David C. Cone, MD

I began working in EMS in 1984, the same year that NAEMSP was founded.  Next year will mark NAEMSP’s 25th anniversary, and there are many second-generation and even some third-generation EMS providers working on the nation’s streets right now.  We have trained well over 200 EMS fellows in over two dozen fellowship training programs, and are making considerable progress toward subspecialty status.  We are only a few months away from the completion of the fourth edition of our textbook – but despite this fairly lengthy history, it became apparent during a recent conference call of the textbook’s editors that we still do not have an agreed-upon term for what we do.

In preparing the third edition of the textbook back in 2000/2001, a number of us on the editorial board championed the use of the terms “medical oversight,” attempting to eliminate terms such as “medical command” that might convey more of a master/subordinate relationship than most EMS physicians are comfortable having with the field personnel whose care they oversee.  Specifically, we proposed that “direct medical oversight” replace terms such as “on-line medical direction” and “on-line medical command”, and “indirect medical oversight” replace “off-line medical direction”.  We argued that the term “medical oversight” appeared in the title of the text from the very first edition back in 1989, and that it conveyed more of a collegial, supervisory relationship with field personnel.  We eventually prevailed, and the terms medical oversight, direct medical oversight, and indirect medical oversight replaced the older terms in the textbook glossary, which serves as NAEMSP’s quasi-official terminology source.

But the term “oversight” can have a negative connotation: “Sorry, doc, not giving that patient nitroglycerin for her CHF was an oversight on my part.”  So from time to time, there is discussion regarding whether this is really the best term or not.  This discussion resurfaced in the last month or so, with several senior members of our subspecialty suggesting that we choose a term that does not have an alternative negative meaning.  During email discussions among the board, Dr. Henry Wang pointed out that in the Merriam Webster on-line dictionary, the negative meaning is secondary, with the primary definition being exactly what we want:

“a: watchful and responsible care

b: regulatory supervision <congressional oversight>”

(www.merriam-webster.com)

These definitions nicely encompass the watchfulness that medical directors like to keep over the clinical care delivered by EMS personnel, the degree of responsibility that we accept for the care delivered by these field personnel, and the (admittedly very variable, from state to state) regulatory relationship between the medical oversight physician and field providers.

So a wary consensus appears to have emerged among the board to retain the term medical oversight, at least for the time being, and for the next edition of the textbook.  I suppose it is only natural that a field and its attendant terminology evolve over time, but I still can’t help feel that as we approach our 25th anniversary, this most basic concept ought to be codified in terminology more solidly.  I am told that the authors of one of the chapters of the textbook will be proposing the terms “administrative medical direction” and “clinical medical direction,” and perhaps that will start the debate all over again!