For EMS’ers, Is PA School Just the Next Thing to Do?

“Why do most people get married?” asked my young, “cool” religion teacher at my Catholic high school about 20 years ago.  After a few answers about finding love and soul mates, he shook his head no.  “Most people get married for the same reason people go to college, get jobs, and have children.  Because it’s the next thing on the list to do.”  He explained that this society puts pressure on people to do things within a certain time frame, and that something must be wrong if you haven’t accomplished those things at a given age.  Nothing on the list has any validity.  If you make big life choices based only on that list, he explained, you will not find satisfaction after completing the next thing on it.   

For  EMS people in the US, I’m afraid, the next thing on a list is to leave.  After about 5 years as a paramedic, the calls you ran yesterday looked similar to the ones you will go on tomorrow, and five years from now.  Even the interesting calls don’t seem as interesting as they used to, and they become more and more spread out.  When you reach the point where you’ve mastered the protocols, there’s little room for clinical growth.  Even if you enjoy the work, there is an expectation that it is a stepping stone to something else.  People ask if you’re still a paramedic, and then how much longer you plan to do it for. If you do it longer than what others believe is too long, they think something is wrong with you. 

For the people who do leave, I wonder if that decision leads to the fulfilment they hoped it would.  I have seen a lot of good EMS people become physician’s assistants, both at the minimum-wage McAmbulance and higher-paying, clinically-advanced municipal services I have been with.  It seems like a logical next step.  Unlike nursing, you start out as a master’s level clinician.  According to Wikepedia, the average starting salary is $90,000, and $100-200,000 for ER and surgical sub-specialties.  PA’s also seem to work fewer hours and have more flexible schedules than EMS agencies.  There seems to be no shame involved in staying with the profession.  There’s nothing unusual about PA’s working for the same employer for decades.

The career field started around the same time as paramedics in the late 1960’s and grew in the 1970’s, and also has its roots in the military.  While we word indirectly under a medical director, the physicians they “assist” may be at a remote location and simply review their charts days later. Unlike paramedics, PA’s have embraced formal education.  It takes 5-7 years of post-secondary education to become a PA while we still squabble over the hours it takes to become a paramedic.  This gives them a more in-depth knowledge base than we do about many things.  Take spinal clearance as an example.  Rather than really assess patients for spinal injuries, we are taught to assume that everyone with a bump on their head has a broken neck and should be immobilized.  Once we arrive at the hospital, a PA often determines if it is safe to clear them off the board.  There are also areas to specialize, which is something paramedics in this country do not have yet.  In 40 years, PA’s have managed to become a respected, organized, and well compensated profession.  In EMS, we’re still trying to find our identity, much less communicate to the public what it is. 

While PA’s enjoy respect and high salaries (important, but not the most important factors in a career change), I wonder if former EMS people really end up with more satisfaction in the day-to-day work.   When you work in a hospital or office, you’re expceted to look busy the whole time you’re there.  There’s no such thing as leisure time between calls.  PA’s in most emergency departments I’ve seen work in fast track, and deal exclusively with the low-acuity patients many EMS people complaint about.  At the end of the day, is that better than managing patients by yourself, some of them very sick, and helping them feel better?

I guess I want what PA’s in the US, and paramedics in other coutnries have.  I want us to value longevity, embrace formal education, and to develop areas for us to specialize.  I want paramedics to be organized and united under one mission, and for the communities we serve to know what it is. 

And when the best paramedics look for the next thing to do, I want them to be able to find it as paramedics.  I wish more of them would hang around to make EMS that way.


  1. I’ll be starting a PA program next year. I mirror most of your thoughts; I would like to stay with EMS, but it’s so difficult to make a career there in the current environment that it often ends up being masochistic. (As Thom Dick says, no matter how much you love it, it’s not going to love you back.) As a clinician there’s little career arc, job stability, or room for growth.

    I do think that PA is a sensible path for those who want to practice medicine. Medical school is an option, but for those who have already developed meaningful careers in EMS, I think the transition to PA can be more natural and (particularly if you’re older) more feasible. The bug may never leave you, but I hope there’s still room in life to work the occasional shift on the ambulance or maintain other involvement with the field.

    For what it’s worth, the actual use of the PA varies wildly by region, facility, and affiliated physician. At least a couple of the Boston-area hospitals use them in the ED as non-acuity-tiered resident equivalents; they see their own patients from the general pool and the attending is merely available for any necessary consultation. In some rural areas they may be the only practitioner in the ED. Much depends on your experience and so forth.

    I do find it interesting that, although the profession has developed fairly well, in some cases PAs still face similar “image” problems to EMTs and medics. The average layperson may have no idea what they do, their level of training, or even what their initials stand for… and the average medical professional may have mixed opinions of their competence and appropriate role, due to varying degrees of professionalism and passion for medicine exhibited by their colleagues. You may still have to prove yourself most days… but that’s nothing new for us, right?

    • emspatientperspective says:

      Thanks Brandon. I am sad that you’ll be leaving EMS as your primary profession. A lot of EMS workplaces are masochistic, but we contribute to that. We’ve made EMS so easy to get into that there’s an endless supply of new people to replace the ones who leave. My boss at McAmbulance frequently reminded us about how replaceable we were. I hope that enough smart EMS people hang around (with help from the people who stay involved after leaving) to build room for clinical growth and stability.

      • Yes, I agree. And I do feel a little cowardly running instead of staying to fight that fight. But I just don’t have it in me to give my life to it. I’ve said that if EMS has sorted itself out somewhat in ten years, maybe I’ll be back on the road.

        I do wonder if midlevels might play more of a role in the whole community paramedicine model, but my hopes are cautious. As inefficient as it is to bring all these patients to an emergency department, I’m not sure it’s any more efficient to send around practitioners to see them one by one.

        • emspatientperspective says:

          I certianly don’t blame you. I’ve thought about PA school myself, and sometimes think that staying to fight is an excuse for me to keep doing the job I’m comfortable with. As far as community paramedics, I agree that it inefficient to visit patient’s one-by-one. I interpret the logic as being that they are going to call 911 at some point anyway, so it is better to visit them when it is convenient for us and hopefully prevent one. It also justifies making paramedics available to rural areas if they have something to do between 911 calls. We’ll see.

          • A lot of people talk about that inertia (“I was just gonna do this for a year, then I turned around and it was ten”), and I don’t think it’s necessarily so evil. We all like doing things we’re good at, and it’s hard to leave that to be the new guy in a different setting. And you’re right that the work environment (and patient dynamic) is unique for in EMS; I think that’s a bug that never fades for some people.

            Either way, drop me a line anytime if you’d like, I’d be happy to share some of my experiences.

          • emspatientperspective says:

            Thanks Brandon. Will you be staying in the Boston area? My sister lives there, and we should meet the next time I go visit her.

          • Either Boston (MCPHS) or more likely Maine (UNE in Portland). Let me know if you float through, I’d love to meet up.

  2. It’s a route I’ve prepped for “way back then” and couldn’t afford. Now I make more $, but I have a family, and still can’t afford it, and my core prereqs are too old, so I’ll have to go back and repeat them, but I still want to go to PA school. ALS is rare and can take, literally, hours to get in most of my state. I want to be able to work as a MLP in rural areas, responding in a chase car with or after an ambulance to keep people out of ER’s who don’t need to be there, give them a weekend dose of antibiotics or whatelse is needed, and schedule them for a primary care appointment. It should help save the systems a little $. Rural areas are also sorely understaffed for advanced care services, like critical care transports. How can you take the only RN at a rural hospital away for a transport because the flight team is grounded. Basics and Intermediates shouldn’t be taking premies, cardiac patients, infusions and vents on long-distance transfers. I can also work the ER/ICU between calls and teach EMS providers.

    Maybe if the fiscal cliff has an invisible safety net just over the edge, then those federal funds that pay back your student loans in exchange for a couple years of contract rural hospital service will still be there in two more years and I can go on to PA school and work in my favorite areas. It beats 4 more years to go to med school, plus three more for residency, plus more for specialty.

    Incidentally, you said, “If you do it longer than what others believe is too long, they think something is wrong with you.” You know, after 18 years, I can confirm that there really is something wrong with me. 🙂

    • emspatientperspective says:

      Thanks Unwired. It’s funny. When I started out with McAmbulance, my partner and talked about the expanded scope of practice for paramedics. He explained that people become paramedics to be superheroes. We want capes, not prescription pads. I hope that one day paramedics can do the things that you mentioned in rural areas. I think we’re getting closer but we’re going to attract people besides aspiring superheroes. That will require a fundamental change in our initial education.


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