Today’s question is interesting as it’s a true forward thinking academic question.
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.