EMS 2.0: The Logistics of Change
If we're truly going to re-invent EMS, the people we'll need to influence are the public policy makers
"Amateurs study strategy, professionals study logistics" — General Omar Bradley
In my previous column, I issued a challenge. I asked you to speak up, to question the status quo in EMS. I accused the national EMS leadership of being disconnected from the concerns of rank-and-file EMTs. And I pointed out that those same rank-and-file EMTs are ineffective at influencing the course of EMS as a profession because they are politically naïve, bent on thinking like EMTs instead of like the policy makers we need to influence. Many of you took up that challenge, voicing your concerns with the state of EMS.
Last week I was at EMS Today, where the conference was abuzz with the words EMS 2.0, and the Chronicles of EMS was on everyone's lips. In Chronicles, San Francisco FD paramedic Justin Schorr and UK paramedic Mark Glencorse embark on a unique, cross-Atlantic EMS cultural exchange, and pose the question to each other, "What is wrong and right with our respective systems, and what lessons can we learn from the other in order to improve our own systems?"
As of yet, there are no hard answers to those questions, but at least the questions have been asked — and by an ever-increasing horde of EMTs. There were live podcasts from the exhibit hall floor, streaming video from the producers of Chronicles and others, and all of them were flush with possibility that perhaps this is the impetus we need to take charge of our profession, and guide the future of EMS. This might be the spark that starts the forest fire of change. You could smell the hope in the air.
Listening to it all, however, I was struck by one thought:
We're still thinking like amateurs.
In the column last month, I got comments that ranged from blaming the evil nursing lobby for our delayed professional maturity to the need for more extensive education and degree programs in EMS and for strong medical direction — with a little muted vollie-bashing thrown in for good measure. One commenter even called me out for not speaking out more forcefully.
At EMS Today, the responses were essentially identical, albeit voiced by a more well-known circle of EMS thinkers. But the elephant in the room that everyone ignored is the one fact that will keep us from realizing this system reboot, this EMS 2.0:
We don't hold the reins of EMS. None of us do.
The efforts of talented, passionate people like Justin and Mark are important, certainly, and they have emphatically proven the power and potential of social media in empowering the rank-and-file EMT to affect change within their organization. Justin and Mark's administrators are paying attention to where this is going. Many of the most respected thinkers in EMS were mingling among the EMS bloggers. They saw the potential of social media to improve communication in an organization.
But change EMS as a whole? Not so much.
Also, let's not overestimate the impact the EMS 2.0 movement will have. The passion I saw at EMS Today was truly inspirational, but let’s not kid ourselves that what we were seeing wasn't a raging case of selection bias. The people we see at the national conferences, the ones that actively participate in EMS discussion forums, are not your average EMT.
Heck, if you asked the average medic, "What's the greatest impediment to the advancement of EMS as a profession, ignorance or apathy?" the answer would be, "I don't know, and I don't care."
If we're truly going to re-invent EMS, the people we'll need to influence are the public policy makers. They hold the reins of our profession, not us. Heck, not even our medical directors have much influence. They struggle to even influence the health care reform legislation that directly affected their own practices, much less the limited medical practice they delegate to us.
And if you think we have a beef with the ivory tower types who run our national EMS organizations, ask a few practicing physicians whether they think the American Medical Association represents their interests, or its own. Our dissatisfaction with our national leadership is hardly unique.
No, the people who will shape the future of health care in America, and by extension EMS, are politicians and policy wonks who know little of our concerns. Their concept of EMS is still shaped by a 40-year -old television series like "Emergency!," or God forbid, NBC's "Trauma." And sadly, many of them have never held real-world jobs.
Medics with MBAs
Advancements like EMS degree programs and higher educational standards are important, but what we really need are EMTs who will pursue the kind of education that policy makers deem valuable, the kind of education that helps us understand how public policy is shaped. We need medics with MBAs and MPAs.
We need people who hold a Masters in Public Health, but still know what it’s like to be puked on. We need to cultivate and mentor that geeky kid who hung around the firehouse and never quite fit in with the boys, because one day he'll hold a PhD in economics, and we’d really like that kid to still hold a deep and abiding passion for EMS.
Don't think of them as people who have left EMS behind, think of them as our sleeper agents in the enemy camp.
Empowering paramedics to refuse transport to non-emergent patients — or refer them to more appropriate avenues of care than the Emergency Department — is doable only in theory, as long as the reimbursement scheme heavily favors transport. We can't tell people, "This isn't an emergency, here's a cab voucher and an appointment card to see your primary care physician on Monday," if there aren't any primary care physicians willing to see those patients.
There are great swathes of this country where income for primary care physicians is so low that driving a truck pays better. The average salary for a cop in Massachusetts is higher than that of most primary care physicians in private practice. With reimbursement so egregiously low, numbers of medical students choosing primary care specialties are plummeting, and the few that do choose primary care are increasingly adopting concierge, cash-only practices.
Where are we going to send those non-emergent patients that don't need an Emergency Department, much less an ambulance? Who is going to man all the clinics we'll need?
If we're going to truly reshape our profession, the Martin Luthers of EMS will need to move beyond refining our tactics, and start studying the logistics of change. Until we learn to do that, EMS 2.0 will be little more than wishful thinking. What we'll have instead will be more like EMS v 1.1.8, Service Pack Thirteen, and much like software developers, the leaders of EMS will still be insisting, "It's not a bug, it's a feature!"