Musings from the Chalkboard
Volume 23, No. 5
If you have been paying attention at all, you are aware of major changes that are coming down the pipeline regarding EMS. These changes are significant and puzzling in the same breath and can severely impact many of you. While these may not even be fully released until 2010 (and of course, textbooks gearing up for shortly after that!) with an implementation date for some obscure date post release, we will need to BR ready and able to make these changes when they come about. Notice, I did not say willing. There is already squawking going on about the new standards and these have been out for review in first and second drafts for some time now. While the noise has been somewhat loud regarding the changes, the curriculum comes from a broad and versatile group of individuals representing many big players in the EMS game, such as the International Association of Fire Chiefs (IAFC), International Association of Fire Fighters (IAFF) and National Volunteer Fire Council (NVFC), not to mention the National Association of EMS Educators (NAEMSE). After all of the reviewing is completed, they seek to submit the new package to the National Highway Traffic and Safety Administration (NHTSA) sometime this Fall.
Some of the changes will involve some standardization of the classifications that seemed to have plagued EMS from the beginning. Many will remember EMT Cardiac Rescue Technician (okay, maybe only the REAL old timers for that one), EMT-IV, EMT-D and so on and so forth. Then we went to First Responder, EMT-Basic, EMT- Intermediate (and for this you used either a 1992 or 1999 curriculum for scope of practice) and of course EMTP. Now they want to go with a simple 4 category standard with some austere name changes. First Responder will become Emergency Medical Responder (EMR), EMT-Basic will go back to Emergency Medical Technician (EMT) and EMT-Intermediate will become Advanced Emergency Medical Technician (AEMT). Paramedic will remain Paramedic (EMTP).
Seems simple enough, right? Well for the name changes, I agree, but the real issue will come in with the hours necessary to acquire these certifications. The words “certification” and “license” seem to be used interchangeably in some of the literature, but realize there is a distinct difference where Project Medical Directors (PMD) “hold” certifications (and allow you to practice under their license) and where a license is held by a regulatory agency and can be interpreted to be “free-standing.” It seems that the real drift appears that these are still meant to be certifications held by the PMDs although some areas are granting licensure at the paramedic level. How that whole process plays with the PMDs and how they are overseeing and “regulating” licensed individuals is still out, but it has been successful in some areas. In reality, I do not think it makes a whole lot of difference or will matter if someone needs a license or certification “pulled.” That can happen in the blink of an eye.
Contact hours for the various levels are also increasing. EMR is increasing to 48 total hours. EMT is going to 166 to 180 clock hours. AEMT will now require 140to166 hours and may require an internship at the conclusion of the didactic and clinical training. Paramedic training will come in somewhere at the 1,300 hour mark, but here is the corker on the whole gig! It is going to be competency-based training and the hours are “recommended,” and are not carved in stone.
Now I’m all for the concept of competency-based education (we really have been doing it for years and, after all, we do want them competent, don’t we?) but this creates a real flux when it comes time to “set the standards” if you will. For instance, if the new standard recommends the airway component to be set at eight hours (and these hours are purely hypothetical and for example only) and one program teaches it in eight hours, but another completes it in four and states it has achieved competency (and might have other variables such as instructor/student ratio), who is to say one is better than the other or one is more competent than the other? If it is competency based, then all you can judge it on is whether or not the student is competent in the areas necessary.
Okay, so what is the problem with this you ask? If we achieve a competent provider, where have we made a mistake? The only way that we have to evaluate the students (or employees if you are a training director given the task of training your staff) is through examinations, both written and practical. Written exams will test the depth and breadth of the knowledge base, and the skills exams test, the psychomotor component or the hands-on skills we work so hard to teach in a lab setting.
How do we keep instructors from “teaching to the test?” If I ‘teach to the test’ will this really give me a measure of any sort of competency in the skill areas? If I “teach to the test,” will I truly be able to measure any sort of real depth and breadth of the knowledge base with the core material? Will my student have any real penetration of the knowledge if my only concern is that he passes the exam?
This has never created good, sound thinking providers and that is what we truly want. All we seem to hear is we need them fast, we need them now; you are not doing it fast enough. The hell with quality (although they don’t come right out and say that…), give us quantity! All we care about is that you can crank ‘em out! More, more, more! If they can pass the national exams and pass the skill tests to get their certs, we are happy. The topic of good quality providers gets swept under the carpet. We ask, “Don’t you want high quality, good EMS providers?” They respond in the affirmative (how can they not?), but then re-assert, “But ya gotta do it fast!” That is what we are hearing from agencies that need trained personnel. No one is denying the need, which is desperate in some areas, but quality cannot be set aside for speed or quantity.
With training facilities having a “sliding scale” for the necessary hours, quantity can be substituted for quality. If students can test out, then they must be competent, right? An individual being tested may know when to perform a certain skill. He may also know how to perform a certain skill, but if he does not know why and does not have the knowledge or the critical thinking skills to back up the how, when, and why, then he is not a health care provider. He is merely a machine trained like a robot. As a robot he is unable to tolerate any variance in the programming. He is stuck “in the box” and cannot climb out of it. Unique patients that present him or her with inconsistent problems that may not fit into the classical mold will not receive the care that they need, or worse, may receive substandard care. That is not the kind of professional we seek to train in EMS. I not only consider this a detriment to the profession but dangerous to the public at large.