Portrayals of a profession: Reflecting on media depictions of paramedics

Introduction

Today's paramedics increasingly come from all walks of life and cultural backgrounds. They are well educated, highly skilled professionals who provide care in many contexts outside of the ambulance.^1,2 It is important to promote a contemporary shared understanding of paramedicine as we continue to evolve from our historical public safety roots and embrace our role as valued members of the healthcare system.^1,3 Mass media impacts and shapes people's perceptions of images that it portrays, which is increasingly relevant given how media-aware and technologically literate today's audiences are. Portrayals of professions and occupations in the media can present accurate - and not so accurate - images which are perceived by the public. Evidence in nursing, for example, suggests that negative media portrayals and stereotyping has impacted recruitment, professional relationships, and even violence against nurses. ⁴ In this editorial we will briefly reflect on portrayals of paramedics in television (TV) dramas and movies, reality TV shows, news media, and images created using artificial intelligence (AI). We will then discuss some potential implications of such portrayals that paramedics need to consider, reflect on, and address. Overall, we propose the need to convey more accurate and balanced representations of the professional work of paramedics in the media, and for paramedics themselves to improve the public understanding of their qualifications, roles, and abilities.

Paramedics in North American TV dramas and movies are often portrayed as ‘you call, we haul’ emergency responders, whose primary function is to drive an ambulance. Classic examples include ‘Emergency!’ from the 1970's and ‘Third Watch’ from the early 2000's. The hierarchical representation of paramedics in medical dramas based in North America such as ‘Grey's Anatomy’ and ‘House’ also portrays them as providing ‘scoop and run’ care. There is a tendency to focus on high-acuity, low opportunity skills, extrication, and difficult or dangerous environments. They are at times presented as incompetent, having missed something important, or overly confident, cocky, and even argumentative. Paramedicine is characterised as a stepping stone profession whereby characters are aiming for medicine, nursing, or something ‘beyond’ being a paramedic. However, in the UK, TV dramas such as ‘Casualty’ seem to offer a more balanced insight into the challenges and triumphs of medical staff including paramedics. Movies about paramedics based in North America such as ‘Bringing out the Dead’ and ‘Danger One’ often depict highly unethical or criminal behaviours like assaulting members of the public, abandoning care, or stealing people's money. Paramedics are often portrayed as depressed burnouts who rely on unhealthy coping mechanisms, have a proclivity for violence, and have troubled relationships. These fictional portrayals of our profession, while perhaps entertaining, are largely distorted and flawed.

Beyond fiction, we note that the reality TV version of paramedicine also provides conflicting insights and portrayals of the profession. North American programs such as ‘Ambulance’ and ‘Paramedics: Life on the Line’, and UK series including ‘999: What's your Emergency?’ highlight paramedic practice dominated by violence, sexual assault, trauma, and drug overdoses. While paramedics do attend these types of events, the careful editing of these programs presents high-acuity, low-occurrence presentations as the norm. In fact, data suggest that paramedics primarily deal with everyday aspects of life and society, with most calls to older adults ⁵ and only a small percentage requiring potential life-saving interventions. ⁶ Other documentary series such as ‘Ambulance’ and ‘Inside the Ambulance’ in the UK and ‘Paramedics’ and ‘Emergency Call’ in Australia appear to offer a more balanced perspective of the workload. In Australia, the portrayal seems to tend towards paramedics as ‘angels of mercy’ who are caring and selfless. Either way, we offer that overall, reality TV tends to emphasise what ‘could’ happen rather than what ‘actually’ happens. Meanwhile, the ethical implications of such reality TV shows require critical reflection and engagement by the profession. As Eburn cautions, “from an ethical point of view people don’t ring [for paramedics] in order to be a source of entertainment”. ⁷ We suggest that these shows are a fundamental breach of public trust and confidentiality by the profession, at a time when people receiving care are at their most vulnerable.

News stories involving paramedics also focus on low-occurrence events such as multi-vehicle collisions and mass casualty incidents. Paramedics - and more so long lines of parked ambulances - are displayed when discussing emergency department overcrowding and ramping or offload delays that impact response times. Media attention often highlights polarising issues such as the toxic drug crisis, violence against paramedics, ⁸ and the impacts of post-traumatic stress disorder (PTSD) on the paramedic workforce. ⁹ These portrayals serve to attain or sustain engagement by emphasising extremes. While these are important concerns and deserve attention (we ourselves are involved in researching many of these topics), the portrayal of paramedicine in news media is myopic and rarely positive. This inevitably influences both the public and our own perception of paramedics.

Lastly, we reflect on the growing use of artificial intelligence (AI) generated images online that are increasingly cost-effective and relatively easy to create. Generative AI engages with publicly available ‘training data’ such as photos and descriptions (along with their inherent biases) that are inputted into the model.^10,11 It is clear from the emerging findings of a study we are conducting that this training data portrays a biased and outdated view of paramedics and their work. The images, without detailed prompting, lack racial diversity, reinforce gender stereotyping, and tend to focus on ambulance-based emergency care. Unfortunately, they represent a new and emerging risk to perpetuating stereotypes of the paramedic profession and other health professions unless clear guidance is developed and followed.

Why media portrayals matter

Informed by our reflections, the image of paramedics depicted by the media has failed to represent the evolving reality of the profession that has emerged in the last 20 years, ¹ and traditional stereotypes of the ‘ambulance driver’ persist. In a 2011 editorial, ¹² Peate raised the alarm on the dangers of outdated paramedic stereotypes. Inaccurate portrayals present a risk to the profession. They can distil paramedicine to an oversimplified cliche, impact progress and growth, and ultimately detract from a profession that is searching for a distinct professional identity. The portrayal of paramedics in the media needs an urgent overhaul. Our reflections lead us to consider the implications of such portrayals for the public, the profession, and the individual paramedic.

Public

From the public's perspective, paramedicine ranks as one of the most trusted and respected professions.^13,14 There are ethical implications for media representations, particularly if they sensationalise or misrepresent the work of paramedics. Inaccurate media portrayals can erode this trust if public expectation and the actual patient experience are misaligned. For example, the shift away from emergency response and transport is a significant change that the public is still adapting to. When people call an ambulance expecting a rapid response and conveyance to the hospital, they can be disillusioned when their call is downgraded to non-urgent, and they are advised to remain at home with a community referral. Public uncertainty is compounded by heterogeneous titles and roles nationally and internationally. Where consistency can be found is in how paramedics are increasingly forming part of the social safety net and helping to address service inequities and social determinants of health.^15,16 Contemporary paramedicine will continue to focus on keeping people closer to home through treat and referral pathways and community partnerships. These shifts to addressing primary and non-urgent care needs in health represent key changes to an evolving portrait of our paramedic profession that the public sees.

Profession

The stereotypical media portrayal of paramedics highlights the ongoing tension between the history of our roots in emergency response and the evolving role of the profession as part of health. Aligning with countries such as Australia, New Zealand, and the United Kingdom, recent Canadian publications advocate for an evolution in paramedic professional culture and identity. ³ We see our position in healthcare emphasised over public safety, with paramedic professional activities presented as complex, person-centred, and interprofessional.^3,17 Our professional identity is tied to the roles, responsibilities, values and ethics of the paramedic profession. ¹⁸ Previously, our professional identity in the public safety sector was clearly delineated from other emergency service providers. How and where we fit in today's complex healthcare systems is still evolving and inevitably will continually shift as our roles change.^1,19

Having a clear and strong identity is essential for the growth and health of a profession ²⁰ and inevitably influences student recruitment and retention. While reality TV may support recruiting the young and keen, it can draw people to the profession for the wrong reasons, leading to role dissonance and career dissatisfaction. ²¹ For example, new recruit expectations for excitement may be unmet when they are primarily faced with an older population needing low acuity, non-emergent care. In the short term the profession may benefit from the media's inaccurate portrayals but ultimately, we need to address this to avoid inevitable disillusionment and high attrition rates. It is also worth pointing out that we in the profession are complicit in over-representing and leveraging the ‘cool’ aspects of paramedicine when it suits us. Some marketing images and promotional videos from educational institutes and service provider websites still feature paramedic images lacking diversity and depicting scenes of major incidents, helicopters, and flashing lights. These sensational portrayals can reinforce prosocial action, inspire others, and lead to more social heroic actions – leading to a sort of ‘professional vanity’. ²² This may further compound who we attract to the profession, and what type of work paramedics value as a profession and as individuals.

How the media characterises intra- and inter-professional paramedic relationships with others is also worth considering. Media portrayals suggest that these can be confrontational, representing an ‘us versus them’ mentality rather than fostering mutual respect, collegiality, and inter-professionalism. This promotes poor conflict resolution, an outdated, paramilitary style hierarchical organisational culture, and authoritative leadership styles. In addition, media portrayals of inappropriate workplace conduct such as intimate relationships with colleagues or hazing newcomers may serve to normalise sexual harassment, bullying, and unethical behaviours in the profession. It is important to acknowledge and call out these behaviours which unfortunately still occur as reported in a number of recent lawsuits and culture reviews across the UK, Australia, and Canada.^23–27

Individual

The stereotypical image of the paramedic in North America continues to be that of a middle aged, white man. Unfortunately, the data that are available support this stereotype with latest figures demonstrating approximately 70% are male and 85% are white.^28–30 However, recent insights into the paramedic profession in England and Australia for example highlight a shift towards a younger, more feminised profession where approximately 50% of paramedics are women.^31,32 There is still a lack of consistent quality data related to other characteristics of the profession globally such as race, ethnicity, and religion. Despite this, we suggest that the paramedic profession as often portrayed, generally does not reflect the diversity of the populations it serves. This can create access barriers for individuals aspiring to join paramedicine as well as promote cultural barriers and characteristic-related biases for our colleagues and people receiving care.^33,34

Beyond shifting demographics, paramedics entering the profession today are more likely than ever to have college or university level education ³⁵ - an essential step towards professionalisation.^36,37 The move towards university education has influenced the contemporary portrayal of paramedicine. Higher education is helping to further prepare graduates with the professional capabilities to be ethically and culturally competent, reflective, and focused on person-centred care and practitioner safety. The tertiary curriculum is also emphasising the importance of individual resilience and wellbeing to mitigate occupational injuries and reduce attrition rates. ³⁸

In some cases, media depictions of ongoing struggles with mental health and wellbeing reflect reality in the paramedic profession. Disproportionately high levels of PTSD, depression, anxiety, and suicidal ideation are reported in the literature.^21,39,40 The causes are complex and multifactorial and have been attributed to occupational stressors such as increased physical and psychological workload demands, a lack of debriefing and recovery time ⁴¹ and role dissonance.^42,43 Notably, providing low-acuity care was viewed as incongruent with the paramedic role and not considered valuable work in one recent study. When the realities of paramedic work are misaligned with role identity, this can further exacerbate emotional and psychological distress and contribute to a lack of professional fulfilment.^21,43 Clearly we need to reconcile this perceived dissonance for the sake of the individual, the wider profession, and the public.

A path forward

In Paramedicine we encourage scholarly debate and generation of evidence to support the evolution of paramedicine, including our understanding of our identity and the influence and impact of evolving roles. We therefore offer some points for the community to consider in relation to our professional image. First, we must critically reflect on how we as individuals talk about and present our profession in media, virtual, and ‘real-world’ spaces. We urge journalists, filmmakers, and content creators to accurately reflect the realities of the profession by working closely with the profession via professional associations. Distorted or inaccurate perceptions of paramedicine are however not only the result of media portrayals - in many ways we as a profession are complicit in reinforcing many of these narratives. We must urgently reconsider our ethical responsibilities as a profession and as individuals to people receiving care over generating engaging content for TV stations to increase viewers and sell advertising. Next, we must engage broadly across the profession to determine what it is that we value in our image, and if this image is inclusive and attentive to embracing diversity. This will require specific attention to engaging historically under-represented voices, seeking the perspectives of other professions, and involving the public as end-users of services. Finally, we encourage the research community within paramedicine to increasingly seek to provide insights on values, perceptions, and attributes of the profession. By engaging in these conversations here in Paramedicine, we can gain clarity on our image and professional identity to guide our path forward.