Simply defined, the practice of medicine is the diagnosis and treatment of illness and injury. EMTs do it, paramedics do it, physicians, physician assistants and nurse practitioners do it. However, it is a matter of degree.
Training and education
After obtaining a college degree, most physicians spend seven years or more in medical education: four years in medical school, then three to five years of post-graduate specialty training in a residency program, and potentially more training years in a sub-specialty fellowship. For example, an emergency physician’s residency spans three to four years; for family practice, internal medicine and pediatrics it’s three years, and surgical residencies require five years.
In addition to a residency, a physician may seek more specialized training. A general surgeon who decides to specialize in thoracic surgery adds another 2 years of training[1], while an internal medicine physician spends another three to five years to become a cardiologist.[2]
Physician assistants (PAs) are required to have at least 2 years of college coursework focusing on basic and behavioral sciences before entering a PA program. Such programs last an average of 27 months and include 2,000 hours of clinical rotations.[3]
Nurse practitioners or advanced practice nurses (APN) generally start out with a Bachelor of Nursing degree, then have further training and education to obtain a Master of Science in Nursing (MSN). Vanderbilt’s MSN for Family Nurse Practitioners requires 805 hours of didactic and laboratory education and approximately 1,400 hours of clinical experience.[4]
Paramedic training varies, but is trending towards a two-year college degree in emergency medical services. Emergency Medical Technicians (EMTs), the foundation provider of many if not most EMS systems across the country, spend 100-plus hours learning their required skills and knowledge.
Of all the providers listed above, who is the most important to healthcare? The answer is, every practicing one of us. The difference lies in the scope of practice.
Scope of practice
The Federation of State Medical Boards defines scope of practice as “the activities that an individual health care practitioner is permitted to perform within a specific profession. Those activities should be based on appropriate education, training, and experience. Scope of practice is established by the practice act of the specific practitioner’s board, and the rules adopted pursuant to that act.”[5]
Once you complete the required education for your level of practice, you have to obtain permission to use that knowledge and skill from the state in which you plan to provide care. Each state or territory defines the practice of medicine and their licensing or certifying requirements.
The granting of a license or certification to practice medicine is a privilege, not a right. It is your responsibility to follow the rules that govern that privilege.
Licensure versus certification
Most paramedics and EMTs are granted the privilege to practice medicine by their state EMS office, with only a few states using the same medical board and process utilized for licensing physicians. States either license or certify EMTs and paramedics to practice medicine.
What’s the difference between a license and a certificate? A license is a document that gives you permission to use your skills. A certificate serves as official recognition that you have completed whatever training and education are needed.
Although the process differs somewhat from state to state, whether a state awards you a license or a certificate as an EMT or paramedic, you may function as one in that state.
State medical boards
State medical boards are specifically set up to license individuals who practice medicine in some capacity. A medical board is comprised of physicians, PAs and other medical professionals licensed by a particular state. Operating a state medical board requires several full-time staff positions to manage licensees and deal with medical practice issues. The primary goal of a medical board is to protect the public from unsafe practice and unsafe practitioners.
Medical boards have an investigative branch that manages complaints brought against licensees. A screening panel made up of active board members reviews each complaint to determine whether the case should be dismissed or further action taken. A medical board’s adjudication panel is also made up of active board members and deals with legal actions concerning licensees.
Most medical boards also support a medical professional assistance program to assist impaired licensees. The purpose of the provider assistance program is to evaluate, recommend treatment and monitor licensees who have behavioral or substance abuse problems, thus protecting the public while assisting many licensees to maintain or regain the practice of medicine.
State EMS offices have many tasks, and most are responsible for licensing or certifying of EMTs and paramedics. Budgets for state EMS offices may need to be stretched to accomplish all tasks assigned, and for that reason may have inadequate resources to match the process of professional licensure offered by state medical boards.
Personally, I’d like to see more cooperation between medical boards and EMS offices. Of course, state EMS offices may not want to pass responsibility to the state medical board, and the state medical board may not want to take on another licensee category, but from a patient perspective, it might be worth a conversation between these two entities.
Practicing across borders
A key point to remember is that you are licensed or certified in a state to practice in that state — you do not get a portable permission to practice in another state. That includes a federal incident, such as a wildland fire. If you are going to practice in another state, you must contact the appropriate state office and determine what is required to practice in their state, and comply prior to functioning as an EMT or paramedic in that state.
Practicing across state borders may get a little easier in the future. A new interstate compact is being developed that will allow EMTs and paramedics in participating states to cross borders and provide care for specific situations. But don’t try to sign up yet — the compact is still in the development stage, and it still must be adopted by the individual states. It’s likely to be a several-year process.
Summary
While only a few states license EMTs and paramedics through the same process used for physicians, it seems logical that paramedics and EMTs would be licensed by the same body that licenses their medical directors. With the trend towards accredited educational institutions for EMS education and development of new ways to utilize your skills and knowledge such as the growing numbers of community paramedicine programs, perhaps it is also time to consider a transition to professional licensure through state medical boards.
References
1. American College of Surgeons website http://www.facs.org/medicalstudents/answer2.html Accessed 9/29/13
2. American College of Physicians http://www.acponline.org/patients_families/about_internal_medicine/subspecialties/cardiology/ Accessed 9/29/13
3. American Academy of Physician Assistants website http://www.aapa.org/the_pa_profession/what_is_a_pa.aspx Accessed 9/29/13
4. Education and Training: Family Physicians and Nurse Practitioners http://www.aafp.org/dam/AAFP/documents/news/NP-Kit-FP-NP-UPDATED.pdf Accessed 9/29/13
5. Assessing Scope of Practice in Health Care Delivery: Critical Questions in Assuring Public Access and Safety. Federation of State Medical Boards, 2005. http://www.fsmb.org/pdf/2005_grpol_scope_of_practice.pdf Accessed 10/9/13
