This month we continue our discussion of professional behavior in EMS by examining the concept of commitment to excellence. To begin, we return to Dr. Herbert Swick's 2000 article "Toward a Normative Definition of Medical Professionalism." Swick said, "Physicians demonstrate a continued commitment to excellence."1 As we have done each month, let's define the terms in Swick's statement so we can begin our discussion on firm footing and then consider how this concept applies to EMS practice.
The two key terms in Swick's statement are commitment and excellence. How would you define commitment? Take a minute to think about it. One online definition describes commitment as "a pledge or promise to do something" and "dedication to a long-term course of action; engagement; involvement."2 Another says it is "the state of being bound emotionally or intellectually to a course of action."3
What is excellence? It seems like a simple idea: the very best, high quality, high performance. How would you define it? One definition includes "the quality of being excellent; state of possessing good qualities in an eminent degree; exalted merit; superiority in virtue."4
What Excellence Looks Like
"The quality of a person's life is in direct proportion to their commitment to excellence, regardless of their chosen field of endeavor." --Vince Lombardi5
How should we as EMS practitioners demonstrate our continued commitment to excellence? I believe we all should promise to serve, respond and provide the best care we can. We also should follow the ideal to "do no harm." There is an echo of core values here.
Each of us, to be the best we can be, must continually strive to keep up with changes and advances in medicine and apply them to our prehospital practice. How many times has the methodology of CPR changed? Several times in my career. Do any of you remember "four staircase ventilations"? We will likely see more changes later this year with the next update.
Why does CPR continue to change and evolve? Because research--scientific inquiry and analysis--shows us what works and what doesn't. We adapt how we do CPR to continuously improve effectiveness. In turn, we hope to improve a person's chance of surviving sudden cardiac arrest. We are pursuing excellence.
How else might this pursuit of excellence manifest? I hear discussions about developing a "culture of safety" in emergency services. This may include always wearing a seat belt, and ensuring everyone else in the vehicle is wearing theirs as well. Do you always wear your seat belt in the ambulance? How about in your personal vehicle?
Pursuit of excellence in safety may mean changing the way ambulances are designed, demanding better configuration before purchasing one. It also means constantly working to be safe drivers. Pursuing personal excellence might include attending conferences, joining professional associations, and political activity such as participating in the development and review of EMS legislation.
The Emotional Bond
"Desire is the key to motivation, but it's determination and commitment to an unrelenting pursuit of your goal--a commitment to excellence--that will enable you to attain the success you seek." --Mario Andretti6
The other night I was thinking about excellence and commitment and how they apply to EMS practice. It occurred to me that it was really about emotion, and how we feel about what we do. Although I have heard discussions about attitude and EMS instructors and educators trying to address the affective domain of performance--the educational domain concerning emotion--we almost never talk about emotions. The work we do is stressful and can have enormous emotional impacts, yet in my opinion we do very little to prepare EMS practitioners for this critical aspect of working in EMS.
How does this connect to a commitment to excellence? Commitment is being "bound emotionally or intellectually to a course of action."3 Here we see the connection. Professionals are emotionally bound to continuously pursue excellence. It is a choice we all must make. It is hard work to always be our best. It requires us to analyze our feelings and our practice to identify our areas of weakness. Then we must improve the knowledge, skills and attitudes we find lacking.
Excellence in practice means being up to date with your protocols and being able to perform all of your skills (when was the last time you used a traction splint? Could you put one on a patient right now?). And it means always paying attention to attitude and emotion.
A few days ago a friend and I were discussing front-line supervisors. We were talking about why some seem to be more engaged than others. One part of the discussion centered on an individual's choice: whether to choose to follow the easy path, or to do the hard work to be better. It always seems easier to disengage. Take stock of yourself, and make sure you are doing what is most beneficial. Should we only be looking out for number one?
Many of us in EMS face challenges related to how we're perceived by the rest of the medical community. There are other challenges as well. Challenges may arise from conflicts within a service. Maybe a challenge stems from volunteer vs. career provider issues. Whatever the case may be, it is up to us, you and me, to personally choose to be better at what we do. Respect is earned. We must earn respect by representing EMS in a positive light regardless of the challenges before us. It may feel like you are all alone in your struggle. But believe me, others will notice, and you will feel better for doing the right thing--doing the best you can and striving to achieve excellence.
Have you ever taken the easy way, or used a shortcut that maybe was in a "grey" area of practice? That is, something not specifically prohibited in protocol, but something you knew was questionable? How did you feel about it? Were you uncomfortable? Did you have that feeling that someone saw you, or that the next phone call was going to be from your boss? Unfortunately, I have to admit, I've been there. I think at some point we all have. That discomfort was an emotional response to a personal choice. At the time it seemed easier to just walk the patient to the ambulance. It was easier to move the patient to the ambulance before initiating care. How did this come to be?
When I first became an EMT and, a few years later, a paramedic, we always carried our equipment to the patient's side and started treatment right there. I remember slinging the monitor over my shoulder, hanging the IV bag from the pen in my shirt pocket, with my partner carrying the first-in bag and the patient holding the O2 on his lap as we carried him downstairs on the stair chair. As time went on, the demands on the system I was working in grew, and as the call volume continued to climb, it became easier to do a rapid assessment and move the patient to the ambulance to start the care. Most of the time the patient just wanted a ride to the hospital to get checked out, so it seemed to not really matter. We changed our practice because we chose to act in a way that was easier for us.
I ask you, how many of you wait to start your treatment until you're in the back of your ambulance? Be honest. Now I ask you, is that excellent practice? Whom does it benefit? When I was a supervisor, paramedics would use excuses like "It was a safety issue," or "We wanted to be in a controlled environment," or "It was filthy, there were bugs, and it was dark." The fact is, these excuses were typically nonsense. The truth was, it was less work, most of the time you could get away with it, and most of the time it really had no adverse effect on the patient. People did it because they could. As time passed this practice became standard, as new folks learned it from the experienced people. No matter what you think about it, I will say here and now that it is bad practice. We have an obligation to assess and, when the patient needs treatment, treat the patient at their side, where we find them. It is bad practice to walk into a home, ignorant of the true circumstances, with no equipment, unprepared for the worst.
My point here is to bring out the core of excellent practice--the choice you must make every day to pursue excellence, and having the pride to do what is right, even though it means more work and even though most of the patients we see won't need advanced care. Excellent practice is putting others' needs first, always choosing to do what is right, and working hard to be better at what we do. We can borrow from the Medical School Objectives Project and ask EMS practitioners to demonstrate "the capacity to recognize and accept limitations in one's knowledge and clinical skills, and a commitment to continuously improve one's knowledge and ability."7
If we all strive to be lifelong learners and demonstrate a commitment to pursue excellence in our EMS practice, we can achieve a win-win-win circumstance: We are improved practitioners, EMS as a whole improves, and our patients get better care and service. Who can argue with that?
"Excellence is an art won by training and habituation. We do not act rightly because we have virtue or excellence, but we rather have those because we have acted rightly. We are what we repeatedly do. Excellence, then, is not an act but a habit." --Aristotle8
1. Swick H. Toward a normative definition of medical professionalism. Acad Med 75(6): 612–616, June 2000.
2. Your Dictionary. www.yourdictionary.com/commitment.
3. Dictionary.com. http://dictionary.reference.com/browse/commitment.
4. Webster Dictionary. www.webster-dictionary.net/definition/excellence.
5. Brainy Quote. www.brainyquote.com/words/ex/excellence162353.html.
7. Medical School Objectives Writing Group. Learning objectives for medical student education--guidelines for medical students: Report I of the Medical School Objectives Project. Acad Med 74(1): 8, 1999.
8. Quotations Book. http://quotationsbook.com/quote/12996/.
Michael Touchstone, BS, EMT-P, is chief of EMS training for the Philadelphia Fire Department. He has been involved in EMS since 1980 as an EMT, paramedic and instructor. Contact him at email@example.com.