In some cases, physicians of progressive hospital systems may want to steer an EMS service toward a procedure that falls outside its current regulatory scope of practice in order to streamline procedures that are currently being performed in their facilities. It can be a precarious balancing act to keep these physicians feeling content and equally valued. In these cases, conservative physicians can serve as a braking mechanism when progressive physicians want to initiate treatment protocols that an EMS service might not be prepared for.
When it comes to chart reviews and questions of quality assurance, an individual medical director will use his or her training and bias to make a unilateral decision on the quality of care. With a medical advisory board, there are no unilateral decisions. This can lead to some very interesting discussions about the field treatment of patients.
In New Jersey, where our EMS service operates, approximately 80% of all treatment rendered to a patient during any given encounter is regulated by state-issued protocols. Once we have exhausted these protocols, we are required to contact an on-line medical command physician for any additional treatment orders we may require. If we are unable to contact on-line medical control for any reason, we can revert to a set of radio failure treatment protocols, which are determined by an EMS service’s medical director or, in our case, our medical advisory board. Here again, there can be a significant difference in how the physicians on a medical advisory board feel a patient should be treated under radio failure protocols.
Although our agency services 11 different hospitals, our on-line medical command comes from one hospital in the system. While the emergency department's medical director of that hospital has a seat on our medical advisory board, the dozen or so physicians who provide medical command and report to her do not. These medical command physicians go through quality assurance in the same fashion as our field staff. In cases where a medical advisory board physician disagrees with a medical command order, the matter will be discussed by the entire board. Again, the biases of different hospitals come into play in the discussion until the board comes to a resolution on the issue. The task of providing feedback to the medical command physician will fall to the ED medical director of that hospital.
There is also the issue of dealing with the overall EMS system in your region. This is where a medical advisory board can truly shine in its ability to disseminate information across a large geographic area. While an individual medical director may only interact with a limited number of providers from other EMS agencies, such as volunteer basic life support or even other ALS services, members of a medical advisory board are far more likely to interact with a much larger number of providers and agencies. Dissemination of information through the members of the medical advisory board can reinforce and even enhance the message of proper prehospital medical care to the EMS community at large. Medical advisory board physicians also serve to educate staff members of their respective emergency departments, keeping them up to date on what is new in the prehospital arena, thus enhancing the relationship between emergency department staff and an EMS agency.
When all is said and done, it is hard to say which system of medical direction works better. The pros of a single medical director system are a much more streamlined decision-making process where new protocols can be rapidly developed and implemented. The cons of a system like this include reliance on a single person’s point of view with little room for dissenting opinion. The major advantage of an advisory board system of medical direction is that no one person has the ability to make a decision. This ensures that there will be significant input from all stakeholders in the development of new protocols. The other side of that coin is that change may tend to come at what feels like a glacial pace. If you have an involved progressive medical director who is supportive of your EMS agency's vision, then a single director system might be to your advantage. If the opposite is true, or if you put a premium on the ability to gain broad insight during the decision-making process, then the medical advisory board is probably your best bet. Both systems can work well under the right circumstances.