Hidden Crisis: Ethics Breakdown in Massachusetts

In June 2010, news broke of a recertification scandal involving emergency responders in Massachusetts. By the time the investigation was done, more than 200 EMTs and paramedics had received punishments ranging from suspensions to permanent revocation of credentials.

This case may have represented the single most egregious breakdown of EMS ethics ever—that we know of. It caused a significant uproar not only in Massachusetts, but across the nation and internationally. This article will explore some of the motivations of those involved, as well as possible causes and remedies for such situations.

Ethics Course

As noted above, suspensions were meted out over the scheme, which recertified providers who had not attended the required classes. Involved participants who wanted to become recertified were required to take an ethics course approved by the state Office of Emergency Medical Services (OEMS). This course was designed and presented by an independent contractor (the author) with OEMS approval.¹

It was designed not to review what the individuals had done wrong—they were well aware of that. Rather, the program was intended to overview current concepts and present a number of clinical situations as springboards for discussion of ethical issues. It was designed as an educational program to fill gaps in knowledge, not as a three-hour punishment session. It contained information on concepts of medical ethics, about 30 vignettes, a short section on professionalism, comments from colleagues, Massachusetts regulatory requirements and a review of the EMT Code of Ethics adopted in 1978.² Of that Code of Ethics, about a third of its 13 tenets were violated in this case.

The case vignettes went from simple to complex. The first involved a depressed elderly woman with a UTI telling an EMT she “just wanted to die.” What, participants were asked, would you do with this information if you received it? Another took the statement “I’m glad he/she isn’t my partner” and asked why people would make it and what implications it might have for them, their service and especially their patient.

The course was presented at different hours and locations a total of 17 times over four months. Some attendees registered in advance; others just heard about the class and showed up. The cost was $30, but was optional if students couldn’t afford it. At the end of the program, participants were asked to evaluate their experiences (see Figure 1). Most did.

Before being given to the providers involved here, the course was trialed five times as a continuing education program for different groups of noninvolved EMTs and paramedics. This comprised a control group. These students included three classes of mixed EMTs and paramedics with varying lengths of service who worked for a private ambulance service; a college EMS group consisting of relatively new EMTs; and a group of paramedics with different levels of seniority from different agencies including fire departments, municipalities and private ambulance services.

The program was ultimately given to 161 involved providers. Evaluation results were tabulated and graphed for comparison to the control group. Approximately halfway through the program, we added an additional data point for time of service in the field.

What Did We Find?

The results and conclusions surprised us. The problems we face are significant in both scope and depth.

The involved individuals were not new to the field: Their average time of service was 15 years. Their experience ranged from 4 years to 35, with 70% having been in EMS between 8–22 years. They had done at least two refreshers, and most had done significantly more.

In reference to the ethics course, more than two-thirds of both the control group and the involved group thought it was worth their time. Most could not remember having been taught the EMT Code of Ethics in their initial training or reviewing it since. But while 84% of the control group said it was important for every EMT to take such a class, less than half (48%) of the involved group believed so.

A surprising number in both groups—two-thirds of the involved providers and more than three-quarters of the control group—felt the course should be mandatory for all new EMTs.

What Were They Thinking?

A question in the last section of the course evaluation was thought to be its most critical: If you have ever signed in on a roster for a class you didn’t attend, what were you thinking?

Potential answers included:

• I am too busy

• This is a stupid requirement

• I don’t have to be refreshed—I do the job

• I’ve done this so much, I could do it in my sleep

• No other professional has to do this

• We should be a National Registry state

• I do this stuff every day

• Refreshers/CPR/ACLS classes are boring

• Everybody does it

• I was there for a while—I got a call/administrative duties pulled me out

• Not applicable, has never happened.

As expected, the vast majority of the control group (82%) marked Not applicable, has never happened. However, this raises the question of what happened with the other 18%. Additionally, 12% of the involved group said this was not applicable and hadn’t happened to them.

The major reasons listed by those involved for having signed off on rosters for classes they didn’t attend were:

I do this stuff everyday                                             21%       

I am too busy                                                          20%       

Refreshers/CPR/ACLS classes are boring                       20%       

Everybody does it                                                    19%.

Discussion and Recommendations

Perhaps the more enlightening information emerged from discussions that took place during the program. It became obvious we are causing significant problems for ourselves with the system that presently exists.

Individual Failures

The individual failures were patently obvious not only to the program leader but to the individuals themselves. It was apparent most of those involved knew it was not right to sign off on the rosters.

What they didn’t realize was the intensity of the anger with which their transgressions were viewed by the public and their colleagues. They were universally surprised, disheartened and mad at the universal condemnation of their actions. They did not understand that while the refresher was just a boring part of the job to them, the public at large views it as a recertification. Recertification is a method now used by all reputable medical practitioners to demonstrate they still have the talent, skills and knowledge to continue in their chosen profession. The public (our employers) want to know and trust that we can do the job we are doing. The public grants us a significant trust—based entirely on the jobs we do, not the individuals we are. They trust us with more information and rely on us more than any other emergency provider. They put us on a pedestal, whether we believe it or not. In return for this belief and trust, they expect and depend on us to be well prepared, professional and appropriate.

When we fail in this responsibility, the public is justifiably angry. These individuals (and a number of my coworkers) did not understand this.

For some individuals, their “EMS job” was secondary to what they considered their primary job: fire, dispatch, police or something else. Accordingly, they wanted to do anything possible to not invest in their refreshers. The good news is that this was a small minority.

They also didn’t have a basic understanding of ethics. The EMT Code of Ethics was hyperbole to them, a grandiose representation of what should be, not what actually is. No one took the time to apply the code’s teachings to day-to-day circumstances or to demonstrate how this wonderful document could apply to their street job.

We missed this boat years ago. There is a reason why ethics is a required course in every major business and law school in the country. It just took us longer to realize where we went wrong.

System Failures

We have allowed a system to survive that encourages these problems. The major problems noted in the program centered on refresher courses and timing.

Anyone in EMS for more than four years has probably learned to look upon refreshers with trepidation and angst. They can be rote and incredibly boring. Instructors who attempt to add variety and updated material are told by their superiors to “stay with the program.” Indeed, many instructors themselves abhor teaching refreshers.

We need to rid ourselves of the word and concept of refresher and substitute what the public really expects: a recertification. We need to prove to the public that we are current, not “refreshed.” Other professional organizations recertify their members and in doing so evaluate their competencies and current knowledge in their specialty areas.

Another option is tailored refreshers/recertifications. In this model, students take an extensive exam before a class begins. The class is then tailored to what the exam shows the students’ needs are. Areas the students master are not reviewed; areas where they score poorly are emphasized. In this way, the class focuses only on areas of actual need, and instructors have time for updating and new material—those things EMS providers attend continuing education programs to receive.

The downsides of this concept are:

• Class sizes must be kept small. This is the only way in which individual needs can be appropriately addressed.

• Instructors must be flexible and adaptable to meet students’ needs.

A final system failure is the two-year recertification model. Refreshing this often is costly and unnecessary. Continuing education is necessary to maintain knowledge and proper to require of all professional EMS personnel, and may be able to bridge longer intervals between recerts. Indeed, many providers would seek out and attend CE courses even if they were not required. One of the involved individuals stated, “Double my continuing education, but don’t make me take a refresher!”

If an EMT or paramedic were to join a new class of graduates and take a complete certification exam (reboarding, in other medical specialties), they could be comfortably certified for 4–6 years, having proven they have the core abilities to be recognized in EMS.

Ethics Training

A recent article by Craig Klugman, PhD, argued for an updated and appropriate set of ethics for EMS.³ Klugman cited a 1992 study that found that 14.4% of all EMS responses involved ethical conflicts.⁴ Now, almost 20 years later, we need to address these issues. We need to provide real ethics training for those involved in patient care that addresses conflicts we face in our day-to-day work—real situations that need to be viewed in realistic terms. This cannot be just a quick mention during the “roles and responsibilities” section of our initial training. It needs to be organized and appropriate for our day-to-day needs.

The implications of 18% of our cumulative control group admitting to claiming they attended classes they didn’t are enormous. In one of those classes, a paramedic refresher with both new and old individuals from mixed backgrounds (fire, public, private and third-service), 42% of the individuals did not check Not applicable, has never happened.

So just how deep does this problem run, and how long has it been running? The author remembers attending one of his first CE classes after being certified and being asked by a coworker, “Would you sign me in? Here is my EMT number.” That was 30 years ago.

Cheating is not new, nor is it limited to these individuals. There have been scandals involving EMS ethical missteps across the country. This case just happened to be especially large and well publicized.

Managers, regulatory agencies and individual providers in their own capacities need to examine this problem and find answers now. To wait is to ignore another ticking time bomb.

References

1. Medical Resources Group, LLC. Master Educator, Massachusetts OEMS.

2. Gillespie CB. EMT Oath and Code of Ethics, www.naemt.org/about_us/emtoath.aspx.  

3. Klugman CM. Why EMS needs its own ethics. EMS World 36(10): 114–22, Oct 2007.

4. Adams JG, Arnold R, Siminoff L, Wolfson AB. Ethical conflicts in the prehospital setting. Ann Emerg Med 21(10): 1,259–65, 1992.