Profession or Trade?

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Neither.

Over a Captain Chair Confessions the old Captain asks Where To Start? One part of his post suggests that we need a national certification process as a first step and points to the National Registry of EMTs as the starting point for that. Which of course we old timers know was what the NREMT was supposed to be way back when it started. While many states use the NREMT as it’s certification foundation, many don’t. It was a good idea back then, but I’m not so sure it is now.

My state doesn’t use the NREMT for EMT and paramedic certification, although it did back when I was first a paramedic. Which is why I still maintain a NREMT-P certification, otherwise I’d probably never have gotten it. Besides, if I ever move and want to become a paramedic in my new state, the NREMT might help.

The NREMT might be the place to start if it’s standards weren’t mired in a 1980s (or ’70s) paradigm. Because it is, using the NREMT for advancing the idea of EMS professionalism is a non starter for several reason.
First the name National Registry of Emergency Medical Technicians is all wrong. Technicians aren’t professionals, they are technicians.

Here is the definition of technician,

technician [tɛkˈnɪʃən]
n
1. a person skilled in mechanical or industrial techniques or in a particular technical field
2. a person employed in a laboratory, technical college, or scientific establishment to do practical work
3. a person having specific artistic or mechanical skill, esp if lacking original flair or genius

#3 is the killer. Now, we can argue if paramedics are technicians by definition or are really professionals because what we do does require some original flair or genius in the real world. Unfortunately, that flair or genius comes not from our training (versus education), but from our experience.

For comparison, here is the definition of professional,

pro·fes·sion·al (pr-fsh-nl)
adj.
1.
a. Of, relating to, engaged in, or suitable for a profession: lawyers, doctors, and other professional people.
b. Conforming to the standards of a profession: professional behavior.
2. Engaging in a given activity as a source of livelihood or as a career: a professional writer.
3. Performed by persons receiving pay: professional football.
4. Having or showing great skill; expert: a professional repair job.
n.
1. A person following a profession, especially a learned profession.
2. One who earns a living in a given or implied occupation: hired a professional to decorate the house.
3. A skilled practitioner; an expert.

This definition is broad enough that there is room to put paramedics in there. Except for the fact that we are Emergency Medical Technician – Paramedics. There’s the rub.

So, are we tradesmen (or tradespeople if that sort of thing hangs you up)?

Sort of,

tradesman [ˈtreɪdzmən]
n pl -men
1. (Business / Commerce) a man engaged in trade, esp a retail dealer
2. (Business / Commerce) a skilled worker
tradeswoman fem n

Closer, but not perfect. Notice that it says skilled worker, not profession or professional.

The problem is that tradesmen often limit who can practice their trade by licensing or even guilds. So, even if you were say a non union plumber, you’d have to have a license issued by the state permitting you to work as a plumber. Said license would limit you to plumbing and gas fitting. You could not work as an electrician because that’s another license all together.

We don’t do that in EMS. Firefighters can be paramedics, EMTs can be police officers (and vice versa). About the only restriction that some states have is that you have to be an EMT or paramedic to work on an ambulance. So, for some specialty care areas (think pediatrics) or specialized transport modes (think helicopters) we have RN/paramedics or RN/EMTs. Note that EMT or paramedic comes last, just as with FF/paramedics. Have you ever met anyone who says that they are a “paramedic/fire fighter”? If you have, you’re a rarity. That doesn’t cover the people who are Security Guards/EMTs or Accountant/EMTS.

Get it? EMT or paramedic is a skill set, not a trade, not a profession.

So, if the people who make up EMS workers are not professionals, can EMS as a whole be a profession?

Probably not.

Which brings us back to the NREMT. Which, if you are wondering is not the main focus of my criticism. It’s just the most visible target right now.

Why do I think that they are part of the problem?

Because of their recertification process. It’s main virtue is that it’s cheap. Which might also be part of the problem.

Every two years, holders of NREMT cards have to recertify. Said process includes a refresher course and a number of hours of Continuing Education Courses. Which are also mostly rehashes of what we were taught in EMT or paramedic school. OK, once and a while we need to recover some of the territory that we originally learned, but every two years? The NREMT also offers “Recertification by Examination” option. Where you can pay $110.00 to take essentially the same test you took to get your original card. Do doctors or nurses have to retake their boards every two years? Or at any point in their careers? I don’t know the answer for sure, but I’ve never heard of it. They are required to attend and document that they attended X number of Continuing Education course pertinent to what they do, but they don’t have to re attend medical or nursing school every Y number of years.

That’s the firsts part of the process, then comes the paperwork. For the NREMT, it’s about a four page form for recertification. I have to document that I took a DOT approved refresher course and 24 additional hours of Continuing Education in a variety of subject. OK, that’s not too onerous. Boring maybe, depending on the class, but not too tough.

Then I have to prove I have a copy of my ACLS card. And a CPR card. Oh, and two or three signatures. My medical director must sign that she’s seen me do the same skills that I’ve been doing since she was in high school, my training director has to sign that I have a CPR card, and someone from management has to sign that I actually work there. So much for being a professional, it’s more like I’m in high school and need to get my report card signed by my parents.

Oh, the last. you have to work for an ambulance service. You can apply for “inactive” status for one recertification cycle, but after that you’re screwed. So, if you or I suffer a career ending injury, as they say in sports, and can’t work on an ambulance, we can become inactive. If we go to work, say teaching EMS related courses at a local Community College or even an independent EMS school, we can’t maintain our NREMT certification for more than two years.

And we’re supposed to be professionals? Sure we are.

I know a man who was an Oral Surgeon for almost 50 years. He retired a few years ago, but kept his license up. He now is a visiting professor at a pretty big name School of Dentistry. I don’t know if he has to maintain his license to teach, but I suspect he does because part of what he does is supervise dental students who are working on live patients. He doesn’t practice, he doesn’t get paid by the school to do procedures, he supervises people learning to be dentists. Yet the board that licenses him doesn’t tell him he can’t have a license any longer because he doesn’t go to his officer every day and charge people for fillings.

So, if we are going to have the NREMT as the basis of our soi disant profession, it had better start treating us like professionals and not school children.

On the other hand, we had better start treating ourselves like professionals and not school children.

If we want to be professionals then the first step is that we have to be self policing. That is the people that oversee certification, re certification, quality assurance, and discipline need to be actively registered and engaged in the EMS field. Not doctors, not nurses, and goodness forbid career bureaucrats. Who if they weren’t regulating EMS would be regulations hair dressers or plumbers.

I haven’t even touched in the issue of whether we need a federal agency to oversee and coordinate EMS across the nation. We don’t because it would likely be as effective as the federal agency we have to oversee and coordinate disaster relief across the nation. Different subject for a different day.

As is whether or not we should require some sort of college degree to be an EMT or paramedic. The only virtue of that, if you want to call it a virtue, is that that the increased cost would keep some people from becoming EMTs or paramedics. Frankly, I’d rather see paramedic be a two year course with things like Anatomy and Physiology built in. As well as writing and math classes or at least an option to test out. If you’ve seen some of the PCRs I have over the years, you’d know what I mean. All too many of us can’t spell, can’t put a coherent sentence together, and don’t know how to construct a narrative that won’t make the doctors and nurses reading them snort soft drink products out their noses as the try to figure out what we’re saying.

Well, that’s my rant for today. Feel free to comment and tell me how wrong I am.

I’ll have fun with those comments too.

And yes, I’ll make fun of your spelling.

I don’t know about you, but I feel better.

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After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.

15 COMMENTS

  1. I won’t disagree with you on definitions, but I don’t think this should be a discussion on definitions. If so, then we should all be called “Paramedics” like they are in Canada. But I don’t want to get mired in that.

    I don’t understand the burden with having to document that you obtained continuing education hours. For the past two recertification cycles, there has been an option to recertify online, which is incredibly easy and fast. As of 2014, there will be no more paper recertifications.

    Those other professions do have to obtain continuing education, by the way, and they have to document such.

    You can maintain your Registry certification as an EMS educator.

    You cite $110, but don’t disclose that NREMT only receives $20 of that. That’s all they receive. The same as if you click “submit” online, or send them a check. It’s less than the cost of a pizza. For two years.

    Like I suggested in my post, what is your answer, as opposed to your complaints? Are we going to have to create a new entity for this? Or are we doomed?

    • The ConEd requirements for Nurses and Physicians are far different than for us. They are also shorter. Mrs. TOTWTYTR’s teacher recertication requirement is 120 hours over five years. Teachers, being the professionals that they are, get to self report their hours. That is, anything that they think contributes to their teaching skills is acceptable. She does not need three people to sign off that she’s not making shit up.

      I haven’t seen an option to maintain certification as a full time educator. Please point it out to me, I’d like to have that information.

      It doesn’t matter who gets the money, I still have to pay it. Oh, and the NREMT is seriously considering requiring recertification by exam in the next few years. I wonder if the state is going to require me to take a driving test every time I renew my driver’s license?

      My answer for a start is at the end of my post, but I’ll recap.

      First, we need better education. I forgot to take my traditional swipe at the NAEMT for having all those “merit badge” courses. Of course the deeper issue is that the material for every one of those classes should be covered in paramedic school. That paramedics have to take all those courses to get skills that they need to do their job every day is a national disgrace. ACLS, PALS, PHTLS (or ITLS), PEPP, NALS, ACLS for OB patients (coming down the pike), ABLS, AMLS, PCP, and any I haven’t thought of exist to fill holes in paramedic education. I might cede ACLS since a lot of medical professionals need it too. On second thought, no I won’t. ACLS or more accurately Emergency Cardiac Care is the main raison d’etre for EMS in the first place. The first paramedics were trained almost exclusively in cardiac care. It’s what we do. We shouldn’t have to take an add on course to understand it.

      Second, we need to be self policing. Each state should have a board comprised of paramedics to review complaints of patient care. This includes paramedic driven QA and remediation.

      Next, we need to define ourselves. When any other trade or profession can easily tack on EMT or paramedic to their skill set, we have no way to maintain our standards. We have people wearing the same patch that you do, who can barely discern an MI from a duck. Yet they mostly have the same scope of practice that you or I do.

      We need to stop identifying ourselves by what we do and start defining ourselves by our knowledge base.

      That’s just a start.

  2. Umm, have you looked at the requirements for renewing an RN license, or even an MD license? RN in California only requires you pay the fee, 30 hours of CEUs (less than paramedic requirements), and a form asking about convictions or license disciplinary action. Physicians likewise require the fee, Continuing Medical Education credits (# not specified on website), convictions/disciplinary actions, and a list of healthcare facilities where the MD has a financial interest.

    That’s it.

    RN re-licensing requirements
    MD re-licensing requirements

    The problem is not the NREMT, both RNs and MDs follow the same general path to recert, and I doubt anyone will question whether they are “professional” or not.

    For the argument of “professional” or not, we need to look at EMTs and paramedics separately. Just as Registered Nurses are professionals and Certified Nurses Assistants are technicians/tradesmen, so should Paramedics be professionals and EMTs be technicians/tradesmen.

    • Notice that they fill out the form and send it in themselves. They self report and don’t need to submit proof of having taken the courses. They do have to maintain certificate in case the state decides to audit them. As a rule they are treated like responsible adult professionals.

      That is far different from what a paramedic or EMT has to do.

      If you want to split EMTs and paramedics, that’s fine. You should consider that carefully, though.

      Thanks for pretty much proving my point, even if that’s not what you intended to do. 😉

      • You make a good point; I’ve always felt uncomfortable about being treated as a child and not as an adult by the Powers That Be. Out of curiousity, do RNs work “under a doctor’s license” the way that paramedics do? Or is their license their own, and they simply follow the instructions of a doctor since he’s the highest level provider at the hospital?

        Excellent point about the education. The bit about tacking on EMT to any profession is the main reason why I think “EMT” should be separated from “paramedic”. The position we now call “EMT” needs better educational requirements, a resulting higher scope of practice, and a better name. Leave “EMT” as the add-on skill set it has become. Maybe relabel them as “Medic(al) Assistants”, and combine the current EMT training with what is currently called medical assistant training (IM injections, phlebotomy in some cases, etc…).

        Adding on “paramedic” to “firefighter” is an even bigger can of worms than I’d like to deal with here.

        • Nurses are licensed and have a degree of independent practice. The extent of that probably varies widely.

          How about “Paramedic Assistant”? No, actually I think something along the lines of the Canadian model would work.

          Please don’t start me on the firefighter – paramedic thing and I won’t start on the plumber – electrician thing. 😉

  3. 1) you don’t have to work for an ambulance service. Hospitals or other health care organizations (like, say, organ procurement organizations, hypothetically) also count.
    2) I confess that the recert by exam is a lot more convenient for me than the education requirement. Is it as effective or useful? No, probably not. But as long as they keep offering it, I’ll keep taking it. I think over this cycle, though (I recert in 2014) I have to take some sort of upgrade class.
    3) at least where I’m from, nurses have to have some number of CE hours *and* be working in a nursing capacity for what amounts to about half-time work over 5 years (I think it’s five years…it’s the relicensure period, anyway). It’s an hour-based requirement, though, so if you work full-time for 2.5 years, you don’t have to work at all the other 2.5. Here again, the definition of “qualified work” is a little tenuous…an RN of my acquaintance managed to count being the (unpaid) school nurse at her kids’ preschool for these hours. And while the CE and work hours are theoretically subject to audit, I’m not aware of any nurse ever being questioned without cause.

    All of these are admittedly nit-picky points, and don’t really address your main question. But I thought I’d make them anyway.

    • I’ll have to go back and look at the NREMT site, because I didn’t see any option except working for an EMS system for maintaining “active” status. You know, because 30+ years of running ambulance calls isn’t enough and I’d rust out if I retired and went to teaching full time.

  4. TOTWTYTR,

    You’re absolutely right. I had a discussion with my school’s head guy over my fire science program and oversees our new paramedic science program. He just came on this year from the greater Seattle area. He outlined a strategic plan for the programs and was looking for feedback.

    His jaw just about hit the floor when he found out that the EMT course’s 6 hour lab on Saturdays only actually goes for about 2-4 and that the kids get trained for the state exam as far as physical skills go. I also explained to him that it’s an EMT course at a fully accredited college. Not some other education for profit place like some of these “EMS Academies.” Our EMT course currently teaches to the minimum, when as a 4 year institution we should be finding the ceiling.

    One of the other major gripes that I’ve had over the past year as an EMT was that we don’t help our new kids at all. We kick you out of EMT class and say “Good Luck!” for the state exams and hiring prospects. If anything, we should have emt classes arranged with ems agencies so that kids can get some mandatory ride time in and learn the job and help make them hirable. I’ve been passed over for EMS jobs twice, and many more applications have gone right out the window because I have no street experience. (Granted, I keep applying Per Diem because that’s all I can commit to at the moment, as I’m a full time college student.)

    I remember going to a EMS symposium (well, a massive con ed session) and there was a guy from OEMS there. The guy was a sleazeball and dipped, ducked, dived, and dodged like a professional politician. Every question that was asked he regurgitated the same crap over and over. We need a open, honest, and PROFESSIONAL organization, at all levels, in order to keep EMS moving forward. Not just doing this “business” of EMS. We need a profession. We’re no longer ambulance drivers, we’re trained and capable EMTs and Paramedics.

    (Well, we need the same name for our people, and it’s not EMT or ambulance driver….I’ll agree with CCC that we should stick to paramedic, and drop EMT. I like the Ontario model, and it’s something we should look into more.)

    But with people in charge that are still stuck in the traditional mindset, things won’t change. The blinders need to come off and we need to wake up and smell the roses.

  5. You’re not wrong, but the politics of the situation(s) will continue to cause problems… If you’re truly professionals, then you’re severely underpaid (but we already know that), if you’re technicians, then you should not be able to perform certain procedures without supervision… You know how that goes…

    • As I get older, I realize that in EMS it’s all about politics. Medical politics, local politics, national politics. They all take precedence over patient care or effective delivery of services.

  6. A complex situation the the USA, no doubt!!

    We have also been grappling with a possible transition to national regulation of paramedic practice in Australia. There are many paramedics in Australia who are currently not working for ambulance services. The issue is on a much smaller scale – we only have eight jurisdictions – however, many of the complexities remain the same.

    For those interested in reading the recent national consultation paper on options for regulation of paramedics in Australia, and for general information regarding the current state of play in Australia, visit the following link:

    http://www.paramedics.org.au/programs/registration/

    For what it is worth, paramedic services have been moved out of the government emergency service/community safety departments in six out of eight jurisdictions in Australia (i.e. they are no longer are grouped with fire services and police services). In these six jurisdictions they now come under the government departments of health. The base qualification to practice as a graduate (novice) paramedic in a government ambulance service is now a Bachelor of Paramedicine (or equivalent, e.g. Bachelor of Paramedic Science).

    Thanks for your article, it provides much food for discussion.

  7. I’ll be posting a blog about the UK situation very soon. You might find it of interest. Just getting the referencing sorted as you read. Oh, referencing…its what I learnt on my paramedic science foundation degree.pp

    Tj

    @meditude

  8. Sir,

    My wife, Cindy is both a medic and certified ER RN. No, other than the trauma center where she works requiring a periodic TNCC course and her desire to satisfy her knowledge with other subjects, there is zero ongoing requirements for RNs to recertify.. Secondly, the vast majority of medics that I know (been in EMS since 71) have zero desire to upgrade their knowledge unless money is forthcoming. Critical Care transport certification is kind of a joke because many of those individuals who take those courses come away in 80 to 120 hours believing that they can walk on water but in fact unless they can figure things out when they haven’t seen something before are not any more talented than anyone else. Thirdly, many of our medical directors profess to allow medics to be enlightened when in fact they are secretly dumbing us down and don’t want us taking the advanced ACLS provider course because they wish us to stick to hard and fast protocols. Finally, I love it when our bosses expect us to be abused by people who, though are our patients, should be up on charges for striking us whenever they so desire and frequently attempt to dominate us when all we are trying to do is offer some pt care and comfort. How often do any of us receive an atta boy. More often we receive criticism about how a particular call was handled. . I consider myself forever stupid. Whenever I attend a certifying class, even though I’ve worked in the field longer than many were out of grade school and am also a working deputy K9 officer I don’t know anything. I say this because I’m forever being corrected on every EMS subject known. By the way, do you remember when people only called the ambulance when they were truly acutely ill. Now almost every call has a psych component and if a pt is ill they have at least two or three things going on with them because very few of us working class people can afford an ambulance transport. even from our own service. Remember when private providers use to at least issue a duty shirt annually. Now they require us to purchase everything despite our pts frequently contaminating everything we wear with MRSA etc. We will continue to be professionals in our own minds and when it’s convenient for our employers to critique us. Otherwise unless we are cross trained as FF or public safety officers, we’ll always double as ambulance drivers.

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