Dustin Holland, MD, MPH
EM Resident, Indiana University
Member-at-Large, ACEP EMS Section
As an emergency medicine (EM) resident, life is busy. Between clinical duties, didactics, research, credentialing, and studying, there’s not much time remaining to pursue specific interests within EM. Emergency medical service (EMS) is a niche within EM that draws considerable interest from residents, but finding time for EMS experience in residency can be difficult. Many EM residents acquire some EMS experience prior to residency, but for those without prior experience, residency is a great time to get to know EMS providers and better understand what they experience during shifts. EM residencies are required to provide a basic EMS education, which offers only a glimpse into the world of EMS. But many residents want more than a basic introduction into EMS. We want to be more involved in prehospital care, develop a better understanding of the system, and learn from our EMS colleagues.
When I was asked to write an article as a member of the EMS section, I was initially overwhelmed with the number of topics that face our specialty today. These are exciting times for EMS professionals! With the development of board certification and accredited fellowships during a time of rapid changes in the nation’s medical infrastructure, EMS is becoming a more popular field of interest for residents. My objective here is to provide something useful for residents interested in EMS. The first section will provide some strategies a resident can use to maximize the EMS experience. These strategies and words of wisdom were passed down to be by my mentors and other leaders in the field. The second section will examine some very important factors that should be included in the consideration of an EMS fellowship. To provide more substance, the second section includes opinions and perspectives I collected from nearly 120 attending physicians across the country.
Maximizing your EMS experience in residency
Each EM residency takes a different approach to EMS education while meeting minimum criteria set by accrediting bodies. There are certainly some residencies that make it easier to gain EMS experience by offering EMS electives, an EMS track, or other structured prehospital experiences. If your residency does not offer an organized EMS curriculum, it may be more difficult to get involved with EMS while also fulfilling your residency requirements. Ask about EMS opportunities early in residency and take advantage of those opportunities. It is important to develop a thorough understanding of EMS, including medical direction, protocols, and quality assurance. These are topics you may be faced with after residency, whether you like it or not! In fact, some new EM graduates, even those with no interest in EMS, may be assigned to an EMS position at their first job. A good understanding of EMS is critical to being a well-rounded EM physician.
My goal here is not to tell you what you already know – work hard, play nice, treat others as you would like to be treated… your parents should have taught you that. My intent is to provide more useful recommendations to improve the EMS experience. These are lessons and words of advice passed down to me along the way.
#1. Residents are outsiders, so know your role and understand how you can help the team. Resident duties in the emergency department and in the prehospital setting are very different. To EMS providers, residents are doctors and outsiders. These two qualities can create a substantial barrier during EMS shifts or ride-alongs. Accept that you know very little about how to be an EMT or paramedic (even if you were an EMT in a previous life). Even though you may have more years of formal medical training, your ability to recite Rosen’s does not trump real-world experience. Just accept it.
Be humble, courteous, and leave your ego at home. Ask to be treated like a new paramedic or FTO student, and dress the part. Do some research and find out what the EMTs in your area wear and dress in a similar way during your EMS shift. It can be awkward the first time you ride out with an EMS crew, and you may feel like you are in the way. Offer to help by carrying the monitor or medication box, pushing the stretcher, taking vital signs, checking a blood sugar, starting an IV, or cleaning up after a run. Remember, EMS providers can easily perform their job without you there, so bring something to the table. If you are spending the day in a firehouse station, pitch in money for lunch or dinner and take time to get to know your colleagues.
Remember you are there to primarily to learn. Ask questions and look for opportunities to improve your skills, but never steal procedures. There are countless opportunities to learn from EMS providers, especially the ones who have been around a while. Ask questions and learn about different ways to provide patient care outside of the emergency department. EMTs often want to teach residents as much as they want to ask questions and be educated. Some newer EMTs may be nervous or intimidated to have a physician on the ambulance, but they need to know it’s encouraged (and necessary) to tell you what to do from time to time.
Ask about the frustrations and rewards of the job and see how you can work to reduce those frustrations. Ask what EMS providers like physicians to do when they bring a patient to the ED (it might surprise you). These strategies will break down the barrier between you and EMS providers and prove you can be a valued member of the prehospital team.
#2. Residents lack historical and political knowledge of EMS systems and are unaware of the barriers to physician acceptance into EMS systems. Before you show up for your EMS shift, do some reading. There are many great resources for physicians interested in EMS. Ask your local EMS medical director for some recommendations. The FEMA medical directors handbook may draw criticism from some providers, but it’s a great start. Know the role of the on-scene physician within the EMS command structure, and understand that you are not the boss – prehospital care is a delicate balancing act of politics and medicine. If you want to go above and beyond, complete the NIMS online courses (100, 200, 700, and 800). If possible, spend time with mid-level supervisors, chiefs, district lieutenants, medical directors, or an EMS fellow. All of these positions carry very different responsibilities, and if you really want to understand and be accepted within EMS, you need to understand this culture.
#3. Residents lack EMS skills and experience, and there’s no substitution for time on the job. The fact is spending time with EMS crews enhances your understanding, builds stronger relationships, and improves your skills. If you expect to obtain sufficient EMS knowledge from a few required EMS ride-alongs, you’re in for a surprise. Take extra shifts, even if on your own time, complete an EMS elective, or join an EMS track if your residency offers one. Better yet, consider a fellowship (more on that later)!
Know the EMS protocols. Each EMS agency had a set of protocols that guide patient care and you should know them cold. Chances are, they aren’t much different that what you would do in the ED. A quick way to lose respect and trust from an EMS provider is to suggest patient care that drastically deviates from established protocols. If you don’t know the protocol, just ask and be open to some teaching!
Consider that approximately 70% of EMS calls result in a transport to the ED, and all of those result in a potentially meaningful interaction with EMS in the department. As you look forward into your future as an EM physician, knowing as close to 100% of what EMS does in your community just makes sense. It will improve your patient care and relationship with other providers. Don’t make the mistake of thinking you “know EMS” because it’s just an extension of your ED – that’s a fallacy.
Participate in or create an EMS elective or track. Many residencies now offer a focused curriculum in EMS that provides residents with a unique and structured EMS experience. If your residency doesn’t have one, start one! Look into developing a formal curriculum and requirements for the track, and consider participation in one or more of the national EMS conferences. If you need ideas, reach out to other programs and residents. A well-constructed EMS track can provide a resident with the skills necessary to function as a community EMS medical director following graduation.
And finally, get credit for your work! If your residency requires you to maintain a procedure log, make sure you record any pre-hospital procedures you perform. Offer to give lectures to local EMS agencies and attend EMS meetings (audit and review, protocol, research, safety, etc.). If you’re in need of an elective and your residency doesn’t offer an EMS rotation, look into opportunities for away rotations at programs with a larger EMS presence. Remember to keep your CV well maintained and include all of you relevant EMS experiences.
Above all, have fun. You may not have the same EMS opportunities as an attending, so soak it in while you can. You may never have another chance to run a code in a hotel bathroom, help extricate someone out of a wrecked car, or intubate in the rain! Take a step back and realize the awesomeness that is your job!
Making the decision: EMS fellowship?
Now that you’ve maximized your EMS experience during residency, its time to consider the question, “Should I do an EMS fellowship?” For most EM residents, the answer to this question is a simple, “No.” For others, “Absolutely!” For everyone else, it’s a loaded question to which the answer could mean another year of longer hours with less pay and another board exam… but also a career with endless opportunities, rewarding experiences, and excitement.
EMS is now a board-certified (BC) subspecialty within EM, complete with its own certification exam. There are currently three ways to qualify to take the exam: practice EMS for 5 years and meet specific criteria, practice EMS for 2 years and complete an unaccredited fellowship, or complete an ACGME-accredited EMS fellowship. The first two pathways will end in 2019, after which the exam will be open only to physicians who have completed an accredited EMS fellowship (for more details, please see the ABEM EMS website). If you anyone who has taken the EMS certification exam, you’ll get an earful – the exam is not easy, has a relatively low first-time pass rate, and (some say) is more confusing than it needs to be. Suffice it to say, an EMS fellowship is a considerable undertaking and the decision should not be taken lightly.
As a resident involved in the EMS track at Indiana University, I have been fortunate to have EMS opportunities that were created and improved by faculty and residents who preceded me. I serve as an assistant medical director for a local fire department and have protected time for EMS activities, lectures, and meetings. We have several prehospital elective opportunities and a physician/administrative response vehicle that is operated by our senior residents and EMS fellows. We respond to back up critical calls, operate as on-scene medical control, and work on EMS administrative skills. After completing the requirements of the EMS track, many of our graduates have accepted positions as EMS medical directors without a fellowship, but I know this in not the norm nationally. If residents can become medical directors without a fellowship, I found myself asking the following questions: When is a fellowship necessary? Will this change in the future? Is board certification really that important? I know I’m not the only resident with these questions.
My perspective on this topic is both bias and limited, so I sought opinions and perspectives from our vast large alumni network across the country. To collect this information, I sent a survey to alumni to collect some basic demographic data, community and practice environments, and, of course, EMS responsibilities and perspectives. Of nearly 120 attending physicians who responded, nearly 40% work in urban private/community groups, 25% work in large academic centers, and 35% work in small town private/community groups. Almost 20% are EMS medical directors / assistant medical directors, 25% have a minor role in EMS, and 55% have no EMS involvement. Only 6% are currently board-certified in EMS, 6% plan on taking the boards and 88% have no intention to pursue EMS board certification.
To all of these physicians, I posed two simple, yet important questions. First, “If your group/practice were to hire a new physician for an EMS-related position, how important would EMS board certification be when considering applicants?” Second, “Do you foresee your group/practice eventually requiring EMS fellowship/board certification for EMS positions (if applicable), especially roles such as EMS medical director or assistant EMS medical director?” In response to the first question, approximately 40% of respondents said EMS board certification would have little or no effect on the hiring process, 25% said is would give an applicant a moderate advantage, and 35% said it would either be necessary or give an applicant a significant advantage. In response to the second question, 25% of respondents foresee their group eventually requiring EMS BS for EMS positions, 50% do not, and 25% were unsure.
So how do we interpret this information? Although this sample of physicians doesn’t represent every EM group, there is something to learn. In order to interpret this information, ask yourself: What do I want to do with my career and where do I want to work? The answer to this question will play the biggest role in your decision to pursue a fellowship.
If you will work in a small town or small community/private practice, you probably don’t need fellowship training to obtain an EMS leadership position. Many of the respondents who work in smaller community departments see no benefit for EMS fellowship or board certification, for now. In smaller groups, survey respondents said, EMS responsibilities tend to go to the physician who is interested in taking on those responsibilities. Sometimes, those duties are just handed down to the “new guy” as many seasoned community EM physicians don’t want the additional responsibility. If you simply have a desire to be active in EMS, it may be enough to get you all the experience you want. One small-town physician said, “I can't even get another board certified EM doc in my group, let alone someone so specialized as EMS boarded.” But remember, getting the job and being good at it are two different things. If you are going to work in a small town or private group and really want EMS responsibilities, an EMS fellowship would likely be very helpful to prepare you for the job, especially if your residency does not offer a robust EMS curriculum.
On the contrary, if you want to work in a large urban academic center and take on EMS leadership positions, you should probably complete a fellowship. It will provide you with the knowledge, skills, certifications, and professional connections you’ll need to compete in a larger market. Physicians in larger urban centers seemed to put more emphasis on the EMS qualifications, and many said that EMS board certification would be necessary or give an applicant a considerable advantage over non-EMS trained applicants.
Arguably, one of the best moves you could make in residency is to reach out to the employers or groups that interested you. See if they already have EMS boarded physicians, or if they foresee a need for such a position. Each group will have different needs depending on their role in the EMS community. I recently contacted a group with several physicians who had completed EMS fellowships, but none of them were involved in EMS! In a smaller group, respondents said, you’ll need to practice clinical medicine (in the ED) at least half or 75% of the time to make an appropriate contribution to the group, and spending the majority of your time in EMS may not be favorable among your partners.
Finally, consider where EMS is heading. It is a relatively newer subspecialty and is expanding rapidly. While we can’t predict the future, it is probable that EMS certification will become an expectation rather than an exception. Currently, as one survey respondent said, “There are not enough EMS trained physicians to fill all the roles.” Another said, “I think it will take a few years…before board certification will be required at a small community practice. Even then, I think experience will still be a stronger factor in consideration.”
So, whether or not you decide to complete a fellowship, remember your EMS training and strive to build and maintain professional relationships with our EMS colleagues, advocate for your specialty and subspecialties, and take the opportunity to learn something new everyday. Reach out to physicians involved with EMS and find a mentor who can help you tailor your training for fit your career plans. Most importantly, continue to show respect and for our EMS colleagues and take the time to get to know the specialty – it will make us all better physicians.
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