The results of this study can be used to contribute to the development of policies that are related to maintaining competence of EMT-Ps including CME requirements, practice frequency, reregistration periods, reexamination, etc. The data supports the position that continued education and ongoing clinical experiences are important to maintaining competence. The fact that EMT-Ps were more likely to pass the exam if reregistration was 2 years or less suggests that 2 years could be a reasonable time frame for requiring recertification.
Several variables were significant for both reregistering and passing the NREMT competency exam. These variables included having more CME, having a bachelor’s degree or higher, and having more years of experience as an EMT-P. Those who passed the exam also had more clinical experience related to emergency calls. An important finding was that it appears that some common traits may help to explain the differences found. However, the study was designed to answer the principal question only, and these suggestive findings can now be explored more vigorously and with greater precision given that the principal hypothesis appears to be true.
A limitation of this study is that the sample size (determined by cost factors) was not large enough to examine the interactions among all the variables related to reregistering as well as passing the exam.
Another limitation is that passing an exam does not necessarily translate into complete clinical competence. The study was designed to detect the difference between reregistered and non-reregistered EMT-Ps at given intervals and it is not known how predictive this is of clinical competence.
Also, CME is a challenging variable to measure. It is difficult for paramedics to recall an exact amount and type of CME they had in preceding years. Once they have reached their recertification thresholds, many paramedics do not continue to formally record further credits. CME is also difficult to categorize, since it may be formal or informal in nature. Employers may have regular, mandatory, continuous quality-improvement or quality-assurance sessions that may not be perceived as formal CME. In addition, regular reading of professional journals or being involved in a good quality assurance process are examples of processes that may provide the same benefit as formal CME.
Only EMT-Ps who had access to a computer could enroll in the study. This may have biased the sample selection since those people with computer access may have been more associated with those subjects who are more affluent and thus more likely to pay for reregistration when it was not required for employment.
Selection of all subjects from States where EMT-Ps are only required to take the NREMT-P exam to enter the profession, but not required to maintain State certification, and comparing them with EMT-Ps from States where maintenance of NREMT-P certification is mandated may have allowed for more forceful policy implications. Such a sample would have better reflected the general population of EMT-Ps. Indeed, a completely different sampling plan that lessened self-selection, and forced a more representative sample of the target population would have strengthened the study. Designing future studies to be better able to detect differences in the major demographic and professional differences within the cohorts by increasing the sample size would also be desirable.
An observation needing further study is that a smaller percentage of EMT-Ps living in rural areas or small towns passed the exam than those living in urban areas or larger towns. There are many possible explanations for this finding. EMT-Ps living in rural areas could have a lower level of education, limited access to strong training programs, or less clinical experience because of the density of the population served. In addition, people living in rural areas could have less access to continuing education. Moreover, many of the Nation’s rural services are provided by volunteers who have competing issues for their time. These are all areas that could be explored further.
Another area of future research is exploring this same question but at the EMT Basic or EMT-Intermediate levels of certification. Given the much larger numbers of EMT Basics compared with those at the paramedic level, the implications of the finding that more CME is related to better test scores might have an even greater impact. Also, it would be useful to compare States that mandate continued registry certification in order to practice with those who do not.