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A Giant Step Backward for Paramedics
[Editor's Note: NREMT 22-RESOLUTION-13] was rescinded following the publication of this editorial. For more information click here.]
In Better Call Saul, the series protagonist, Jimmy McGill (later he changes his name to Saul Goodman), attends the American Samoa Law School and is never really taken seriously by his colleagues or clients. While the American Samoa Law School is fictitious, the Breaking Bad prequel illustrates a real problem in professional education: unaccredited academic institutions.
Would you seek important legal advice from someone who did not go to a recognized law school? Even if he was a nice guy and seemed knowledgeable, would you trust your freedom to someone who simply eked out a passing score on a bar exam? Probably not.
We are now facing that exact problem in the EMS professions. The National Registry’s Board of Directors has recently decided (22-RESOLUTION-13) to allow paramedics to be eligible for national certification without completing a nationally accredited educational program. This is a dramatic reversal of years of progress in paramedic education, in violation of the EMS Education Agenda for the Future and to the detriment of our profession.
To be clear, all health professions are facing enormous workforce challenges. In the next few years our country will be facing unprecedented shortages of physicians, nurses, and virtually every allied health profession.
EMS is not unique in this respect; however, systemic issues are the real source of our perennial paramedic shortages that have been exacerbated by COVID-19, not caused by it. As data clearly shows, low wages, insufficient benefits, inadequate worker protection, poor working conditions, the physical and psychological toll of the job, burnout, and lack of respect/professional recognition (by employers and the medical and public safety communities) are the root causes of the inability to recruit and retain a sufficient EMS workforce.
Paramedic shortages are not caused by education, accreditation, certification, or COVID-19. Lowering our educational and certification standards will not solve, and very well may worsen, the real reasons for our workforce shortages.
In the 1990s I was privileged to participate in a number of national projects that endeavored to improve EMS education. It was initially felt that we simply needed to update the National Standard Curricula every few years, and that would be enough.
Unfortunately, these projects were expensive, time-consuming, highly contentious, and created “one size fits none” documents that virtually every state and educational institution felt the need to modify. Because no system and few standards existed, over 50 levels/titles for EMS professionals had emerged. It was the “Wild West,” and we were asked by NHTSA to find a better way.
When we wrote the EMS Educational Agenda for the Future, it was not a visionary document. It was, in fact, what virtually every other profession had implemented years before and was literally the least we could do to move away from a standardized curriculum model. A system that included mutually dependent elements of educational standards (not standardized curricula), accreditation of educational institutions, and national certification was not unique but was novel in EMS at the time.
We held lengthy and heated debates about recommending single vs. multiple ways to achieve certification and educational program accreditation. These conversations were every bit as passionate as the ones today—in fact, they were mostly the same arguments. The final recommendation for single national accreditation and certification was based primarily on the fact that a standard is not possible with multiple entities performing accrediting and certification functions. In fact, our research found that other professions that have multiple pathways (a few do) wrestle with the “double standards” that create an inevitable “race to the bottom.”
In the end the strong majority concluded that students, the public, and the profession were best served by recommending that a single independent entity perform educational program certification and accreditation. While we have a long, long way to go, this system has incrementally improved EMS education, especially at the paramedic level. With one decision the National Registry board would erase the hard-fought progress of the past 20 years.
Paramedic workforce challenges are real and need real solutions. If we are to solve our recruitment and retention problem, we must improve the remuneration, respect, recognition, and working conditions of frontline paramedics.
This is a moment of truth for our profession. We must advocate for and secure resources to address these big problems and not get distracted by those who claim reasonable educational or certification standards are the cause.
If we just let anyone who can pass a test be a paramedic, we will forever be viewed as the Saul Goodmans of health care and public safety.
Gregg S. Margolis, PhD, NRP, is director of health policy fellowships and leadership programs at the National Academy of Medicine.
Comments
Agree completely. Thanks again Greg for once again articulating an important issue so that everybody can grasp it.
—Skip Kirkwood
Thank you Dr. Margolis for perspective and context. Knowing your previous relationship with the NREMT this resolution surely must sting. I totally agree with your comments. We cannot undo our hard fought strides to professionalize our industry. If Covid-19 and the current opioid crisis has taught us anything it is to recognize how essential EMS is. We need to raise its value of respect, recognition, and remuneration as you pointed out. Short term solutions like lowering the standard is at best myopic and cause long term harm.
—Arnold Alier
Spot on. Many EMS professionals and industry leaders that have been committed to improving the education and professionalism of EMS over the last 30+ years are adamantly speaking out about this. It's hard to believe that the National Registry's board would not have consulted with these individuals, or created some sort of review committee first, before even considering making this resolution. It's a huge disservice to the industry and a major step backwards.
—Beth Crittenden
I have been an EMS Medical Director for 49 years. I have seen the evolution of change in EMS providers’ training during this time and have found the importance of a standardized training program given through an accredited academic agency to be critical in assuring that patient care, being given under my watch, is of the highest quality. I am in total agreement with Dr. Margolis’ mindset on this.
—Michael Wilcox, MD
I’ve taught in many EMS programs and whether basic or paramedic I taught the same. I chose to go beyond the surface and delve into the”why” we do what we do as medics. I wanted my students to understand how a drug worked at the cellular level. How the body works and reacts to all stimulus. To me, you had to know what your actions could produce by taking the classroom knowledge and transform that knowledge to your hands
We don’t need”test taker medics”. It’s life that we treat and life is more than a written test.
—Mark French
If we continue down this “road” of just test taking and not being required to attend and pass classes we will become relic's of a by gone generation. What happened to the talk of paramedic providers with college degrees? It comes down to money, and agencies needing bodies.
—Robert Carter
I recently re-read Abraham Flexner’s 1910 scathing critique of American Medical Education. He was right. The advances in modern medicine reflect the high standards and continuous accreditation that we have evolved over 100 years. Taking the compact we have made with our patients and the public seriously is the foundation of that precious trust.
Any examination, however well vetted is a frail surrogate for the continuous competence under critical stress that our jobs in EMS require.
I had thought, after 50 years of we could rightly call ourselves professionals. Maybe not.
—Joseph Ryan
It is not the accreditation of a teaching institution that makes good Parramedics but rather the individual and their passion for EMS. If someone can pass the National Registry Exam and each states specialized requirements they should be allowed to become a nationally registered and certified Paramedic. Maybe the "teaching institutions" are the reason we have a decrease in the number of paramedics. Many of the 'accredited' institutions are nothing but an over regulated, under staffed school with sub par instructors, but they have the accredidation so must be the best?(sarcasim) Focus more on active practices to improve peoples perception of our profession. Hold Paramedics & EMT's to higher standards while in the field and work on interaction with the nursing unions / boards and we may acheive progress. Many of the very best Paramedics and EMT's never went through an accredited program and have become exceptional practioners.
Treat the patient, not the numbers/machine. Judge the individual not the individuals source of accredidation.
—Mike Sandy
For the past 2 weeks I've been working on a draft so I could comment on this important EMS matter impacting the EMS profession. My involvement with NAEMT also involved me in review and input into the EMS Educational Agenda for the future. After reading Gregg Margolis comments, I don't think there is anything I could say that Gregg hasn't already said.
—Ken Bouvier
Greg Margolis is spot on as usual!
—Jon Politis
Very well written Greg. You have always been the voice of reason with factual information to support your point. I could not agree more with your assessment that this will be a deathblow for Paramedics in the USA and will have further impacts to the other EMS levels. If this were to move forward anyone who wishes to enter the State of Wisconsin and seek licensure through reciprocity, will never get past the initial question. Did you come from an accredited educational program?
—Dan Williams
It's all about money even if it's to the detriment of our health care. To utilize paramedics to their full potential, they must be well educated. As a 30 year EMS medical director, it appears that EMS education is being sacrificed to attract and retain underpaid and undereducated EMT's and paramedics. Thank you, Gregg, for making this point.
—James Pointer, MD
Absolutely agree. Thank you for this thoughtful, articulate analysis.
—Melissa Callahan
I've said many times before that there are a number of people in EMS who passed registry who I wouldn't let touch my dead dog. Basically, I don't believe that by merely passing a national registry makes a person competent.
I agree with your stance expressed here. I truly appreciate you shining light on the concept this shortage in EMS professionals did not result from the pandemic or the rigors of achieving accreditation. It's my understanding that even people who are home schooled need to satisfy a prescribed curriculum in order to award a high school diploma.
Although a single entity for accreditation makes sense, I am of the opinion that adequate oversight to ensure quality would be logistically a nightmare. A national standard is a good foundation, possibly followed by a state standard, then a standard at the local level.
—Elsie Kusel
Thank you for writing about this. Your perspective is the same as many EMS educators, and providers I know.
—John Cockrell
Greg, Spot on. I agree with your comments and have seen the progression of EMS since I joined in the late 1970's. Without the framework of accreditation, it is harder to progress and be in line with our healthcare brethren.
—Richard Ellis
As a former Paramedic program director I have to agree with the general ideas in this article. That being said, the lack of support and overall poor attitude of the accepted accreditation agency chosen was the rain we have come to this point. CoAEMPs as an organization was less than"user friendly" to say the least. Every former program director that I have spoken to points to CoA as the reason that they are no longer involved with EMS education. Leadership in the organization is arrogant and they soak down to educators who have been mentoring paramedics for the entirety of their careers. There has to be a better way. That being said, NREMT needs to find a solution to those issues without blowing up the whole idea of standardization.
—John Coyne
I respectfully disagree. Jon Politis and I took our NREMTP exams together as some of the first from NYS to have first passed NREMT and when the paramedic boards became reality we drove from NY to Alanta where a two-year accredited program was hosting. When word went out as the students entering the exams signup that the practical skills stations had different equipment the graduates of this two-year accredited program were panicked. So, Jon and held quick study class in the bathroom to prepare them where their program had failed. Jon and I were at that time from NYS certified but NONACCREDITED programs but both of us learned our skills from the Albany City ambulance in the late 60's and seventies. Jon and I gained experience at the same regional EMS agency where he was director of NONACCREDITED paramedic training and I was teaching BLS and EMT programs and all were unaccredited. training programs and some of us were the best EMS and ACLS providers in upstate NY. We trained many thousands, and I also was on the ASTM NHTSA committees and chair of F30.03.06 and I say all this because what made Jon and I survivors in EMS lore was not accreditation but self-discipline and dedication. We found out years later how to make a living with it. I saw all this because there must be a method for anyone who might also be dedicated and disciplined, to challenge the exams for NREMTP. Even NYS allowed R.N.'s to sit for an EMT exam even though one needs more training in skills. I have a non-traditional college path but not even Jon could match my I.V. sucess or teaching skills. So, leave room for what makes America really great; the unknown and strange bedfellows that end up not only outshining us all but saving us all. I visited family last August in Albany and almost died from Sepsis and had to be removed from my plane by Colonie EMS and some of the very students I trained thirty years ago in our nonaccredited programs, and they stayed in service to community for decades. They saved my life. I read the opinion that Jon admired and linked and found it likely from an academic that no longer does patient care in the streets and likely trying to keep, get, or protect a job. ASTM and FM F30 was filled with such all looking to justify their travel budgets and not like those of us who went to years of committee, subcommittee and task group meetings on our own dime.
—James Thomsen
Right on... here is the text of a letter that was read into the record at the most recent New York State EMS Council meeting:
Dear Training and Education Committee:
This statement is a compilation of thoughts expressed by over a dozen paramedic program directors in NYS. It represents our desire to form a cohesive group moving towards the improvement of educational standards, policies, and ultimately patient care for the end-user of the prehospital care system. We have significant concerns over the National Registry 22-Resolution-13, which updates the current initial certification requirements criteria to include “state EMS office approval”. We are opposed to New York State being an alternative to accreditation standards. As discussed on NYS BEMS sponsored conference calls, the Bureau of EMS is over two years behind on processing their course sponsor renewals. They have only just begun managing the 2020 renewals. An increase in workload with the attendant need for more guidance and clarification of standards and regulations seems impossible, especially as the current work is already several years behind.
We recognize there are many challenges with both CAAHEP accreditation and with the National Registry adopting policy that could effectively create 50 “standards” across the country. Though Director Greenberg has gone on record recently supporting the accreditation process, we have significant concerns as to how this will be enshrined in Bureau of EMS Policy, and how the state will handle reciprocity with National Registry candidates originating from non-accredited programs. Stepping backward away from accreditation would be inconsistent with other areas of healthcare and do significant harm to the profession. We would like to work with New York State Bureau of EMS, SEMAC, and SEMSCO to resolve disagreements arising from accreditation standards, significant problems with COAEMSP, the National Registry resolutions, and New York State policy.
As Director Greenberg indicated that he looks forward to meeting, we also look forward to meeting within the next month to initiate discussions on these matters.
—Don Hudson
Agree on many points Greg. This is a multifaceted problematic issue that has been festering for years (decades?). Increased remuneration from insurance companies would certainly be an aid in resolving this but not the cure. It would allow Services to be more selective in their choices of candidates. However strong, engaged Medical Direction (oversight) is also an important component of the process. Many EMS Medical Directors are forced, due to clinical commitments (EMS engagement and oversight produces no RVUs) to take that responsibility as a “side job” many times with no remuneration. This contributes to accepting marginal or minimally qualified Providers into the industry.
—Jeff Wess
Having attended a paramedic program prior to national accreditation and now being a program director of a nationally accredited program, the only difference I see is the strain on program directors to ‘check all the boxes’ for the accreditation. I have worked as a medic for over 20 years and I was a product of my state approving my education hours and competencies to test the National Registry. I believe the problem exist due to the inability of the accreditor to deliver what was promised 20 years ago. We are spending large amounts of money every year for what? My teaching isn’t going to change…just my paperwork workload.
—Amy Lee
This position is short sighted and contrary to what is needed in order to address the workplace shortage nationally. The EMS workforce is a technician level program (we happen to be health care professionals also) In the "streets" the education is applied. We did quite well supplying EMS personnel to the field prior to accreditation and will continue to do so. The NREMT was and is a verified testing alternative to State exams, Nothing more. Now there are multiple sources of verifiable exam resources and there is no need to give NREMT a monopoly on Testing. States should take an active role in the certification of EMS personnel seeing as how NREMT "certification" gives candidates clearance to become State certified or licensed! Let's keep the record straight.
—Mark Self
I completely agree. There is no accountability for those non accredited programs. We will see them charging $30,000 for a certificate with low pass rates.
--Matthew Green
Greg has stated this clearly and is exactly correct. NREMT Board should be embarrassed.
--Kurt Krumperman
I agree, there needs to be a standard and the bar needs to be held at a higher level. Allowing unaccredited education to go forward would be not only a mistake but a grave mistake!!! I have been a National Registered Paramedic for over 23 years and working with state certification for over 30 years, it was a great privilege and recognition to be NREMT.
I understand that even nursing programs that are not accredited can take the NCLEX but it also says a lot about the person taking those courses in a program that is non-accredited. I feel in order to obtain the recognition and be compensated properly we must maintain some type of single accreditation for licensure. If unaccredited programs are allowed to pass anyone through their courses with no oversight then the care that is displayed once licensed might me short of substandard. Once again we have a great group of population that will soon need the care of such personnel and it would be a great mistake to then find out the and error has been committed by allowing just anybody to be a paramedic. Since anybody could kill somebody, then somebody will be lamenting when anybody was allowed to without somebody's oversight. That is not just a riddle but the truth.
–Daniel Macias
By having a double standard in emergency healthcare who does this benefit? When two paramedics arrive on the scene are they equally equipped to handle what society expects them to be able to professionally execute? These and other questions should honestly answered. Moreover, watering down the process will have long term deleterious outcomes across the board. Progress moves forward, this proposal amounts to retreat which will come with many unforeseen management and legal expenses down the road if implemented.
—Paul Costello
I agree that this is a BIG step backwards for our profession, sadly just one of many in the past several years. One of my bigger concerns is the DECREASE in the standards for re-certification. Many of us remember when it took 72 hrs over a two year cycle, that was changed to the new 40, 50, 60 concept. While I like the addition of topics such as stroke and EMS Research, topics such as burns, pediatric trauma, thoracic trauma all were lost in this "upgrade".
--Michael Sullivan
Lowering standards is never the answer. EMS must secure financial support from taxes- like law enforcement and fire- to be able to recruit and retain EMS professionals. EMS should also be separate from fire. It's time.
--Marie Diglio
Couldn’t agree more. Having needed EMS services a few times for critical illness, I’m impressed by the professionalism of the San Antonio Fire Department EMS and the professionally trained paramedics. All law enforcement officers in Texas must be trained in accredited programs and keep up to maintain their basic peace officer designation. We need more educational programs to provide the pipeline of health professions.
Greg. You are 100% correct. The only way forward is upward.
—Jim Cole
Qualifications for a certificate as a _____________.
A certificate of registration as a _________ shall be issued by the Board to any person
who meets all of the following qualifications:
(1) Has attended an approved_______ school for at least 1528 hours.
(2) Has completed a 12-month apprenticeship under the supervision of a licensed
_______, as provided in G.S. 86A-24.
(3) Has passed a clinical examination conducted by the Board.
(4) Has submitted to the Board the affidavit required by G.S. 86A-24(c) certifying
that the applicant has served the apprenticeship required by subdivision
While I would love to say that these professional requirements are for a Paramedic, nope it's how to become a barber in NC. Professional licensure has been required since 1945. We as a profession need to quit bickering with each other and move our profession forward. Educational standards are the key to our collective futures and not a barrier to staffing.
—Christopher Warr
Hello Gregg - I know that the decision not to add these proposed changes to the accreditation process has been rescinded, but I wanted to comment anyway. I enjoyed your comments on this issue of backing off our accreditation process to fix a problem that comes from the very thing we fought hard to change to give our profession more credibility and respect. I agree with every point you make, and I believe I could have authored this same article. I began my career in EMS in the mid-seventies, and we were thought of then as nothing more than stretcher jockeys and ambulance drivers. I can vividly recall several occasions bringing patients into ERs who didn't know anything about what paramedics were doing and being questioned by physicians and nurses about who gave us authority to do some of the procedures we were doing. I have been an educator since the 80s for the primary reason that I not only value education, but I see the importance of building EMS credibility through education to support our profession. When we began down the path of accreditation of our education system, I supported that completely. I love your "Better Call Saul" analogy. One of the things I push on my students is the only thing you have is your credibility and professionalism to fall back on, and if you lack a good education foundation, then it is almost impossible to be taken seriously. I also do National Registry psychomotor exams for my state, and to a certain extent, you can tell what kind of education the student received by how they do on their exam. I know in the college I teach for, we have no problem getting students. We have the opposite problem. So, I know these students appreciate a great program and want quality education. The problem I see is many of these students aren't using EMS education for EMS entirely. It's surprising how many of them are using it to get into pre-med and PA programs. I truly hope this is the last time we hear anything about taking this step backward in education to fix a problem that has nothing to do with education.
—Robert Cesario
Completely agree that this is a major step backwards. I would question the initial part of your editorial, however. How many of us have asked where our doctor went to school and what they got for grades? In most cases in this country, you are just happy you were able to see a doctor period. I have never asked the nurse caring for me where they went to school and what they got for a grade. Based on your opening paragraph it implies that if a paramedic failed their first attempt at the national registry exam, then they should not be considered a qualified paramedic, I don't believe that was your intention but that is how it read to me.
Accreditation of training programs where everyone is trained to the same measurable standards is key. We see this in other professions, and we need to keep pushing for EMS to get BACK to that standard for Paramedic training.
—Art Groux