Introduction

The emergence and maturation of the specialty of emergency medicine has spawned and nurtured the development of EMS. In turn, EMS has become a subspecialty of its own, attracting a subset of emergency and acute care physicians whose focus of technical expertise and clinical acumen has been directed to the provision of care from the moment of system access to the arrival of the patient at the emergency department [1]. The original EMS medical directors were those individuals fascinated by the possibility of extending “sophisticated” methodology to the patient at the scene. Equally intriguing to them was the opportunity to provide this technical sophistication using individuals operating under the broad-based concept of “extension” of the physician. Not surprisingly, and by the very nature of EMS itself, those physicians attracted to this subspecialty of emergency medicine were captivated by the eclectic and unique attributes of medical practice in this complex arena.

They were soon faced, however, with daunting challenges concerning their own creativity in an equally complex arena, the political one. The multiple interfaces required of the medical director, within and outside the medical community, have created an especially challenging section of emergency medicine practice, where technical expertise by itself proved insufficient in creating a workable system. While the magnitude of this challenge is attractive for some physicians, the emotional energy required and the intense, continuous interaction in the political arena may cause an abbreviated career for even the most innately passionate physicians. As with most areas of medicine, if not life itself, an “apprenticeship” is the means of conveying a “practice” from veteran to neophyte. The growth and development of training programs in emergency medicine, while initially tentative in developing “fellowships” in EMS, have now witnessed substantive progress. In turn, this has hastened the exposure of young physicians to the political realities incident to EMS system development and sustenance.

While there are numerous structures within which the medical director may work (full-time academic; full-time public safety with academic affiliation; part-time volunteer), none guarantees success. The skillful political behavior of the physician in his or her role ultimately determines the success of system function, and may even alter the administrative structure within which the physician resides.

Politics and economics are omnipresent forces with which the medical director must work as he or she attempts to craft and manage an EMS system. These “forces” are usually not familiar, understood, nor embraced by individuals who originally entered the field of medicine in pursuit of the satisfaction derived from patient care. Many opportunities for frustration and disappointment thus await the unwary and idealistic physician who fails to acknowledge these forces, or is unable to master their elements. Similarly, those physicians who appreciate the “leverage” to be gained from an understanding of politics and economics will be rewarded by the growth and development of their systems. Some thoughts and perspectives are herein shared with the interested reader to enable a means of creatively employing these forces for the ultimate benefit of the patient, and the community.

For most physicians, the difficulty, indeed the resistance to comprehending the political climate in which EMS activities are crafted is deeply seated. How many physicians entered medicine because of a love of politics and economics? These are not motivating factors frequently identified by anyone in medicine. In addition, few individuals can provide an apprenticeship for the aspiring medical director that addresses the political realities requiring mastery.

Residency programs are now committed to providing a formalized experience in EMS. Still, the attempted metamorphosis of the clinician into a political “statesperson” is far more complex and arduous than the acquisition of technical expertise in the field. Further, the frequently misperceived position of physicians as “superior” to other members of the health care team seduces them into behaving as such with non-medical individuals, with predictable and disastrous results. Political acumen, if not prowess, must be forged slowly, over time, and with a mentor (an “Obi-Wan Kenobi” of sorts) who nurtures the individual physician.

The disaffection for politics found inherently in most health care providers arises perhaps from the physician’s affiliation with the precepts of the “craftsman.” As one of four “corporate types” defined by Maccoby in his seminal book, The Gamesman [2], the craftsman experiences perhaps the greatest disparity between the reality and the ideal. It is most difficult for this individual to juxtapose the desired medical goals of a “perfect” EMS system with the political realities found in any community. Friction between value systems surfaces. For most, the emotional cost produced by this paradigm discordance is high, and for some it is too great to sustain a career of permanence in this aspect of practice of emergency medicine. In the pursuit of quality, however, the craftsperson is handicapped by the lack of a definition easily communicated to the political veterans in the community. Quality, as with style, class, poise, and pornography, tend to be attributes of human behavior which are recognizable but poorly articulated. Political awareness is not usually found embedded in the “genetic code” of the health care practitioner. At most, it remains a dormant gene which needs to be “turned on.”

While many definitions of politics abound, it is based, practically speaking, on an attempt to engender, gather, manufacture, or express consensus. The relationship to the technically “ideal” system, at best, is viewed as oblique, from the perspective of the scientifically forged physician.

The genesis of EMS systems is not founded on logic and rationality. These attributes are not legal tender in the political community. He who possesses the power or the money, and who “sleeps” with whom, are more often the determining factors.

While the medical director may desire an arena devoid of political influences, this is as impossible to achieve as eliminating the vagaries of human behavior itself.

Case studies

Examples of the influence of politics in medicine are ubiquitous but often subtle. Even in the most academic aspects of EMS, such as the creation of medical protocols for providers (e.g. ACLS), the political process is operative. Most obviously, legislation to enact seat belt, helmet, and drunk driving laws must of necessity enlist widespread public support in the very citadel of the political process, the statehouse. Between these two extremes, political processes are operative to varying degrees. Examples include:

• determination of hospital destination policy for ambulances
  
• trauma center designation
  
• creation of a combined (unified) communications center
  
• participation of a hospital in an emergency medicine residency, helicopter program, etc.

Specific examples of the use of the political process abound, but are difficult to scrutinize from a distance. They are known only by those involved in the creation of a specific program, and shared infrequently and usually in confidence. Yet it is only through the process of sharing case studies that the “apprenticeship” process is actualized. Clearly, forums to achieve this are necessary, on a local and national scale.

As an example, the unification of the Denver EMS system in 1979 lacked the formalized participation of the fire department. A plan was drawn up to achieve such formalized control, and assure the competence of the firefighters, serving in their capacity as first responders. When presented to the fire chief, it was found unacceptable for a variety of reasons, not the least of which was the perception of power ceding to physicians at Denver General Hospital (now Denver Health). This medical director then donned firefighter’s clothes and, after direct observation and participation with firefighters in the provision of emergency medical care, designed a curriculum for first responders. This was joined with the course of the same title by the Department of Transportation, and gained acceptance within the fire service. More importantly, the educational process and the creation of a more formal involvement of the fire service were embraced by a sufficient number of city officials to encourage a “reevaluation” of the position taken by the fire chief. Ultimately, a document prepared by the physician emergency medicine staff, and acceptable to the fire service, was issued as an executive order by the mayor. The process took 2 years. While the process was cumbersome, the outcome has proven durable.

The emplacement of paramedic presence at Stapleton International Airport, and subsequently at Denver International Airport, provides another example of the political process in EMS systems design [3]. The growth of the population in Denver at the periphery of the city (the social epiphyseal plates of the community) produced an area of increasing demand for EMS services. As response time increased, complaints were heard from members of the city council whose constituents populated these areas. The support of council members was obtained through a citizen oversight council, to enable funding of a paramedic response unit on a golf cart at the airport. The latter site was chosen because of its identified volume of calls (approximately 5% of system total at the time), and the large number which were fraudulent, cancelled, or refused. By providing paramedic presence at the airport, triage could now be accomplished by system paramedics, redirecting ambulance-based paramedics to those who were both ill and willing to be transported. By encouraging the airport to financially support the endeavor, a public relations benefit could be realized, and overall system performance improved without additional cost to the fiscally strapped municipal hospital.

The citizen oversight council and the City Council were publicly praised for their insightful and creative address of a technically complex, operationally driven solution to the problem. The paramedic presence has been increased over the years, consonant with growth of the new airport facility (Denver International Airport). By avoiding the obvious solution of increasing the number of ambulances serving the entire system, the overall number of paramedics remained small (maximizing individual experience rate) and increased efficiency was gained. City ambulances were now available for more calls, as a delegated, dedicated, and focused solution for the airport population had been created. A byproduct of the new system was the more rapid availability of Advanced Life Support care at the airport to passengers and employees. Were this the initial objective of the project, it is highly unlikely that the Stapleton International Airport Mobile Paramedic Unit (SIAMPER) would have been emplaced, simply because most passengers at the airport do not vote in the councilmanic districts of Denver, since they are from out of state.