Close But No Cigar: A Comparison of Paramedics and PAs

Welcome to my fourth installment in a series of guest editorials. My goal for these articles is to shake up and change the EMS establishment for the better. To do this, I need your help. Here’s one way you can participate: Drop me a line and let me know how you would change EMS as a career field. No area is sacred and all your ideas and opinions count. You can reach me at Docbeaker@aol.com. Put “Solutions for the Future” in the subject line.

Should paramedics be physician assistants (PAs)? Should we be PAs in the field? I broached this topic once before as related to nurses: Should paramedics be reclassified as Prehospital Emergency Nurses? Many of the responses to the nurse issue bordered on, “Yes, but please tell me there’s a better solution.” Maybe this is it. Maybe turning medics into PAs would be a good idea. Read on and I’ll try to convince you.

First, a little more about PAs, straight from the source—the American Academy of Physician Assistants (AAPA): Physician assistants are healthcare professionals licensed to practice medicine with physician supervision…PAs conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive healthcare, assist in surgery, and in virtually all states can write prescriptions. This definition comes from the Information About PAs and the PA Profession section at www.aapa.org. As I outline the comparisons, I think you’ll see that as far as two careers in the healthcare field go, we aren’t that different.

Paramedics are also healthcare professionals licensed or certified to practice medicine with physician supervision. I know some people say we don’t practice medicine, but we do. We practice medicine under our medical control physician’s license. We conduct physical exams, except we call them patient assessments.

We also diagnose and treat illnesses. I was taught in various EMS classes that paramedics do not diagnose. If that is true, then how do we know what to treat for? If I have a patient with pain, diaphoresis and ECG changes in all the right places, I’m going to diagnose a myocardial infarction and treat accordingly. The truth is that we diagnose illnesses and injuries every day we work on an ambulance.

Here’s one where we upstage the PAs: We don’t order and interpret tests; we choose the tests we run and interpret them ourselves. Regular-duty medics run ECGs every day and interpret the strips. We run fancy tests with names like pulse oximetry, capnography and blood glucose on a regular basis. Extended-practice medics test blood gases.

We also counsel on preventive healthcare. When we have long transports or the call isn’t an emergency, we often sit beside the stretcher and talk to our patients. I’ve spoken to patients about smoking and obesity. I’ve encouraged new mothers and young babysitters to attend infant/child CPR classes. Paramedics are usually the first line in preventive healthcare, although we seldom realize it.

While certainly regular-duty paramedics don’t assist in surgery, interns in paramedic school are frequently allowed to view surgeries. Some paramedics actually perform surgical procedures as part of their job. Surgical cricothyroidotomies, chest tubes, central catheters, postmortem cesarean sections and field amputations are only some of the surgical skills that many paramedics in the United States are authorized to perform.

PAs do not even have us on the prescription medicine issue. Webster’s Dictionary defines a medical prescription as a designation or order for the use of a treatment or medicine. We are prescribing every time we give aspirin, epinephrine, morphine and so on, are we not? While we may not write prescriptions to fill at a pharmacy, we do prescribe medicines.

What about the differences between medics and PAs? The two main ones I see are education and salary.

Physician assistants are trained using the same model as doctors. This model is used because PAs work closely with physicians and for all practical purposes act for physicians in many settings. The majority of educational programs require a bachelor’s degree prior to entering. Many pre-PA students take the same pre-medical courses as aspiring doctors. Once the student graduates PA school, he is awarded a master’s degree.

This is the case at the physician assistant program at the Medical University of South Carolina, near my home. A graduate student in MUSC’s PA program must complete a 27-month program that begins with 15 months of coursework and ends with 12 months of clerkships in various medical specialties. The end result is a Master of Science in Physician Assistant Studies.

Upon receiving their degrees, all prospective PAs take a national certification examination. Every subsequent two years, they must complete 100 hours of continuing education. Recertification occurs every six years.

To receive an associate’s degree as a paramedic at Greenville Technical College in South Carolina, my alma mater, students with at least a high school equivalency must complete a 24-month curriculum. The curriculum includes 60 semester hours of classroom education and another 13 semester hours of clerkships in EMS internships and hospital clinical time. Paramedics are also subject to continuing education and recertification requirements.

While the prerequisites are not the same, the actual education time and intensity aren’t that different in the two programs. However, PA courses revolve around hospitals and physicians for the most part and encourage students to know everything, or at least know where to look it up. In contrast, paramedic degrees revolve around EMS and emergency rooms and encourage paramedics to know everything, because you don’t have time to look it up and your partner may be your only backup.

As far as salaries go, according to the Occupational Outlook Handbook published by the U.S. Department of Labor, the median annual salary for PAs in 2002 was $64,670. The highest 10% earned more than $90,350. For paramedics, the median annual figure was $24,030 and the top 10% earned upwards of $41,980.

Although there are many variables that go into the reasoning behind the salary gap, I see two as having the most impact: education level and place of employment. Paramedics are not required to have a degree to be certified, whereas PAs must go through an accredited degree program, often a master’s degree program. Medics are often employed in private, nonprofit or government jobs. PAs are employed in the military as officers, in hospitals and in doctor’s offices.

I don’t believe that medics and physician assistants will ever merge professions, although I can always dream. I also don’t believe we’ll ever see PAs as regular crewmembers on ambulances. Not many systems would be willing to pay their salaries, nor would many PAs be willing to take a large pay cut. However, because of the unique education and responsibilities required as a paramedic, I believe the most equitable solution is for paramedics to become PAs. I’d hate to lose experienced providers to the world of hospital medicine, but just think, a few more years of education and you could double or even triple your salary.

In that frame of mind, I believe an alternative needs to be looked at for experienced paramedics. PA programs should look into fast-track programs for medics. Once a few of our best medics become PAs, maybe they will start working the medic-PA idea from that end of the spectrum. As paramedics learn more and more skills and expand our efforts into new arenas, something new will have to be done, not only to license us higher up the medical food chain, but also to pay us for what we do.  

INSURANS RAWATAN DAN KESIHATAN SEMAKIN DIPERLUKAN

Pada masa sekarang, permintaan untuk rawatan perubatan dan perkhidmatan penjagaan kesihatan di Malaysia adalah sangat tinggi. Ini adalah kerana semakin ramai orang menghidapi penyakit yang dikaitkan dengan tekanan pekerjaan dan juga dengan taraf hidup yang lebih baik. Pada masa yang sama, kemajuan dalam bidang perubatan juga membolehkan orang ramai menikmati jangka hayat yang lebih panjang. 

Terdapat dua jenis program perkhidmatan penjagaan kesihatan untuk rakyat Malaysia sekarang ini - satu adalah di bawah pengelolaan Kumpulan Kewangan Simpanan Pekerja (KWSP) dan yang satu lagi adalah polisi insurans rawatan persendirian. 

Pencarum KWSP dibenarkan mengeluarkan sebahagian daripada carumannya untuk perbelanjaan perubatan bagi penyakit kritikal. Bagi mereka yang bukan merupakan pencarum KWSP pula, mereka boleh membeli polisi insurans rawatan persendirian yang mungkin termasuk pelan penghospitalan. 

Beberapa organisasi pernah menyeru supaya satu skim perkhidmatan penjagaan kesihatan kebangsaan yang mengutamakan hak kesaksamaan dan keadilan dilaksanakan. Hak kesaksamaan merujuk kepada kemampuan untuk mendapatkan rawatan kesihatan dan hak keadilan adalah mengenai peluang bagi setiap orang untuk mendapatkan rawatan kesihatan yang terbaik. 

Malaysia masih belum mencapai tahap seperti negara maju yang mempunyai skim kesihatan insurans kebangsaan untuk rakyatnya. Namun, sudah terdapat beberapa cadangan untuk melaksanakan skim seperti itu. Kebanyakan daripada cadangan tersebut bermula dengan satu skim pembiayaan. 

Perkhidmatan 

Satu kajiselidik mengenai skim perkhidmatan penjagaan kesihatan yang dilaksanakan di negara lain menunjukkan bahawa skim tersebut biasanya dibiayai oleh empat sumber utama iaitu melalui cukai langsung, insurans sosial wajib, insurans kesihatan persendirian dan skim yang dibiayai oleh individu itu sendiri. Kebanyakan skim pembiayaan merupakan kombinasi keempat-empat sumber tersebut. 

Rancangan Malaysia Ketujuh telah mengesyorkan penubuhan Lembaga Pembiayaan Kesihatan Kebangsaan sebagai badan tunggal untuk membiayai skim penjagaan kesihatan kebangsaan. Namun sehingga kini, rancangan tersebut masih belum terlaksana. 

Terdapat juga beberapa cadangan yang mengesyorkan bahawa setiap orang membayar sejumlah premium kepada lembaga pembiayaan. Jumlah ini haruslah sama bagi setiap individu tanpa mengira umur, jantina, bangsa atau keadaan kesihatannya. Ini adalah untuk memastikan yang prinsip asas hak saksama itu terpelihara. 

Ianya juga adalah untuk memastikan bahawa mereka yang miskin dan menghidapi penyakit serius tidak terbeban dengan tanggungjawab kewangan yang berat dan mereka yang berisiko tinggi turut dilindungi. 

Jenis perlindungan ini dirujuk oleh sesetengah pihak sebagai insurans yang dinilai mengikut kadar komuniti. Prinsip ini adalah berbeza daripada konsep insurans yang dinilai mengikut kadar risiko. Mereka yang memerlukan perlindungan tambahan boleh mendapatkan insurans rawatan persendirian jika mereka mampu. 

Pembiayaan kos penjagaan kesihatan bukan sahaja merupakan tanggungjawab seseorang individu tetapi juga pihak majikan dan kerajaan. Seperti skim KWSP, kedua-dua pihak pekerja dan majikan boleh mencarum beberapa peratus tertentu daripada gaji kepada skim pembiayaan penjagaan kesihatan. 

Bagi individu yang tidak bekerja dan terlalu miskin serta tidak berkemampuan untuk mendapatkan perkhidmatan penjagaan kesihatan, pihak kerajaan pula boleh memberi peruntukan tambahan yang dikumpul daripada cukai langsung 

Penjagaan 

Skim penjagaan kebangsaan bukan sahaja merangkumi aspek menyediakan perkhidmatan penjagaan kesihatan kepada semua lapisan masyarakat tetapi juga untuk memastikan yang kos pembiayaannya adalah setimpal bagi semua. 

Satu lagi aspek yang memerlukan pertimbangan serius untuk menjadikan skim penjagaan kesihatan kebangsaan lebih efektif adalah melalui penggabungan perkhidmatan penjagaan kesihatan swasta yang sedia ada dengan perkhidmatan penjagaan kesihatan awam. 

Kedua-dua sektor ini harus saling melengkapi dan bukan bersaing antara satu sama lain kerana pada dasarnya perkhidmatan yang diberikan adalah serupa, begitu juga dengan sasaran pelanggannya. 

Dengan mengintegrasikan kedua-dua sektor ini, ia akan lebih memanfaatkan orang ramai. Perkhidmatan yang diberikan juga boleh diseragamkan. 

Buat masa sekarang kerjasama di antara dua sektor ini sudah wujud. Bagaimanapun, integrasi yang lebih luas akan lebih memanfaatkan orang ramai. 

Sistem penjagaan kesihatan di Malaysia pada masa sekarang adalah sangat kukuh. Ia telah dibina di atas landasan yang kuat dan mempunyai rangka yang fleksibel dan boleh diubahsuaikan mengikut keadaan semasa. Taraf kesihatan di negara ini juga setanding dengan negara maju walaupun terdapat banyak kelemahan yang boleh diperbaiki mengikut masa. 

Untuk melaksanakan program penjagaan kesihatan kebangsaan, Malaysia tidak perlu melalui setiap peringkat proses pembelajaran. Ia boleh belajar daripada pengalaman negara lain dan mengorak langkah ke hadapan dengan lebih pantas. Tambahan pula, di Malaysia sudah terdapat perubatan digital iaitu "teleperubatan" dan sistem komputer dalam talian bagi sesetengah perkhidmatan yang disediakan oleh pihak hospital. 

* Rencana ini disediakan dengan kerjasama Persatuan Insurans Hayat Malaysia (LIAM). Rencana yang telah disiarkan boleh didapati melalui laman web LIAM www.liam.org.my.