Updated June 2015
After 35 years with Toronto EMS, Alan Craig joined American Medical Response’s national leadership team in 2012. As vice president of clinical strategies, Craig’s goals are to improve patient care through the use of evidence-based practices and to help develop new delivery systems, such as mobile integrated healthcare, that take the focus of EMS off of transporting to emergency departments and move it into a more preventive or primary care role, in partnership with other healthcare providers.
“Mobile integrated healthcare programs are the future of what we currently call EMS,” Craig says. “I think we will eventually no longer be called EMS, but mobile healthcare. It’s going to be my life for the next 15 years.”
Craig got his start as a firefighter and public information officer for the Toronto Fire Department. Five years later, wanting to be more involved with patient care, he switched career tracks and became an emergency medical care attendant (Canada’s entry-level EMS responder) for Toronto’s EMS system. He became an advanced life support paramedic in 1987. He was promoted to senior EMS planner in 1992 and named deputy chief in 1999, a position he held for 13 years before retiring from the department last year.
Craig is well-known as an EMS educator, speaker and researcher. He’s published numerous papers in peer-reviewed journals; was an investigator at the Li Ka Shing Institute, a research collaboration between the University of Toronto and St. Michael’s Hospital focused on improving patient care by bringing best practices and new research to bedsides more quickly; and was an investigator for the National Institutes of Health’s Resuscitation Outcomes Consortium.
Now living in San Diego, Craig has a bachelor’s degree in urban geography and a master’s in urban planning from the University of Toronto. He spoke with Best Practices about making the transition from Canadian to U.S. EMS, his plans at AMR and where he sees EMS headed.
What brought you to leave Canada and begin a new job?
I’ve had deep involvement with EMS in the United States for most of my career. I’ve known people from AMR for a very long time, and I’ve always respected the work they’ve done. Partly because of their size and the quality of the people they have, they have the opportunity to do innovative things. So when I was approached by AMR when I was getting ready to retire, it was a pretty natural fit. Plus I really like living in San Diego—after 24 years and nine months, it was time for me to stop shoveling snow.
How do you see EMS evolving in the coming years?
We’re always going to do 911 calls. There are always going to be immediate emergencies—chest pain, car accidents. But the truth is, most of what we do is not critically urgent. Many people turn to 911 as access to healthcare, as opposed to thinking they need light and sirens to their house and the emergency room.
Our only option has been to say, “Don’t come with us,” or, “Do come with us, but the only place we can take you is the emergency department.” There, many people wait for hours to get care, and then they’ll either be told to go home, or referred to the care they really need, or they will get expensive care in the emergency department that could have been delivered elsewhere, less expensively and with higher patient satisfaction.
We’re on the edge of figuring out how to sort some of that out. Some people we think of as paramedics may become care navigators as much as anything else, the idea being, let’s figure out what’s wrong, consult with other healthcare professions as needed, and develop a care solution for that patient.
Part of the reason for the situation we’re in now is that the incentives were aligned to do the transport. The EMS agencies and the emergency departments got paid based on the number who came through that door, so there was no incentive to find alternative solutions. But that’s changing.
How is AMR pursuing the concepts of community paramedicine and mobile integrated healthcare practice?
These are early days. In December of last year, a group got together in Chicago and said, We need to think of this more broadly than the notion of a new class of paramedics, or new things for paramedics to do. This is much bigger than that—it’s mobile integrated healthcare. It’s probably going to involve a range of practitioners, and we will do a better job if we involve the full range of practitioners. AMR always wants to be at the forefront of developing new care systems.
We have some preliminary experience with this, such as in Arlington, Texas, where we have a program called PRIME to help navigate patients who contact the EMS system a very large number of times. We are looking to broaden our experience. What AMR wants to look at is how this fits into integrated care, not just paramedic care.
We have really good examples to draw from elsewhere in healthcare. And EMS agencies—whether they’re fire-based, private, government or volunteer—will do a better job if they look to other parts of medicine to see how things are done. When you come into an emergency department and say, “My hand hurts,” they don’t say, “Go to the trauma bay and get a CT scan, because all of our patients go to the trauma bay and get a CT scan.” When you come in with chest pain, you get a very short response time. If you come in with a three-day-old soft tissue injury to the wrist, you will be seen later.
I think EMS would do well to draw from some of the lessons that the rest of medicine can teach us. Not everything is the same and not everything requires the same kind of response. We need to learn the same lessons that all of medicine has learned. I think we are learning, although in some communities we need to be mindful of the fact that our customers have expectations and we need to help them think this through.
We’re working with all of our partners across all levels of healthcare on programs such as reducing the risk of hospital readmission. We’re going to work with our providers to see what training they require to take on new roles outside the 911 environment, and we’re going to work with our regulators to show them what a good paramedic can do in non-traditional roles. We’re also going to work with our funders [Medicare, private insurers] to show that mobile integrated healthcare has the probability of reducing overall health costs and improving outcomes and patient satisfaction.
One reason we think this can work is we’re not asking for new money here. This is a matter of going to people exposed to these costs and developing solutions we haven’t thought of before that take the same money and spend it better.
The patient experience is critically important to this. People get better when they are well treated and feel they’re well treated, as opposed to saying, I suppose it worked, but it took me 15 hours to get it. Customer experience is very important in this because it supports good health.
The California EMS Authority has asked for proposals for pilot projects. They are in a unique position to work with state regulators to alter the regulatory environment to support these innovative programs. Right now in California, there are strict regulations that impact the practice of paramedicine written at a time when no one envisioned this form of healthcare. But California had the foresight to build an agency that has the statuary authority to suspend regulations to support innovation. If the pilots are safe and successful, they can propose permanent regulatory changes to the state legislature and the Health and Human Services department. These pilots will be done in partnership with the medical community, payers, hospitals and our emergency partners such as fire departments.
In Toronto, you famously changed the system from all ALS to a tiered system that includes lower-level responders, known as Paramedic 1’s. Why did you do this?
Between 1984 and 1996, we had a two-tier system. Then we went to a one-tier system. EMS theory at that time was if every ambulance was an ALS ambulance, you would always have the skills that you needed, and that it was financially more efficient, because in a two-tier system you have to send a BLS ambulance and at least dispatch an ALS ambulance, knowing that it may get canceled if it’s not needed.
What we had missed was that to provide really good ALS care, you need strong, continuous experience with sick patients, and there are only a limited number of sick patients. When we put more and more paramedics on the road, we diluted their experience so that when they encountered things, they had less to draw on. Having a smaller group of paramedics gives them more experience to draw on. We decided it was probably better in the long run to switch it back to a two-tier system.
We’re the only healthcare profession that assumes once people are trained, they’re ready to practice independently. But that isn’t true. They need experience. When you’ve finished your training, you’re ready to start learning. Our mistake in Toronto was we assumed they didn’t need dense experience. We were wrong about that. Under the one-tier system, we found the average ALS crew would see three cardiac arrests per year. In a two-tier system, they see about 18 to 20.
Even after becoming deputy chief, you frequently worked shifts on the ambulance. Why was that important to you?
When I was deputy chief, each month I would take a full shift and either ride on an ambulance or do first response. In addition, I did a lot of first response on my daily commute. It was a great luxury, and great stress relief!
Doing ride-outs is an opportunity to talk with my paramedic colleagues. It’s the time you can find out what’s going on, learn their issues, hear their suggestions and incorporate their understanding of the realities of our business. It’s an opportunity to go and listen. On the days I did ride-outs, I was always surprised how widely known it was that I was on the street. When you go to change something, paramedics know that you’re still connected with the business. It’s a matter of trust, collegiality and respect for what they do.
In EMS, I never wanted to lose touch of what we’re doing. I never wanted to leave it, either. A very wise person, an emergency doctor I really respect, said, “One-third of your job should be seeing patients. One-third should be teaching and one-third is doing everything else.” Seeing patients is the great job of EMS. Teaching is the sharing of what you’ve learned. Then you spend the other third of your time trying to run the EMS system. If you do the first two well, the third is very simple.
You’ve spoken about compassion fatigue. What is this?
For some time, I’ve been teaching people that every EMS call is an opportunity for an act of compassion. Most of the calls we do, we don’t need to do anything fancy from a medical point of view. We don’t intubate many. We don’t give drugs to many. But every patient needs to be treated with compassion. You may be the only person that person sees who actually cares about them. Making compassion a core value of EMS is critically important to our success. It’s often not about technical medical skill; it’s about treating people well, with intentional compassion to connect with them and say, I care about what happens to you.
Yet there is a growing understanding that some people who work in caring professions end up feeling, I used to care but I don’t care anymore. Their ability to care and be compassionate is blunted by constantly being confronted by other people’s pain, suffering and difficulties. In fact, there is fairly well-defined literature that has codified this. Some call it secondary post-traumatic stress syndrome, or infectious stress. You become stressed because you spend your time around people who are suffering. We need to figure out how we can both prevent it and resolve it. It doesn’t happen to everybody; this isn’t inevitable. If we can sort out why some don’t feel this and remain compassionate and able to extend themselves to their patients, then we can teach other people how to get back to where they want to be, which is taking care of people.
How can supervisors spot EMTs or paramedics at risk of compassion fatigue?
Sometimes people stop taking are of themselves. They place patients ahead of their own self-care. They work lots of overtime. They are always mentally at work. They take to heart the difficulties of the patients they encounter.
In EMS, we have always assumed we don’t have to teach people how to be compassionate, that being compassionate is wired into being a human being. But I think it has to be taught. This is an EMS leadership issue around how we communicate core values. We sell EMS to people who want to be around lights and sirens. We show videos with a fire truck screaming down the street and say, “Wouldn’t that be fun?” But that’s not the business we’re in. We’re in the business of compassion.
For some, the reality of the business they’re in is a disappointment for them. They thought they were going to save someone’s life every shift and be revered for it. The truth is, most of what we provide is primary care. If you are disappointed about the profession you’re in, you don’t have the strength to draw on to continue to extend yourself to people. You need to have leadership that says, In this organization, we place an extra high value on compassion, even over your technical skill.
Being compassionate requires a tool kit, and some of it is learned technique. It’s not enough that we hope to select people we think are compassionate. We have to give them the tools to be compassionate. If the organization appears to be more committed to lights and sirens and saving lives than it is to being compassionate, then even when you are feeling compassionate, you will feel out of place.
There’s a final piece of this that concerns me deeply, which is a growing group of people in EMS who talk about feeling they need to be armed or carry a gun. If you convince yourself that patients or the people around patients continually pose a real threat to your safety, it is going to be incredibly difficult to reach in and find your compassion.
Is there anything that surprised you about how EMS is practiced in the U.S.?
In Canada, EMS systems have largely grown up as independent third-service emergency services—government agencies that are independent of the fire department or the police department, but who work in partnership with local police and fire.
The second piece is how EMS is funded in Canada. It’s funded on capitated care: You have a budget for EMS in a certain city, and you are responsible for taking care of patients in that city. Most patients seen in Canada don’t receive a bill; it’s a part of government-funded healthcare. That has its strengths and its weaknesses. The strength is no money changes hands, and we know the EMS system funding is independent of the number of calls. On the other hand, it means there are fewer incentives to look at highly innovative programs such as mobile integrated healthcare.
Yet EMS systems in the U.S. and Canada are remarkably similar. The people are the same; they’re great people. We see the same kinds of patients. I’m struck much more by the similarities than the differences.
