Sunday, May 20, 2012

What's wrong with the Paramedic profession?

I guess it's a testament to Facebook's ingenious targeted advertising, but I am bombarded by ads from various online schools offering to help me 'earn my RN in just a few months'.  I'm sure I'm not the only one in my circle of friends who receives this kind of thing in their ad strip.

I don't typically pay it much attention, but a while back I was in the company of a British Paramedic and was showing him some pictures on my Facebook when he remarked about the ads in question. "Why would a Paramedic become a Nurse?" he asked. A fair question.

For the answer, one needn't look much further than the ads themselves. 'Increase your salary by 15% in as little as 12 months' is one of the recurring sales pitches. 

I explained to him that a newly minted RN, straight out of nursing school stands to earn 30-50% more than a newly minted Paramedic, and that the Paramedic will start to plateau after 15 years while the RN continues to creep up gently. This is a generalization, but it's true on a macro level.

What I have discovered throughout my experience of working all over the world, with Paramedics from Singapore, the UK, Canada, South Africa, Australia and New Zealand, is that this is almost exclusively an American phenomenon. In fact, in multiple cases, including the case of my current co-worker Terrence (Australian) I am seeing people who used to be Nurses and are NOW Paramedics - a transition practically unheard of in the U.S., and for good reason . . . pay.

But why is the American paradigm so starkly out of step with the rest of the world? What is the factor that makes a newly minted RN more valuable than a newly minted Paramedic?

Before I tackle this question I want to be clear on something. I have zero disrespect for the nursing profession.

None at all.

I have many friends, some of whom will undoubtedly read these words who are Nurses. Some that I've worked with in critical care transport, some I know through spending too much time in emergency rooms and some are friends from my childhood who I learned years later (thanks to Facebook) went on to become Nurses.

I give this long-winded qualification because when I've been proximate to this discussion in the past, I've heard a few explanations from Nurses that are incorrect. I want to address the incorrect-ness without appearing bitter or flippant.

To the question "Why do Nurses make more?" I've heard:

"It's because we're licensed."

 . . . It's not because of licensure.

"It's because we're 'educated' as opposed to 'trained'." 

. . . This is a fallacy, but even if it were true, it wouldn't explain anything about pay. At the end of the day, the amount anyone gets paid comes down to a basic question of supply and demand. This is true of everyone from the janitorial staff to the CEO.

The CEO is not paid more because he/she has a PhD or MD or whatever . . . pay is not a reward for hard work or intelligence. The CEO is paid well because there aren’t many people who possess the qualifications and experience necessary to do that job effectively (low supply).

The janitorial staff is paid poorly because the necessary qualifications to do that job effectively do not exist. Therefore the vacancies are easier to fill; therefore there is no need to pay more (high supply). If you go to or or any of those sites and type in "Nurse", stand back and watch the mountain of vacancies come rolling in. Type in "Paramedic" and you needn't stand back. Your search results will likely be far fewer and will be laden with lots of RN vacancies, but whose description includes the word "Paramedic" somewhere in the text. Filter those out and you may have a few dozen jobs nationally.

Simply put, the demand for Nurses is just a whole lot higher. Why is that?

It all comes down to billing.

If you're a hospital or smaller medical center and you want to be able to bill medicare/medicaid (and hence the rest of the health insurance industry) you have to be accredited. The Joint Commission (JCAHO) pays close attention to Nurse-Patient ratios and can close a hospital's doors if they don't have the requisite number of duly qualified Nurses.

Consider also, the multitude of different specialties that the newly minted RN can gravitate towards and become an expert in. Then consider all the career paths for Nurses who want to get out of the clinical setting; informatics, case management, public health, on and on . . . So not only do you need nurses, you need specialized nurses in many areas.

Has anyone ever heard of JCAHO threatening to close a hospital because there weren't enough Paramedics? Of course not. JCAHO would scarcely notice such a thing. So if the bulk of the medical industry cannot utilize a Paramedic in a patient care capacity, while still maintaining the type of staffing necessary to be accredited - demand will be low. If there is no career ladder, and no clear avenue into some "specialized" form of Paramedicine, the Paramedic just stays put and hopes to hang in long enough to get promoted into a position that won't destroy their back, knees and sanity. Sounds promising and rewarding, right?

In any given locality there are usually a scant handful of employers looking for Paramedics. Back home I can think of three agencies in a 100-mile radius; three potential places to ply your trade in a population center of about 300,000 people.

In North Carolina, the Office of EMS says a Paramedic can only work for a legally chartered EMS service under an approved medical director. Doctor’s offices, clinics, urgent care facilities and the like couldn't hire a Paramedic - even if by some miracle, the idea occurred to them in the first place. The law limits our options by relegating us to one task - emergency response; which according to medicare, is of no value at all unless we transport. What good could we possibly do in a living room, right? What problems could a bunch of ambulance drivers solve all by themselves? How could such services possibly be billable?

And that's the box we find ourselves in, literally and figuratively. It is the confinement of role and the resulting lack of demand that constrains pay. There is no other explanation.

Once you leave the domestic setting and enter the international arena as I have, you enter a whole new scale of demand. When you look at all of the governments, NGOs, mining companies, seismic exploration companies, shipping lines and the like, you have a pool of employers who have long been aware of the value of the Paramedic skill set and are happy to pay a whole lot more for it than your local ambulance company or fire department.

Right now, in Queensland and Western Australia, Paramedics are commanding $700 to $1300 per day in the mining sector, depending on additional qualifications and experience. I'm not kidding.

For these employers, a Nursing credential is a nice adornment, but it is seldom if ever requested, let alone required. Since you are outside the confines of your home jurisdiction, the legal significance of licensure is null. The employer's insurance carrier is interested in the verifiable skill set of the provider only. The legitimately credentialed and experienced Paramedic, with augmented training in primary / occupational health and advanced trauma modalities has that skill set. 

But I did not start writing this to bang the drum of remote duty paramedicine, and I did not start writing this to throw down the gauntlet of spite before the throngs of Nurses out there (whom I love . . . honest!)

I started writing this note because these little Facebook ads are indicative of a tremendous problem that appears to be unique to the American healthcare system. The problem is this:

We have - in the Paramedic, a wealth of capability and skill that translates into a public health jackpot. A medical bargain of the century! And yet, because of the narrow, antiquated thinking of the agencies responsible for accreditation and compensation - we have been deemed utterly worthless, unless of course we drive someone to a hospital, where the real professionals are located . . . 

It is this confinement of our role that suppresses our compensation and it's our tepid compensation that makes us want to jump ship and become Nurses!!!!

If you're an American Paramedic and you're reading this, ask yourself: Have you ever considered the jump to nursing? Do you know anyone who has made the jump? Did any of them do it for any reason other than:

a.) Pay


b.) "I'm getting too old for this shit" . .?

Did any of them do it because they felt they were legitimately improving themselves personally? We all know the answer. So what does that tell us?

It tells us that the international community is light years ahead of the United States of America when it comes to valuing and utilizing the public health resource that is the Paramedic. I contend that the country with the most expensive and least comprehensive health care system in the civilized world has no excuse for undervaluing or underutilizing ANY health resource.

It is criminal for us to fail so completely, on a national scale, to get every last drop of value we can get out of every resource at our disposal, and that is a contention that should be shared by everyone from the CEO to the janitor

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