Paramedic Practitioner: Is this where we should be heading?

[Bieber]

I am completely for paramedic practitioners. I do not think that they should be entering the hospital or clinic realm, as NP's and PA's and physicians already hold dominion over those areas; rather, I believe that we should focus on transitioning ourselves from emergency medical services to mobile health services. The notion itself is expansive, but it has a lot to do with our own perceptions of our profession, even down to little things such as referring to ourselves as out-of-hospital providers rather than pre-hospital providers (the latter implies that the next step is necessarily the hospital, something which we know to be untrue, even if it is the most commonly practiced model currently).

Things such as community paramedics will pave the way toward this transition, I believe, and indeed may assume the roles of the first "paramedic practitioners", but as a current community paramedic student I will be the first to admit that the educational level needs to continue to grow and increase. Still, it's the first step.

Some people have suggested that NP's or PA's fill the role of these out-of-hospital practitioners, which is something I simply cannot support. Since its inception, EMS has always been under the thumb of another, frequently unrelated group of professionals. Now, we certainly need to maintain some oversight, and that is perfectly fine, but on the same token we have to take charge of our own profession and become more self-regulating. EMS-based EMS. It's a great misfortune that through our own ignorance and lack of motivation that we have allowed our profession to be at the mercy of so many others; something which I do not see occurring among other providers or professions. We need to get away from that, and have the self-determination to truly become self-regulating; this means increasing our educational standards and improving our clinical practices from within, not waiting for other professions to elevate it for us.

Someone also remarked that EMS shouldn't enter into the realm of primary care. Unfortunately, this is impossible. The majority of our calls are already non-emergent, but rather than provide us with the education and the tools to treat these conditions, we have simply relied on the expensive method of transporting all patients to the ER, where their needs can be somewhat met until the next exacerbation. In order to provide a greater benefit to our patients, we have to become stronger preventative and primary care providers; after all, it's from lack of these two care types that the community paramedic was born. This isn't to say that we should enter the hospital or clinic realm, but instead we should become a part of that continuum of care working in collaboration with the patient's physicians, NP's, PA's, hospitals and clinics and serve as the out-of-hospital barrier to preventable hospitalization.

While I don't know if prescription powers are necessary or wise, I think that limited dispensing might be prudent in some circumstances. There are other skills and tools we need to add to our repertoire in order to become more potent primary care and urgent (non-emergent) providers in order to give the right treatment to the patient on scene instead of transporting them unnecessarily, but the primary focus should be on increasing our educational level. Associates degree minimum NATIONALLY, more Bachelors options, and even Masters and above.

In doing all of this, we're going to have to avoid getting greedy. Ultimately, EMT's and paramedics exist because other health care professionals won't work for our wages. And while we certainly deserve better pay than what we receive now, I'm hesitant to feed into the mentality that increased wages aren't something that we must earn through elevating our standards. When that happens, though, and when the CMS changes the schedule of billing for ambulance services, I suspect we will face a greater challenge to hold onto our profession than we have before. Nurses will say "we have mandatory degrees, we're the right ones to do EMS!", NP's and PA's will say "why use community paramedics when we will do the job!" The answer which keeps EMT's and paramedics as the primary out-of-hospital health care providers will HAVE to be "we have equivalent education, and we'll do it for less" if we're to hold onto our jobs.

Just as nurses vehemently oppose paramedics working as paramedics in the hospital, and NP's and PA's will oppose community paramedics, and as physicians have opposed mid-levels, we in EMS have to hold firm onto our profession if we want it to remain ours. Like I've said, since our inception we have pretty much constantly been under the beck and call of another group, whether it be fire or nurses or physicians, and if we're to survive and truly be our own PROFESSION, we've got to distance ourselves from the rest, be self-regulating, and demand the same level of professional autonomy as these other groups do. But at the end of the day, the cards are in our hands. Nurses have no vested interest in us increasing our educational standards, and may in fact have a vested interest in us remaining uneducated; NP's and PA's likewise have no vested interest in our community paramedics and paramedic practitioners becoming a greater threat to them. The ONLY ones who have a need for EMS to evolve are EMT's and paramedics, and until we realize that and start fighting for our own profession, we will never be just that: a profession.

Going back to the clinical aspects of paramedic practitioners, yes I feel there is a need for better out-of-hospital health care. There are too many preventable transports, exacerbations of disease, and too many people without access to adequate primary care. We can provide that care, and we will provide it, if we get our hearts in the game.

[triemal04]

I completely agree...and disagree. While I am all for EMS being run by, and for paramedics (which I think is ever so slowly becoming slightly more realistic), and it's because of that that I am vehemently opposed to anything other than a very limited role for nurses in the prehospital/CCT world, I think, if done correctly, that using PA's to fill a real need in EMS would be appropriate, and the right choice.

Of course that's ignoring that things are rarely done "correctly" when it comes to EMS...

While I think that paramedics and EMT's should retain (or attain) primacy when it comes to prehospital care, using PA's to provide in the field primary care wouldn't neccasarily endanger that. And using an allready established profession with known educational standards, licensing requirements, physician oversight and lobbying groups would be much easier than trying to create something new from scratch. Especially with the current state of the overall US healthcare system.

As long as the PA's came from an EMS background (as in were practicing paramedics up till the point they entered PA school) and became PA's specifically to fill this role I think there would be less of a worry about anyone trying to force their way into a new field.

Realistically, once a funding source was set up, it wouldn't be extremely hard to do, at least initially. The biggest hurdle would be getting a college to recognize the paramedic curriculum as a good sized chunk of the credit requirements for a bachelor's; as far as I know most PA school's require similar schooling to med schools (year of biology, chemistry, physics and I think anatomy). Let potential PP's (or PA's) take those required courses, use their paramedic school and background as a working paramedic for the rest of the requirements, and be given a bachelor's. After that it would just be a matter of being accepted into a PA school, and making it through the program.

The really hard part would be eventually getting the option of focusing on both EMS and field primary care put into the curriculum. And since PA's can allready choice to focus more on various fields...and since EMS is now a recognized specialty by the AMA...and PA's are pretty closely linked to MD's...I think it would be doable.

This ignores that you would need to get local funding to run such a program (since, as with EMS the return for billing wouldn't really offest the cost), that you would have to mandate that candidates were working paramedics up to entry into school, have a medical director agreeable to it, local facilities that would let the PA refer patient's directly to specific specialties, etc etc etc.

But it's very doable. And much easier, and safer, than trying to create something new from scratch.

[Bieber]

I completely agree...and disagree. While I am all for EMS being run by, and for paramedics (which I think is ever so slowly becoming slightly more realistic), and it's because of that that I am vehemently opposed to anything other than a very limited role for nurses in the prehospital/CCT world, I think, if done correctly, that using PA's to fill a real need in EMS would be appropriate, and the right choice.

Of course that's ignoring that things are rarely done "correctly" when it comes to EMS...

Where's the benefit to EMS in using PA's rather than appropriately educated, appropriately trained paramedic practitioners? Other than to fund our industry's resources into another profession?

While I think that paramedics and EMT's should retain (or attain) primacy when it comes to prehospital care, using PA's to provide in the field primary care wouldn't neccasarily endanger that. And using an allready established profession with known educational standards, licensing requirements, physician oversight and lobbying groups would be much easier than trying to create something new from scratch. Especially with the current state of the overall US healthcare system.

As long as the PA's came from an EMS background (as in were practicing paramedics up till the point they entered PA school) and became PA's specifically to fill this role I think there would be less of a worry about anyone trying to force their way into a new field.

I would argue that if that were the case then PA's and NP's would have already slid into the position now being filled by community paramedics. I don't imagine there will be any greater interest in EMS by PA's, NP's or nurses until we're able to bill for service; other than to attempt to regulate our profession to protect theirs.

Realistically, once a funding source was set up, it wouldn't be extremely hard to do, at least initially. The biggest hurdle would be getting a college to recognize the paramedic curriculum as a good sized chunk of the credit requirements for a bachelor's; as far as I know most PA school's require similar schooling to med schools (year of biology, chemistry, physics and I think anatomy). Let potential PP's (or PA's) take those required courses, use their paramedic school and background as a working paramedic for the rest of the requirements, and be given a bachelor's. After that it would just be a matter of being accepted into a PA school, and making it through the program.

I agree with that general degree progression, except for the PA part.

The really hard part would be eventually getting the option of focusing on both EMS and field primary care put into the curriculum. And since PA's can allready choice to focus more on various fields...and since EMS is now a recognized specialty by the AMA...and PA's are pretty closely linked to MD's...I think it would be doable.

This ignores that you would need to get local funding to run such a program (since, as with EMS the return for billing wouldn't really offest the cost), that you would have to mandate that candidates were working paramedics up to entry into school, have a medical director agreeable to it, local facilities that would let the PA refer patient's directly to specific specialties, etc etc etc.

But it's very doable. And much easier, and safer, than trying to create something new from scratch.

Again, what about the community paramedic programs that are already up and going? What EMS system is utilizing PA's in the same manner? And why (yet again) allow others to do for us what we can do for ourselves, if we're willing to take on the challenge.

[paramedicmike]

Where's the benefit to EMS in using PA's rather than appropriately educated, appropriately trained paramedic practitioners? Other than to fund our industry's resources into another profession?

Many PAs come from an EMS background. They know the system. They know how it works.

PA programs are already in place with the educational requirements clearly defined. There's no need to create anything from scratch including a scope of practice, reporting requirements and, as already mentioned, educational requirements.

I would argue that if that were the case then PA's and NP's would have already slid into the position now being filled by community paramedics. I don't imagine there will be any greater interest in EMS by PA's, NP's or nurses until we're able to bill for service; other than to attempt to regulate our profession to protect theirs.

You just negated your own argument when you started talking about funding. The biggest reason you don't see NPs or PAs in these roles now is because of money. First of all, there isn't an EMS agency out there that can afford to pay the salary demanded by a PA or NP. Until there is a massive, major and total reconstruction of billing services and fee schedules for EMS providers, changes that take the masters level training that PA/NP providers receive, you just won't see it happen.

Coincidentally, increase the educational requirements for paramedics to fill this role will also not be financially supported given the current structure. (These comments are based on the current US model. Our international friends may already have systems in place that would make such a change possible.)

I agree with that general degree progression, except for the PA part.

ETA: I had something I wanted to add in here and totally forgot what it was. I'll add it later when I remember.

Again, what about the community paramedic programs that are already up and going? What EMS system is utilizing PA's in the same manner? And why (yet again) allow others to do for us what we can do for ourselves, if we're willing to take on the challenge.

They're not using PAs because they won't, and can't afford to, pay the PAs what they're worth. Along those lines, it'll be interesting to see how these programs progress given the (lack of) education currently involved in moving to such a model.

The argument seems to be to wanting to turn paramedics into primary care providers in the field. PAs and some specialties of NP are designed to be primary care providers. I think that's something that's being overlooked so far.

Edited March 26, 2013 by paramedicmike

[triemal04]

Where's the benefit to EMS in using PA's rather than appropriately educated, appropriately trained paramedic practitioners? Other than to fund our industry's resources into another profession?

I would argue that if that were the case then PA's and NP's would have already slid into the position now being filled by community paramedics. I don't imagine there will be any greater interest in EMS by PA's, NP's or nurses until we're able to bill for service; other than to attempt to regulate our profession to protect theirs.

I agree with that general degree progression, except for the PA part.

Again, what about the community paramedic programs that are already up and going? What EMS system is utilizing PA's in the same manner? And why (yet again) allow others to do for us what we can do for ourselves, if we're willing to take on the challenge.

As I said, it's not reinventing the wheel; it's using an established provider with established and ACCEPTED educational standards for what they do, established licensing requirements, oversight, lobbying ability (if a real bond between PA's and EMS was forged that'd be huge) and billing and reimbursement ability. For what I envision community paramedics, paramedic practitioners or whatever the name would be, actually doing, there would be a very real need for much more education than what is out there now, even for places that already have some type of program in place. And again, it wouldn't just be getting that educational standard, but getting it accepted, both by MD's, and insurance companies and medicare. Why reinvent the wheel?

On a personal level I think that the healthcare system is so fucked up that adding another type of provider, midlevel or otherwise is just plain wrong. This would give you the best of both worlds.

Don't get me wrong; I think that part of doing it "right" would be getting the PA profession to agree that the only providers who could specialize in field primary care would have to have a prior extensive background as a paramedic. I really think that would help with preventing any type of takeover, which, realistically, I don't see coming from the PA field. It's not something I'd be to concerned with.

I think a lot of the reason that you HAVEN'T seen PA's (you'll notice I'm ignoring NP's) trying to do more of this already is varied. While the need is definetly there, it's really not recognized on a level high enough to get traction. There's no funding for it; as I said, with the type of patient's that would be seen no amount of billing would cover the costs, so another source of funds would be required. And...nobody is doing it. While there are a very few agencies who are trying to do this (and I think some place in Colorado actually did almost exactly what I'm talking about with PA's years ago) it's really not widespread, and there is no standard.

I understand your feeling about wanting to keep this soley in house. In a perfect world I agree that it would be the best way; it's just that the way things are it really is a more realistic goal to use PA's with an EMS background. And again, that would also help create an alliance with another established medical profession, something that I think you can agree EMS definetly needs to do.

The problem I have with the systems that are doing this is that, to do it right, they need something along the lines of a midlevel provider. They need someone with the background to be able to provide real primary care to people who otherwise won't be getting it, and it a setting that's a bit different than a clinic or hospital (that's were getting a subspecialty for field primary care would come in). They need to be able to prescribe all the same drugs that you would get in a clinic, administer or order all the same tests, interpret the results, AND be able to get the patient admitted, not just sent to an ER, but actually admitted under a specific service within a hospital.

Could it be done your way? Sure...maybe. But...we can't even agree on what it takes to be a paramedic or EMT, and the accepted minimum standard is pathetic. Do you really want to try and create a whole new level of provider using the current national system as a base?

[chbare]

Let us not forget that residencies and fellowships are beginning to become more commonplace for PA's. Emergency medicine residencies and fellowships are starting to be available for PA's. As stated, the PA educational model revolves around primary care already, now we can add on formal specialization.

I do not realistically see mid level paramedics happening any time soon in the United States. As stated, we still have shake and bake programmes that offer little in the way of basic sciences. In addition, the EMS lobby is nowhere near as strong or organised as other groups. We also need medical directors on board as I do not see the role that physicians play changing in the United States anytime soon.

Unfortunately, what I fear is just another 100 hour shake and bake add on that lacks any real educational experience or value when compared to other allied health providers let along mid level providers.

[Bieber]

Many PAs come from an EMS background. They know the system. They know how it works.

Proof that most PA's come from an EMS background?

PA programs are already in place with the educational requirements clearly defined. There's no need to create anything from scratch including a scope of practice, reporting requirements and, as already mentioned, educational requirements.

Community paramedic program are on the rise, as are Bachelors level programs. Do you think that PA-based EMS confers some sort of advantage over EMS-based EMS in any way which is insurmountable given that we increase our educational standards? Is it better for us to continue to be carried along by other professions?

You just negated your own argument when you started talking about funding. The biggest reason you don't see NPs or PAs in these roles now is because of money. First of all, there isn't an EMS agency out there that can afford to pay the salary demanded by a PA or NP. Until there is a massive, major and total reconstruction of billing services and fee schedules for EMS providers, changes that take the masters level training that PA/NP providers receive, you just won't see it happen.

We already have more higher level educational programs popping up. Additionally, I suspect that even an equivalently educated paramedic practitioner will still command fewer wages than a PA or an NP.

Coincidentally, increase the educational requirements for paramedics to fill this role will also not be financially supported given the current structure. (These comments are based on the current US model. Our international friends may already have systems in place that would make such a change possible.)

While the lack of an appropriate pay incentive may keep paramedics from pursuing higher educational degrees, that may change once the CMS schedule of billing is improved. And until that happens NP's and PA's won't be interested in joining EMS anyway.

ETA: I had something I wanted to add in here and totally forgot what it was. I'll add it later when I remember.

Lol, sure thing.

They're not using PAs because they won't, and can't afford to, pay the PAs what they're worth. Along those lines, it'll be interesting to see how these programs progress given the (lack of) education currently involved in moving to such a model.

The argument seems to be to wanting to turn paramedics into primary care providers in the field. PAs and some specialties of NP are designed to be primary care providers. I think that's something that's being overlooked so far.

It's not about turning paramedics into primary care providers, it's about meeting our patients needs. Would you see EMS restricted to the few true emergencies we actually care for, and continue to confer little to no benefit to the vast majority of patients? Or would you rather see us provide the kind of care our patients are increasingly needing.

[scubanurse]

Purely anecdotal but every PA I know, around 20 or so nation wide, were at a minimum EMT-B first but the majority were practicing paramedics for years.

[Bieber]

Let us not forget that residencies and fellowships are beginning to become more commonplace for PA's. Emergency medicine residencies and fellowships are starting to be available for PA's. As stated, the PA educational model revolves around primary care already, now we can add on formal specialization.

I do not realistically see mid level paramedics happening any time soon in the United States. As stated, we still have shake and bake programmes that offer little in the way of basic sciences. In addition, the EMS lobby is nowhere near as strong or organised as other groups. We also need medical directors on board as I do not see the role that physicians play changing in the United States anytime soon.

Unfortunately, what I fear is just another 100 hour shake and bake add on that lacks any real educational experience or value when compared to other allied health providers let along mid level providers.

It's actually 300 hours. But you're right, that's not enough. But it's a step in the right direction, and even a single step is something we desperately need.

[paramedicmike]

Proof that most PA's come from an EMS background?

I said many. I did not say most.

I did a quick search to see if I could find information about PAs with and EMS background. My n=1 experience has shown that a surprising number of PAs I've met, worked with or went to school with had an EMS background. This is especially true in E-med settings. Unfortunately, I was not able to quickly find any specific numbers.

Community paramedic program are on the rise, as are Bachelors level programs.

True. But this will all be held back by the segment of EMS that wants to keep it simple. Specifically, fire departments who run EMS are the lobbying power here.

Do you think that PA-based EMS confers some sort of advantage over EMS-based EMS in any way which is insurmountable given that we increase our educational standards? Is it better for us to continue to be carried along by other professions?

Yes. I do. I think PAs are actually taught medicine. They're taught in a similar manner to physicians (which is entirely different from NPs and the nursing model of education). This is different from the vast majority of EMS providers who largely, even with the growth of college level programs, aren't taught much more than protocol based treatment with only a passing reference to pathophysiology.

(Coincidentally, I think you and I, among some others here, tend to forget that at times because of our EMS educational foundation.)

We already have more higher level educational programs popping up. Additionally, I suspect that even an equivalently educated paramedic practitioner will still command fewer wages than a PA or an NP.

I agree in part. As we discussed, the current fee schedules and financial system as it relates to EMS barely supports the system as it exists. However, masters trained paramedic providers, depending on their local scope, could very much demand the same level of compensation as mid-levels. And they'd be foolish not to do so.

While the lack of an appropriate pay incentive may keep paramedics from pursuing higher educational degrees, that may change once the CMS schedule of billing is improved. And until that happens NP's and PA's won't be interested in joining EMS anyway.

I don't know. The ability to pursue advanced education is there regardless of CMS scheduling. I managed to do it. I know a number of others who managed to do so with an EMS background. It's not necessarily the pay incentive. I think one of the biggest reasons EMS providers don't advance is that they get sucked into working more than one job to make ends meet and don't want to give that up to take out student loans to go back to school.

Just like physicians, though, there will always be those who are interested in other fields of medicine. Just as EMS is becoming a sub-specialty of emergency medicine, there will be PAs with an EMS background who would be willing to work in that kind of environment. Especially if they're able to provide care and do some good.

It's not about turning paramedics into primary care providers, it's about meeting our patients needs.

Really? That's sure what it sounds like with the idea of being able to refuse transport and refer to appropriate follow up care.

Would you see EMS restricted to the few true emergencies we actually care for, and continue to confer little to no benefit to the vast majority of patients? Or would you rather see us provide the kind of care our patients are increasingly needing.

I would like to see EMS limited to true emergencies. I'd also argue that the patients EMS increasingly sees don't really need a whole lot of care. At least not from EMS providers.

To try and pull this back from money for a moment, I've said it before and I'll continue to say it. Education is the single biggest issue facing EMS today. Fix education and everything else will fall into place. Well, fix education and get buy in from all 50 states and fire based EMS and everything will fall into place.

That being said, EMS needs to focus on their introductory education before they can be focusing on advanced education. In the mean time, there already exists a provider level(s) that could appropriately fill this role of providing referrals or primary care if it's needed. And there are even models in other countries we could use as a basis for such a program in the States.

It's actually 300 hours. But you're right, that's not enough. But it's a step in the right direction, and even a single step is something we desperately need.

Not if it's a mish-mash of inappropriate and undirected steps. That's a major cause of all the problems EMS has right now.