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Emergency Medical Services (EMS)

Authors

Jared Ross, DO, FF/EMT-T
Assistant EMS Medical Education Director, Detroit Fire Department EMS
Emergency Medicine Resident
Ascension St John Hospital and Medical Center

Avram Flamm, DO
Emergency Medicine Resident
Wellspan York Hospital

Faculty Editors

Joshua Bucher, MD
Assistant Professor - RWJMS Department of EM
Assistant EMS Medical Director - RWJ - Mobile Health Services

Matthew Chinn, MD
Assistant Professor
Section of EMS and Disaster Medicine
Department of Emergency Medicine
Medical College of Wisconsin

Special thanks to our 1st edition writing team

Joshua Bucher, MD
Matthew Chinn, MD
J. Liu, MD, MPH

INTRODUCTION

Description of the specialty
Emergency medical services (EMS) is the administration, coordination, and delivery of medical care outside of a hospital or medical facility (also known as “prehospital care” or “out-of-hospital care”).

History of the specialty/fellowship pathway
Emergency medicine and EMS share a common ancestry, as both evolved from the core purpose of taking care of patients with time-sensitive conditions at their moment of injury/illness. Although EMS has been practiced for hundreds of years, EMS medicine recently became a board-certified subspecialty of emergency medicine in 2013 (2006 by the AOA). EMS fellowships are uniquely positioned to give emergency physicians (and physicians from other specialties) the knowledge and experience to provide, oversee, and improve pre-hospital care. 

Historically, EMS fellowships have varied widely in terms of the experiences for individual fellows. However, with the arrival of subspecialty certification and ACGME accreditation, there is now a standard core curriculum for EMS fellowships. Fellowships include field response, where the fellow rides on EMS vehicles and responds to emergency calls. Some programs have a dedicated vehicle for physician response. Many fellowships are attached to a flight program as well, which provides the opportunity to serve as a physician on aircraft for inter-facility transfers and emergency requests.

In addition to clinical prehospital care, EMS fellowships train physicians in the medical oversight of EMS systems. Fellows are intimately involved in many aspects of EMS education, as well as continuous quality improvement activities. EMS policies are constantly in flux due to changing research and guidelines, and fellows learn how to create, implement, and evaluate policies and protocols. Fellowships also offer opportunities in scientific research, as well as disaster planning and response.

Why residents choose to follow this career path
This field attracts physicians who are interested in becoming involved in the EMS field, such as clinical providers, researchers, educators, and/or medical directors.

EMS board certification may translate into increased funding, whether directly through a monetary payment from a medical direction contract or via funds to offset clinical time in the emergency department for EMS related activities.  EMS agencies and municipalities are increasingly recognizing the value of EMS board certified physicians and seeking out those with the training to fill their positions.  Many physicians who are interested in EMS complete a fellowship to gain experience and engage in the field of their interest. Board certification also has the added benefit of allowing for more diversified work, and may decrease long term burning by allowing you to have other work activities outside of emergency department shifts.  Additional training may also increase competitiveness for obtaining academic emergency medicine positions that prefer fellowship trained faculty.  

How do I know if this path is right for me?
A career path in EMS may not be right for all physicians. Being involved in EMS requires significant time dedicated to the furthering of the EMS organization. This involves collaboration with multiple committees and working groups, meeting with members of the community, public safety agencies, and governmental bodies. EMS work requires skills in interpersonal communication, outreach, diplomacy, and politics. Serving as an EMS medical director requires some knowledge of finance, administration/management, and policymaking. 

Career options after fellowship
There are local, state, federal, and private positions that are opportunities for physicians interested in EMS. Many states and larger EMS systems have a dedicated full-time medical director. Some larger organizations require multiple physicians. Tactical teams and local law enforcement, large event organizations, sporting arenas, and international medical groups may employ the services of an EMS medical director or physician. The medical director position in larger EMS organizations is typically filled by a physician with a background in emergency medicine and prior EMS experience or training. However, there are many EMS agencies who still do not have medical directors with EMS experience or training. Completing an EMS fellowship will greatly help your chances of obtaining a job as an EMS physician or medical director. Some EMS physicians build upon their administrative and management experience in the pre-hospital setting and take on positions in the emergency department and hospital setting as well.  

Splitting time between departments
Depending on the specific position and organization in which you are employed, an EMS medical director position may include working clinically within an emergency department, or it may not include any clinical work. Some EMS positions may require a full-time administrative commitment, which would mean the individual has to make his/her own arrangements for clinical work separately. Other smaller agencies only have funding to hire a medical director for a few hours per week and thus some EMS physicians will combine contracts from several EMS agencies.  There are also still many departments where time may be uncompensated and done as a community service. The largest challenge for a physician involved in EMS is often balancing the time spent between EMS and non-EMS work, as well as clinical, educational, academic, and administrative work within EMS. 

Academic vs. community positions
There are both academic and community based positions in EMS. An EMS agency may be university-based, hospital-based, fire-department based, municipal, or a private organization. They may be associated with a medical school or academic department, or may have no affiliation. All of these variables can affect the working environment and responsibilities requested of a medical director/physician.

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
There are currently 52 ACGME accredited fellowships, with more in the accreditation queue. Lists and links to current programs can be found on the ACGME website, the National Association of EMS Physicians website, and EMRA Match

Differences between programs
With the implementation of ACGME accreditation of EMS fellowships in 2013, all fellowships are required to provide their fellows with a foundational level of knowledge regarding the basic tenants of EMS, however the programs differ significantly in their focus and flavor. 

The joint ABEM and ACGME “EMS Milestone Project” provides a framework for assessment of the development of the fellow in key dimensions of the elements of physician competency in EMS. They reside in the domains of patient care, medical knowledge, system-based practice, practice based learning and improvement, professionalism, and communication skills. The Core Content of Emergency Medical Services Medicine, published by ABEM, lists the skills that should be acquired during an accredited fellowship. This is also the content on which the board exam is based. The ACGME has established a specific set of program requirements for any EMS fellowship. Many of these requirements are similar to other specialty residency and fellowship programs. These requirements can be found in the ACGME Program Requirements for Graduate Medical Education in Emergency Medical Services.

The execution of these requirements is left to the individual program, with significant variability. Programs generally focus on one or more aspects of prehospital care including operations, administration and research, and offer different and unique prehospital opportunities.

Operational experience may range from ride-alongs with various EMS units to a vehicle that allows the fellow more flexibility to respond to incidents as they occur. This may be a shared vehicle or a dedicated take-home vehicle. Similarly, aeromedical exposure may vary from occasional shifts as an observer to weekly scheduled shifts as part of a crew. Most programs will have different opportunities to be involved in the planning and execution of special event and mass gathering medicine. Fellowships may also have operational opportunities in disaster medicine, wilderness medicine, tactical medicine, and/or rural EMS.

Administrative duties may include appointment as an assistant or associate medical director for an EMS agency with scheduled continuous quality improvement activities, regular meetings, conducting investigations, rewriting clinical policies and planning. It may also involve different levels of governmental involvement. Clinical oversight and supervision may range from on-scene medical direction to online medical command provided by phone or radio to EMS providers. Fellows will also likely have an opportunity to review and revise written EMS protocols. Many programs offer opportunities to teach both clinical and didactic material to EMS providers.

All fellowships require the completion of a scholarly activity. However, this varies widely between programs, as it can range from a popular media publication or quality improvement project, to retrospective or prospective trials and peer-reviewed publication.

With the ACGME accreditation of EMS fellowships, other pre-hospital fellowships in disaster medicine or tactical medicine fellowships have been merged into EMS fellowships. Generally, they all offer training in ground and air medical services in such areas as patient care, communications systems, system design, quality assurance, education/training, and disaster medicine, among others.

Length of time required to complete fellowship
ACGME-accredited fellowships are 1 year; however, some fellowships offer an additional year for an advanced degree (MPH, MHA, MBA) or other endeavors.

Skills acquired during fellowship
As mentioned, all accredited fellowships are required to provide their fellows with a foundational level of knowledge regarding the basic tenants of EMS. The Core Content of Emergency Medical Services Medicine and “EMS Milestone Project” described the knowledge and skills graduates of accredited programs are expected to have mastered.

Typical rotations/curriculum during fellowship
EMS fellowships differ on the specific structure/schedule they use to deliver the curriculum. Most intersperse various areas and topics throughout the year. Some fellowships have set rotation schedules where the fellow spends a specified period of time in one area/topic, and then rotates to another. Additional areas that may be covered during fellowship are mass gathering medicine, disaster medicine, tactical medicine, wilderness medicine, medical education.

Board certification afterwards?
Beginning in 2013, EMS subspecialty board certification is available through a written certification exam administered every 2 years by ABEM. Subspecialty certification is open to any primary specialty, provided they meet the requirements for EMS certification. Fellows who complete an ACGME-accredited fellowship may take the board exam at the next offering after completing their fellowship.

Currently a practice pathway (“grandfathering” pathway) exists for those who either completed a non-accredited fellowship or who have been practicing actively in EMS without any fellowship training, both pathways are set to close in 2019, after which the only way to be eligible for board certification is to complete an accredited fellowship.

Average salary during fellowship
Most programs offer a PGY salary equivalent to your level of training, at minimum. For some programs, this is the sole source of salary. However, others offer a varying stipend for clinical shifts worked during fellowship (which may or may not be considered “moonlighting”). This stipend will vary in amount by institution, and must follow ACGME work hour restrictions. Some fellowships may come with clinical instructor or other academic appointments as well. In addition to the salary, fellowships may offer CME (Continuing Medical Education) budgets, retirement plans, or other additional compensation.

PREPARING TO APPLY

How competitive is the fellowship application process?
Although there are still more positions available than applicants, the fellowship application process may become more competitive over the next several years. The designation of EMS board certification has led to a surge in interest in fellowship training. EMS is also a field rapidly growing in physician involvement and research.

Requirements to apply
EMS fellowships are open to any board-eligible or board-certified physicians, however the vast majority of applicants come from emergency medicine. 

Suggested elective rotations to take during residency
Your EMS rotation during residency will be an important area of focus. Fellowship programs are looking to train people who will be committed to improving EMS care. Different programs have different requirements and opportunities, but any involvement in EMS is a good way to demonstrate dedication and to obtain some experience in the topic. Getting involved with EMS provider education and training during residency is a great way to get involved. Completing ride-alongs, with ground or air-based EMS, especially if done outside of your mandatory rotation, will further solidify your commitment,

Suggestions on how to excel during these elective rotations
The best way to excel during these rotations is by displaying strong clinical skills, teamwork capabilities, and enthusiasm for pre-hospital medicine. 

Should I complete an away rotation?
Away rotations for EMS are relatively rare, though may be a consideration if your residency program does not have a strong EMS component and you wish to bolster your experience. Away rotations may increase your competitiveness if you have a strong desire to match to a particular program. 

What can I do to stand out from the crowd?
To stand out from the crowd, fill your CV with activities that display a strong interest in EMS and leadership skills. Participating in or creating an EMS track in your residency program is another way to gain EMS exposure and demonstrate commitment. Prior EMS experience also strengthens your CV. 

Should I join a hospital committee?
Hospital review committees involving EMS, such as STEMI, stroke care, and trauma care, provide administrative experiences that will help to solidify your candidacy. 

Research requirements
As with many subspecialties, prior research experience is helpful when applying to an EMS fellowship. There has been an increasing drive towards evidence-based medicine in EMS, and having research experience demonstrates commitment in this area of importance. Certain EMS fellowships are known for their research focus, in which case such experience is extremely important. 

Publications other than research
Non-research publications are also helpful for your application. As a resident, there are many opportunities for publication, such as EM Resident, the magazine published by EMRA, or one of the many newsletters, such as ACEP Now. There are also EMS specific publications including JEMS and EMS1. 

How many recommendations should I get? Who should write these recommendations?
Most programs require 3 letters of recommendation, with one being from your department chair or residency program director. A recommendation from your local EMS director, or any EMS faculty in your department, is very helpful and recommended. However, like with all fellowship and job applications, having a good recommendation from your department chair and/or residency program director are equally as important, as they demonstrate your overall ability as physician as well as your personal character.

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Almost all EMS fellowships will accept physicians who have been practicing as an attending before applying. The key is to ensure that you stay involved with EMS as part of your practice. Again, fellowship programs are looking to train people who will remain committed to EMS. However, it is important to note that many people find it hard to “switch back” to a trainee rank, salary, and lifestyle after being an attending. Most fellows come directly out of residency.

What if I’m a DO applicant?
Most EMS fellowships do not differentiate between MD and DO applicants. 

What if I am an international (IMG/FMG) applicant?
Most EMS fellowships are more concerned with where you completed residency than where you attend medical school.

What if I am an international residency applicant?
ACGME-accredited fellowship programs, by regulation, can only accept board-eligible or board-certified physicians. Plus, most EMS fellowships help to offset the costs of training a fellow by having a fellow cover clinical shifts in the emergency department. Both of these factors mean the individual has to be licensed to practice medicine and have completed an ACGME/AOA accredited residency. However, some EMS fellowship programs have an international track designed for physicians who are not trained/licensed in the United States. These tracks would not be eligible for board certification. Also, usually, the individual would have to pay tuition to cover the costs of training.

APPLICATION PROCESS

How many applications should I submit?
This is highly subjective, depending on your qualifications, geographical restrictions, and family considerations, among many others. Numerically, there are more EMS fellowship positions than applicants, so barring any personal preferences, there is likely to be a position available. Even if you have your mind set on a single program, it is a good idea to apply to or visit several programs to provide some perspective. 

How do I pick the right program for me?
The right program is also a very subjective question. Most fellowships have a website you can visit for highlights about their program. Additionally, the EMS community remains a relatively tight-knit subspecialty, so EMS faculty in your department are often able to provide insight into other programs. The application and interview process also is very revealing, and the impression you get from meeting the fellowship director and core faculty can have a huge impact on picking the right program. In addition to the program elements, many applicants have their own family, geographical, or other requirements that may shape their decision of picking the right program. In the end, as with choosing any job, trust your gut.

Common mistakes during the application process
It cannot be stated enough that the EMS community remains a small and tightly knit one. Always be professional and honest throughout the application process. 

Application deadlines
In the past, there was a lack of a true formal process for fellowship applications, and dates were highly variable. Applications are typically accepted as early as July with interviews occurring in September and October.

Beginning in 2018 for programs starting July 2019, EMS fellowships will be in the NRMP Fellowship Match. 

The dates for the 2018 Emergency Medicine Fellowship Match for 2019 appointments are:

  • August 22, 2018 Match Opens
  • September 26, 2018 Rank Order List Entry Opens
  • October 31, 2018 Rank Order List Certification Deadline
  • November 14, 2018 Match Day

Tips for writing your personal statement
Your personal statement can serve to both emphasize points on your CV as well as delve into those intangible things that don’t fit on a CV. For instance, it is your opportunity to show the reader why you decided to go into EMS medicine. Be honest and concise. Writing individual letters to each program emphasizing why you would be a good match for them and demonstrating that you have done some research into their program is a good idea as well. Having a faculty member review your draft statement can often be valuable. The American Medical Association, EMRA, and many other organizations offer personal statement advice you can review as well. 

Is this a match process?
Beginning in 2018 for programs starting July 2019, EMS fellowships will be in the NRMP Fellowship Match. 

What happens if I don’t obtain a fellowship position?
If you do not obtain a fellowship position, you have several options. As stated before, there are usually more positions than applicants, so if you have no restrictions you have a good chance to place somewhere. Another option can include applying during the next cycle.

INTERVIEW PROCESS

How do I stand out from the crowd?
During any interview process, it is always of benefit to you and the program to be yourself. There is no advice specific for EMS fellowship interviews. Program directors (like any supervisor) are looking for energetic candidates with a commitment to learn about EMS and take that knowledge to improve the field. 

What types of questions are typically asked?
Questions may range from EMS specific to generalizations. For example, questions regarding the aspects of EMS that you feel are important, the latest science of EMS, or opinions about specific issues are all valid questions. Be knowledgeable about the latest controversies, scientific breakthroughs, and news in the area of out-of-hospital medicine. Most importantly, be prepared to explain why you want to complete an EMS fellowship and your career goals. 

How many interviews should I go on?
There is no “magic number” of interviews. You should interview at an adequate number of programs depending on your competitiveness. If you feel you are not a strong candidate, you should interview at more programs to increase the likelihood of obtaining a position. Remember there are still more positions than there are applicants, so the odds are with you. However, with the increasing interest in EMS fellowships, this may change over the next several years, so you may want to apply to more than you feel is necessary.

PREPARING FOR FELLOWSHIP

Textbooks to consider reading
There are no required texts to read prior to fellowship. Some considerations include the seminal texts and papers in EMS that may offer some background on the specialty. One of those foundational papers is the EMS Agenda for the Future. The NHTSA website contains links to many others. The NAEMSP publishes what is considered the core textbook for EMS medicine: Cone’s (2015) Emergency Medical Services: Clinical Practice and Systems Oversight. NAEMSP also advocates for some additional reading materials that may be used as references. Certainly, you should be familiar with all of these materials by the end of fellowship and before taking the board exam. Thus, it doesn’t hurt to start reading them before beginning your fellowship.

Important skills to practice while in residency to prepare for fellowship
Getting solid emergency medicine training should be your focus during your residency. You have to know how to practice medicine in the hospital before you can adapt it outside the hospital. Showing EMS interest through research, involvement in medical direction, or other avenues is encouraged during residency.

Tips on how to succeed as a fellow
Fellowship should be a fun experience. Everyone entering this field has a desire to work in the prehospital setting. Work hard, enjoy your time there, soak up the mentorship from your peers, network with others, and never forget your roots in emergency medicine.

CONCLUSION

Additional resources
There are further resources for EMS for those who are interested. The National Association of EMS Physicians (NAEMSP) has a wealth of resources available on their website at www.naemsp.org, as well as a podcast that interviews authors of major articles. Prehospital Emergency Care (or PEC), published by NAEMSP, is considered one of the most influential journals for EMS medicine.

National organizations
NAEMSP is one of the most important organizations for EMS physicians. NAEMSP provides resources for new and established EMS physicians, publishes position papers on important topics, and promotes opportunities for research and networking. NAEMSP also publishes the journal Prehospital Emergency Care quarterly. NAEMSP offers a medical director’s course annually, which is an excellent three-day course that helps prepare you for becoming an EMS director. NAEMSP welcomes resident and fellow members.

Conferences
NAEMSP hosts an annual conference in January that is highly recommended for those interested in EMS. 

How to find a mentor
Finding a mentor is an important part of the journey to become an EMS physician. EMRA offers a fellowship mentor program where you can apply to be paired with a mentor or to work as a mentor, if interested. Ideally, a mentor should be located at your site of practice/ residency and they can be a valuable resource to assist with your involvement in EMS and making the decision if an EMS fellowship is right for you. SAEM and ACEP both have EMS sections that can provide a forum to seek advice and make connections.