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Remember the bad night we talked about last month? Seven responses in a row, the last three for incidents that were not close to life-threatening emergencies. Dinner reheated until it was nasty. And finally, when sleep was approaching, a call at 3:17 a.m. that turned out to be for a sick dog named Roscoe. When we decided to become EMS practitioners, I think most of us made the choice because we wanted to help others. I'm not sure we understood what that was going to mean. I never thought I'd get calls for a sick dog, a leaky faucet, a stuck garage door or "itchy teeth," but I did. We often respond to calls for help that are not really medical problems. How should a medical professional react to what some would consider an inappropriate call to 9-1-1?
For guidance we can turn to Dr. Herbert Swick's list of professional behaviors in medicine. The first item on his list is subordinating personal interests to the interests of others. To begin our discussion, we need to define subordinate. Here are some definitions that help to clarify the meaning.
I had a conversation recently with a medic about the word subordinate. The individual I was talking with said he experienced a negative feeling in response to the word. I've been thinking about his reaction and trying to figure out the reason for it. If we look at some other definitions of the word, it makes some sense that people might interpret subordinate in a negative way.
Belonging to a lower or inferior class or rank; secondary.
I feel it is important for each of us to examine our reactions to the idea of being less important than others or subject to someone else's authority. We need to be prepared and overcome negative responses, because we all are subordinate at some time or other.
Look at the structure of an EMS service. I work in a fire-based service, and our department is a paramilitary-style organization. There is a distinct rank structure and a clear hierarchy. When I worked in a hospital-based system, there were shift supervisors, who were given the rank of lieutenant, and there was a director--a clear structure and line of authority. The same was true in the third-service combination ambulance corps where I began my career nearly 30 years ago.
One obvious reason for this structure and the hierarchy of authority is the seriousness of the work. In emergency services, there are times when lives are literally on the line. During those times it is critical that individuals follow orders and adhere to clear lines of authority. If people freelance, the consequence could be a bad outcome resulting in injury or death.
It seems that people, particularly some younger people, have a hard time accepting subordinate positions. But every organization, every team, every community has defined lines of authority and hierarchy. In a restaurant kitchen, on a ball field, in church or on a team, there are leaders and followers. In fact, there are no leaders without followers.
So why the negative feelings for the word subordinate? I believe it is often due to the nature and behavior of individuals in authority. Sometimes people feel those in authority have not earned their positions. Sometimes a person in a higher position is thought to be less educated. Sometimes the person in authority does not behave in the way we expect of a leader or a professional. However, if a company, agency or department has given an individual authority, those in a lower position are by definition subordinate. I have often heard the saying, "You don't have to respect the person, but you do have to respect the rank."
Subordination in EMS
In light of the difficulty some individuals seem to have taking subordinate roles in their organizations, how will these same people feel about subordinating their personal interests to the interests of others on a call? What does it mean to EMS practice?
Let's return to Swick and look at what he said about subordinating self-interest: "Medical professionalism reflects the physician's open willingness to subordinate his or her interests to best meet the needs of patients."3 The same standard can be applied to EMS practitioners. What do you think Roscoe's owner needed when she called 9-1-1? I think she needed reassurance and interaction with a compassionate person to provide guidance. She called for help. The help an EMS practitioner could provide would be asking about friends or family she could call, or helping her find veterinary care for her dog--maybe by helping her with the phone book, maybe even by making the calls. We may not have training in canine medicine, but we do have an obligation to provide the best service we can. Remember saying the reason you wanted to become a paramedic was to "help people"?
Can you think of other examples of situations that call for us to subordinate our interests to the interests of others? Anytime we find ourselves in circumstances that include any form of risk--auto extrication; high-angle, confined space or swiftwater rescues; working on the highway; treating persons with communicable diseases--we do this. Then there are cases like the street person with lice who hasn't bathed in days, the intoxicated college student, the noncompliant diabetic or seizure patient. Although it is sometimes difficult, as professionals we must act as patient advocates, even when the person we respond to is not technically a "patient," and do what we can to help them.
Now let's turn to another dilemma: How can we teach and evaluate the behavior of subordinating personal interests? This question relates to selecting educational methodologies, setting standards and identifying observable behaviors. There are a few ways I can think of to teach these difficult behaviors. One is role-modeling. Another is role-play. Finally we can facilitate discussions. Can you think of others?
One of the most important means to teach and demonstrate subordination of personal interests is through role-modeling. Instructors, preceptors, field training officers, supervisors--we all have to be role models. We have to put the needs of the people who work for and with us first, and we have to put the needs of the people we respond to ahead of our own. If we demonstrate this professional behavior, we will begin to instill it in others.
We can teach subordination in the classroom through role-playing scenarios. We must determine the observable behaviors that reflect subordination. Some examples are:
Letting others go first;
Offering to spend time helping others;
Taking direction and following orders.
Scenarios could include situations like the call to help a sick dog, or responding to the home of someone who has no heat or just wants you to fix their stuck closet door or leaking faucet.
Role-play lets those playing the roles practice the behaviors and, in different scenarios, experience what it's like when people put their own interests first in the context of EMS practice. Role-play scenarios must be well crafted, monitored and controlled. Everyone participating should perform in all the roles in positive scenarios. Students and other practitioners should also experience what it's like when selfish individuals respond. All of this takes time, but just as with practicing trauma or medical scenarios, all participants can derive significant value from it.
Discussions are also time-consuming; however, the time invested in such activity leads to better understanding. We can explore feelings in a safe and controlled setting. We can impart new information. Instructors and supervisors can assess the development of their students and subordinates. Discussions incorporating questions allow you to evaluate understanding and knowledge. You can write effective multiple-choice questions related to this sort of performance and behavior, but this assessment method should only be one part of the broader process of instruction and evaluation. We will return to these tactics over and over in our discussion of professional behaviors.
Although we might not have been told we'd be called to incidents where the "patient" turned out to be a dog named Roscoe, I believe people who have nowhere else to turn, or don't know what else to do, will continue to call us for help. We have been teaching people for years to call 9-1-1 for help. It is up to us to remember that medical professionals choose to subordinate their own interests to the interests of others, and that we must always be professional.
Swick's Professional Behaviors
From his article "Toward a Normative Definition of Medical Professionalism," Dr. Herbert Swick's behaviors that define medical professionalism:3
Subordinating personal interests to the interests of others;
Adhering to high ethical and moral standards;
Responding to societies' needs, reflecting a social contract with the communities served;
Demonstrating core humanistic values: honesty, integrity, caring, compassion, altruism, empathy, respect for others and trustworthiness;
Exercising accountability for yourself and for colleagues;
Demonstrating a continuing commitment to excellence;
Exhibiting a commitment to scholarship and advancing the field;
Dealing with high levels of complexity and uncertainty;
3. Swick H. Toward a normative definition of medical professionalism. Acad Med 75(6): 612–616, June 2000.
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. He has participated in EMS leadership, management and educational development initiatives at the local, state and national levels. Contact him at firstname.lastname@example.org.