Which Way From Here?

     The subject of recruiting and retaining paramedics is on the agenda of many in EMS today. Agency leaders are wondering how, in the face of a shrinking workforce and growing demand for service, they will maintain enough staff to meet the needs of the communities they serve. EMS educators are looking for ways to fill classes. Working paramedics hope their agencies' vacant positions get filled, so overtime will diminish. Labor officials wonder when the law of supply and demand will kick in, resulting in higher wages as employers compete for employees.

     I've spent a lot of time talking with EMS professionals about this topic. Most of them love what they do, and would like nothing more than to have had interesting and diverse careers in EMS. But although most love patient care, those past the 10-year mark are often burned out from performing the same ambulance medic duties they've done since getting certified. Many have started to look for more interesting and stimulating alternatives that might provide brighter economic futures. For many, that means leaving EMS for other public safety or healthcare disciplines. What a loss! Why has the EMS community failed to provide depth and breadth to career opportunities for its people?

A FLAWED SYSTEM

     EMS agencies in the United States are part of a system that badly needs change. The bad news is that we built much of this system, and have become so invested in it that we may be threatened by the needed changes. Our basic faiths will be challenged. Here are some design features of a system that keeps us in a maze with no discernable endpoint.

1. We deliver an essential public health/public safety service. Essential public health/public safety services in the United States are paid for out of local government budgets. Yet we have, for the last 25 years, sold our services as requiring few or no tax dollars. For competitive advantage, we've cut our services off from funding streams that might serve us better than the ones we have. We've instead adopted a flawed "medical care" funding model for a service that's vastly different from a physician's private practice or an outpatient radiology service.

2. Our sole revenue source, in most cases, is transportation revenue. No transport, no revenue, and if we transport to somewhere besides a hospital emergency department, no revenue. So we have no incentive (in fact, we have a negative incentive) to provide other services beyond emergency treatment and hospital transport that might be better for our communities--services that would prevent unnecessary EMS calls, or that would take patients to places other than overcrowded EDs when ED capabilities are not required.

3. Our funding is completely dissociated from the rest of the healthcare system; thus we have no incentive to provide other contributions we are perfectly capable of making. Our counterparts in Canada, the United Kingdom, Australia and New Zealand are part of nationalized healthcare systems, so their funding comes from the overall healthcare budget. In some places, this has helped enable expanded scopes of practice. If it makes more sense to send out a paramedic to put in a couple of sutures than to transport someone to the hospital, we have to find ways to make that happen.

4. We've built a network of local (and sometimes sublocal) services that are small, financially weak and struggle continuously for survival. Underresourced organizations may cut corners in places like safety, personal protective equipment, compensation and benefits, management and supervision, training and more. They do not have, individually or cooperatively, the flexibility and infrastructure larger, more stable organizations can provide. It's often more important that it be "mine"--independent and free from outside control--than that it be "good" for the organization, its community and its employees. A friend of mine calls this the "captain of the rowboat" syndrome: where someone would rather be the chief of a tiny, precariously positioned organization (a rowboat) than a first lieutenant on a larger, stronger, more stable craft (like an aircraft carrier).

5. We've spent more than 25 years telling elected officials and municipal executives that EMS should be cheap. We've glorified systems whose hallmarks were high unit-hour utilization, low real estate cost and low cost per transport. We've been successful, and now many of these officials believe their communities can have EMS that is both good and cheap or free! We've focused on efficiency in a narrow domain, instead of seeking to broaden the scope of services we deliver.