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Why do good providers go bad?

What can we do about dead weight, lazy, ambivalent, substandard providers in our midst?

It's a reasonable question, given the deplorable level of patient care in many areas — yours not included, I'm sure. But I think the more important question is this: Do good providers really go bad, or is there something we're not seeing?

I view this issue, like everything else, through the prism of the law and its relation to EMS. So let's look through that prism at the quality of care an individual provider delivers. What does the law see?

Does the provider complete a thorough, systematic patient assessment on every call?

The law does not know what is or isn't wrong with any given patient any more than the provider does before arrival.

However, the law does know what is expected of every provider with regard to asking questions and getting answers, identifying potential or likely problems and following up to rule in or rule out. When assessments are abbreviated because you already know the answer, the law will be waiting to show you why you are wrong.

Does he or she provide appropriate patient care based on established standards, protocols and procedures as they apply to objective findings?

Again, the law knows what you are supposed to know and what you are supposed to do. The law was there when the standards were established and the protocols written, and the law is arbiter of what is proper and acceptable.

The law does not care that you are tired or frustrated or burned out. The law — to which you agreed by accepting the responsibility of being a provider — demands that you perform to the highest standards every time, without question and without fail.

Does he or she create complete, accurate documentation with a clear understanding of who will be reading it and why?

The law relies on your documentation for the exact same reason you do: To keep and maintain an accurate description of what happened, what was done, why and by whom. However, where information is missing, the law will fill in the blanks by assuming that missing information equals the failure to perform — ergo the maxim, "If you didn't write it, you didn't do it."

Moreover, where information provided is incorrect, the law will assume that the provider was likewise incorrect — hence, "If you wrote it wrong, you did it wrong."

Perhaps neither maxim is necessarily true in real life, but the law is very real and controls our lives.

Now that we are looking at the question through the same prism, let's define the term "bad."

  • Bad is the provider who believes that he or she is more valuable, more important than any patient.
  • Bad is the provider who performs anything less than a thorough, systematic assessment.
  • Bad is the provider who withholds treatment because treating is inconvenient or the patient is "faking."
  • Bad is the provider who treats based on subjective opinions rather than objective findings.
  • Bad is the provider who cuts corners, manufactures vital signs, believes they are untouchable.
  • Bad is the provider who doesn't know what he or she does not know.

When I set out to answer the original question, several people came to mind. First among them was Victor Oseguera. Vic has been in the field, running calls for more than 23 years, and he remains the best paramedic I have ever known.

Even now, with plenty of seniority, Vic chooses to work one of the busiest rescue ambulances in Los Angeles because he loves his job and genuinely cares about his "constituents," as he calls them; he treats all patients as if they are the most important because to him, they are.

He knows what he knows, and he knows what he doesn't, and he continues to strive for improvement, to be better.

He and other providers like him deliver only the highest quality patient care because there is no other way. They have inspired me.

Sadly, there is the other list, and it is far longer: The list of providers (and I use that term loosely) who have no clue what they are doing and don't seem to care, who treat the world like a litter box and patients the product to be removed, who see EMS as an annoying chore.

As I considered the question and the people whose influence would help me answer it, I was struck by the obvious: Why do good providers go bad? They don't.

The question assumes that all providers start out being good — models of proper care and compassion — and that is simply not true. The qualities that make up a "good" provider are and have always been simply absent in those who are not; they didn't care to begin with.

I have long contended that there are only three types of providers:

  1. The naturals for whom EMS flows in their veins
  2. Those who have to work very hard to be good at it and do
  3. The rest who have slipped through the cracks and don't belong in EMS

The real question is, which provider are you?

The next, even bigger, question is what to do about that third type of provider who plagues the streets, who holds EMS in the realm of "job" instead of "profession." What can we do about the dead weight, the lazy, ambivalent, substandard providers in our midst?

Rather than exclaim the obvious, "Remediate, retrain or replace," I will submit that question to you.

What do you hink? What will you do?

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