Professional Development: Part 4--The Social Contract

   EMS needs good leaders and managers. What can you do to become one? This is the latest installment of EMS Magazine's Professional Development series, a comprehensive curriculum for forward-thinking EMS providers wishing to improve their leadership and management skills, increase their authority and responsibility within their organizations, and change their field for the better. We welcome your comments on this series and invite ideas for future content. E-mail nancy.perry@cygnusb2b.com.

   When our tones drop, when the BlackBerry buzzes, when the PA announces an address, why do we go? On our way to incidents, we are allowed, after ensuring all have yielded, to proceed through red signals. Why? When we arrive on location, someone there expects us to do something. How come? Because all of those things are part of our "contract" with the communities we serve.

   Last month we discussed morals and ethics. One aspect of the EMS Code of Ethics is acknowledging an obligation to society. Dr. Herbert Swick, whose work on medical professionalism guides this series, addresses this obligation directly with the fourth of his defined professional behaviors. Swick says, "Physicians respond to societal needs, and their behaviors reflect a social contract with the community served."¹ He goes on to say that any profession best meets its obligations when it pays attention to duty and actively strives to address community and societal needs. As EMS practitioners, we also act in response to society's needs and in acknowledgement of a contract with our communities.

   This can be a difficult set of concepts and behaviors to grasp. As EMS practitioners, the easiest way to get a handle on the idea of responding to society's needs is to examine what we do every day: respond to requests for help. But there is more to the concept of responding to society's needs than just jumping into the ambulance and driving.

   The first thing we can do is assess our communities. Who needs help? What can we do to provide assistance? It is clear that we provide a service that assists people who have experienced "emergencies." Their emergencies may be related to acute or chronic medical problems, or to injuries suffered in traumatic events. Or, an "emergency" might be a request for some sort of assistance completely unrelated to medical problems or trauma. We also provide a medical "safety net" for those who have limited access to other healthcare. Sometimes we meet needs that are less medical than social. When someone needs help and has nowhere else to turn, very often that person will call 9-1-1.

   What are some of the other needs we can meet in our communities? Does society need to reduce deaths from sudden cardiac arrest, or the number of people injured and the cost to treat them? What can we do to meet these needs? Perhaps we can provide CPR training or injury-prevention programs such as car seat installations, bicycle helmet and safe-rider programs, seat belt education for grade-school children, pool safety for middle-school students, anti-drunk driving education for high-school students and adults, and "trip and slip" prevention for the elderly. We could also deliver flu and other vaccines (this is happening now in Philadelphia in response to H1N1). The list can be as long as we choose to make it. Benjamin Franklin recognized the value of prevention more than 200 years ago when he said an ounce of it is worth a pound of cure. The fire service has done a fantastic job in reducing fire-related deaths and costs related to fires. Perhaps EMS should do likewise. I'm certain some of us already are. Are there other ways we, as EMS practitioners, can respond to society's needs and more fully fulfill our obligation--our contract?

The Terms of Our Deal

   What is our contract with our community? Legal scholar Sir John William Salmond says a contract is an "agreement creating and defining the obligations between two or more parties."² The 'Lectric Law Library begins its definition with the following:

   An agreement between two or more competent parties in which an offer is made and accepted, and each party benefits. The agreement can be formal, informal, written, oral or just plain understood.³

   With a basic definition, we can now break it down and determine how it applies to us. There are at least three parties to our contract: the public, who are members of the community we serve; us, the EMS practitioners; and the organization providing the service to the community. What is the offer made that benefits all parties? That the people in the community benefit from knowing someone will respond if they call for help. They expect their EMS practitioners to be competent. The medical community expects reduced morbidity and mortality related to sudden cardiac arrests and other medical problems and trauma situations. The people expect transportation to the hospital. These are the benefits we strive to offer.

   One of the most important dimensions of our contract with the communities we serve is responding when dispatched. When we're called, we go. We have a duty to act that is often described in our states' EMS-enabling legislation. That duty is usually addressed in our organizational rules and regulations as well. Someone has called for help, and that person expects us to arrive quickly and act professionally when we get there.

   How do we benefit? In some cases we are paid. Those who are paid may also get other benefits, such as health insurance and paid leave time. Volunteer benefits include membership in an organization of peers, respect of the community, and perhaps permission to respond to the station or to incidents directly using lights and siren. Volunteers also receive the opportunity to serve--to do good and contribute to their communities. I know of volunteer services that provide incentives such as gift cards donated by local restaurants and businesses as rewards for taking a given number of shifts per month. Volunteers may receive free education and training provided by their organization. What other benefits can you think of for volunteer EMS practitioners?

   Our agreements can be formal written contracts, like the agreement made between a union or volunteer service and a municipality, or they can be less formal, such as the agreement between practitioners and the services they work for, whether volunteer or paid.

   How does the concept of meeting needs and having a contract align with the National EMS Education Standards' standard for professionalism? The components of this standard are exactly the same as those of the NHTSA National Standard Curriculum for EMT-Ps' (see sidebar). It includes at least three professional behaviors that could be considered part of our contract: integrity, careful delivery of service and patient advocacy.

   Some of us might react to this concept of a contract with doubt. What do we owe system abusers, for example? To that I will pose this question: What exactly is a system abuser? How do we make this sort of judgment? I think we can all agree that someone who deliberately calls in a false run qualifies. But when it comes down to it, for nearly everyone who calls for help--even those who call for things we are not trained or educated for--there is almost always something we can do to serve. If you took this job or chose EMS as a career thinking we only respond to life-threatening emergencies, that everything we do is related to illness or injury, you will soon learn that it is not the case. Rather than judge folks who ask for our service for something outside the realm of injury or medical problem, might we all be better off, practitioners and callers alike, if we just tried to help? That really is what our contract is: to serve.

Teaching Behavior

   How can we teach and evaluate EMS practitioners' behavior as it relates to responding to society's needs and reflecting a social contract with the community? The first step is to explicitly describe behavioral expectations early in any EMS program. If program directors and instructors communicate the principle of agreeing to a contract with the community, students will begin on the right foot. We must make clear the behavioral expectations that are part of the contract and the consequences of not meeting them. If this is completed during orientation, students will have no excuse to behave otherwise.

   In the Philadelphia Fire Department, we have a guidebook for every cadet class that includes individual behavioral contracts covering such things as lateness, fitness for duty, academic performance, compliance with rules and regulations, and the chain of command. Each cadet reads the expectations and the consequences of noncompliance, and signs that they understand and agree.

   Another critical educational piece is role-modeling. All EMS instructors and adjuncts must demonstrate professional behavior: treat students with respect, know the material they will teach, arrive on time ready for whatever role they will fill, pay attention to hygiene and appearance--all of the behaviors expected of cadets or students, only demonstrated at a higher level. These same behaviors should be modeled by preceptors and by every member of the organization.

   Meeting society's needs and fulfilling our contract with our communities may not be something we think about on a regular basis, but we should. We could all stand to reflect on our obligations to our services, our communities and the people we serve every day.

   In coming months we will discuss the next of Swick's professional behaviors: demonstrating core human values.

EMT-P Professional Behaviors

   Professional behaviors listed in NHTSA's National Standard Curriculum for EMT-Paramedics:

• Integrity
• Empathy
• Self-motivation
• Appearance and personal hygiene
• Self-confidence
• Communications
• Time management
• Teamwork and diplomacy
• Respect
• Patient advocacy
• Careful delivery of service

References

1. Swick H. Toward a normative definition of medical professionalism. Acad Med 75(6): 612-616, June 2000.

2. Wikipedia. https://en.wikipedia.org/wiki/Contract.

3. Lectric Law Library. www.lectlaw.com/def/c123.htm.

   Michael Touchstone, BS, EMT-P, is chief of EMS training for the Philadelphia Fire Department. He has been involved in EMS since 1980 as an EMT, paramedic and instructor. He has participated in EMS leadership, management and educational development initiatives at the local, state and national levels. Contact him at m-touch@comcast.net.