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Paramedic degree and recruitment

One of the most often utilized arguments in the debate over paramedics and associate degrees is it will be a barrier to entry. What if this is the wrong tact? Could lack of recognition over a degree, in fact be what is preventing potential paramedics from becoming actual paramedics?

Just as there is no evidence-based data that degrees making a better paramedic, I couldn’t fathom survey data that exists measuring how many do not pursue paramedic because of concomitant degree.

This is something that’s been smoldering in the back of my mind for a few months. All I had was anecdotal accounts picked up from reading myriad sources over years. And observations of cultures that put a premium on a college education. I have to look no further than my wife’s parents. My father-in-law constantly informs my kids they can become a doctor, engineer or teacher; according to him, they have no choice. He is foreign-born and I can’t help but wonder how many cultures eschew paramedicine because there is no degreed prestige behind it?

Two items appeared in my Twitter timeline. I could no longer remain silent.

First, a “look inside” becoming a paramedic had a pull quote that spoke volumes [H/T NYC EMS Watch]. According to WJRT, Flint (MI) Assistant Fire Chief Edwards said EMS is “a great stepping stone for people looking to pursue other careers in the medical field.” Hey, on your way to a degreed medical position, why not stop in as a paramedic to get some real life experience! Flexible hours helps you go to school to be something else.

The second tweet was from Dale Loberger [HP_EMS], who expressed a desire to find common ground in this debate after reading EMS is Not Nursing! by Chief Becker. The crux of Chief Becker’s post lies on EMS’s high reliance on volunteers and different method of reimbursement. Both valid points. However, they are used as barriers to end debate on the topic.

After reading his post, I must ask: Are paramedics so good degrees are not needed; or so low on the cognitive hierarchy that degrees are unattainable? This is a somewhat facetious question. While I honestly do not think he questions intelligence, stating that EMS is different from nursing sets us apart. But without elaboration, there is room for doubt. I surmised from reading from several fire-based EMS writers, resistance to degree requirement is funding based. I get fire departments come from a tax-dependent, fixed-budget world. Half of my household’s income depends on local voters approving a tax levy or bonding bill every other year. In spite of this, school teachers must possess an undergraduate degree to work. And in Minnesota they fight for stringent educational requirements!

One line in Chief Becker’s article needs more exploration. He asked, “Since when is having a college degree evidence of being a professional?” Is he referring to a collective profession or individuals being professional? In my opinion, a college degree shows that an individual professional joined ranks of a profession by gaining more knowledge. Degrees are usually required for licensure, board certification or privileges. Unless one went to a so-called diploma mill, he or she has done significant work to earn a degree.

Do we want EMS to be a trade or profession?

If we work toward the latter, we may attract a more diverse workforce made up of those who represent cultures where degrees are an expectation.

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You’re Welcome & Other Thoughts on Gratitude

Today I saw an industrial psychologist. The visit stemmed from a work-related injury and an extended stint of “light duty” (end of April to mid September). In other words, the injury kept me “off the street.” Prior to being barred from doing my job, I failed to see how the job defined me. It became an expression of my worthiness and kept me feeling important. For those not in EMS, any restriction – lifting or otherwise – essentially keeps a paramedic away from working normal duty. During the therapy visit, a conundrum made itself evident to me regarding EMS and us. It has to do with retention, possibly unrealistic expectations of those entering the field, and feelings of both over and under appreciation. The session was fortuitous because I was reconsidering “thank you” and “you’re welcome.” And yes, these are tied together in certain ways.

Allow me to go back a few days. I had been struggling to write a blog post on accepting appreciation. Converting disassociated thoughts to text helped me parse the topic. But I had no convenient way to express thoughts. Marshall Goldsmith is an executive coach and wrote What Got You Here Won’t Get You There (2007; Hyperion). One of the factors he identified keeping people from gaining the next ladder rung is “Habit #17 Failing to express gratitude” (pg. 88). In Goldsmith’s estimation people fail to say “thank you” to a compliment. Unqualified, unmodified thank you; full stop. In my opinion, so many people pay EMTs and paramedics compliments without explicitly saying thank you I don’t even notice. Regardless if I or anyone else notices, too many compliments and heartfelt expressions of gratitude go unappreciated. And payers of compliments go unacknowledged or worse, minimized.

If I ask you what’s your reply to someone who says: “You must see so much. I couldn’t do what you do.” Did you think/say “It’s nothing” or something similar? I do… or used to as of last week. Goldsmith explains anything other than “thank you,” minimizes the desire of the person paying the compliment. It may even dissuade them from complimenting others (and you in the future). Even those whose intention is to only solicit a gory story from making a question out of a statement (“You must see some gross stuff?”) are enthralled with the profession and happy you do it and not them. Those who live vicariously through others often do so because they can’t.

In my observation, co-workers who strive to get recognition and adulation are well outnumbered by those who eschew awards, recognition and fanfare. That’s fine. No one is making you take a damn stork pin. But the same anti-recognition person may gripe about how they are not recognized for doing their job. Having been one of those in the majority, I was blind to the hypocrisy. Why is it unreasonable to get a pin or certificate suitable for framing when you birth a baby or return someone’s circulation so he or she can walk out of the hospital in two days, but not being acknowledged because you completed the start-of-shift rig check every shift? To prevent myself swinging like a pendulum, I’ll go halfway and say both should be recognized. No, I don’t think doing even the minimal tasks of the job on a routine basis requires a ceremony; just a compliment in passing or noted on the annual review would be nice.

So, I have adopted a new strategy. Give an unqualified “you’re welcome” when someone says thank you. People thank others for various reasons, but mostly because the other was helpful or did something they couldn’t do. Such as patients or family members who resorted to calling 911. Realize it or not, you did something important to the patient. Sure it is your job, but you performed it well enough that someone is appreciative of your efforts. Your choosing to the job.

When someone pays a compliment in cryptic messages, like “you must deal with a lot of stuff,” there is no need to minimize EMS or your role. I’ve made a history of saying, it was nothing or “I just cover it up.” To me this is truth and expresses a way to avoid distracting injuries or bodily fluids. But to the nonEMS professional, it diminishes EMS in the minds of others. Likely this person has a specific, personal encounter in mind when they offer a veiled thank you. They aren’t thanking you as an individual for expert care in their situation, rather they are thanking you for being a part of a profession that means greatly to them.

It is similar to thanking a vet or police officer. “Thank you for your service” shows appreciation for their role and general duty, not a specific task or operation they conducted. Being familiar with deflection of appreciative comments, when a vet replies “I didn’t go over seas” or denies taking part in combat, I am forced to reinforce my appreciation. They don’t know it, but I don’t care if they sat behind a desk or drove a forklift stateside. I recognize the loss of choice and control one experiences when signing up or being drafted. I commend vets (in my mind) for not taking credit for missing stress-inducing warfare, I am not only looking to thank combat veterans.

So back to today and my visit with the therapist. After a recounting of my injury and all the trials and tribulations that go along with work comp, he paid me and EMS a compliment. I nearly stopped the psychologist as he was going to say “you are saving lives.” My knee-jerk reaction is to downplay the life saving aspect of EMS because it happens less than often than it does no television. I made some convoluted comment to this effect, to which he thought he may have found therapy gold. “Do you not like working in EMS?” No, I said. Inside I thought, what would give him that impression? Well, the impression I portrayed downplaying the activities that go on in EMS.

He doubled down on his appreciation of EMS and our job and its duties. After recanting the efforts I made to diminish EMS, I explained EMS means so much to me. And thanked him for his appreciation.

And so it dawned on me. I had to think outside of myself and my profession. Experts don’t self-deprecate to clients, those who are reliant on their expertise. Self-deprecation is for families and cohort; it is not decreasing the status in the eyes’ of the public. We may spend 800 hours a year with uninjured elderly patients who fall, get that non emergent g-tube replacement, or transport the runny nose person who refuses to go to primary care. These take up the majority of a shift, day-in and day-out. And this is what I think of when I reply to a thank you or suggestion that EMS must be difficult given what we deal with on a daily basis. So, when I reply “naw” or offer some other qualified answer, the profession is brought down a few notches in their mind and I’ve diminished their gratitude.

From now on I will say thank you to direct compliments. And to admiration for doing my chosen profession, I will say something along the lines of “it is satisfying” or “I am glad to help people.” And ask if EMS has helped them or their family. My goal is to elevate EMS and have some self respect.

UPDATE
My Fitness for Duty test was occurring today. This is the physical agility test “permitting” me back to work after a prolonged absence. In thoughtful consideration, my wife wished me good luck on the test. My first reply was “I’ve already passed several of the exercises. It’s no big deal.” Instead of saying thank you to my wife, showing gratitude for her concern and wishes I do well, I effectively told her her input does not matter. Her reply was a question to the effect of what happens if you don’t pass. I had not concerned myself with this because I was confident in passing the test. Now, not only was I forced to consider a poor outcome, but we were put in a place to ponder more time on light duty. A heartfelt well wish turned to a focus on possible worst case scenario.

Not even 24 hours after writing and posting my intention on correcting my conduct, I failed. Thankfully I did not fail the test! But now, my wife may pause before wishing me luck or showing support. My retort and lack of a simple thank you showed I did not respect her concern. By not accepting her support I counter her unconditional hope that I achieve something important to us; downplay her appreciation of my efforts; or positive thoughts to quell her apprehension.

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Discontent Breeds Distrust and Confirms Bias

I am not a very fast writer. My vacillation and rewriting means I miss the hot take. Case in point: An unidentified bearded man in jean shorts scrawled scandalous messages and awful claims on ambulances and buildings owned by FDNY. In my queue there currently sits draft number two of a post on public perception of EMS. More specifically, how social media griping fuels public distrust of EMS.

This rewritten piece originally began as my thoughts on lambasting EMS on social media. It was timely that this serial tagger struck. With several FDNY personnel able to keep jobs in the sunlight of past illegal behavior, it surprised me little that a person would label (literally) ambulances with horrible things. While I did not search out any

But this is what I was beginning to see. When lawsuits are made public, current and former employees (anonymous posters who identify themselves as such) concur with facts of the case. We cannot ignore all of these discontents as simply fed up. Some may have legitimate complaints; the majority just want to assign misplaced hatred or distrust of whatever on the large company. But when someone, posting with “authority of knowledge” by having worked for the agency being sued, claims this is standard operations for the company, it brings disrepute upon those who employed. We all know a few who struggle, but they do not represent the workforce as a whole.

It began affect me!
I am an insider. I sit around the picnic table and hear the gripes and suffer the same poorly thought out schemes. Yet I am not on social media broadcasting issues making them appear to be similar to every single ambulance service. My employer has had some press-worthy data breaches. Looky-loo nurses perused medical records of those they shouldn’t have and it made the news. As a result, I’ve sat in the ambulance deflecting suspicious inquiry of me, and my integrity when it comes to the electronic medical record (EMR) system.

But that is less hurtful than another EMS provider doing something stupid. No, let me say this: It is more hurtful to see a string of replies on social media that confirm all ambulance services are like this. That is not a quote; rather it is a generalization of any number of ways some anonymous malcontents inflict disrepute on his or her former employer.

I will not name the most derided multi-state provider of EMS care in the country. Suffice it to say, I’ve read some very negative things about the company. Enter “I hate [this company]” and you’ll likely find a sub Reddit. Anyone with a gripe against this company, EMS providers, poor service, “corporate America” or any popular diatribe will find their biases confirmed.

This summer I had the pleasure of traveling to two cities where this outfit provides EMS. I couldn’t help but wonder if the two crew members in there were proficient, happy, caring about those they encounter, overworked, so incompetent through the mismanagement of their overseers, etc. Some of those claims are legitimate; others are not and are painted with a broad brush. But I’ve had it so ingrained from reading social media posts I see their rig and fear for my life should I need an ambulance. I can reasonable decipher the list and extract those issues with legitimacy. The general public may not.

Who do they really hurt?
So who pays for such foul reputation? Not the company. Because of the Keyboard Warrior, an underpaid and overworked EMT or paramedic struggles to care for an untrusting patient who fears he or she may not make it to the hospital.

This is horrible to think. I say to those disgruntled internet posters, where do these multi-state companies get their employees? Do they fly in out-of-towners who couldn’t care less about who they treat or what they do to the community? Or do they employ local people? That is about as close as I will come to defending any ambulance service. My aim is not to prove a subset of employees wrong. I just want to remind them there are still people working there who care for people.

Ok. We know you hate your employer (or former employer). And you have grievances. But can you pause for a few seconds to reconsider a Tweet or Facebook post that harms current EMS professionals and the system people rely on?

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Empty suit?

I’ve always found Brian Behn’s posts at emsqaqi thought-provoking, forward thinking, and reasoned. His “The Empty Suits of EMS” was a bit different. It took a more negative edge than normal… something I felt with each paragraph. This time, his pithy, lighthearted needle poking at EMS was a rusty machete swung with the vigor of someone exacting revenge. Behn’s victim in this case were leaders of an industry that is changing struggling.

I did read his atonement at the end. Alas, by then it was too late. Behn’s vitriol exposed his disdain for those not working the streets anymore. Be they C-suite suits, educators (maybe working one shift a quarter for “street cred”), or CCEMT-Ps and flight medics showing off like Top Gun pilots at a Civil Air Patrol conference.

Empty Suit or Bad Leader?
Empty suits? I cannot defend. There are great leaders, poor leaders and leaders quickly forgotten because they were neither. There are too many individuals; and for every one admirable leader, each of us can recall one or more leaders we regret knowing. Yet poor leaders and those quickly forgotten do not push boundaries of EMS. Rather, they maintain the status quo and look out for their own career. They fear failure and micromanage subordinates as to prevent their reputation from being tarnished. On this Behn is correct. Yet not all leaders can be categorized by the worst amongst them. Exceptional leaders figure out how to make gains by working to better the profession through their agency. The best try to mitigate pain. Yet on occasion, pioneers create situations where pain cannot be completely avoided. With change bumps are inevitable, organizations grow from them.

There were many points to address in Behn’s blog article. Yet degree bearing paramedics is a crucial item that needs to be discussed ad nauseam. This does hit close to home. I work for an agency that now requires new paramedic hires to have (or complete with in six months) his or her Associates Degree (AD). It is difficult to know for sure if scant applications are due to this requirement or an industry-wide shortage.

Why a Degree?
Throughout my undergrad and graduate coursework (which was always focused on EMS), I argued the same point. Currently, demanding paramedics earn a degree is a barrier. Paramedics want to get out there as quickly as possible. There are extrinsic attractors to prehospital work that are not necessarily more powerful than two or four years of college work. And the reality is, many paramedics are not interested in writing ten page papers. Hell, including pertinent negatives is a chore for many. And it is true, more paramedics outside the United States have university degrees. From reading, however, foreign paramedics are not much happier. They spend four or more years getting a university degree to do roughly what we can do in America or work with physicians on their rigs.

With that said, like Behn, I promote the idea of paramedics getting a degree. For an upper level research class, I designed a prospective study to measure certain differences novice paramedics with an AD and those without. Assuming an AD would focus on general education college-level classes and not advanced A&P or pathophysiology, logic and cognitive ability would be the focus of study. Other fields have shown some improvement in performance when degrees are required. But, does that necessarily translate to prehospital practitioners? No one has studied this according to my literature searches.

Advanced, To What Degree?
This begs the question, which will come first: Degreed paramedics or advanced prehospital practitioners? Will a wider scope of practice simply be bestowed upon paramedics out of legislator benevolence? Will medical directors find it in their hearts to allow more autonomous treatment decisions for no reason? Or do we need to stock ambulance services with more educated clinicians before these events happen? I harp on this point because it needs to be addressed. Do we continue to avoid demanding degrees because college educations are inconvenient or those attracted to EMS are less didactic and more hands-on? Doing what we’ve been doing is an easy way out. One that leads to keeping us trusted as technicians rather than clinicians.

Perhaps we stop dwelling on what prevents paramedics from earning degrees and begin encourage degree bearing colleagues. Yes, pay is low. But wages are derived from reimbursement. [Put high call volume and staffing shortages aside.]. Higher reimbursement follows higher capabilities. CMS compensate physicians who use new technology at higher rates to help defray costs of new technology and compensate for the learning curve. If EMS never pushes barriers, stays in present mode, there is no incentive for third party payers.

I did suggest leaders make some bold moves, which may cause discomfort within their agency. Such moves, if failures, may sacrifice their careers. Why can’t we suggest new paramedics take a similar risk? I earned two degrees for intrinsics, the extrinsic have yet to pay-off. In six years to rack up almost debt amounting to 2/3s of my annual income. I get it, my career was solid and it was a personal choice. My degree was a goal of mine regardless of where it took me within EMS.

Cognizant of this, I respect that my situation does not fit all. And one’s situation is a poor template for a whole field. Going full steam into “entry requires a degree” would be detrimental. Studies have shown when supplementary education goes up but permissions and capability does not, paramedics leave the field. Those who desire more leave disillusioned and frustrated. If they stay in medicine; in fields where they’ll be able to apply what they’ve learned. One logical choices is RN.

There I said it. RN. The group paramedics love to elevate themselves above. Yet registered nursing is not an allied health profession. It is a full-blown licensed profession. Leaps-and-bounds beyond what protocol-bound adrenalin junkies are in reality. Consider this, by the year 2020, the Institute of Medicine (IOM) desires to see 80% of registered nurses hold a BSN. Where are we as a profession? Complaining of low pay, no freedom to treat patients and getting treated like crap from nurses and doctors. Therefore, comparing RNs to Paramedics is like apples to oranges.

We are What We Are.
What other allied health professions are out there? [What is an Allied Health profession? Read U.S. Code here.] There is a sizable list by the Association of Schools of Allied Health Professions (ASAHP). Most therapists (physical, occupational, speech) are allied health professionals. I learned that Master degrees for physical therapists are no longer offered in the United States, after certification the default degree is a Doctorate (DPT). We are eons away from this!

Hold the Phone, Now it Makes Sense
I planned to continue my unsolicited rebuttal. Then I stopped to read the linked article after which Behn modeled his. To be honest, I now can see what Behn tried to do. Unfortunately, it did not work. Perhaps it was too personal or Behn wrote it with one leader in mind. Regardless, I stand by my analogy of hacking away with a machete fueled by a personal vendetta. Behn linked to a post by Nassim Nicholas Taleb, critical thinker extraordinaire. In it, Taleb lampoons everyone who thinks themselves so intellectual to be better. Not only do “Intellectuals Yet Idiots” (IYI) only understand scientific “realities” on a superficial level. IYIs are prone to be hypocrites who jump on the next scientific fad, often doing a 180 degree turn from what they once held as sacrosanct.

Taleb did not pull any punches for groups on either side of an (scientific or political) issue. I believe Behn missed the equal opportunity skewering to make his post more palatable. To be in concert with Taleb, Behn should have addressed those in the street who suffer a Mightier than Thou mindset. Instead, Behn’s theme implied: If you are not in the street, you are not EMS. Again, I am not discounting his sentiments wholesale; rather, valid points are lost for me by Behn’s inelegance. Ok, so your EMS Chief may not have been the most adept at scene management. Conversely, could the average Tip-of-the-Spear medic gain votes on legislation to buy body armor or provide line of duty death benefits? Can one be both the tip of the spear, focusing on day-to-day minutia and the one wielding it at targets far and abroad? How about extending or winning contracts with municipalities? How long would day-to-day operations go on smoothly or otherwise without “disconnected” management? We all play a part in EMS. Often left off of EMS is “system.” Systems that provide 24/7/365 medical care are not comprised of 16 daily two person ambulances alone. Nor do we, as a profession, grow without leaders who take risks and suffer the occasional miscalculations or stretch of pain.