February 3, 2019
In California, cosmetologists—that is hair stylists, estheticians, pedicurists, manicurists and theatrical makeup artists—have 1.5 to 3 times more hours of minimum education than the advanced life support paramedics currently serving our communities. In other words, the individual that cuts your hair had greater initial training than the paramedic providing critical prehospital services, from cardiac arrest resuscitation, to public health initiatives, and everything else in between. This statement is not meant to offend or insult our friends in the beauty or effects industry, nor is it meant to dishearten hardworking and highly-skilled paramedics. However, it vividly demonstrates the long-antiquated training standards we set for our prehospital providers.
In our last article, we introduced the need for the modernization of paramedicine in California across three key areas—Training, Treatment, and Transport. In this article, we will explore the topic of Training in the context of an ongoing national discussion around paramedic education.
Last month, the national associations representing emergency medical services (EMS) educators, EMS managers, and flight and critical care paramedics released a compelling joint statement calling for a lift in paramedic education standards across the United States.
This extensively-cited piece provides the historical context of paramedic education and licensure, and argues that the minimum level of paramedic education in our country must be an associate’s degree by 2025, with baccalaureate standards for critical care and specialized roles, such as community paramedicine which is currently taking root in California. The authors argue that paramedicine is becoming increasingly complex and specialized, and that it lacks inherent leadership, paramedic-driven academia and research. They demonstrate that each of these areas have been successfully addressed in other health professions through degree-based educational standards and that the necessary academic infrastructure exists to make this a reality for paramedics. The California Paramedic Foundation and our partners believe that the system is well-positioned for this change.
In an interesting response, national fire service representatives countered with an opposing argument and directed their memberships to fight any and all legislation seeking paramedic educational reform. The statement suggested, against all available evidence, that increased education will reduce the availability of paramedic schools and paramedics and that degree-based education at the paramedic level is “unnecessary” and “arbitrary.” We could not disagree more.
Let us first acknowledge that this issue is mired in political, labor, and economic interests, the complication of which certainly benefits those seeking status quo and stymies educational progress. In looking at this very important issue in our own state, we can clarify much through asking two simple questions: (1) Are increased paramedic educational standards possible? And (2) would increased paramedic education benefit California? The answers to these questions will not surmount every challenge in this difficult and highly politicized task, however it will at a minimum provide California paramedicine stakeholders a true north.
Are Increased Standards in Paramedic Education Possible in California?
The short answer is yes. California’s paramedic educational landscape is even more amenable to a mandated associate’s degree than the national numbers outlined by EMS leaders in their pro-education joint statement.
Each year an average of 890 paramedics graduate from 39 California paramedic training institutions and seek licensure with the California EMS Authority. Of these 39 programs, 25 (64%) already offer optional associates degrees or are affiliated with California Community Colleges, California State Universities, or the University of California. Of the remaining 14 programs, 9 (23%) are run by NCTI, and 5 (13%) are standalone private or fire-based programs. All of California’s paramedic programs are CoAEMSP accredited, as only graduates of accredited programs are eligible for national testing and California licensure.
Associate’s degrees in paramedicine are already widely offered across California and stand as a model curriculum and cost. Looking at examples including West Hills College, Crafton Hills College, Foothill College, and Butte College is instructive. An associate’s degree in paramedicine is comprised of 20-30 units of general education followed by 40 units of paramedic-specific training and instruction. Each unit costs a remarkably low $46 in our California Community College system meaning the marginal additional cost is a mere $920 to $1,380. As such, this is not a financial barrier.
Some have also expressed concerns that these educational increases would lengthen time to licensure for paramedics—however, it is standard practice for emergency medical technicians (EMTs) to obtain a minimum of 6-12 months of field experience prior to attempting paramedic school. This provides ample opportunity for EMTs to pursue general education concurrently.
It is important to put the additional cost of the associate’s degrees outlined above into context with the economic value paramedics currently bring their employers. At around $6,000 total, an associate’s degree program at a community college is a bargain. Private paramedic programs can be nearly twice as expensive, or more. Yet, major California paramedic employers still view these higher cost programs as economically valuable to their organizations and often sponsor an employee’s cost of attendance.
In the runway up to 2025, California’s private programs would have the opportunity to affiliate with community colleges, allowing their paramedics to earn an associate’s degree at their partnering institution. The California community college system already educates 80% of our paramedics, EMTs, law enforcement, and firefighters as a part of the 2.5 million students it enrolls each year. The system also educates 70% of California’s nurses, whose workforce is an order of magnitude larger than paramedics at 330,000 providers. Even if California’s private paramedic schools could not adapt by a 2025 deadline, an unlikely prospect, the robust community college system provides an important safety net where students could certainly be accomodated.
The state of Oregon implemented an associate’s degree standard roughly 10 years ago and saw no such shortage of paramedics. In Oregon, out-of-state paramedics seeking employment can use 3 years of recent experience in lieu of an associate’s degree. Qualified paramedics who are actively completing the general education requirements of an associate’s degree can generally work under employer-sponsored provisional licenses. Additionally, Oregon accepts verifiable associate’s and bachelor’s degrees in fields outside of paramedicine as qualification for licensure. Lastly, it’s important to note that paramedics who were licensed and active prior to implementation of the new standard were grandfathered in. All of these strategies would make sense in a California approach.
As demonstrated above, the move to associate’s degrees is not only possible, it is readily achievable. The majority of paramedic students are already enrolled in programs offering or positioned to offer associate’s degrees. The marginal cost to move certificate programs to an associate’s degree are minimal. Furthermore, Oregon has demonstrated a path to success.
Would Increased Standards in Paramedic Education Benefit California?
Paramedics are a unique bridge between our communities and our incredibly advanced health care systems. Cardiac, neurology, trauma, and emergency medicine specialty teams reach beyond the walls of their hospitals through their utilization of the paramedic’s advanced skillset. However, the ability of paramedics to triage, differentially diagnose, and extend therapeutic strategies from multiple specialties is only as effective as their understanding of human biology and the interventions taken upon it. While paramedics currently do an admirable job providing care in critical situations with relatively little formal education, additional knowledge in areas such as natural sciences, social sciences, reading and writing, communication, and mathematics would significantly improve their ability to provide higher quality and more informed care.
This is non-controversial. The vast majority of allied health providers such as nurses, X Ray technicians, MRI technicians, and respiratory therapists, recognize the value of this foundational knowledge and have included it in their curriculums for decades. Nursing has long mandated degree-based education in its pursuit of increased leadership, self-driven research and improved clinical outcomes. Having already seen the benefits of their move to an associate’s degree long ago, nursing is actively migrating towards bachelor’s level education where they are seeing even more value. Magnet hospitals, known for clinical excellence, aim for 80% baccalaureate level education for their entire nursing staff and as a result experience 7% less patient safety incidents, lower mortality, and shorter stays. It is logical that the improvements from nursing educational advancement would be mirrored in paramedicine, ultimately benefiting the public at large.
Paramedics operating in specialized roles, such as critical care and community paramedicine, have even greater needs for education. These paramedics operate on the bleeding edge of the profession where even deeper formal education, understanding, and knowledge, coupled with the use of evidence-based practice, is correlated to the effectiveness of the complex care they provide. However, it is our opinion that the educational increases specific to these roles should be controlled by their national specialty certification boards, as these are newly developing curriculums. In California, our initial focus should be on appropriately educating our front-line paramedics with associate’s degrees, of which the benefits and curriculum are already well established.
In their opposition piece, fire leadership states support for education while simultaneously claiming additional paramedic education is “arbitrary”—a position that is untenable. The fire service claims 20% of paramedic schools will close, however they provide no evidence to support this claim. The target education implementation date of 2025—a runway of six years—makes this forecast little more than a scare tactic.
It should be more concerning that these organizations call paramedicine educational advancement arbitrary. The vast majority of services that fire departments provide to their communities on a day-to-day basis are comprised of emergency medical care, sometimes upwards of 87%. If 87% of the individuals they provide services to require the care of a paramedic, and this care could be bolstered by improved education, how can anyone characterize that as “arbitrary?”
Paramedics are incredibly important bridges to advance systems of care in our complex healthcare landscape. Evidence clearly shows that increased educational standards in allied health professions bring direct benefit to the medical patients they treat. Arguments to the contrary appear politically motivated and unfounded in data. Appropriate education is fundamental to the critical services paramedics offer in our communities, and the benefits undoubtedly outweigh the costs in this important effort.
The Modernization of Paramedic Training
The time has come for California’s antiquated paramedic educational standards to evolve. Paramedic education must rise to a level that is commensurate with their crucial role as emergency medical providers throughout our communities, on our streets, and in our homes.
Returning to our example of the cosmetologist, can we really argue that paramedics should continue to operate with less education than our local hairstylist, when they literally have our lives in their hands? Can we keep a straight face and call educational advancement arbitrary when it is already having a demonstrably-positive impact across healthcare?
The California Paramedic Foundation calls on stakeholders and legislators to recognize the importance of this issue, work together to modernize paramedic educational standards, and secure these changes in state law.
Arthur Hsieh, MA:Arthur is a paramedic and educator in Sonoma County, CA. Arthur currently serves as the Director for the Santa Rosa Junior College Paramedic Program, is on the board of directors for both the California Rescue Paramedic Association and the California Paramedic Foundation. In addition to his current work, Arthur has extensive experience in paramedic education through his previous work at the Hospital Consortium Education Network, the George Washington University Emergency Health Services Program, the San Francisco Fire Department, and the San Francisco Public Health Department Paramedic Division. Arthur has also previously served as the president of both the California Paramedic Program Directors Association and the National Association of EMS Educators.
David J. Olvera, NRP, FP-C, CMTE: David Olvera is a Nationally Registered Paramedic, Certified Flight Paramedic and Certified Medical Transport Executive and currently serves as Clinical Education Manager and department chair for the national research committee of Air Methods Corporation. He serves on the boards of the International Board of Flight and Critical Care Paramedics and the MedEvac Foundation International and works as a subject matter expert with the Air Medical Journal. He is recipient of the 2016 Tim Hynes Award and the 2017 ASTNA Jordan Award for excellence and significant contributions to prehospital medicine. He has been an item writer for both the National Registry and the Flight Paramedic Exam. Additionally, he serves on the faculty of the Difficult Airway Course EMS and is extensively published on the topics of prehospital airway management, resuscitation and advancing paramedicine. David is a proud Veteran Combat Medic of the United States Army.