The American College of Emergency Physician’s theme for the 2012 EMS Week was “More Than a Job. A Calling.” My reaction was that EMS was far from a career. Compared to our nurse, physician, and “accident room” technicians; ems caregivers were still in poorly paid, low esteem jobs while our street medicine colleagues have found structure, recognition, political power, and professional compensation. This realization started a journey that has me struggling with learning regression analysis this semester and building an academic skill set to do a deep dive into this question – do ems caregivers really want to be professional?
Replaceable Semi-Skilled Carbon Based Productivity Components
A speaker at the Fitch and Associates Pinnacle EMS leadership conference was the chief executive officer of a commercial ambulance company that could be found in many regions of the United States. His presentation acknowledged that many of his younger caregivers were waiting to get a fire department job. He used the fast-food industry approach, expecting a high turnover of caregivers that perform services using standardized tasks and responsibilities in a regimented format. I thought Skip Kirkwood’s head would explode.
That CEO, as well as the corporation, is no longer in the medical transportation industry. But his approach may be based on workforce reality. We have two distinct ems caregiver workforces: private/jurisdictional and fire department. As well as two generations. Let’s look at the available data.
The 2019 AAA/Avesta Ambulance Industry Employee Turnover Study provides details concerning the private/jurisdictional/community EMS services. This is the second year this survey has been conducted. The overall annual turnover shows:
- Full-Time Paramedic: 19%
- Part-Time Paramedic: 37%
- Full-Time EMT: 28%
- Part-Time EMT: 47%
Part-timers, or per-diem caregivers, are the hardest to retain. Per-diems represent up to 50% of the ambulance service workforce in commercial and jurisdictional services. Only full-time paramedic positions have a slightly better annual turnover than the national rate of 20% for all occupations.
EMS Is A Professional Afterthought
Michael Corman points out in his 2017 industrial ethnography of Alberta, Canada, paramedics that there has been little sociological attention paid to EMS providers. Donald Metz was a professor of sociology who produced a 1981 ethnography of ambulance work while he was a part-time Emergency Medical Technician (EMT) for a private ambulance service providing urban 911 services.
Metz pointed out the incongruity of an ems caregiver police-style uniform as found in the early 1980s – collared shirt, badge, shoulder patch, name tag and metal jewelry showing authority – and the requirement to use a clip-on tie. The clip-on tie is to protect the caregiver if the patient or a bystander grabs the tie. Metz also pointed out that EMTs in the private ambulance service as well as EMTs and paramedics in the fire department face no future advancement – “EMS work is at best a detour, and perhaps even a barrier, on the road to advancement” (page 185).
Sociologist Eddie Palmer (1989) looked at paramedic performances and “trauma junkies” indicating that the street performance of paramedics was similar to police officers. “Within an occupational milieu of excitement, danger, and public attention, paramedics perform a variety of roles constituting street work similar to that documented for police officers. Playing the roles of authority figure, lifesaver, information specialist, partner, grief manager, and counselor, paramedics are immersed in a work world replete with teamwork demands, conflicts with medical and nonmedical personnel, vaguely defined legal standards, and occupational uncertainty due to the newness of their medical niche.”
In a small qualitative study looking at recruitment and retention of ems caregivers in 2005, P. Daniel Patterson’s team identified three themes:
- EMS Is a Professional Afterthought
- EMS is an Emotional Paradox
- EMS is an Educational Black Box
In Theme 1, many of those interviewed by Patterson did not originally plan to be an EMS caregiver. This job was chosen after completing their first career, often military or nursing. Or they chose this job after failing to complete training for another, more attractive job.
When I ran an online bachelor degree completion program at a private university many of the students were going back to school after suffering an academic or career crash 4 to 10 years earlier. Now, often with a spouse and children, they want to go back to their original plan. About 12% of the bachelor degree graduates went on to get a master’s or professional degree with 6 of them becoming physicians. All of them were credentialed as a paramedic before 2014.
University of New Mexico EMS Physician Scene Response Program – Albuquerque
Pay, Unionization and Education
The paramedic recredentialling exam as administered by the National Registry of EMTs (NREMT) includes industry research questions. Paramedics must take the recertification exam every two years. In 2013 NREMT asked those who identified that they worked for Zero EMS agencies the reasons they were not working as a caregiver and their intention to return to practice (Cash) . The most frequent reason they were not working as a paramedic was a desire for better pay and benefits.
Paramedics, especially the majority who do not have union labor representation, fall into the lower-middle class level of pay. The California 2017 study of ems caregivers identified that there was a 39% difference in pay from those working for commercial ambulances and those working for fire-department based ambulances. (Jacobs) The single-role, non-firefighter, paramedics working in California fire departments are members of IAFF, the local labor organization.
The second most frequent reason paramedics were not working was the desire for further education. It appears this further education is to move beyond the role of a paramedic and to become a nurse (18% of the respondents) or go to medical school (5%). This reinforces Patterson’s Theme 1 that “EMS is a Professional Afterthought.”
Despite the vigorous pushback by old school paramedic leaders at the proposal to require an Associate Degree before credentialling as a paramedic, a 2020 study of the demographics of National Registry credentialed caregivers show that 28.5% of paramedics possess an associate degree (Rivard).
This is due, in part, to the caregivers that received their initial training since 2014, when the new Educational Standard went into effect. A snapshot from the Committee on Accreditation of Allied Health Education Programs shows that there are 375 paramedic programs run by a two-year technical or community college where the student is required to complete the degree requirements before they are eligible to sit for the NREMT paramedic credential exam.
In addition, there are 171 accredited paramedic certification programs not directly affiliated with an academic institution or teaching medical center. An example would be a paramedic training program run by a fire department. To meet the new Educational Standard, they were required to have a consortium agreement to allow academic transfer credit for successful credentialed paramedics. For many of these students, they will need to complete about 15 semester hours of general education courses to get an associate or technical degree from the consortium educational partner.
The Next Generation of Caregivers, 2014 and onward
It appears we may be seeing a change in the demographics of paramedic caregivers with the 2014 implementation of the 2008 Educational Standard for initial paramedic training. With many paramedics having a “clinical caregiver career” of just 3-7 years, many single-role paramedics initially trained before 2014 will be aging out. On the other hand, fire department paramedics, both single role and firefighter/paramedic, tend to work an entire 20-to-30-year municipal career (Byron).
If You Were Credentialed as a Paramedic AFTER 2013 What Do You Need to Become an EMS Professional?
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ACEP (2020 May 16) “EMS Week” Irving, TX: American College of Emergency Physicians. Accessed May 16, 2020: https://www.acep.org/administration/ems-resources/emsweek/
AAA/Avesta (2019 July) AAA/Avesta 2019 Ambulance Industry Employee Turnover Study. McLean, VA: American Ambulance Association.
Ethnography is a set of qualitative methods that are used in social sciences that focus on the observation of social practices and interactions. Its aim is to observe a situation without imposing any deductive structure or framework upon it and to view everything as strange or unique.
Corman, M (2017) Paramedics On and Off The Streets: Emergency Medical Services in the Age of Technological Governance Toronto: University of Toronto Press
Metz, D. L. (1981) Running Hot: Structure and Stress in Ambulance Work. Cambridge, MA: Abt Books.
Palmer, C. E. (1989). Paramedic performances. Sociological Spectrum, 9 (2), 211-25. http://dx.doi.org/10.1080/02732173.1989.9981884.
Palmer, E. (1983) “Trauma junkies” and street work: Occupational behavior of paramedics and emergency medical technicians. Urban Life, 12 (2), 162-83. http://dx.doi.org/10.1177/0098303983012002003
Patterson, P.D., Probst, J. C., Leith, K. H., Corwin, S. J., Powell, M. Paige. (2005) Recruitment and Retention of Emergency Medical Technicians: A Qualitative Study. Journal of Allied Health 34 (1) 153-162.
https://emed.unm.edu/clinical/emergency-medical-service-consortium/physician-ems-field-response.html
Rebecca E. Cash, Remle P. Crowe, Riddhima Agarwal, Severo A. Rodriguez & Ashish R. Panchal (2018) Exiting the Emergency Medical Services Profession and Characteristics Associated with Intent to Return to Practice, Prehospital Emergency Care, 22:1,28-33, DOI: 10.1080/10903127.2017.133974
Jacobs, K.; Heller, H; Waheed, S & Appel, S. (2017 February 7) Emergency Medical Services in California: Wages, Working Conditions, and Industry Profile. Berkley, CA: UC Berkley Labor Center and UCLA Labor Center http://laborcenter.berkeley.edu/emergency-medical-services-in-california-wages-working-conditions-and-industry-profile/
Rivard, M.K., Cash, R.E., Mercer, C. B., Chrzan, K. & Panchal, A. R. (2020): Demography of the National Emergency Medical Services Workforce: A Description of Those Providing Patient Care in the Prehospital Setting. Prehospital Emergency Care. DOI: 10.1080/10903127.2020.1737282
CAAHEP (2019) Emergency Medical Services – Paramedic. Clearwater, FL: Commission on Accreditation of Allied Health Education Programs https://www.caahep.org/Students/Program-Info/Emergency-Medical-Technician-Paramedic.aspx Accessed November 15, 2019.
Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, EMTs and Paramedics. Accessed April 22, 2020: https://www.bls.gov/ooh/healthcare/emts-and-paramedics.htm.
Byron, J. (2018) Career Paramedic-Firefighter Staffing Problems: Is Recruiting Women Part of the solution? (master’s thesis) Naval Postgraduate School, Monterey, California. Retrieved from https://www.hsdl.org/?view&did=821413