EMS Physician Certification

For at least the last ten years, members of the emergency medical services (EMS) physician community have been working to develop a process whereby a physician completing an EMS fellowship program could take a certification examination andbecome formally credentialed, recognizing the unique skills that the physician possesses. As with all new certification programs, physicians who completed fellowship programs in earlier years, or could demonstrate equivalent qualifications through practice andexperience, could take this examination for a limited period of time (“grandfathering”), after which the only route to the examination would likely be through formal fellowship training. This process would effectively constitute specialty certification in EMS, though the exact terminology would depend on the system andthe process involved.

The first serious effort in this direction was directed at working through the American Board of Medical Specialties (ABMS) in the mid-1990s. Due largely to concerns that EMS represents a largely administrative field, lacking the unique clinical practice andbody of medical knowledge that would constitute a subspecialty, this first effort was unsuccessful. Subsequently, the National Association of EMS physicians (NAEMSP) began looking globally at the subspecialization/certification issue. It has become apparent that there is a specific, unique body of knowledge that is required for physicians to function effectively as EMS physicians and/or EMS medical directors. That body of knowledge includes both clinical and administrative issues that are not adequately taught to physicians during their postgraduate training. Even emergency medicine residency training provides only the basics of prehospital care, anddoes not adequately prepare a physician to serve as an EMS medical director or EMS physician.

Before proceeding, it is worth noting that there are probably actually three distinct roles for physician specialists in EMS. The “EMS medical director,” though variously defined (primarily by state statutes andregulations), is generally thought of as the physician with overall responsibility for the medical components of an EMS system under the broad umbrella of “medical oversight.” These include such things as the actual out-of-hospital care delivered by the system (through oversight of communications, field clinical practice, andprovider education, as well as system evaluation andresearch), administration (including oversight of the qualifications andutilization of personnel, system financial planning, andliaison activities with the rest of the medical community), andpublic health (through oversight of public education, illness andinjury prevention, legislation andregulation, information systems, andintegration of health services).[[1]] The term “EMS physician,” though less clearly defined in the literature, may be a good descriptor for a physician with an active field role. Such a physician may be a member of a physician response team, yet not the medical director of the system. Some states (such as Pennsylvania) offer prehospital credentialing for physicians with particular training andskills, allowing them to function as advanced life support (ALS) personnel with their local EMS system. Finally, an “academic EMS physician” is probably the least well described of the three. Such a physician is a leader in EMS education (perhaps through curriculum development) or research, andmay or may not serve in either of the other two roles.

At the 2005 NAEMSP annual meeting this past January, the Physician Certification Task Force met to regroup andwork toward developing a new strategy. As the group's discussions proceeded, it became apparent that we had been missing a big piece (four pieces, actually) of the puzzle. The group realized that the EMS Education Agenda for the Future: A Systems Approach (www.nhtsa.dot.gov/people/injury/ems/EdAgenda/final/index.html) provides the model, andthe missing pieces of that puzzle, that the EMS physician certification process should follow (Figure 1). This concept was endorsed by the NAEMSP Board of Directors at its meeting a few days later.

Figure 1 The framework of the EMS Education Agenda for the Future.

The discussed model actually began with the publication, in 1998, of the EMS Agenda for the Future.[[2]] Part of the vision of this document was the transition of EMS to a more community-based health management system, while ensuring that the EMS system continued to serve as the health care safety net for the community. Two years later, the EMS Education Agenda for the Future was developed to allow for the implementation of the educational needs of this broad vision.[[3]] Five separate components of the EMS Education Agenda have been described, each representing one component of the overall education andcertification model.

The first component is the core content. A “prototype core content” for EMS fellowship programs was written in the early 1990s,[[4]] as a joint project of NAEMSP andthe Society for Academic Emergency Medicine (SAEM). A more comprehensive document, the National EMS Core Content, which is defined as a “comprehensive list of skills andknowledge needed for out-of-hospital emergency care,”[[3]] has already been developed as a joint project of NAEMSP andACEP (under the sponsorship of the National Highway Traffic andSafety Administration's (NHTSA's) EMS Division andthe Health Resources andServices Administration's (HRSA's) Maternal andChild Health Division) as the first stage of the implementation of the EMS education agenda.[[5]] In theory, this core content includes all of the material that EMS personnel, including EMS physicians, need—perhaps not organized in a way that is user-friendly for medical oversight activities, but it's there. It may be necessary to analyze differences between these two documents as a step in the Physician Certification Task Force's process.

The second component is the scope of practice, which essentially “divides the National EMS Core Content into levels of practice, defining minimum knowledge andskills for each level.”[[3]] The lack of a defined scope of practice for each of the recognized levels of prehospital personnel has recently been recognized as a major flaw in the nation's EMS education paradigm. Until recently, the national standard curricula created for each level have essentially driven the scope of practice, instead of the other way around. The scope of practice is also likely the component of the educational model that has garnered the least attention at the EMS physician level. The development of the National EMS Scope of Practice is well under way, attempting to delineate the provider practice levels. The current draft (available at emsscopeofpractice.org) does not consider the role of the EMS physician or medical director (or that of the dispatcher), but instead focuses only on field personnel. There has been very little attention paid to the scope of practice of the EMS physician, andin a close analogy to the field providers, we wrote a core content[[4]] andthen jumped right to a related curriculum[[6]] for EMS fellowship programs back in the early 1990s when we really should have been defining the scope of practice. It remains to be seen whether one scope of practice can fit all three EMS physician types.

The third component of the model is the education standards. Until now, we have had a set of national standard curricula written under NHTSA sponsorship for each of the standard field provider levels. However, now recognizing that the scope of practice should drive the curriculum, andnot the other way around as has happened historically, the next step will be to develop the relevant National EMS Education Standards, which will contribute to the system by “specifying minimum terminal learning objectives for each level of practice.” The physician curriculum[[6]] developed in 1994 by NAEMSP andSAEM has been used as the basis for most EMS fellowship training programs since then. While NAEMSP andSAEM have, for the past few years, been working toward revising andupdating the EMS fellowship curriculum, it seems that we should instead be putting our energies into developing the EMS physician scope of practice, based on the existing National EMS Core Content andthe existing (and perhaps updated) EMS fellowship core content,[[4]] before we look to update the fellowship curriculum.

It is interesting that the 1994 core content is not really directed at the EMS physician, but rather at EMS fellowship programs, illustrating the complexity of the educational model andsome of the previously encountered problems. It appears to cover the activities of the EMS medical director (through didactic activities, such as studying the components of an EMS system as outlined in the EMS Act of 1973, andexperiential activities, such as participation in protocol development), the EMS physician (primarily through experiential activities, such as participation in hazardous materials training), andthe academic EMS physician (through a research requirement, completion of formal course work in statistical methods, etc.). A separate document issued by SAEM in 1999 seems to be directed more toward the training of an academic EMS physician,[[7]] but work is likely needed to better define these roles andadjust the various components of the model to better address them.

The fourth component is accreditation of training andeducation programs through a process of “verifying educational program quality for the protection of students andthe public.”[[3]] Through SAEM's review andcredentialing of EMS fellowship programs to qualify them to serve as host sites for the SAEM/Medtronic Physio-Control Fellowship in EMS, we already have the basics of this component in place. Since it is based to a large extent on ensuring delivery of the 1994 NAEMSP/SAEM fellowship curriculum, this credentialing process will almost certainly require updating andrevision after the curriculum itself is updated. Further, consideration will need to be given to whether this credentialing will constitute “official” credentialing for fellowship graduates to sit for a hypothetical certification examination. Will it be permissible for a fellow who graduates from (or graduated from) a non-credentialed EMS fellowship program to sit for the examination? Should a new credentialing system be developed, or is there no advantage to reinventing the wheel we already have? Answering these questions is critical to developing an effective certification process. We will also need to consider whether we wish to maintain a separate process for the accreditation of programs for EMS physicians, or whether we instead wish to integrate this process into whatever process is developed for EMS provider training andeducation programs. It is the intent of the EMS Education Agenda that a single, universal accreditation process be in place for all levels of EMS personnel.

The final component is a process for national EMS certification. The emphasis on “final” is intentional: without the prior four components, it is difficult, andperhaps impossible, to develop a rational certification examination. What would this examination test, if there were no scope of practice andstandard curriculum to guide it? Sure, it would be relatively easy to start developing test questions, but could we create a valid, fair, defensible, andlegitimate test without really knowing what it is we are testing? Likely not. The certification examination would be available to those who complete a training program that is accredited as described above. Details of a “grandfathering” process would of course need to be worked out for those who have already completed fellowship training, or have similar training or substantial experience.

There is much information regarding potential options that still must be gathered. The exact answers to the questions above are still to be determined—and some questions are still to arise. The largest of these, likely, asks whether subspecialty certification for EMS physicians is necessary andwarranted. There are a number of factors suggesting that the answer is “yes.” The EMS Agenda for the Future will lead to the provision of continued care by EMS personnel, in expanding andmore sophisticated roles, as the health care safety net for the country. Knowledgeable EMS physicians will be needed to help lead those systems. Recent residency graduates entering practice as EMS physicians are realizing that their initial residency training does not qualify them to easily assume any of the three physician roles in EMS. Recognizing that it does require a unique body of clinical andadministrative knowledge to lead those systems, we need to ensure that those physicians who do so are appropriately qualified. Subspecialty certification provides that assurance. NAEMSP is committed to this process.