Women and Minority Groups Remain Underrepresented in EMS

Talk of “workplace diversity” is nothing new across many industries. But when it comes to healthcare and emergency medicine, creating a workforce that reflects the communities being served can help reduce some very real barriers. Unfortunately, in EMS, we often struggle to talk about diversity, afraid that we may offend someone, or feeling unwilling to accept that this is a problem.

A recent study took a closer look into the makeup of first responders to see if diversity truly is an issue, and if so, present some ideas to help in this area. The results of the study bring to light some concerning trends – namely that minorities and women in EMS are underrepresented – and suggest a few channels of outreach to help ensure that this trend might be changed in the future. 

Why Diversity Matters in Emergency Medical Services

As healthcare professionals, we know that we work hard to provide the best care to all patients regardless of race, ethnicity, gender, or any other characteristic. It’s jarring and upsetting to even consider that we could possess unconscious attitudes or stereotypes. Nevertheless, there is a growing body of research related to the role of “implicit biases” on healthcare disparities, and EMS professionals are not immune.

Implicit bias refers to attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner. These biases are activated involuntarily and without our awareness or intentional control. We know that providing prehospital emergency care to acutely ill and injured patients in the uncontrolled environment inherently exposes providers to mental strain, incomplete information, and time pressure. These demands may increase susceptibility to implicit biases that in turn may unintentionally impact clinical decisions and lead to disparities in patient care.

While most EMS professionals strive to provide the highest level of care to all patients in any given situation, statistics show that treatment remains surprisingly disproportionate. For example, one recent study has shown that black patients were 40 percent less likely to receive pain medication than non-Hispanic white patients. Further, black patients who did receive pain medication often received smaller quantities compared to non-Hispanic white patients.

Conversely, studies in other medial fields are showing that increasing diversity in gender and ethnicity among healthcare professionals is associated with improved equity in healthcare delivery. For example, studies among physicians have shown that higher levels of racial diversity have been linked to improved patient involvement in medical care, greater satisfaction, and better health-related outcomes. Increased gender diversity has similarly been associated with increased trust, more preventative screenings, and increased patient-centered communication.

This does not mean that the demographic characteristics of individual healthcare professionals have to match those of each patient in order for diversity to benefit care. Rather, it’s the indirect effects of diversity that have an important impact. Being surrounded by people with diverse backgrounds, beliefs, and cultural experiences allows colleagues to learn from each other far more meaningfully than simply reading a chapter on multiculturalism in textbook.

Examining the EMS Workforce ‘Pipeline’

Describing and understanding trends in representation of gender and racial/ethnic groups in EMS over time is a first step toward identifying the need for and developing initiatives to improve diversity among this critical healthcare workforce. My colleagues from the National Registry of EMTs and The Ohio State University and I undertook a project to examine diversity among recent EMS graduates likely to be entering the EMS workforce as a first sign of changes to come.

Since there is currently no database of every EMS professional earning initial licensure to practice in the United States, we decided to examine the gender and racial/ethnic composition of EMS professionals who earned initial National EMS Certification between 2008 and 2017. We then would compare the 2017 EMS data to estimates from the U.S. Census Bureau’s Current Population Survey, to see if there were any gaps in representation and if any location-based differences existed. 

Research on Female and Minority Representation in EMS

The study ended up encompassing a total of 588,337 EMTs and 105,356 paramedics who earned their initial National EMS Certification in this 10-year period. We found that there were noticeably fewer minority and female paramedics and EMTs among newly certified EMTs and paramedics throughout the 10-year study period. While some encouraging changes were observed over that same timeframe, the diversity of EMS professionals earning initial certification did not reflect the diversity of the population served.

Some key findings included:

• The proportion of females earning initial emergency medical technician certification rose from 28% to 35% between 2008 and 2017. In 8 out of 9 of the year-to-year comparisons the proportion of female EMTs increased.
• The proportion of newly certified EMTs belonging to a minority racial/ethnic group rose from 22% to 27% between 2008 and 2017.
• People of minority racial/ethnic groups comprised 13% of newly certified paramedics in 2008 and 19% in 2017.
• The proportion of EMS providers identifying as black remained near 5% of the EMT cohort and 3% of the paramedic cohort throughout the 10-year study period.
• The proportion of newly-certified Hispanic EMTs rose from 10% to 13% and the proportion of newly-certified Hispanic paramedics rose from 6% to 10% during the 10 years.

Overall, we found that gender and racial/ethnic gaps were more pronounced and changed at a slower rate among paramedics compared to EMTs. This is important to note because paramedics often provide more critical invasive interventions compared to EMTs and make complex, time-sensitive decisions regarding care. Also important to note is that newly certified EMS professionals can be viewed as a representation of recent graduates entering the workforce, meaning that these finding suggest that the overall diversity of the EMS workforce is unlikely to change substantially in the near future.

Differences across Geographic Regions

While the modest increases we observed among some groups appear promising, when comparing the EMS observations to overall Census demographics, it was clear that the representation of females and minority racial/ethnic groups was far from representative of the U.S. population. For example, in all regions, newly certified EMTs and paramedics who identified as black, and those who identified as Hispanic, and females were underrepresented compared to the U.S. population.

• In the West region, there were 67% fewer EMTs who identified as black compared to the U.S. population (2% vs. 4%, respectively).
• In the Northeast, there were 93% fewer EMTs who identified as black compared to the U.S. population (4% vs. 11%).
• The same trend was present for the paramedic cohort with black persons being underrepresented by 67% in the West (2% vs. 4%) and by 138% in the Northeast (4% vs. 11%).
• Newly certified EMTs and paramedics who identified as Hispanic were most underrepresented in the Northeast by 86% and 100%, respectively. The gaps in representation for EMTs and paramedics identifying as Hispanic were smallest in the South and West regions.

Efforts to Increase Diversity in EMS

While efforts to improve diversity among healthcare professionals are increasing on a national scale, few have specifically targeted EMS agencies. Key recommendations to achieve equitable care for all patients include undertaking efforts to increase the proportion of underrepresented minority groups in the healthcare workforce and integrating greater cross-cultural education in healthcare training programs.

Some medical schools have seen success in this area, as large-scale efforts to increase diversity – including a more holistic review process – have seen an increase in enrollment among students from underrepresented groups. Other student pipeline and internship programs are being used to enhance recruitment of underrepresented groups in healthcare and public health.

While local efforts to improve diversity among EMS professionals exist and have been successful, more coordinated national efforts are needed. Examples of direct and indirect practices that could lead to increased recruitment of a more diverse workforce of EMS professionals include partnerships with schools and community engagement activities that involve youth activities and classes.

Looking Forward: How ESO Advocates for Greater Diversity Among EMS Professionals

Diversity among EMS professionals is important for fomenting multicultural awareness, enhancing patient-provider communication, and improving equity in care. However, looking at the recent numbers of graduating EMS professionals across the nation suggests that, without action, substantial improvement in diversity is unlikely to come in the near future. Improving diversity in the EMS workforce will require us to be open to having uncomfortable conversations and working towards developing coordinated national recruitment efforts to encourage underrepresented groups to pursue careers in EMS.

Read the full paper on this topic in the National Library of Medicine now.