Pinnacle: EMS Nomenclature and Degrees Debate

In recent years, two of the most controversial topics dominating discussions in EMS are 1) whether or not we should standardize the nomenclature used for EMS providers, and 2) whether or not college degrees should be required for paramedics. In the Pinnacle session, “One Hour, Two Debates: Nomenclature — Paramedicine vs. EMS & Should Higher Education be Required,” Brian LaCroix, NEMSA president, and Bruce Evans, fire chief and president-elect of NAEMT, provide arguments for and against these positions. Michael Gerber, MPH, of RedFlash Group, moderated the debate.

Education Requirements

Bruce Evans, AAS, BS, MPA, took the opposing side to this argument. He made it clear that he’s not against education—he graduated from a paramedic program; requires degrees for anyone in middle management positions or higher at his fire company; is the founder of the USFA’s Fire and Emergency Services Higher Education initiative, and taught at the College of Southern Nevada for 20 years. It’s because of his experience in education, however, that he understands the difficulty of changing educational paradigms. The U.S. Department of Education utilizes the Carnegie Unit system to measure academic credits. Instead of earning one credit per hour, three college-level credit hours equate to one course, or 45-48 contact hours total over one semester. This system makes turning certification programs into degreed programs complicated.

“It’d be a heavy lift to switch that and convince academic committees to take content material up to that field internship of 600 hours to get 600 credits,” said Evans, noting that it’s a broken system. “It’s not fair and doesn’t reflect the real experience.”

He drew comparisons between the degree debate and MAST pants debate that ultimately phased out their use in the field for trauma patients after the 1980s. While a small subset of trauma patients did, in fact, benefit from MAST pants, the cost of the device proved not to be worth the benefits it provided. He wonders if the same holds true for the cost of revamping the academic system to accommodate for new degree requirements.

“Does education really make a difference, or does it make people feel better?” Evans asked the audience. “Does it make you more professional or just anecdotally feel professional?” Plumbers and mechanics, despite the fact that most of them are without college degrees, are financially stable and considered professionals, Evans pointed out, but our culture of “academic snobbery” makes people believe that everyone has to have a degree to be respected.

But should education be the hygiene factor in pay? Evans said that reimbursement is a major limiting factor to boosting salaries even with a degree under your belt. The funding isn’t there if we’re getting reimbursed $200 for a $1,000 Medicaid transport. Plus, student loans are a heavy burden to bear in a field with low pay. Not to mention if an agency does partially or fully fund an employee’s education, they may not end up getting a great ROI. While many believe that medics will stay longer with their employers after earning a bachelor’s degree, employee retention tends to decline. Paramedics last less than five years upon completion of their schooling, and head to PA, nursing, or medical school. Of course, these employees may be upwardly mobile regardless, said Evans, but it’s worth noting.

With that said, Evans believes we need to conduct further research to determine the cost benefit of this paradigm shift in education. He proposed the idea of an EMS bill modeled after the GI Bill to incentivize education rather than mandate it. Verified by tax or employment records, the bill could be awarded after three years of service as an EMT (in any delivery model) and fund a paramedic degree program that’s an actual bachelor’s degree. Evans said there is an untapped resource that could fund this kind of program—the Department of Labor has nearly $60 million of unspent job training funds every year, which could be structured into the bill similarly to how Pell and Stafford Grants are structured.

Brian LaCroix agrees with the idea of encouraging degrees for paramedics but doesn’t necessarily think they should be required.

“We need to change because we don’t own our profession,” said LaCroix. A degree could “offer secondary components that can be helpful in addressing patients,” considering how our social interactions with patients are evolving as the scope of practice and demands of paramedicine also evolve. 

Right now, we are “physician extenders” working in a “Mother, may I?” system, he said. Earning a degree could move the profession away from that through the enhancement of medics’ critical thinking skills and give the profession more credibility and autonomy. Paramedicine in the U.K., for example, is moving towards a more independent practice by not working under medical directors.

“We can learn from other allied healthcare professionals,” LaCroix said. “We need to have some sense of an education standard to become our own professional workforce.”

Nomenclature

Some argue identifying all providers as ‘paramedics,’ like they are in many other countries, makes things less confusing for the public, while others contest that they worked too hard for their paramedic licenses to be lumped into the same category as EMTs. However, it’s impossible to ignore that the landscape of EMS is evolving. Some agencies have rebranded themselves to reflect those changing services that are not all emergency-based (MedStar Mobile Healthcare of Fort Worth, Tex., for example). The question is whether these name changes represent who we are and what we do.

LaCroix believes we have too many names in our roster: EMT, EMT-Intermediate, AEMT, paramedic, flight paramedic, EMT-P, to name a few. “The public doesn’t care. They just want to know paramedics are coming,” he said. “We need to standardize our language.”

The lack of standardized language doesn’t help the profession because if regulators, city council members, citizens, and stakeholders don’t know what to call us uniformly, we might be writing ourselves out of critical legislation.

“There’s no reason not to adopt this [standard language] to better serve our communities,” said LaCroix. “We’re hurting ourselves and we’re not advancing our careers.”

Bruce Evans, on the other hand, isn’t sure it’s all worth the hassle. “It’s taken decades to not call us ambulance drivers,” he said. “It’s how we wrap it and perceive it.”

While he doesn’t feel ready to give up his paramedic title because of the hard work he invested in becoming one, he does agree consolidating the language is important.  

“We may find the set of skills we’re supposed to be doing that are evidence-based may contract to the point where it only requires one level,” Evans said. With evidence showing good CPR, good ventilation, and rapid transport being the core critical prehospital skills, “ALS skills are moving into BLS as paramedic skills dial back. BLS work truly makes a difference in most cases, with some outliers.”

Ultimately, though, Evans believes that “culture change must happen before the name changes. Once it does, it’ll make sense."