Frozen in Time. This pic is of an ambulance in our fleet that stopped at our HQ station for supplies during an ice storm in Seattle in early 2012.
Are you jumping on board with the EMS freight train paving the way to move EMS from a vocational to academic industry?
The EMS Education Agenda for the Future has a vision and it is a bright one. If you’re an educator, manager or EMS industry leader, I’m sure you’ve read the EMS Education Agenda, reviewed the National Core Content, and the EMS Education Standards that fell gloriously from the sky into our anticipatory laps earlier this year. But where were the changes/improvements in CME requirements?
The new EMS standards increase the depth and breadth of information required for EMS providers. After working over 18 years in EMS I can clearly see where our industry has significantly increased in complexity. From BP cuffs, stethoscopes, EOA’s and monophasic machines to biphasic 12 Lead EKG, capnography, Easy IO, biomarkers, and autoventilators, our equipment, diagnostic tools, medications, and procedures have increased our access to tools that may allow us to provide better care in the field.
As the level of complexity increases, so does the level of knowledge required and thus the need for CME to dust off the old, introduce the new and shiny and bridge the gaps during changes. But, in my opinion, CME requirements in EMS are one of the paradoxes that I think keeps EMS from progressing into the future and instead leads to stagnation, complacency and apathy in EMS professionals. I see a variety of interrelated factors for this paradox.
1. The EMS professional’s attitude towards education and training – I generally see two types of EMS attitudes towards continuing education. The obligatory bored provider and the provider who just doesn’t do it until their certification /livelihood is threatened. Both of these attitudes eventually lead to liability.
2. The instructors ability to engage the audience, deliver content with effective instructor methodologies, and the instructors ability to build upon existing knowledge (continuing education) vs. just refreshing knowledge (re-certification classes).
3. The CME requirements of the regulating agencies.
- Our state law sets the EMS provider up to receive refresher type information instead of requiring the provider to increase and expand their knowledge base by requiring CME programs follow the National Core Content and EMS Instructional Guidelines. I think this is excellent for initial education and I believe a certain amount of review is necessary. However, for example, when an EMT takes an ACLS course or a college anatomy / physiology course that increases the breadth and depth of knowledge and contributes to professional development, the provider is not given credit for CME obtained outside of what’s defined in their scope of practice and core content for their level of care. This creates an environment of decreasing extrinsic motivation for an audience that clearly thrives on extrinsic motivators, and decreases professional development opportunities.
- The number of card classes required for providers is excessive and expensive. ACLS, PALS, PHTLS, ITLS, AMLS, EPC, PEPP, GEMS, CPR, NRP, STABLE, and I could go on and on. I have yet to see any convincing evidence that mandating (if your agency does this) all of these courses as often as we do actually improves the quality of care. I do not see a paramedic of 20 years who has had to attend PHTLS course 5 times provide better trauma care than a paramedic who has attended it 2 times.
- The CME requirements between most States and NREMT is inconsistent leading to providers having more requirements in CME than what may really be necessary.
4. The quality of EMS instruction needs to improve and should with mandatory accreditation of EMS programs. EMS instructors need to be able to teach well. Taking a 40 hour DOT instructor course barely prepares you to instruct a group of students effectively and move them through the four levels of understanding.
I want to approach CME requirements from the same perspective that we should be approaching the new equipment and techniques we are using in EMS today. Driven by data and CQI programs. Evidence based medicine.
What if an EMS Professional’s CME was determined by the following;
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a minimum number of hours/competencies to be completed based on their performance as a practitioner during their certification period.
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a minimum number of hours/competencies to be completed based on their performance on recertification or ongoing education and training tests.
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a minimum number of hours/competencies to be completed in new industry standards, technology, etc.
We’ve “improved” our initial education standards, and the complexity of our paramedicine, but we have yet to address the best way to maintain the best practices, encourage professional development by increasing the breadth and depth of knowledge over time and motivating students to achieve more.
In my opinion, our EMS CME requirements are keeping us rooted in the past.
Hello! I'm Salty Medic, a Seattle-ite living my dream in the Emerald City. As an EMS professional, I work as a Clinical Manager, Critical Care Paramedic and Senior EMS Instructor for a private ambulance organization in the Greater Seattle area. I want to share my experiences and discuss challenging aspects of EMS with other professionals. I hope to share ideas and resources with others. Feel free to look around, chat me up and tell me what you’d like to read more about. Email me at; sweetlaurel2000@yahoo.com.
I think one of the greatest traps we fall into as providers is complacency. We have BP cuffs on the monitors, so why auscultate a pressure (forget the fact that they’re rarely accurate)?
I think continuing ed brings us to a fine line. On the one side is that little nudge to keep us from getting complacent. On the other, though, they’ve reached the point of being ridiculous. People are more concerned with the alphabet soup after their name than the skills those letters are supposed to represent.
I think we’d honestly be better off dropping them all together. You’re either a provider, or not. Let’s go back to actually assessing our patients and treating them, rather than analyzing them and treating our equipment.
Well said kindofafireguy. EMS has always been an egotistical industry. When I’m exposed to critical care conferences and CME for my CCEMTP, I’m reminded of how little I actually know as a paramedic. I wonder if the ego subconciously finds itself challenged regularly. Perhaps we make up for this assault on our ego with capturing as many card classes or sub academic courses we can in recognition for what we do.
I think there are several different, connected issues that contribute to less than optimal continuing education. You’ve touched on some of them.
One of the most common problems with education, in general, has to do with the quality of instruction. Teaching requires a specific skill set, but in many places, it is left to people with very little (or no) training in how to teach. They are expected to be good teachers because they have good skills in what they are teaching- but that is not necessarily, or even usually, the case.
When the people who are expected to be teaching don’t really know how to teach, then every presentation they give tends to be boring beyond belief, and have little or no relevance. This, in turn, leads to a very negative attitude about continuing ed. I can’t blame people for not wanting to take classes that are deadly dull and useless.
I strongly agree with something you mention, that I’ve seen some other folks talk about. There needs to be more of a focus on new information and skills, and less on refreshing. Not that practicing already-learned skills is unimportant; it’s not. But it’s fairly easy to provide a way for someone to show competence in something they’ve already learned, especially if they’ve been doing this for many years. I would prefer to reward providers who are keeping up their skills well by giving them more opportunity to learn and work on new things, than to bog them down with having to re-take classes they don’t really need. We all have busy lives, with limited available time, so I’d rather make the most of it, than waste it.
Besides the widespread concern of poor instruction, I think the biggest thing holding back a good continuing education program is a lack of leadership and encouragement. If the folks in charge have the attitude of just getting the right paperwork signed, and doing as little as is legally mandated, then most providers there will accept that as appropriate. I recently had an experience of going to another agency for a recertification I needed, and was stunned by the attitude there of “good enough.” I won’t go into details here- but I also won’t be going back there. I want every class I take to MEAN SOMETHING. I want to learn from it. I want to improve my skills. I want to be a better provider. I am distinctly uninterested in anything remotely resembling faking it just to “meet the requirements.” “Minimum competency” isn’t for me.
One last thing I want to mention, that you didn’t specifically write about (but may have alluded to) is the difference in requirements for providers in different circumstances. A provider who works full time on a busy ambulance in a big city has very different educational needs than a volunteer in a low volume non-transporting rescue squad in the middle of nowhere. A new provider has different needs than a seasoned veteran. A provider in an agency that has an excellent ongoing training program has different needs than someone in an agency that provides no ongoing training. I’d like to see someone take those concerns into account when deciding what educational requirements should be.
Hello Hilinda, Thank you for your post. It sounds like you agree with me on the quality of instruction in EMS. Perhaps you have thoughts on the NAEMSE National Instructors credential. Do you think the National Instructor credential is equivalent to an academic instructor tenured at an academic institution with an accredited program? Do you think this credential is worth the financial investment and will it change the way we teach with requiring Instructor 1 and 2 courses?
Great article! Thanks for sharing.
I enjoyed your post. This is an issue that I have been thinking about alot too. Thankfully I don’t deal with conflicting CE requirements because my state just goes by the NREMT requirements. Based on those requirements, I do think it is possible to do good refresher training if the various stakeholders involved will buy in to it. I would ditch the card classes in favor of a course based around case scenarios, discussions and simulation using the service’s protocols and SOP’s as a guide.
Hi Jeff, thank you for your post. In which state do you practice? Our state is trying to to become more consistent with NREMT con-ed requirements, but is not quite there yet. The new NAEMT EPC curriculum is very case based with discussion and simulation. Have you taken the new EPC course and if so, what did you think of the end of course discussions?
I’m in Louisiana. I have not taken the EPC class. All of the services around here require PALS so the other pediatric classes haven’t gained traction here. EPC sounds like a great course.
I very much enjoyed this post and have long held similar beliefs, much to the dismay of many co-workers and fellow EMS instructors. I started my EMS career in Pennsylvania and New York, worked in rural California, and now reside in Western Washington (although I am not actively working in the field at this point). I retain state certification in the states in which I have worked and also maintain my NREMT-P. Although I am happy to see that many states now permit EMS providers to recertify via so-called “continuing education” what I have found is that it is generally a re-has of material that most of the providers already know. Sadly, I have not seen very much true continuing education material made available that furthers providers’ knowledge of new and emerging technologies, disease pathophysiology, etc. Even the NREMT requires paramedics to submit to a DOT 48 hour refresher course every two years. If the NREMT is supposed to represent the nation’s EMS providers as a standard of excellence for certification, clearly their mandate of the refresher program as the mainstay of re-certification is indicative of the overall state of affairs in EMS education. Speaking candidly I feel that the current state of affairs is shortsighted and does little to truly advance the knowledge of EMS clinicians.
I recently related a story to a fellow paramedic and EMS instructor and said that I really disliked the thought of taking PALS for the ninth or tenth time as I have taken it every two years since first becoming a medic in 1993. I was surprised when I said that the thought of PALS refresher bored me and my colleague jumped down my throat telling me that PALS is “a great class and all we need to know about managing peds patients”. I countered with the example that I do not know anyone who would be comfortable taking their critically ill or injured child to a children’s hospital and having the child treated by a clinician whose only “credential” was having taken a 16 hour course. Imagine a child has been poisoned and is unresponsive. I’d want that child treated in a specialty pediatric ER with a pediatric toxicologist, not someone who said “I’m not a doctor but I did just take PALS today.” Having heard the reaction I did from a fellow medic and respected educator really got me thinking about all of this and it’s a topic that I think you are on the right track with. If you contact me via email I’d love to discuss this in greater detail with you! Thanks!