Medical Direction in EMS: Get the Doc On the Line!

Medical direction is a growing subspecialty within the world of emergency medicine and emergency medical services (EMS). A physician, who serves as medical director, guides or “directs” emergency medical technicians and paramedics as they provide prehospital care to patients. EMTs and paramedics must work under the guidance of the medical director.

Historical Perspective
The history of physicians in EMS has evolved over the decades, but the goal has remained the same: to guide EMTs and paramedics in the prehospital care of sick and injured patients through direct and indirect control aspects of medical direction.

In the early days of EMS in the 1960s and 1970s, there was little medical direction other than a handful of physicians pioneering the role.¹ Two legislative acts were key in the development of EMS. First, the Highway Safety Act of 1966 created the National Highway Traffic Safety Administration (NHTSA), which was charged with developing EMS systems, training, and funding for state-level EMS agencies. And second, the EMS System Act of 1973 allocated federal funding to create EMS systems and training programs. One of the components listed in the EMS system was medical direction.

In 1982, ACEP released a position statement regarding the medical direction of prehospital EMS.² It outlined the requirements of medical direction and initiated the ideas of direct and indirect control (discussed later). However, it was not until 1985, with the development of the National Association of EMS Physicians (NAEMSP), that the importance of the physician in EMS was truly recognized.¹

Since then, there have been several iterations of position statements released by ACEP regarding the physician medical director’s role in EMS. Most recently, in 2017, ACEP established a list of 15 principles reaffirming its commitment to physician medical directors and their leadership of EMS.³ Some of these principles include the active direction and oversight of general operations, credentialing programs, quality improvement programs, evidence-based education development, and promotion of EMS research initiatives.

Another advancement for the physician medical director is the recognition of EMS as a subspecialty within EM and the formalization of EMS fellowship programs beginning in 2010 with examinations beginning in 2013.⁴ Not only are EMS physicians involved in the medical direction of EMS agencies, but they are also involved in the initial education of prehospital providers. From the beginning of formal EMS education, physicians have been involved with medical oversight. Since 1978, EMS education programs seeking accreditation are required to have a medical director in place. While medical directors are not required to be emergency physicians, they must have adequate training and experience in prehospital care. The NAEMSP has recognized that an EMS board-certified physician is best prepared to meet the expectations of an EMS medical director.⁵

However, as of 2022, no state requires EMS board certification, and only 8% of states require board certification in emergency medicine.⁶ While ACEP provides a position statement on the roles and responsibilities of the EMS physician, the ultimate decision on specific job descriptions is determined by the state where the physician works, as well as by the individual EMS agency through contractual agreements.

Direct vs. Indirect Control
Several levels of medical oversight are generally included in all EMS systems under the headings of direct and indirect control.

Direct control includes online direction, active participation in protocol and guideline development, and working alongside personnel as a prehospital provider. Online direction is the ability for immediate consultation for specific procedures, medications, or other orders, and may not be provided by the agency’s specified EMS physician but rather by a physician at a designated facility. Direct control may also be implemented in the form of an EMS physician on scene providing direct patient care alongside prehospital providers.

Indirect control includes offline direction and administrative responsibilities. Offline medical direction is generally in the form of protocols and standing orders.

The EMS physician may assume other roles as part of the incident command system at large-scale incidents as well as in education, prehospital provider support, and performance improvement.⁷ While there has been minimal research on how much involvement the EMS physician should have in the EMS system, several studies have shown that active involvement in EMS education, continuing education, oversight, skills training, and case review has a positive impact on prehospital provider satisfaction and patient care.^8,9,10

Importance of Presence
Medical direction not only has written and verbal components, but also presence and visual aspects. Medical directors should be available, accountable, and on the frontlines with their EMS crews. Crews need their physicians as leaders to help guide them toward best practices for jurisdiction and population. EMTs and paramedics respond positively to leaders who work with them on calls, in stations, and at hospitals. Medical directors who only appear when something is amiss are perceived as disciplinarians rather than teachers or mentors, which may lead to mistrust or apprehension; this negative association may cause crews to avoid their director. The goal should be open communication, as this has been shown to increase responders’ training levels and ultimately improve prehospital patient care.

A 2000 study at the University of Maryland showed medical directors had 100% involvement in instances of deviation from protocols, which is certainly required, but significantly less involvement in dispatch, system evaluation, and other vital aspects of their EMS systems, which strays from national guidelines.¹¹ All physicians in the EMS agency are held accountable for providing both online and offline medical direction to their crews.¹² This guidance is supported by an active quality assurance program and allows crews to work more autonomously for most cases by providing the minimum standard, or higher quality, of care.

Medical directors must support their first-response teams when skills and knowledge are questioned by the public, fellow first responders, and hospital staff. Appropriate oversight, education, practice, and remediation will build confidence between medical directors and their first responders.¹³ One study by Studnek et al. quantified the amount of interaction EMS personnel nationwide had with medical directors. More than a third of respondents reported not having any contact with their medical directors within the past 6 months. Medical director involvement varies based on the EMS agency’s size, type, and setting (urban, rural, etc.).¹⁴ Medical director involvement, when provided consistently and appropriately, can be a powerful force that strengthens EMTs and paramedics.

Growth and Future Prospects
The field of EMS — and alongside it, the role of the EMS physician — is growing each year. Thanks to this rapid growth in the past few decades, the idea of medical direction is evolving and developing well beyond its humble beginnings, though much advancement is still possible.

A 2022 study at Penn State University reviewed all EMS fellowship programs in the U.S. since they were first created in 2010.¹⁵ Their systems and curriculums varied widely, and the outcome of those variations is unknown. Researchers suggested that programs share resources to allow fellows nationwide to have similar experience and training. More research is needed to better identify traits that have the most impact on high-quality medical direction. Individualized system-wide review is also needed to parse out the most effective and efficient means of medical direction for each agency.

The ultimate goal — improving the level and quality of care by prehospital providers — can be achieved through active and continuous involvement with EMS agencies and advancement of the scope of medical direction.

Take-Home Points

• Medical direction is a growing subspecialty within EM and more important than ever as prehospital care continues to increase and expand.
• A major responsibility of the EMS physician is medical direction of EMS agencies. This includes both direct and indirect control.
• Active and ongoing engagement with EMS agencies and positive interactions with personnel are keys to successful medical direction, which leads to improved personnel satisfaction and higher quality of patient care.
• Participation only to resolve issues or complaints can build a bad relationship and create negative feelings toward the EMS physician.
• Medical director involvement can be a powerful force that strengthens personnel within a system when provided consistently and appropriately.

References

1. Handbook for EMS Medical Directors. U.S. Fire Administration. https://www.usfa.fema.gov/downloads/pdf/publications/handbook_for_ems_medical_directors.pdf. Published March 2012. Accessed July 25, 2022.
2. American College of Emergency Physicians. Medical control of prehospital emergency medical services. Ann Emerg Med. 1982;11:387. doi:10.1016/S0196-0644(82)80371-5
3. American College of Emergency Physicians. The role of the physician medical director in emergency medical services leadership. American College of Emergency Physicians. https://www.acep.org/patient-care/policy-statements/the-role-of-the-physician-medical-director-in-emergency-medical-services-leadership/ Published October 2017. Accessed August 4, 2022.
4. Ross J, Flamm A. Emergency Medical Services (EMS). In: Bucher J, Chinn M eds. EMRA Fellowship Guide, 2nd Ed. Emergency Medicine Residents Association, 2018
5. National Association of EMS Physicians. NAEMSP position statement: Physician oversight of emergency medical services. Prehospital Emergency Care. 2017;21(2):281-282. doi:10.1080/10903127.2016.1229827
6. Sharkey-Toppen T, Kurth JD, Saadoon O, et al. State requirements for medical directors in the United States. Prehospital Emergency Care. 2022. doi:10.1080/10903127.2022.2098435
7. National Association of EMS Physicians. Guide for preparing medical directors. NHTSA. 2001. https://www.nhtsa.gov/people/injury/ems/2001GuideMedical.pdf
8. Cushman JT, Hettinger AZ, Farney A, Shah MN. Effect of intensive physician oversight on a prehospital rapid-sequence intubation program. Prehospital Emergency Care. 2010;14(2):310-316. doi:10.3109/10903121003760200
9. Greer S, Williams I, Valderrama AL, Bolton P, Patterson DG, Zhang Z. EMS medical direction and prehospital practices for acute cardiovascular events. Prehospital Emergency Care. 2012;17(1):38-45. doi:10.3109/10903127.2012.710718
10. Tataris K, Mercer M, Brown J. Translation of EMS: Clinical practice and system oversight from core content study guide to best practices implementation in an urban EMS system. Prehospital Emergency Care. 2014;19(2):302-307. doi:10.3109/10903127.2014.959224
11. Roger M. Stone, Kevin G. Seaman & Richard A. Bissell (2000) A Statewide Study of EMS Oversight: Medical Directors Characteristics and Involvement Compared with National Guidelines, Prehospital Emergency Care, 4:4, 345-351, DOI: 10.1080/10903120090941083.
12. Wuerz RC, Swope GE, Holliman CJ, Vazquez-de Miguel G. On-line medical direction: a prospective study. Prehosp Disaster Med. 1995 Jul-Sep;10(3):174-7. doi: 10.1017/s1049023x00041960. PMID: 10155426.
13. Cushman JT, Zachary Hettinger A, Farney A, Shah MN. Effect of intensive physician oversight on a prehospital rapid-sequence intubation program. Prehosp Emerg Care. 2010 Jul-Sep;14(3):310-6. doi: 10.3109/10903121003760200. PMID: 20397866; PMCID: PMC2946630.
14. Jonathan R. Studnek, Antonio R. Fernandez, Gregg S. Margolis & Robert E. O'Connor (2009) Physician Medical Oversight in Emergency Medical Services: Where Are We?, Prehospital Emergency Care, 13:1, 53-58, DOI: 10.1080/10903120802471964
15. Flamm A, Burch K, Lubin J, Mencl F. Characteristics of EMS Fellowships in the United States. Prehosp Emerg Care. 2022 Jan 25:1-6. doi: 10.1080/10903127.2021.2015023. Epub ahead of print. PMID: 34874808.