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College Degrees and the Affective Domain

A respected colleague posed a provocative question: “What does a college degree bring to EMS in its current form?” EMS educators typically reply with the more focused question, “What is our system expecting from new paramedics?” A comprehensive answer is based on a discussion of current educational requirements, the needs and expectations of our shared patients, and an unequivocal endorsement of the value of education.

Back to School

The first day of any paramedic class is predictable. Everyone wants a seat in the back. Introductions precede a slurry of forms, copies of policies, standing in line, and of course lunch. After anticipating the start of their first IV, a piece of paper with the phrase affective domain prompts someone to ask, “What is this?” Students start wrestling with their goal: to develop the ability to set troubled patients at ease and actively listen to problems and concerns. Educators face a more daunting challenge: How will they direct and measure the growth of something intangible succinctly described as empathy?

Bloom’s taxonomy classifies three educational domains: cognitive (your knowledge), psychomotor (your skills), and affective (your character and conscience). While essential for learning, the affective domain has been described as the least studied, most overlooked, and hardest to define and evaluate. But paramedic preceptors always recognized the importance of these skills; I remember one saying, “We can pull anyone off the street and teach them how to start IVs. My job is to make sure the patient trusts you to do it.” His dry wit highlighted the nuances separating “training” and “education.”

Into the Water

Investigating how to directly discuss expectations for the affective domain with our students led to “Into the Water—The Clinical Clerkships,” a 2011 article by Massachusetts physicians Katharine Treadway and Neal Chatterjee.1 The article depict the experience of students transitioning into clinical rotations during their third year of medical school. Chatterjee refers to his resident describing “a recent patient who arrived with minor abdominal pain and left with a CABG, cecectomy, and two chest tubes.” That might not seem applicable to a paramedic student—until you read the next sentence: “This remark was apparently funny, as I surmised from the ensuing laughter. And the resident sharing the anecdote—slouched in his chair, legs crossed, and coffee in hand—seemed oddly…comfortable.” Does the same thing happen to our students?

The title, “Into the Water,” references David Foster Wallace’s 2005 commencement address at Kenyon College.2 He opened with the following parable: “There are two young fish swimming along, and they happen to meet an older fish swimming the other way, who nods at them and says, ‘Morning, boys. How’s the water?’ Eventually, one of them looks over at the other and goes, ‘What the hell is water?’”

Recognizing the water requires breaking students out of their “skull kingdoms” where the perception of events unfolding around them occurs as a story about things happening to them.

The process of “growing” a paramedic is complex. The behaviors that embody the values expected in the affective domain must be compelled over time within them, not for them. With this in mind, our program changed orientation. Instead of a typical introduction, we had our medical director introduce the article. As part of the presentation, students read Chatterjee’s observation—then a similar observation written by a graduate. The next: “I’ll never forget the moment his mother looked me in the eye and said, ‘Is my son going to die?’” Then students are told this contribution is from their medical director. An open discussion follows, then homework. We ask them to read the article and e-mail their thoughts: “Tell us what you think. Do you think this will happen to you? Do you agree or disagree with the authors?” Their responses are not graded, and they can write as little or as much as they wish.

Their responses described bearing witness to traumatic events involving neighbors and friends. A first cardiac arrest in the gymnasium of their former high school. Arriving at a fatal car accident and recognizing a classmate. They reported being uncertain how they should feel and recalled receiving varying levels of support. Some responses said, “I can’t let that stuff in.” No one said, “Nothing like that has ever happened to me.” What we should have asked them was, “When did this happen?”

We can’t change their prior experiences. However, the conversation introduces our expectations for the affective domain while emphasizing the importance of peer support. We tell them the affective domain will be assessed daily. Did you show up on time? Were you prepared? Did you use appropriate language, treat your classmates with respect, and follow the dress code? We updated field and hospital preceptors about the expectations. The message was simple: Not every patient needed an IV placed. Patients, their families, preceptors, and hospital staff all deserved an introduction and treatment with respect.

Out of the Barn

In 2019 a paramedic’s success depends on staying abreast of changes in the field and consistently treating patients in a way that adds value to their clinical outcome and experience. The public and other healthcare providers expect paramedics to be “conscientious and judicious” in how they care for patients.3 To meet these expectations, the industry has made significant developments through program credentialing and incorporation of advanced simulation and educational theory in the classroom, as well as standardized cognitive and psychomotor examinations.

But development of tools to track cognitive and psychomotor skills may have outpaced those used to assess the affective domain. When the values of the latter domain are considered, the value of an English class is the ability to process and analyze an experience from someone else’s point of view. This is where Wallace’s message for graduates about the “real value of an education” applies: “The really significant education in thinking that we’re supposed to get isn’t about the capacity to think, but rather the choice of what to think about.” The degree about to be conferred did not make them “educated” any more than possessing a piece of paper makes one a professional. My colleague’s point about the stratification of paramedics with any degree in his home state speaks to this misconception. For a healthcare provider being educated means having the ability to successfully navigate the gap between scientific evidence and how those conclusions are applied to patient care.

Educators didn’t put the cart in front of the horse concerning paramedics and degrees.4 From our point of view, the horse was already out of the barn. As a practical matter, the cognitive domain for the current paramedic curriculum is not manageable without an appropriate foundation in reading comprehension, math, and basic science. Expectations for new paramedics have grown and developed as our EMS system has evolved—this is a credit to everyone who has contributed. I ask you to consider degree requirements as a result of the growth and needs of the system, the expectations of our patients, and the evolution of the responsibilities entrusted to paramedics.

Including the affective domain in a discussion unequivocally advocating for degree requirements for paramedics is meant to point out an area of learning that is critical to all students in healthcare despite being difficult to quantify. This domain was always present, even when we were not measuring it. Today an essential part of the paramedic curriculum is to educate students about the “water.” That’s not lip service—it is what connects treatments grounded in evidence-based medicine and a highly specialized skill set with the delivery of empathetic patient care. Other healthcare professions aptly describe this to their students as “the art of caring” or “the art of medicine.”


1. Treadway K, Chatterjee N. Into the water—the clinical clerkships. N Engl J Med, 2011 Mar 31; 364(13): 1,190–3.

2. Wallace DF. This Is Water: Some Thoughts, Delivered on a Significant Occasion, About Living a Compassionate Life. New York: Little, Brown, 2009.

3. Sackett D. Evidence based medicine: what it is and what it isn’t. BMJ, 1996 Jan 13; 312(7,023): 71–2.

4. Bledsoe B. A Rational Look at the EMS College Degree Issue. J Emerg Med Serv, 2019 Aug 2.

Michael W. Schmitz, DO, MS, FACEP, is medical director for the paramedic program at Southern Maine Community College in South Portland, Me.

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