Today’s question is interesting as it’s a true forward thinking academic question.
I’m asked:
Now that paramedics are a registered health profession, I’ve had the same conversation with quite a few colleagues who, like me, envision fully autonomous paramedic practitioners becoming a reality in Australia. Those conversations usually revolve around the question ‘what next?’ in terms of expanding the capabilities of the profession. As far as we can see there are four major legal hurdles: (1) the ability to bill directly to Medicare, (2) the ability to prescribe medications, (3) the ability to refer to medical specialists, and (4) a ‘drug license’ (for lack of a better term) that allows us to autonomously take authority for medications, i.e. paramedics taking ketamine out of a pharmacy under their own authority for their medical kit in a trekking expedition they’ve been hired to take care of. I recognise that some paramedics in some parts of the country can do some of these things, but I don’t believe there are paramedics anywhere in Australia that can do them all.
My question for you, from your perspective in law, is this: do you think these are all necessary, and do you think that in sum these four would be sufficient, or do you believe that there are other major steps that we need to take to become fully autonomous medical professionals?
I suppose one cannot answer the question until you define what you think makes a professional a ‘fully autonomous health care professional’. I don’t think paramedics should aim to be ‘fully autonomous medical professionals’ because they are not medical practitioners, they are paramedic practitioners – they should aim to create a unique space for paramedics.
Personally, I think the most important step would be ‘a ‘drug license’ (for lack of a better term) …’ When the right to carry, supply and administer drugs comes with registration then paramedics are trusted health care professionals with an ability to create their own practice environment.
Having a Medicare provider number and being able to bill Medicare would certainly assist paramedics to develop an effective business model but there could be other ways to manage a business eg fee for service as event paramedics or billing health insurance companies for patient transport. One doesn’t have to charge the patient so having relevant Medicare items and an ability to charge Medicare would, I think be helpful for paramedic business but – and without having an explicit definition of what constitutes a ‘fully autonomous health care professional’ in mind – I don’t think it’s essential to demonstrate professional autonomy.
The right to prescribe medication and refer patients to other health care practitioners would certainly open up business and practice opportunities particularly in extended and community care paramedicine. Both would demonstrate ‘autonomy’ as the paramedic could form a view of the patient’s condition and provide care without having to refer them to a third party, ie a doctor.
This takes me back to an earlier point which is that paramedicine is not medicine. So one needs to think about what sets paramedicine apart from medicine. Paramedics don’t need to be ‘almost doctors’ (which of course is odd, given the root of the word ‘para-medic’ but whatever the linguistic history behind the word paramedic, it’s a word that’s taken on its own meaning with registration). If paramedics don’t have to be as close to ‘medical practitioners’ as possible then they have to define what are the essential issues of paramedicine. If paramedicine is about out of hospital care, and in particular out of hospital emergency care, then I think the need for prescribing and referral is less important than the right to carry drugs.
At the moment paramedics are registered health professionals but the right to carry an essential tool of their trade, the drugs they use for the benefit of their patients, belongs to their employer. Until that is resolved they are not truly independent health professionals because they need their employer’s permission to practice their profession. When that’s attended to then they will, in my view, be ‘fully autonomous health care professionals’. The other issues – Medicare, prescribing and referral will help define and dictate what paramedic practice looks like. They would be useful to give paramedics the widest scope of practice and communities the benefit of practice. But my answer to the question (remembering that I’m not a paramedic) is the essential step is a drug authority that comes with registration, not employment.
Another issue, I’m not sure if it’s required to ‘become’ fully autonomous health care professional or will be evidence that the profession has achieved autonomy, is to be personally accountable for decisions. This is an idea that Megan Jane-Johnston raised in her book ‘Nursing and the Injustices of Law’ (W.B. Saunders/Bailliere Tindall, 1994). Her argument (if I remember it correctly) was that whilst nurses were not sued because they were employees of institutions and were simply following ‘doctor’s orders’ they were not and could not be considered independent professionals. It is still the case that we rarely if ever see nurses getting sued because they nearly always practice as employees. Equally in cases where paramedics are allegedly negligent it is their employer who is the defendant. When paramedics start having their own business practices and their own independent relation with patients then that may change. It may not be an indicium anyone wants, but it is I think an interesting argument. If paramedics could charge Medicare directly, prescribe medication and refer a person to a specialist, then it would certainly be the case that they would be personally liable for their decisions and that would indicate that they are indeed truly autonomous professionals.
Having said that I think (without rationalising the arguments in full) that those issues would expand the ways paramedic could practice and could help widen the definition of what paramedicine is, but they are not essential for saying that paramedics are able to practice as autonomous paramedic practitioners.
But at the end of the day, defining what is or are the essential elements of paramedicine is not for me; it’s for the profession and bodies such as the Australasian College of Paramedicine. Once there is some consensus on what it is to be a paramedic – what is essential to paramedic practice – then it will be possible to define what is required to ensure that paramedics are truly autonomous health care professionals. Registration was a critical first step.
Australian Emergency Law 
Very interesting discussion Michael, thanks for that. I think your differentiation between what advances professional stature (for lack of a better term) and what would facilitate a paramedic business model is important and insightful, and not a differentiation I had considered. I also agree that until paramedics are held responsible for their own practice we will continue, in a sense, to be less ‘autonomous practitioners’ than we are ’employees’. As nice as it currently is to be able to hide behind the excuse “my Medical Director made me do it!” there will be responsibilities and privileges that come with us being held directly accountable for our own actions.
The responsibility is obvious – it will be us on the stand defending our actions, not our employer, and that’s an intimidating prospect.
But I believe the privilege that comes with this accountability will be that when our employer attempts to dictate that: ‘you MUST do the following’, we will have the right to respond by saying “I’m wholly responsible for what I do, so I get to choose what that is. You have no right to dictate what I may or may not do when I am the one who will be held accountable. for the consequences of my decision. So I’ll take your opinion on board, but at the end of the day MY practice is MY responsibility, not yours.” That will be a big change in the culture of our practice.
I guess the definition of what a paramedic ‘is’, is still really up for discussion. To me (for what it’s worth), I see paramedics in Australia becoming much like what we see in the UK. I spoke with a UK MD who had moved to Australia fairly recently and he said “I think paramedics are like the best possible cancer in health care in that they’ve metastasised into every setting in the NHS. You can’t go anywhere without working with paramedics”. I see paramedics occupying much the same role as Physician Assistants do in North America, or as Nurse Practitioners do in some cases here in Australia. I think a core element of what defines a paramedic is their fluency and familiarity with acute resuscitation and trauma. That’s what most people think of when they think of paramedics, and I think it’s correct for them to do so. I wouldn’t like to see us lose that historical ‘core’ to the profession. But I think we are, and should, be able to step up to more advanced levels of practice.
I think that paramedics employed by the Jurisdictional Ambulance Services should have extensive training which would allow them to essentially act as the now-long-gone mythical family physician who would come out at night, have a look at the patient, and then either treat them on the spot (if possible) including dispensing prescriptions, and/or refer them to an appropriate pathway in the health care system – either sending them to their GP for follow up (with a report sent to the GP electronically), or sending them directly to a specialist, or, directing/transporting them to the emergency department.
I also see that paramedics have a role in EDs and Coronary Care Units. They could also work in much the same way that Nurse Anaesthetists do in the United States. I had an outpatient procedure done a little while ago and an anesthetist administered midazolam to me for twilight sedation. I think paramedics can do that very capably and be much less expensive than anesthetists are.
I think paramedics have a role in primary care, especially in rural and remote medicine. I also think that paramedics have a role in interfacility critical care transport which could be much more comprehensive than it currently is in Australia. For example, in Ontario (Canada) there is a province-wide network of paramedics who perform interfacility critical care transports at a level that would be described as ‘Retrievalist Practitioner’ here. They work without doctors or nurses on board on land and aircraft (I’m referring to Ornge).
Whether is Physicians Assistant, Nurse Practitioner, or Paramedic Practitioner I think there is much in health care that can be done by a masters-degree-level ‘Advanced Care Practitioner’, working in conjunction with doctors. Much of what physicians do COULD be done by Advanced Care Practitioners, whether PAs (though Australia seems to have decided not to encourage that model), Nurse Practitioners, or Paramedic Practitioners. However amorphous a vision or definition that is, it’s the general direction that I see our profession moving in.
As always, thanks for the thought-provoking posts, we’re lucky to have you as a member of our community.
Having practiced in South Africa for most of my career, we that were paramedic by definition and registration ie in some form on par with Australian ICP’s with in most cases greater scope in terms elective procedures in particular to invasive and ICU transportation which included ventilation, negative and positive inotrope support etc. practiced as independent practitioners.
The rest of the EMS personnel were registered as supervised practice. With independent practice came the possibility to practice independently, register a personal vehicle as an emergency response vehicle, start an EMS service, provide emergency medicine outside a particular employer. In fact a large cohort often worked independently. In this form all medications on scope that were issued or acquired by the paramedic whether by service or self from pharmacy had to kept on the practitioners personal drug register, if issued by service the personal drug register has to correlate to service register.
So i guess this concept of autonomous or independent practice for paramedics in not unknown. With that I fear we may be light years away from that in Australia. Jury is out as to whether that is good or bad.
Please see link below, it has been a decade since I practiced as a independent registered paramedic/ flight / intensive over there
but I believe practice has not changed much.
https://www.hpcsa.co.za/