In 2012, EMS World and the NAEMT named New Orleans EMS their Dick Ferneau Paid EMS Service of the Year. A little more than five years later, NOEMS’ respected director and medical director, Jeff Elder, MD, was abruptly ousted from the system he’d helped rebound from the devastation of Hurricane Katrina.
At the time and since, new Mayor LaToya Cantrell and other leaders have been tight-lipped about the reason for Elder’s dismissal. Elder was replaced by an ER physician with experience treating patients but not running a large, growing, complicated, and sometimes messy modern emergency medical services system. While that successor may do a wonderful job, the move, absent any explanation, left a lot of observers scratching their heads.
But Elder hasn’t been the only top doc moving on or feeling uncomfortable in their chair lately. As EMS is in rapid and substantial flux, a number of medical directors both prominent and long-serving have experienced sudden changes of employment.
The official reasons vary, as no two situations are the same, but there’s no doubt the role is difficult. For one, the medicine of EMS is advancing and complex, increasingly requiring tight, specific integration and coordination with other players across a volatile political landscape. Beyond that, the whole concept of EMS is evolving a more proactive bent, with concepts like mobile integrated healthcare and population health shaping how systems tailor their capabilities. Overlaying all is a looming mandate to provide value to payers, consumers, and those who make law and policy, all while continuing to deliver exceptional care.
Those are big challenges, on top of the other big challenges system leaders face, and they can put a lot of pressure on medical control physicians to not only define top-notch care deliverable at a reasonable price, but to innovate and keep their departments on the clinical cutting edge. They also create ample opportunities for conflict.
“You’re trying to align a bunch of things in which organizations may not have a lot of expertise,” says Jim Dunford, MD, who stepped down in December after 20-plus years as medical director for the city of San Diego and its fire and EMS. “When it comes to billing and collections and innovative care models and bundled payments and value-based care and what’s coming, that’s not traditionally the strength of the fire department, and you can’t even assume it’s going to be found in an ambulance business. But that’s the kind of expertise you need to have checks and balances. So it’s a complicated ecosystem right now, where cities are trying to engage but don’t really have people who have ever done that.”
Similar factors weigh on the operational sides of EMS houses. All that innovative care docs covet must be delivered, expediently but not expensively, and compatibly with existing mechanisms and ever-rising call volumes, by systems that may not be designed or constructed for it. On the ops side, chiefs and managers have the same ultimate goals as their docs, but approach their execution from the practical, real-world, wheels-on-the-road view. Medicine is half the battle; delivering it is the other.
“I feel like I have a high level of expertise to lead my system, and I don’t really need an EMS physician to teach me what modern EMS looks like,” says Tom Bouthillet, battalion chief over EMS for Hilton Head Island Fire Rescue in South Carolina, whose town is currently hiring a medical control physician. “What I need is somebody who shares that vision and can come in and help with the training and things like that, so when we introduce video laryngoscopy, they don’t tell me, ‘Oh, all patients should be intubated!’ The field is not the ED, and the way they may approach airway management is not the way EMS should approach airway management in 2018.”
It’s not surprising, then, that the clinical and operational priorities of modern EMS systems sometimes conflict. (Folks on the ops side change jobs over this too, but generally with fewer headlines.) Docs are worried about quality of care, medical efficacy, CE and remediating poor performers, and maintaining strong protocols and review. Operations leaders are concerned with staffing, response volume, compliance issues, and ensuring their systems function. The challenge lies in reconciling those competing interests (and attending alpha personalities) by some method short of replacing top personnel.
What Docs Want
The highest-profile breakup of doctor and department in recent American EMS occurred in 2016, when medical director Jullette Saussy, MD, FACEP, left the capital’s oft-troubled D.C. Fire and EMS. Reflecting a brief tenure marked by squabbles over operational issues, her public resignation letter was four pages of fire-breathing frustration, citing a culture “highly toxic” to the delivery of quality medical care.
Among Saussy’s specific complaints: a lack of performance measurement from response times on; a lack of accountability at all levels, resulting in an undisciplined workforce; and an org chart unreflective of the department’s EMS-heavy call volume.
Some of the fixes would be easy enough, Saussy indicated. But assessing the competency of medics was derailed by labor concerns, and simple operational changes such as requiring providers to answer their radios and not just vanish for hours after dropping patients at hospitals found no traction.
In this case the problem wasn’t resistance pushing through advanced changes—it was dealing with the most fundamental operational requirements of running a department. Despite a string of high-profile miscues, the will for major change wasn’t there, according to Saussy.
“If you don’t want to be assessed because you know what the outcome will be, then you just bully and intimidate,” she says. “And then you keep on harming people, doing the same thing over and over again. And they tell you, ‘Just sign the paper. We can’t prove they’ve taken any tests or are competent, but sign here and attest to it.’ And everybody just looks the other way.”
Saussy came to the District from New Orleans, where she’d preceded Elder as head of New Orleans EMS and guided the system during and after Katrina. Even during those immense trials, she says, the department was supported by government and their colleagues in public safety—“a very different culture and setup,” she says.
Still, D.C. is just one big-city fire-based EMS service. On the other coast, San Diego’s system has a better reputation but has experienced its own problems.
“It did have to do with conflicts,” says Dunford of stepping down. “There were a number of issues of disagreement, so I thought it was probably time to move on.”
A pair of those issues came again to the forefront with recent reports from San Diego’s grand jury. In May that body released a document reviewing the response to a hepatitis A outbreak that killed 20 last year. Its conclusions: The county should have declared a health emergency more quickly, and the city should have acted more forcefully on sanitation efforts in its impacted homeless communities. But while the report praised the use of vaccination foot teams in remote areas and more than 100,000 people were ultimately vaccinated, that process was slow to get started.
“We knew other EMS systems, including some in Florida, had rapidly authorized their paramedics in regions affected by Hurricane Irma to provide vaccines for hepatitis A,” says Dunford. “Here we recommended that for months and months before it actually occurred. And there were a number of findings in terms of communications between the city and county health department, and within the city itself, that reflected things I was feeling quite acutely.”
A month later, the same body released a postmortem on the city’s late Resource Access Program (RAP), a paramedic-based surveillance and case-management system for superusers. That program ended in 2016 when local ambulance provider AMR wanted to redeploy personnel to traditional crews for staffing purposes. The grand jury urged the mayor and city council to explore ways to “replicate the success and benefits” of the program, which it determined saved roughly $543,000 in ambulance transports and ED visits in fiscal 2016–17.
“We were one of the community paramedic pilot programs in California, and we were right at the top of the class in being able to show cost savings, and the program ended up getting defunded,” says Dunford. “I just really felt like I couldn’t communicate effectively to people why they should fund and stick with the program. I found myself kind of isolated from the decision-makers, and I think if they’d really had more clear information and input from myself and others, the program wouldn’t have had to be torn down and rebuilt again.”
That point about isolation is an important one. Certain organizational structures can carve medical control docs out of other decision-making entirely.
“If you’re not at the table in the first place, then all those decisions are going to be made in an operational way,” says Neal Richmond, MD, medical director for Texas’ MedStar Mobile Healthcare and previously both medical director and CEO of Louisville Metro EMS in Kentucky. “And your average fire chief probably comes in with a much stronger skill set in those areas—staffing, scheduling, all that kind of stuff—than physicians. These, and things like sick leave, FMLA, and separations often become the primary focus—all necessary but often overshadowing the mission of delivering high-quality patient care.”
What Operations Wants
What a system needs from its medical control doc will vary based on things like the care levels and types it provides and where the doc fits on the org chart.
“It’s like a community paramedic program,” says Bouthillet. “What looks right to me in 2018 is not going to be the same thing that looks right to a private ambulance company or to a municipal versus a county third service. It depends on where you are in your journey.”
Medical control physicians have responsibility for protocols, ensuring provider performance to standards, quality assurance/improvement, perhaps training, and ultimately patient outcomes. Those are all clear and measurable metrics that reflect needed hard skills. They should also have familiarity with modern EMS, and hopefully certification in that ABEM subspecialty. For every major system with a well-known rock-star doc, there are multiple others whose medical direction comes from a contracted physician at a local hospital who may not have experience with field medicine.
“You don’t want someone you have to explain push-dose epinephrine to, or whom you have to fight to use ketamine,” says Bouthillet. “You’d hope it’s someone who’s kind of dialed in to modern EMS practice.”
Most systems don’t get medical control from the type of high-profile PubMed-heavyweight EMS physicians who speak at the Gathering of Eagles or get quoted in magazine articles. Many can’t pay for full-time medical control docs to be involved in the day-to-day and focused on improving care. Instead they pay for intermittent guidance from a doc who may be willing but have multiple other priorities.
Beyond the hard skills lie some key personal qualities. First is open-mindedness. There will be other smart people at that decision table. A doc should know what he/she doesn’t know and when to defer to those with grounding in other areas.
Medical control also requires leadership. Leaders can pursue change but understand poor performance usually has more roots in bad systems and structures than bad people. They wield the same soft skills at the meeting table as they do at the bedside.
Finally, there’s little substitute for credibility when promoting a vision. A medical control doc can carry that from having an EMS background and having served in the trenches or earn it through fierce advocacy for their crews. One example: After he initiated a spinal-clearance protocol at North Carolina’s Wake County EMS, then-director/medical director Brent Myers once reportedly got up at 3 a.m. to set straight a new attending who’d chastised a medic crew for not backboarding.
“You don’t see that every day,” says Bouthillet. “One thing I can tell you about [fire and EMS providers] is, if you’re credible and they know you’re going to go to bat for them, and you show them respect and understanding, they’ll jump over the moon for you—they’ll do anything. But if you come at them the wrong way, you’re chum in the water, and you won’t get a second chance.”
Bringing Them Together
There’s not a simple answer to minimizing problems between the clinical and operational interests of modern EMS—both sides are complex and not getting easier. But here are some ideas to consider.
Fit—Before you ever swipe right, make sure the chief, doc, and top personnel are philosophically in tune. If you’re a more conservative department, great, but avoid a cutting-edge doc who wants to try a lot of new things. If you’re a progressive department used to pushing care envelopes, a late-adopting skeptic isn’t your best MD fit.
“They have to be somewhat aligned,” says Frank Babinec, chief of Florida’s Coral Springs-Parkland Fire Department. “If you have a chief who’s trying to move things along and a medical director who’s not willing, or a medical director who wants to move things forward but a chief who doesn’t, that’s not going to work.”
Qualification—A medical control physician or medical director in EMS should be familiar with prehospital medicine, not just the ED. Ideally they should hold an EMS subspecialty certification.
Data—Collect as much outcomes and other data as possible about the care you provide and the effect of changes.
“We’re fortunate to have a data analyst working for the department,” says Babinec. “This helps us evaluate everything we do.”
Buy-in—Successful change requires the support of line personnel. Involve them as much as possible, through mechanisms like protocol and equipment committees, in weighing and making changes. No one likes imperial edicts handed down. Also, training all members as a team can help build unity and underscore and reinforce the value of all aspects of the mission.
Collegiality—This boils down to soft skills like communication and holding each other in basic respect. Docs talking down to field crews shouldn’t be tolerated. Similarly, ops chiefs may not realize their decisions can affect the delivery of quality care.
The org chart—Think carefully about the role of your medical control physician and where he/she should reside on your org chart. “One of the things the grand jury called out here in San Diego was that my replacement was appointed to report to a deputy fire chief,” says Dunford. “When I was EMS medical director when the system was created in 1997, I didn’t report to the fire chief at all—I was accountable to the community, as their physician.”
Generalizing about medical/operational conflicts is almost impossible. Systems are different, personalities unique, anecdotes aren’t data. But clearly problems can occur across resources, culture, and more.
Clashes are often blamed on differences in personality. Really they often go deeper.
“I think personality really has little to do with [conflicts],” says Richmond. “It has to do with profound philosophical differences about what the roles of these services are, as well as the different skill sets, training and experience these individuals bring to their positions.
“In most systems I believe it’s the operations that drives the medicine, not the other way around. We talk about financial sustainability, but even from the operational end—staffing, scheduling, retaining tenured providers, discipline, all of that, in addition to basic quality of care and safety of patients—I think we would do so much better if the medicine drove the operations. But that’s not really how most services are constructed. If we don’t provide personnel with the tools to ensure appropriate clinical decision-making on the front end and don’t have the necessary resources to quality-assure that decision-making on the back end, then the emphasis will continue to be on process.”
“Every EMS system is at a starting point, and you go through certain eras as a department,” says Bouthillet. “I need a doctor who can help me get from where I am to where I want to be. To me what we’re talking about is improvement culture. But to make that happen I think 100% requires those soft skills. Otherwise, it’s like a marriage: A lot can go wrong.”
John Erich is senior editor of EMS World. Reach him at firstname.lastname@example.org.