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Graduate prepared paramedics: The cause for concern

Is building a new kind of clinician merely a Herculean task or a fully Sisyphean one?


What do you think of the NEMSAC proposal?

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This article has been updated to include an additional note from the author.

Many have read the draft of the letter cosigned by the American Ambulance Association, International Association of Fire Chiefs, International Association of Fire Fighters, and National Association of EMTs opposing the drafted NEMSAC proposal for the establishment of a clinical Master of Science in Paramedicine program, as well as federal recognition of graduate-prepared paramedics as advanced practice providers. I encourage you to read both documents (available below) in their entirety.

I am a member of the NAEMT, but no mouthpiece for any of the organizations involved. At this time, I oppose the adoption of the draft NEMSAC proposal as well as the general plan to establish a graduate prepared paramedic (GPP). I agree with some of the opposition letter’s points, but I believe there are additional factors worth considering.

1. Do the ends justify the means?

The PA profession took most of its 50-year history to see 50-state recognition, licensure, prescribing authority and reimbursement from payers. I am skeptical of any suggestion that creating a GPP role is going to take any less time or effort.

NEMSAC’s standing proposal, if adopted, accomplishes extremely little, and leaves mountains of statute to be passed by Congress and the POTUS, piles of regulation to be written or re-written by federal bureaucracies, and many states to establish licensing and oversight boards.

There is limited political, human and monetary capital available to the profession to press changes at these levels. If the GPP presents a solution to any of EMS’s systemic problems, I contend that there are much simpler, more feasible and more immediate solutions.

2. Is the service gap that the GPP would step into even empty?

A GPP would have advanced 911 scene capabilities and advanced community paramedicine capabilities. The GPP could solve a 911 scene-call problem by stitching a laceration, sending a script for some antibiotics and dispositioning the patient as “treated in place, no transport deeded,” essentially, “discharged.” The GPP would also provide quasi-independent primary care services in the community paramedicine setting.

Can EMS already provide those services? Yes. Austin-Travis County EMS in Texas has fielded PAs in this exact role successfully for years. The GPP is not necessary to provide these services. Both the Society of Emergency Medicine PAs (SEMPA) and the National Association of EMS Physicians (NAEMSP) have working groups and/or position papers explaining such a model.

PA school is direct entry from any bachelor’s degree which meets pre-requisite requirements. The characterization of PA school as “leaving paramedicine” is, in my opinion, an artificial and unnecessary distinction for a paramedic pursuing an EMS PA career. The GPP is, I worry, a redundant solution to a problem already solved. Qualified, potential EMS PAs are already available (full disclosure: I speak graduating from a PA program in December, currently practicing as a paramedic, and intending to find or create an EMS PA position).

3. Is the schooling gap for the GPP even empty?

Prior paramedicine experience is common among PAs practicing in the emergency department. As EM PAs have stepped into the exact role the GPP is meant to fill, PA education has been validated in filling the gap between a paramedic and a professional capable of doing the job.

The decision to provide treatment in place dispositions in the field is roughly akin in clinical and medico-legal significance to completing an EMTALA-compliant medical screening exam and discharging a patient from the ED. I believe CMS would set nearly identical requirements for reimbursing such evaluation and treatment, including a similar standard of care. An advanced EMS clinician must be a fully competent ED provider. To train the GPP, GPP education will end up re-inventing PA education with the slight alteration of assuming the NRP skillset. Speaking from my experience, that difference is quite small on the scale of the totality of the skillset which must be built.

I believe that the effort of building curriculum standards, program conduct standards, testing standards, program accreditation guidelines and the multiple national-level organizations necessary to write, maintain and enforce those standards will only duplicate what PA education already has built at tremendous cost.

4. Would a GPP program be financially viable for an institution of higher learning?

A GPP program could not be viable without a consistent stream of applicants turning into students. These students will expect to turn into graduates, and they will expect a return on their investment. We need to estimate how many GPP positions EMS could sustain. GPPs will have to prove their worth by staying busy and seeing patients, assuming reimbursement materializes. Realistically, rural and low-volume services will never sustain GPP positions, limiting the number of EMS service areas that will sustain GPP coverage.

Assume that it would take at least 100,000 people to sustain a GPP position. There are approximately 330 incorporated areas in the U.S. with a population of 100,000 or more. Assuming every single one of those places could justify and fund continuous GPP coverage with three full-time positions, that leaves an approximately estimated 1,000 full-time GPP positions in the entire country. I believe this to be a high-end estimate.

If multiple GPP programs opened, the entire system could very quickly become top-heavy with credentialled and student debt laden GPPs still working with their line paramedic colleagues. Alternatively, or, worse even, simultaneously, it could suppress GPP wages as supply of GPP labor outpaces the demand, leaving these GPPs trapped with no ability to lateralize elsewhere in medicine (unlike PAs).

EM PAs could easily step out of the ED into EMS PA positions as they emerge over time without causing a new degree of staffing crisis in the ED. As the role becomes broadly accepted, systems can encourage and empower their top-tier paramedics to pursue PA school so they can be brought back as EMS PAs. Formalizing EMS PA training by establishing post-graduate training programs working in tandem with EMS physician fellowships, possibly funded by the agencies who desire to hire them, is far more feasible than the creation of a GPP field.

5. Is there any evidence the GPP will solve the paramedic staffing crisis?

I would characterize the proposal’s contention that availability of upward career progression will solve the paramedic staffing crisis as, at very best, purely speculative. More realistically, I would describe it as contrary to available evidence. (1)

Objectively, the field of nursing is better organized, more cohesive, better lobbied-for, and better understood and trusted by the public than paramedicine. Nursing has several modes of career progression. There are more advanced nursing practice programs graduating more nurse anesthetists, nurse midwives and nurse practitioners into the workforce than ever, not to mention the administrative roles. Availability of upward progression in nursing is inarguably present, yet there remains a nationwide shortage of basically qualified nurses to staff the regular line positions open in hospitals.

The evidence from nursing does not indicate that we will make any headway toward gaining and retaining excellent paramedics by building the GPP.

6. Where will the reimbursement come from?

Reimbursement for described on-scene services from an NPI-numbered clinician will take regulatory change. The ATCEMS EMS PAs are out validating the model of EMS PA care delivery right now. We can already begin to make a data-driven case to legislators and regulators from real-world experience in terms they (and the law) already speak if we are not spending our resources creating redundancies.

Share your thoughts

I do not doubt the genuine, positive intent of those behind the NEMSAC proposal, nor do I intend any disrespect to any of my colleagues. I would be happy to engage in serious conversations about providing the best care to our patients and advancing the profession. For all of the reasons above, I believe the sculpting of the GPP is a sub-optimal allocation of resources.

What do you think?

Author’s Note

1. The NEMSAC proposal does present relevant evidence in the form of workforce surveys. Please read the full proposal. It is my opinion that the historical analog we have in the form of the experience of the nursing field is more compelling evidence, specifically to the contrary.

Daniel Martin is an emergency medicine physician assistant, licensed paramedic, boarded tactical paramedic, author, consultant on matters of tactical paramedicine policy and practice, and educator in matters of both EMS and personal safety. He holds multiple instructor credentials across relevant disciplines. He currently is working on the ambulance in the area of San Antonio, and offers training to EMS agencies and ER personnel on handling armed patients and occupational firearm safety.