Most people who choose EMS love what they do and would love to have full careers in it. Yet they are painfully aware of several things.
First, most EMS organizations are small and built around flat organizational structures, so opportunities for advancement are limited. Second, the same characteristics that make them great medics make them prone to boredom and driven to seek variety in their work. Third, as EMS is organized today, it is difficult for providers to achieve financial security. Fourth, we have failed to build the infrastructure nationally or at the state and local levels to train EMS providers for career development.
Let's look at each of those issues in a bit more detail.
Organizational Structures and Career Ladders
Many EMS organizations are small. How many career options can a small organization provide? It's no wonder these organizations lose employees to larger outfits that offer them more options. And even larger EMS organizations tend to have limited hierarchies.
Establishing a career ladder can be daunting. Many medics want paths that provide increased pay and status for simple longevity. Some employers have acquiesced. Where this occurs, it reduces opportunities and incentive to advance.
Another barrier is EMS' lack of a standardized system of rank and position. We often use functional titles that have different meanings from place to place and make interagency comparisons difficult. In my agency, a field training officer is an experienced paramedic with some special training who is assigned to teach and evaluate a new paramedic during their first few months of employment. Two counties away, a person with the same title is a shift-level officer responsible for the training of all personnel assigned to that shift. Confusing? You bet! What happens when your HR staff tries to compare salaries?
Career Breadth and Lack of Lateral Opportunities
"Horizontal," non-promotional career opportunities are almost totally lacking in EMS. The law enforcement patrol officer, without promotion, can be trained as a K-9 officer, school resource officer, tactical officer, bomb technician or more. A firefighter can become a prevention officer (inspector) or investigator. Why has EMS failed to develop similar opportunities? The roots lie in the historical accident whereby insurers pay for ambulance transportation, rather than medical care.
A common tactic used by private-sector ambulance operators to woo elected officials has been the "little or no subsidy" offer. To win local contracts, they promise to operate with zero or minimal tax funding, and cost-shift to cover their expenses. In doing so, though, they often provide only what's mandated--often only "ambulance" response and transportation. Many EMS systems are now strangling because of the entrenched belief that they should live within the transportation-based revenue stream.
We now know EMS and ambulance service are not the same thing. EMS consists of both ambulance operations and special operations--e.g., mass-gathering medicine, technical rescue/USAR medicine, and a variety of other services. It is in the special operations arena that advancement opportunities lie. After cutting his teeth on an ambulance, an experienced medic could be assigned to patrol on an EMS bike team, or work with a service's specialty teams (tactical, WMD, etc.). And were they freed of the burden of living within transportation-revenue streams, EMS systems could provide a variety of additional services--think injury prevention or medication-compliance programs, school resource paramedics, etc.
Personal Survival and Economics
As opportunities for cost-shifting evaporated, so did the ability of ambulance services to pay a living wage. Many large private organizations came to accept that they could get 3--5 years out of a medic before the medic moved on, so they built their business models to accommodate the revolving door. Public and non-profit agencies got dragged along through "market comparability."
And let's not forget about the volunteers. Volunteers are noble, but they have contributed to the economic difficulties of their career colleagues. When you look at the cost of providing EMS, it only takes a few zeros in the compensation column to drag the market average down. Why should anyone pay more when right down the road there are communities getting it for free?
Career Development Infrastructure
In EMS, we have failed to develop comprehensive pre-service educational programs, leaving the development of our new members to institutions committed only to following a nebulous national standard curriculum. It's amazing that we're still debating whether we should teach hazmat awareness or emergency vehicle operations in our EMT and paramedic schools. Is there an accredited police academy in the country that doesn't teach EVOC, defensive tactics or shooting?
Look at the advertisements for senior EMS positions in our trade journals. A college degree, some experience as a supervisor and a paramedic license, and you're eligible, whether or not you've ever managed an MCI or built a budget. What are the competencies truly required of a chief EMS officer? Where is the road map? What does an intelligent, energetic and ambitious young medic do to set his or her course for the future?
Those of us in EMS leadership may have failed our followers. We have not effectively advocated for career options within EMS, and we have failed to provide the structure and infrastructure for our providers to see and effectively navigate career paths. What can we do now to improve this situation?
1. The EMS community must understand the difference between "ambulance service" and "EMS" and work to ensure every community enjoys a full spectrum of emergency medical services.
2. We need to decouple EMS funding from transportation. Elected officials must understand that EMS is an essential element of communities' quality of life, and that using tax dollars to fund it is not inherently wrong.
3. We need to develop career breadth for medics whose aspirations may not involve supervision.
4. We must build a commonly recognized rank structure and adopt it across the industry.
5. We need to develop an accepted set of educational and technical competencies for EMS officers at all levels, then develop the educational and credentialing infrastructure to support them. Any EMS provider with career aspirations should be able to see a road map that leads to their desired destination.
Skip Kirkwood, MS, JD, EMT-P, is Chief of EMS for the Wake County (NC) Department of Public Safety.