few states such as Oregon and Texas have degree-based paramedic providers, the vast majority do not.
Most accredited paramedic programs award a significant number of college credit for successful completion; in many circumstances a paramedic student would need to only complete a few general education requirements to receive an associate's degree.
The completion of a degree is significant. Achieving college-level proficiency in English and math skills may improve EMS-related tasks such as patient care, report writing and problem analysis. Liberal studies in philosophy, language or social sciences may help expand the mind and lead to greater possibilities or alternative perspectives on an issue.
The lack of a degree requirement is not lost upon other health care providers. Physicians, most levels of nursing, and nearly all allied health providers require a degree to practice.
These vocations are considered professions; that is, their members possess qualifications gained through extensive learning, demonstrated through rigorous testing, and are self-powered to admit and discipline themselves.
Given that at the paramedic level at least, the level and intensity of education is deemed worthy of at least half to two-thirds of the credits needed to complete an associate's degree, points to a reasonable expectation of a degree requirement.
While a national EMS certification may permit EMS providers to work across state borders, a degree creates portability across the profession. Credits associated with a two-year degree are much simpler to transfer to a four year institution.
Degrees are often required to enter EMS-related fields such as biomedical technology support. Even within the industry, promotion to a supervisorial or administrative leadership position is increasingly at least partially based on the candidate's degree status.
The expense of education
Inevitably, critics point toward the perceived lack of value of a college education in EMS. Superficially, the facts would bear that out; few agencies tangibly recognize the college-degree paramedic through a higher starting salary/benefit level. Employers are also concerned that the additional education and training will result in a higher-cost employee.
Looking beyond the surface, such concerns may be of significant benefit to the industry overall. The provider's dedication to obtaining a degree, coupled with higher employment benefits, may raise the level of organizational loyalty.
The gain in employee longevity may in turn reduce the incidence of mistakes associated with inexperience. Collectively, the body of knowledge gained by the profession through its long-term members may expand far greater than what currently occurs.
Stabilizing the workforce is but one benefit. Recognition and respect among other health professions is gained through the professional recognition of degree awards.
EMS providers work hand in hand with other medical providers, each with their specialized training, education and skill set. There is enough technical, operational and clinical expertise associated with the out-of-facility provider that other health care providers can recognize as a separate and integral medical profession.
This recognition of the individual as a valued member of the health care continuum may translate more importantly at a higher-level service reimbursement.
Government health insurers such as the Centers for Medicare and Medicaid have not been kind to EMS. The fact is, most financial reimbursement is centered on transportation services, not medical care.
It's reasonable to expect this, if the profession itself does not value the investment of education for the benefit of the patient. Current demonstration projects in community paramedicine may change the reimbursement formula — if the industry is prepared to follow through with a greater depth of educational preparation.
The EMS industry faces a decision point in regards to the preparation of its providers. As the education model continues to formalize and create consistency in quality, EMS professionals will need to self-advocate both within and outside of its boundaries.
This move toward a profession will benefit its members, their patients and ultimately society as a whole. Higher education serves as the foundation needed to build upon the profession.
1.National Association of State EMS Officials. A report to the National EMS Advisory Council on Statewide Implementation of the Education Agenda. Retreived 10 July 2014.
2. Letter from NEMSAC to NHTSA EMS Division Chief regarding updates to the National EMS Education Standards. Retrieved 15 July 2014