Which Way From Here?

     The subject of recruiting and retaining paramedics is on the agenda of many in EMS today. Agency leaders are wondering how, in the face of a shrinking workforce and growing demand for service, they will maintain enough staff to meet the needs of the communities they serve. EMS educators are looking for ways to fill classes. Working paramedics hope their agencies' vacant positions get filled, so overtime will diminish. Labor officials wonder when the law of supply and demand will kick in, resulting in higher wages as employers compete for employees.

     I've spent a lot of time talking with EMS professionals about this topic. Most of them love what they do, and would like nothing more than to have had interesting and diverse careers in EMS. But although most love patient care, those past the 10-year mark are often burned out from performing the same ambulance medic duties they've done since getting certified. Many have started to look for more interesting and stimulating alternatives that might provide brighter economic futures. For many, that means leaving EMS for other public safety or healthcare disciplines. What a loss! Why has the EMS community failed to provide depth and breadth to career opportunities for its people?

A FLAWED SYSTEM

     EMS agencies in the United States are part of a system that badly needs change. The bad news is that we built much of this system, and have become so invested in it that we may be threatened by the needed changes. Our basic faiths will be challenged. Here are some design features of a system that keeps us in a maze with no discernable endpoint.

1. We deliver an essential public health/public safety service. Essential public health/public safety services in the United States are paid for out of local government budgets. Yet we have, for the last 25 years, sold our services as requiring few or no tax dollars. For competitive advantage, we've cut our services off from funding streams that might serve us better than the ones we have. We've instead adopted a flawed "medical care" funding model for a service that's vastly different from a physician's private practice or an outpatient radiology service.

2. Our sole revenue source, in most cases, is transportation revenue. No transport, no revenue, and if we transport to somewhere besides a hospital emergency department, no revenue. So we have no incentive (in fact, we have a negative incentive) to provide other services beyond emergency treatment and hospital transport that might be better for our communities--services that would prevent unnecessary EMS calls, or that would take patients to places other than overcrowded EDs when ED capabilities are not required.

3. Our funding is completely dissociated from the rest of the healthcare system; thus we have no incentive to provide other contributions we are perfectly capable of making. Our counterparts in Canada, the United Kingdom, Australia and New Zealand are part of nationalized healthcare systems, so their funding comes from the overall healthcare budget. In some places, this has helped enable expanded scopes of practice. If it makes more sense to send out a paramedic to put in a couple of sutures than to transport someone to the hospital, we have to find ways to make that happen.

4. We've built a network of local (and sometimes sublocal) services that are small, financially weak and struggle continuously for survival. Underresourced organizations may cut corners in places like safety, personal protective equipment, compensation and benefits, management and supervision, training and more. They do not have, individually or cooperatively, the flexibility and infrastructure larger, more stable organizations can provide. It's often more important that it be "mine"--independent and free from outside control--than that it be "good" for the organization, its community and its employees. A friend of mine calls this the "captain of the rowboat" syndrome: where someone would rather be the chief of a tiny, precariously positioned organization (a rowboat) than a first lieutenant on a larger, stronger, more stable craft (like an aircraft carrier).

5. We've spent more than 25 years telling elected officials and municipal executives that EMS should be cheap. We've glorified systems whose hallmarks were high unit-hour utilization, low real estate cost and low cost per transport. We've been successful, and now many of these officials believe their communities can have EMS that is both good and cheap or free! We've focused on efficiency in a narrow domain, instead of seeking to broaden the scope of services we deliver.

A JOURNEY INTO THE FUTURE

     Now let's take a journey to a mythical EMS world where these features have been altered. Assume our services are funded in the same manner as schools, law enforcement, fire suppression, highways, libraries and public health. Sure, we still bill for ambulance transportation, but that revenue goes back to the taxpayers who fund everything they want us to do. We're not expected to fund ourselves any more than law enforcement, schools or the libraries. And let's assume we've happily and successfully combined EMS organizations into larger, regional provider organizations that serve 1–2 million people or, in more sparsely populated areas, up to several thousand square miles regardless of population.

     Establishing a career ladder can be a daunting task. Many workers want systems that simply provide additional pay for longevity. Absent alternatives, some employers have acceded, resulting in systems where some individuals are paid more than others for doing the same work. In the human resources world, this is not considered a good thing. It can be a source of resentment and fodder for lawsuits. And the happiness generated by longevity compensation is short-lived. In the end, boredom and burnout will prevail, and dissatisfaction will reemerge.

     The ladder concept typically connotes opportunity for vertical advancement. Yet most EMS organizations have organizational structures that are quite flat. An unpublished survey conducted by the National EMS Management Association (NEMSMA) in 2006 revealed that EMS organizations did not have a standard for span of control (supervisors to employees), and that spans of control typically ranged from 15-48 employees. In some agencies, the ratio was as low as one supervisor for 100 employees.

     There are a variety of issues at play here, but for this article it means that opportunities for advancement are limited by the number of available supervisory and management positions. Most EMS organizations can offer supervisor, manager or executive spots to perhaps only one of every 10 employees. We need some good, solid organizational research to define appropriate levels of supervision and, for agencies, appropriate spans of control and numbers and types of specialists and support staff.

     Let's do a comparison with the other disciplines with which we interact each day. For discussion purposes, assume good-size career organizations serving the same jurisdiction.

     The pyramid in the law enforcement and fire protection world (Figure 1) is 11 levels high. And in general, these steps are not mere artificial creations. Each rank has a corresponding set of responsibilities, competencies and qualifications distinct from those above and below it. The corresponding EMS agency, not atypically, is four levels high. It is easy to see the discrepancy in vertical opportunities.

     However, there is another concept alive and well in these organizations that provides for career variety, personal growth and a hedge against boredom and stagnation. That is career breadth. For purposes of example, look again at law enforcement and fire, and add nursing. Career breadth, or horizontal diversity, is created when organizations expand the scope of the services they provide, creating opportunities for service-provider (line)-level employees to move beyond the basic functions of the job to work that is different, stimulating and rewarding.

     Start with a nonsupervisory paramedic. Their career breadth opportunity consists of:

• The front of the ambulance;
• The back of the ambulance.

     Not very stimulating for the next 20 years, is it?

     Now look at a nonsupervisory law enforcement officer. After mastering the basics of uniformed patrol, that officer might specialize in:

• K-9 operations;
• Investigations (e.g., homicide, narcotics, organized crime, technical crimes, financial crimes, etc.);
• Traffic enforcement and accident reconstruction;
• Special operations;
• Community policing;
• School resource officer.

     A nonsupervisory firefighter may have opportunities in:

• USAR;
• Hazmat;
• Fire prevention/inspections;
• Fire investigations.

     An RN's opportunities similarly extend beyond general-service hospital-ward nursing. At the first rung are opportunities in a wealth of practice areas (ED, critical care, surgical suite, labor and delivery, etc.). Next are nonsupervisory opportunities like clinical nurse specialist, nurse practitioner and nurse anesthetist. None of these advancements require the nurse to leave their chosen profession. They represent additional, value-added service beyond the professional core.

     So why have we developed so few nonambulance career opportunities for our personnel? Go back to the design features described above—follow the money. The only revenue stream most EMS agencies have is transportation. Anything that reduces or doesn't produce transportation revenue is therefore "bad" by definition. Thus, we do not develop valuable services and diverse career opportunities for our personnel. We've abdicated nonambulance emergency medical service functions to other organizations, who have stepped up, performed the services and enhanced career opportunities for their personnel.

     There are many valuable enhancements to public health that EMS personnel might deliver. Breaking the funding paradigm--either getting funded like other essential local services or getting our funding integrated within better--developed healthcare systems—would allow the development of our paramedics' knowledge, skills and mobility for many career-broadening opportunities. For some examples, see the sidebar Career Breadth for Paramedics.

     With these functions in place, we would have the ability to "surge" additional EMS resources during big events. How do major cities handle their policing needs after disasters or for major events? If they need to augment their uniformed patrol forces, individuals on special assignments are called back to perform their core duties. Few EMS organizations today have the depth to expand much beyond their daily operational capacity.

WHO'S WHO?

     Another way we've made career mobility difficult is through the nonsystematic use of functional titles rather than a standard rank-based system. We have eschewed the semi-military rank structure used by fire, law enforcement and even the U.S. Public Health Service, and developed one-deep niche roles for individual managers.

     One of the ways fire and law enforcement agencies provide career diversity while at the same time engaging in succession planning and improving internal "bench strength" is through rotation of assignments. Individuals with ranks like assistant fire chief or law enforcement major spend two, three or four years in one assignment (for example, operations) before rotating to another (like support services or training). One step below, police captains and fire division or district chiefs may rotate between precincts, districts or special unit commands. It is a rare EMS agency where the QI manager, the communications manager, the operations manager and the logistics manager share sufficient common background, knowledge, skills and abilities where they could rotate assignments.

     The EMS community would be wise to embrace and adapt two models developed by the fire service to identify professional development needs and foster appropriate education and training. The first is a standard analogous to NFPA 1021, Standard for Fire Officer Professional Qualifications. Through this standard, the fire service identified and achieved consensus on the required competencies for supervisors (first-line company officers), managers (second-line supervisors such as battalion chiefs), administrators (division and other staff chiefs) and executives (chiefs and deputy chiefs). With this roadmap in hand, an individual aspiring to a career in the fire service can identify the knowledge, skills and abilities needed to progress upward.

     The second is a higher education model. The USFA's Fire and Emergency Services Higher Education program has developed a model to standardize the academic preparation of future leaders. This model is similar to that adopted for the fire service (see www.usfa.dhs.gov/nfa/higher_ed/feshe/feshe_strategic.shtm).

     There are differences that remain under discussion. For example, most EMS organizations do not have a function similar to that of a company officer supervising the crew of a single motorized response unit. And while the FESHE fire hierarchy is tied directly to NFPA 1021, the EMS model has to make certain assumptions, because the EMS community has not yet developed a consensus standard to outline the core competencies of the layers of EMS officers we'd deem appropriate.

CONCLUSION

     For EMS to prosper as a profession and an industry, we have to do better by our people. We must provide them with meaningful, stimulating career opportunities with sufficient variety to stave off boredom, dissatisfaction and departure.

     To offer an alternative to "McJob" EMS, we have to come to grips with a few fundamental issues. This will require strong leadership, unity among our various models, cooperation between labor and management, and outstanding advocacy.

• We must shed the medical fee-for-service funding model and reeducate a whole generation of public officials.
• We must develop new funding models that fund community EMS services in the same manner as other essential public health and public safety functions.
• We must encourage mergers, consolidations, regionalization and the development of EMS organizations large and strong enough to operate beyond mere survival mode, and that have the depth and flexibility to provide multiple services and career opportunities.
• We have to develop meaningful measures of the value we add to our communities. We must find out what our communities want in terms of mobile emergency and preventative health services, and create metrics to show we can deliver good value for the money they give us.
• Last, we have to develop our leadership hierarchy in a way that is rational, logical and based on consensus standards. As an industry, we need to look at our structures, functions and needs, and identify the competencies necessary for the layers our organizations require to function effectively and efficiently.

     It is possible to develop an EMS environment where individuals join an agency with the idea of staying there for a full career. The question is, are we up to the challenge?

     Skip Kirkwood, MS, JD, EMT-P, EFO, CMO, is chief of Wake County EMS in North Carolina.

Sidebar: Career Breadth for Paramedics

     Broadened career opportunities for EMS providers might include work as:

• Community health paramedics,who could reach out to the indigent and other frequent users who often really don't need an emergency ambulance response or the services of an ED. Imagine the 9-1-1 calls that could be eliminated if someone visited your chronic noncompliant diabetics, checked their blood sugar and talked to them about medication compliance. Imagine the respiratory distress or CHF calls that might be prevented by visits every couple of days to check blood pressure and for pedal edema. A small program of this type in San Francisco has generated favorable responses among both the homeless population and the public health community.
• Injury-prevention paramedics,who could visit elderly and other fall-prone citizens and help them fall-proof their homes; visit new parents and help them "kid-safe" their homes; and visit homes with newly installed swimming pools to educate about pediatric drownings.
• Initial response/patrol paramedics,in light vehicles, on bicycles or motorcyles or Segways or what-have-you. This mode of operation is seen widely in the U.K. and European countries. A 40,000-pound fire engine is not necessary on all EMS calls.
• School resource paramedics,assigned to large schools or high schools. Like their law enforcement counterparts, these medics could be part teacher (health, first aid, even EMT classes), part responder, part counselor and mentor.
• Special-operations paramedics, who handle areas like tactical EMS, hazmat and USAR EMS, and medical management of mass gatherings.

Sidebar: Advancement Opportunities Fall Victim to Economy

     In theory, everyone supports greater career opportunities for EMS' best and brightest. But we don't exist in theory. We exist in a reality that is, at the moment, economically turbulent, and applying terrific pressures to EMS systems fighting to survive.

     Those pressures can work against expansion of the EMS career ladder. In many cases, agencies tighten their belts by stripping down and going back to basics. Consider the recent proposal to eliminate the Columbus (OH) Division of Fire's ALS capability. The city, America's 15th largest, has offered advanced-level EMS since 1968.

     In New Bedford, MA, the victims were paramedic supervisors. New Bedford EMS laid off four in February, among nearly 180 workers (including 38 firefighters) sent packing citywide.

     In an organization with relatively few management opportunities, the position represented advancement, says one of the four, Thomas Pimental, Jr., NREMT-P, RN, CEN, a 32-year veteran of EMS. "One of the reasons for it was so people who'd worked in the system and shown their dedication over the years could have something to aspire to besides just being a staff paramedic," Pimental says. "That's important, because otherwise you can feel stagnated."

     New Bedford created its paramedic supervisor position in 2003. Among the position's duties were managing and mentoring medics, assisting on challenging calls, coordinating resources during major incidents and spot-checking the performance of field crews. "We were active quality control on the streets," another laid-off supervisor, Joe Rebello, told the local press.

     New Bedford's mayor and EMS director say losing a midlevel layer of supervision won't hurt the quality of care the agency delivers, and the medical director will be keeping a close eye on how things progress. But from the career ladder perspective, those are four vertical advancement opportunities that no longer exist for deserving field providers.

     -John Erich, Associate Editor