EMS Medical Director's Handbook
Report and stethoscope
Understanding the nuances involved in the oversight and direction of an EMS agency requires specialized knowledge, skills, and abilities beyond the typical curriculum of emergency medicine or alternative acute care medical practices.

Frequently Asked Questions

EMS Agency Leaders

Should we require prospective medical director candidates to be Board Certified or Board Eligible in Emergency Medicine in order to become our agency medical director?
We are considering offering compensation to our medical director but are unsure what should be offered or what are the different models of payment structures we should consider?
When my medical director first started, they were very engaged and active. How do I keep that initial level of motivation from waning?
My medical director (contract position) is continually encouraging me to take employment-related action (promotion) on a provider because they think the provider is fantastic and the medical director wants to be a part of the promotional process. How do I address the situation?

EMS Medical Directors

I am interested in becoming an EMS medical director but would like to talk with active medical directors first. How can I locate active medical directors in my area?
Are all EMS medical directors compensated by their agencies?
I am a new medical director an am interested in additional training. Where might I look for resources?
How often should I review my job description and functions with my agency?
I am discussing compensation with my EMS agency. What are some examples of legal issues I should be aware of?
I have some concerns about some of my agency's patient care practices that do not seem to be of much concern to the agency administration. How can I get them to listen and act on my concerns and suggestions?
I am interested in getting involved with the field operations of my agency but don’t have any prior experience. How should I proceed?
Will I have to be involved in having to obtain controlled substances for my agency?
Can I order controlled substances using my office or hospital prescriptions blanks?

EMS Agency Leaders

Should we require prospective medical director candidates to be Board Certified or Board Eligible in Emergency Medicine in order to become our agency medical director?
Answer:

Some states have requirements that an EMS medical director be trained in emergency medicine, but most do not. If you are not sure what your state requires, contact your state EMS oversight agency to determine any specific credentialing requirements.

In 2010 the American Board of Emergency Medicine approved the sub-specialty certification in Emergency Medical Services. This certification will be available to all physicians who hold current primary certification issued by the American Board of Medical Specialties. 

For additional information, review the Handbook for EMS Medical Directors, "Becoming a Medical Director" chapter, specifically in the section titled "Education and Training of the Medical Director."

We are considering offering compensation to our medical director but are unsure what should be offered or what are the different models of payment structures we should consider?
Answer:

The decision to compensate your medical director will be dependent on numerous factors. You need to clearly identify the expectations of the position. For example, the amount of time commitment, the types of activities, the attendance requirements for training sessions, meetings and other activities, etc. The size of your agency (number of providers, annual call volume, etc.) and the level of services (BLS, ALS, specialty services, etc.) will also impact the decision. 

Compensation models can vary greatly by location. Your agency may have limited resources but could provide the medical director a uniform, protective equipment, ensuring administrative support and pay for liability insurance coverage. Other examples of compensation can include paying for the medical director's attendance at one national conference a year to obtain continuing education.

Other examples compensation models seen across the nation include:

  • Dollar amount per patient transport
  • Dollar amount per 911 dispatches
  • Dollar amount per hour performing oversight activities
  • Fixed compensation amount

For additional information, review the Handbook for EMS Medical Directors, "Becoming a Medical Director" chapter, specifically in the sections titled "Affiliation Agreements, Performance Expectations, Compensation and Benefits, and Liability Coverage."

When my medical director first started, they were very engaged and active. How do I keep that initial level of motivation from waning?
Answer:

Communicate, communicate, and communicate! Establish a regular meeting schedule with your medical director and discuss on-going issues, new initiatives, performance measures and resource needs. Maintaining an open line of communication and routinely reviewing efforts and expectations will keep all involved engaged.

My medical director (contract position) is continually encouraging me to take employment-related action (promotion) on a provider because they think the provider is fantastic and the medical director wants to be a part of the promotional process. How do I address the situation?
Answer:

In your example of your agency contracted medical director, there is a clear separation of duty between the medical director' oversight activities and agency employment related decisions. You need to have a discussion with your medical director on this separation of duty. While I am sure you appreciate their enthusiasm and interest in the EMS providers, there needs to be a understanding the medical director's role is related only to the provider's medical practice authority and any agency employment decisions (hiring, promotion, discipline or termination) are a responsibility of the agency. 

For additional information, review the Handbook for EMS Medical Directors, "Becoming a Medical Director" chapter, specifically the section titled "Areas of Caution for Medical Directors."

EMS Medical Directors

I am interested in becoming an EMS medical director but would like to talk with active medical directors first. How can I locate active medical directors in my area?
Answer:

It is always a benefit for prospective, new and incumbent medical directors to network. Ask your local agency for a list of medical directors in the other EMS agencies surrounding your area. If there is a regional EMS office in the area, they will also be able to provide information. In addition, the state EMS oversight agency will also have a list of EMS medical directors.

Are all EMS medical directors compensated by their agencies?
Answer:

Some medical directors in small communities work on a non-compensated, volunteer basis. Other physicians act as agency medical directors through the auspices of their hospital-based practices that provide time and/or monetary compensation rather than the agency itself. However, most large EMS agencies do compensate their medical directors. If you are compensated by your EMS agency, check with your tax professional to discuss income tax liability issues generated from agency compensation.

For additional information, review the Handbook for EMS Medical Directors, "Becoming a Medical Director" chapter, specifically in the section titled "Affiliation Agreements."

I am a new medical director an am interested in additional training. Where might I look for resources?
Answer:

There are a number of organizations that focus on physicians involved in EMS such as the National Association of EMS Physicians (NAEMSP) and the American College of Emergency Physicians’ (ACEP) EMS section. NAEMSP offers an annual meeting focusing on EMS issues and basic as well as advanced courses for EMS medical directors.

There are also on-line resources available such as the Critical Illness and Trauma Foundation (CITF) online course developed in conjunction with NAEMSP. NAEMSP has published a four volume set covering the core knowledge for EMS medical direction; information is available at their web site. 

There may also be resources available in your home state. Check with your state EMS oversight agency as a place to start. Colleagues that are involved in EMS locally and regionally may also be good resources to gather information not only on educational opportunities but also first hand information of dealing with issues.

For additional information, review the Handbook for EMS Medical Directors, "Becoming a Medical Director" chapter, specifically in the section titled "Education and Training of the Medical Director."

How often should I review my job description and functions with my agency?
Answer:

At a minimum, annually. It is recommended that the medical director and agency leaders establish a regular meeting schedule to keep communication lines open where routine feedback is exchanged among all parties

I am discussing compensation with my EMS agency. What are some examples of legal issues I should be aware of?
Answer:

Before entering into any binding agreement, the medical director should seek independent financial and legal advice. There are numerous IRS issues associated with compensation ranging from taxes to rules against excessive compensation of key individuals in nonprofit organizations. Depending on the compensation model, there may be legal issues related to anti-self-referrals laws and anti-kickback laws. Therefore, it is best to obtain professional financial and legal advice prior to finalizing any binding agreement between the agency and medical director.

For additional information, review the Handbook for EMS Medical Directors, "Becoming a Medical Director" chapter, specifically in the sections titled "Affiliation Agreements, Compensation and Benefits, and Liability Coverage."

I have some concerns about some of my agency's patient care practices that do not seem to be of much concern to the agency administration. How can I get them to listen and act on my concerns and suggestions?
Answer:

The primary goal is to work with your agency leadership collaboratively to address your concerns. Establishing a positive relationship with the agency’s administration before a controversial issue develops may be the most important step. A clear definition of the medical director’s responsibility and authority in your written agreement or contract is also helpful to make sure that all parties are "on the same page." 

If you have concerns about individual providers, make sure that they are discussed in advance with agency leadership, addressed in partnership, and managed within the agency’s personnel structure. Medical directors should enter such discussions well informed from an evidence-based practice perspective, and also be familiar with best practices in the industry, particularly those in similar agencies close to home. Stepping outside of the agency or bypassing the chain of command may seem attractive, but usually leads to failure and a breakdown of the working relationship with agency leadership and providers.

I am interested in getting involved with the field operations of my agency but don’t have any prior experience. How should I proceed?
Answer:

Almost all agencies and providers are pleased to have their medical director participate in field operations and patient care. Field participation increases your credibility with your providers and presents unique opportunities to observe patient care and provide real-time clinical education.

Discuss your desires with your agency leadership and find out what they will require. Your agency will desire that you can operate effectively with the agency’s command structure and that you can function safely in situations which may be physically challenging and hazardous. You will be required to receive the agency’s infection control training and you may need to have other training such as emergency vehicle operations, hazardous materials training, or how to function as part of a team in tactical operations.

You should also make sure that you are protected in the case that you are injured in the course of field operations, so explore that specifically with agency leadership. If your field practice will involve direct patient care, make sure that you have medical malpractice coverage as well as general liability coverage from the agency. If your agency is interested in your participation in field operations, then it is reasonable that they help you obtain appropriate training and appropriate equipment for your activities.

For additional information, review the Handbook for EMS Medical Directors, "Agency Oversight" chapter, specifically in the section titled "Medical Director in the Field."

Will I have to be involved in having to obtain controlled substances for my agency?
Answer:

If your EMS agency provides advanced life support level care, they will need to either have an agreement for the supply of or stocking capability for their controlled substances including parenteral narcotics and benzodiazepines.

In some systems the agency obtains its supply of controlled substances through a hospital pharmacy that stocks and restocks those drugs for your agency. In other systems, you will need to use your DEA license to obtain controlled substances for the agency. Federal regulations require that you obtain a separate DEA license for your EMS agency. Typically, the cost for this separate DEA license is paid for or reimbursed by, the EMS agency.

For additional information, review the Handbook for EMS Medical Directors, "Agency Dynamics" chapter, specifically in the section titled "Medication Supply and Storage Practices."

Can I order controlled substances using my office or hospital prescriptions blanks?
Answer:

No. Federal DEA regulations require that you use a DEA Form 222 to order all controlled substances from vendors. The DEA 222 forms are available free of charge and are preprinted by the DEA with your DEA number and the address of your EMS agency.

For additional information, review the Handbook for EMS Medical Directors, "Agency Dynamics" chapter, specifically in the section titled "Medication Supply and Storage Practices."