When it comes to promoting the professionalism of EMS personnel, few EMS institutions are as important as the National Registry of Emergency Medical Technicians (NREMT). For 24 years, William “Bill” Brown was the Registry’s executive director, working tirelessly to build support for standardized training and testing requirements for EMS providers until his retirement in May.
When Brown took the helm in 1988, 29 states used the Registry to certify EMS providers and 300,000 had been certified. During his tenure, that number grew to 46 states. Some 1.7 million have been certified by the Registry since its inception, including 270,000 currently.
Brown grew up in Youngstown, Ohio, the son of a firefighter and the oldest of four children. With the Vietnam War raging, he enlisted in the U.S. Air Force and became a pararescueman. From 1969 to 1972, he conducted rescues in Cambodia, North Vietnam and Laos. In 1971, he received the Distinguished Flying Cross for rescuing a pilot who had been shot down over Laos and spent nine hours dangling in his parachute which was tangled in a 200-foot tree.
Brown’s wartime service was among his most formative experiences, he says, teaching him self-discipline and focus, but also about the fleeting nature of life. “For a young guy, you really learn the value of life and how precious it is,” Brown says. “If you learn that young, it becomes a part of your character … I was not afraid like when you go to a scary movie. I was in fear for days at a time. Three or four times it was, I’m going to die.”
After leaving the military, Brown enrolled at Youngstown State University. After Vietnam, term papers and studying didn’t seem too daunting. “Holy smokes, it was pretty easy compared to special ops in Vietnam,” he says. “There, you experienced every single emotion you could possibly feel.”
After receiving undergraduate degrees in nursing and law enforcement administration, Brown worked as an emergency department nurse at Indianapolis’ Wishard Hospital, a Level 1 trauma center. He went on to earn a master’s in health and safety education, and then returned to Youngstown State as director of the paramedic education program. He joined the National Registry in 1985 and became executive director three years later. A mountain climber and long-distance bike rider, Brown has climbed to the summit of Mount Whitney in California and rode 3,195 miles from Disneyland in California to Disneyworld in Florida to celebrate his 50th birthday.
Brown spoke with Best Practices about the importance of the Registry and the long road to earning the industry’s acceptance of the organization.
What is the toughest challenge you had to face during your time with the Registry in terms of earning acceptance?
It was getting people to understand that the Registry is really trying to protect the public. We’re not the National Association of EMTs; we don’t advocate or lobby for people. We can’t just pass you because you’re a good old guy, or because you really, really want to be an EMT—you need to have the knowledge, skills and abilities. We are a standard-setting organization. We got that message across one state at a time, one phone call at a time.
What do you consider your proudest moment as the executive director of the Registry?
It’s a culmination of a lot of things, but good overall acceptance of the Registry is probably No 1. I’ve received a lot of Lifetime Achievement Awards, and I’m certainly proud of those, along with some of the comments I’ve heard people say about the job I did. But pride is not a very good characteristic to have. You’re better off to be humble and stay focused on the mission. For me, it started out with pararescue. Their motto is “That others may live,” and I’ve held onto that throughout my life.
Why wouldn’t every state want to be a part of the Registry?
There are only four that aren’t: Illinois, New York, North Carolina and Wyoming. In North Carolina, somewhere along the line in the development of EMS, in order to get it through the legislation, the state said that volunteers wouldn’t have to pay for testing and licensure. But the Registry can’t conduct its business for free.
But the Registry is used by certain EMS agencies in North Carolina. In the major metropolitan areas such as Wake County and Charlotte-Mecklenburg County, you have to be nationally registered to work there.
Illinois and Wyoming used the Registry at one time, then they dropped it. I do believe Wyoming is making movements to come back into the national standard, but I don’t know what is going on in Illinois.
I love those folks in New York. We’ve had leaders from Albany, Buffalo and Syracuse serve on National Registry committees, and they are scratching their heads about why New York isn’t a part of the national standard.
The National Registry is willing to work with the remaining states to become part of the national standard. But it takes such energy to keep the 46 states that are part of the national standard happy. At some point, it’s, Never mind the four that aren’t. Our concentration of energy has to be on the 46 that are.
What are the most significant changes you’ve seen in the Registry since you started?
We increased the number of people taking the exam from 29,000 to 142,000 annually, and we went all paperless for certification and recertification. We use the premier testing methodology and science to determine the pass-fail score for our exam, called computerized adaptive testing. It’s fair, precise, secure and efficient.
There is a lot more that goes into developing these test questions than people realize. It takes a year of developmental time before questions can show up on the test. You have to have people from all over the United States weigh in. You have to quality-assure the items. Then you have to put them on the live test as pilot items that don’t count. From there you have to calibrate them on the difficulty scale. Then you have to present them to candidates so that they receive questions matched to their ability level. When they have shown that they have met the standard, the very sophisticated computer switches off and the test is over.
We also went from having 29 states using the National Registry to 46. All Army and Air Force medics must be nationally registered. We went from a staff of nine to 32.
Acceptance of the Registry is huge. The National Registry can be viewed as the boogeyman by people who fail. But it is our job to assure the public that when an EMT or a paramedics walks into their home, they know enough to have the skills to do the job at the entry level. When a person fails, it’s a heart-breaking situation for them, but our customer is the public.
What percentage of people who take the test fail?
For first-time test takers, 35 percent fail. I believe that transitioning from selling pizza or parking cars or working as a waiter in a restaurant to working in the back of an ambulance and having to manage patients with all sorts of diseases and injuries after a 10-week course is one of the most challenging academic endeavors that one can undertake. There are so many age groups, so many diseases and so many ways people can injure themselves, it’s a pretty big mass of knowledge that people have to gain rapidly.
What are the limitations of the Registry?
The National Registry’s mission is to make sure EMTs and paramedics know the minimum amount they need to know to get into the back of that ambulance. It’s up to their employers and their peers to make them a really excellent EMT, and it’s obviously up to the individual, too. No one, no certifying body—not the American Board of Emergency Medicine, or the American Board of Nursing Specialties, or the NREMT—would say this person is going to be an excellent physician, nurse or EMT. The standard is entry level. Excellence, you must develop yourself.
The Registry website says the NREMT increased fees in 2002 for the first time since 1973. What are the costs to take the exam, and how have you kept the price reasonable?
The fee to take the National Registry exam is $70. About $50 goes to the test administrator; the National Registry gets around $20. We started out getting $10 in 1971, and we’re getting $20 in 2013, 42 years later.
If you look at the Consumer Price Index, we should be charging $150 right now. But we are a nonprofit corporation and we take that seriously. We don’t believe we should be charging money if we don’t need it. Our volume is so huge, and we are highly efficient, so we don’t need to.
You’ve described EMS as a ‘sleeping giant.’ What do you mean by that?
About 1.7 million have been certified by the National Registry. In the earlier days, when states wrote their own licensing exam, we figure more than 1 million took those. So it would seem logical to me that if there are 1.7 million who have been certified and another million or more who were state licensed, it’s not a stretch to say there are probably 3 million EMTs in the United States, either now or in the past. There are only 300 million Americans. That means 1 in every 100 citizens is now or was an EMT. That is a huge contribution EMS has made to the health and safety of the United States of America.
If all those people who were or are EMTs spoke with a unified voice about an issue, they could create some major change in the United States. There are about 600,000 physicians; there are 800,000 to 1 million EMS providers. We are the second largest health care occupation in the United States—only nursing is larger than EMS. Yet how much influence do physicians have over the crafting of rules, regulations and laws compared to EMS? [He laughs.]
We spend more mental energy trying to determine if EMS should be delivered by paid, volunteer, fire or third service. Then throw in episodic issues like drug shortages and put low pay into the mix, and oh my. Nothing kills EMS worse than low pay. It results in high-turnover personnel and a failure to have the psychic energy to develop a unified voice.
Is there a particular mentor who stands out for you?
I have a bunch of them. Dr. Roger White was the first one. He’s an anesthesiologist and resuscitation expert at the Mayo Clinic, and he was on the National Registry board for more than 20 years. He was a wise man and an adviser to me when I was a young executive director. He ingrained in me that right is the master of might, and as long as you do the right thing and you do it for the betterment of the patients, you’re going to be OK regardless of who gets upset with you and why.
Drew Dawson is another one. We met in 1989 and have remained friends even today. Drew taught me about process, that things don’t change overnight—it takes consensus, science and collective thought. A lot of people are better than one or two people, and it takes a long time to achieve buy-in. Even if it’s a high-quality product, people are not going to endorse it without time to review it, to reflect on it and time to make it a part of their own belief system. A lot of times we think the product is the most important, but the process you went through to develop that product can be just as important.
My other mentor was my department chairman at Youngstown State who passed away, John Yemma. He taught me to hire great people and let them run. That’s what I did at the National Registry. I’m very proud of the team that we assembled in 1989 and kept right through 2005. Why was the Registry so successful? It was a team of very, very dedicated, bright people who were great communicators who sacrificed a huge amount for the organization to be successful.
How did the Registry come to host the LEADS (Longitudinal EMT Attitudes and Demographics Study) project? Why is it important?
LEADS is a longitudinal study hosted by the National Registry. It started in 1998. The impetus for LEADS are the rumors we hear in EMS—that we have the highest divorce rate, that EMTs are getting killed every day, that there is a high level of burnout, that we are underpaid. But where were the facts on all of this? So we started this project and examined people entering and leaving the profession for a 10-year period so that we would have data on who we are and what has happened to us as a profession. The first survey involved 17,000 people from eight cohort groups: new EMTs, minority EMTs, experienced EMTs, experienced minority EMTs, and then the same four groups at the paramedic level.
There have been 35 peer-reviewed papers that have talked about what we found. Now we’re trying to do one big overview of the project over the whole 10 years. The final report is being written up now.
LEADS is going to continue, allowing us to conduct more analyses. In 2008, we redesigned it. This year, we enrolled 1,000 paramedics and 1,000 EMTs, all new people in the profession who consented for a 10-year-period to be surveyed once a year about their work activities, working conditions and job satisfaction, including whether they are still in the profession.
Has anything emerged from the LEADS data that surprised you?
The satisfaction of people in EMS is unbelievable. So is the sleepiness. We perform the worst on the sleep scale of any profession, including truck drivers and airline pilots. That startled me.
What else startled me was the number of people who took an EMT course and never entered the occupation. Half of those who take a class never fill out a trip report within a year. We found there are a large number of people who take an EMT course as preparation to be in law enforcement, nursing, the military or an allied health profession. They want to see if they are interested in EMS. So they take the exam and the license but they never look for a job in EMS.
We’ve also found that EMS workers are highly dedicated to the job. They love the job. They love the mission. They love the tasks. But if somebody offered them a job for more money, they would leave in a minute. Satisfaction is very high, but their occupational commitment is very low because of the low pay.
Do you think the paramedic profession should eventually move toward requiring a four-year degree?
Do I believe that academic credentials should be a part of being a paramedic? Yes. If you go to the U.S. Department of Labor’s job classifications, in the health sector, EMS is one of only three that require a minimum of a high school education. The others are home health aides and pharmacy techs. In order to scrape crud off your teeth, a dental hygienist has to have an associate’s degree. To be an X-ray technician—“Excuse me, can you hold your breath? Click”—you have to have an associate’s degree. But to save a life, you have to have a high school education.
What would you tell a new EMT or paramedic entering the profession?
I would tell them to always seek higher credentials. Life is over when you stop learning, so why not have it be in a formalized setting where you can get a degree? Nothing is better than a degree. If you enjoyed getting an associate’s, get a bachelor’s. Don’t stop there. Get a master’s. Get a Ph.D. Learning is one of the most positive human endeavors. Continue your education.
What are your plans for retirement?
Right now I’m on terminal vacation, though I have plans to get involved in some books. I’m a Christian, so wherever God takes me and whatever doors he opens up, I will try to figure out if that’s the one I want to pass through. It’s been more than 40 years since Vietnam, and I’m still happy to be alive. Every day is a gift to me. My roommate was killed in Vietnam. The two guys in the room with me got Silver Stars for heroism. When I left, the guy who came in to occupy my bed, he was killed. Believe me, you learn the value of life.
You recently talked about your ‘10 Principles of Life’ in a speech at the National Association of EMS Educators. What are they and how did you come up with them?
I was doing a farewell address at the meeting and I came up with Bill Brown’s “Top 10 Pieces of Advice.” Many people said they wanted me to do it again, but I said, “You only say goodbye once.” These are things that are just ingrained in my character.
- Love thy neighbor as thyself.
- Never come to a meeting unprepared.
- Success comes at the crossroads of preparation and opportunity.
- The view from the summit is not as clear as it was during the ascent.
- Establish realistic expectations and you’ll always achieve them.
- When the pressure is on, step back and think.
- Live within your means.
- Fitness is intellectual, physical and spiritual.
- Don’t do anything until your wife says it’s OK.
- This is what it is all about: “That Others May Live.”
