Towards sociological praxis in paramedic education – A response to Hill and Campbell

The Letter to the Editor by Hill and Campbell ¹ presents some important reflections and we are grateful to the editors of Paramedicine for extending us the opportunity to respond. We believe that critical discussion and discourse is important, encouraged and welcomed in a professional, academic and constructive manner. Therefore, in this response letter, we want to address some of the concerns raised in the hope of furthering this important conversation while also clarifying elements of our article.

The response by Hill and Campbell is based on the fact that the authors, ‘create curricula, teach, assess, and lead on paramedic programs’ and are ‘qualitative researchers’. Their arguments came out of ‘discussions with [their] respective teams’, with unfortunately no detail of what such discussions consisted of or who they actually took place with. Furthermore, a lack of references makes it difficult to appraise the evidential basis of the letter's perspective. Nevertheless, we take seriously the critiques provided.

First and foremost, our article ² was a Scholarly Perspective – not an empirical article – that we wrote in response to a special issue call by Paramedicine to challenge, ‘existing professional constructs’ in the spirit of proposing ‘new paradigms’ that can ‘attend to societal perspectives on issues such as equity, representation, and reconciliation’. According to Paramedicine:

Scholarly Perspectives allow authors the opportunity to provide one or more focused arguments and/or high-level syntheses of value to the field of paramedicine. It may include theorizing about issues in our field, problematizing a topic intended to stimulate discussion, addressing a serious challenge, proposing counter-arguments to conceptual advances, providing new ways of thinking about a topic, or advocating for ideas. These are intended to help to contribute to a topic area or as a means of advancing paramedicine broadly. The author(s) usually have extensive expertise and/or programs of research in related spaces. Perspectives should be aligned with the mission of Paramedicine.

In fact, the Special Issue ‘encouraged’ submissions that specifically ‘propose novel concepts, stimulate new ways of thinking, or challenge existing professional paradigms’. While some degree of generalisation is unavoidable in the context of a Scholarly Perspective, our article was based on nearly five decades of combined experience studying paramedicine, over 15 years of combined experience (MC and PP) teaching paramedics, and – despite the claims made by Hill and Campbell that our article lacked empirics, conflated paramedic education and practice, and overstated a critique of contemporary uses of the biopsychosocial approach in health professions education – we cited nearly 80 sources to support our perspective, most of which were peer reviewed from paramedic and corollary fields (e.g. medicine). Furthermore, in addition to being reviewed by two anonymous reviewers, we received excellent constructive suggestions/feedback from two of the editors at Paramedicine, which we valued greatly.

In their letter, Hill and Campbell make claims that appear to ‘strawman’ our article. We invite the authors to re-read the section of our article where we discuss ‘the great progress’ in the field of paramedicine (p. 206), or the framing of the article as a ‘call for the sociological imagination to be a vital component of the profession's development moving forward, both inside and outside of the classroom’ (p. 206), or how we point out that ‘paramedic education increasingly, and rightfully so, aims to incorporate interprofessional practice, social determinants of health, and other progressive elements, such as a focus on improving the well-being of paramedics through a focus on the social organization of mental health and resiliency’ (p. 207). Furthermore, nowhere in our article do we claim that sociology is ‘absent’ in paramedic education, as Hill and Campbell claim. Rather, we articulate that much change is afoot in paramedicine and that our contention is that a stronger integration of sociology, one that ‘sticks’ and is not displaced or subsumed by the tyranny of the bio-psycho-medico, is needed. To further support our framing (remember it was a Scholarly Perspective), we used words or statements like, ‘while not reflecting a generalizable/statistical understanding of the education and training in paramedicine across international domains…We wonder if’ … ‘it is our contention…’ (p. 207), ‘in part…’ (p. 209, 211). We further stated:

While a more in-depth discussion of the diverse ontological and epistemological underpinnings of the education and training of paramedics is outside the scope of this article, it is important to note that we are not suggesting other paradigms/orientations do not exist in the education and training arena of paramedicine. (p. 208)

Suffice it to say, we feel as though Hill and Campbell's reading of our article is unfairly polemical. Yes, our article is critical and perhaps provocative at times – as aligned with Paramedicine's special issue and the purpose of Scholarly Perspectives as noted above – but our thinking and writing was motivated by the best intentions, that of commenting on an enduring and significant issue in how we go about the complex and diverse work of educating and training in the paramedic space. It certainly was not our aim to attack or belittle any person or institution nor would such an attack align with the sociological imagination. Furthermore, such a polemic reading does not align with comments we have received from multiple individuals from around the world in the form of personal communications. We have included a few of these comments below:

As a sociologist and paramedic embedded inside a medical school, this makes my heart sing. Well done team! (Professor, Paramedic, Sociologist, Dean)

Amazing article and excellent perspective. Thank you for this! (EMS Educator and Author)

Amen! As someone who has worked both clinically (albeit ages ago..) and in a paramedic clinical educator/education director role, this commentary…resonated strongly…This kind of problematizing is the way we build and develop professionalization within paramedicine. (Paramedic Educator and Director)

…I wanted to say I have just finished reading your article…It is one of the best things I’ve ever read. A staggeringly accurate and insightful work – at least from my personal experience, which I felt was reflected in every sentence. (PhD Student, Paramedic, Author)

…We read your article with great interest and would like to warmly congratulate you on its publication. It truly caught our attention, as we deeply identify with the ideas and perspectives you have shared… (Director of Paramedic Education)

We could go on but as academics who, in part, position our work as supporting a project of professionalisation in paramedicine, we are quite curious and perplexed by Hill and Campbell's reading of our article as ‘antagonistic and cynical’ and the defensive posture taken in their letter. We hope our response here clarifies some of our intent.

Furthermore, the authors suggest that we assert a direct relationship between paramedic education in universities/colleges and the continuation of unwanted and inappropriate behaviours of those working in ambulance services and the pre-hospital space. Not only is this a positivist interpretation, which is not aligned with the non-positivist framing of our article, but to clarify our point here, what we were trying to do in the article is not lay the blame entirely on an out of touch and reform-proof ‘old school ambulance culture’. Rather, our interpretation of this is wider, more complex, and inevitably socially organised. If this was not clear in our article, we invite Hill and Campbell, and others interested in this important topic, to read some of our published work.

Lastly, we take issue with the suggestion that our article left readers ‘open mouthed’ or that our article ‘degrades’ the work of instructors, which would be asociological. To clarify again, our article aimed to facilitate/activate a critical reflection for those involved in paramedic education and training; we suggest all of us involved in the paramedic education space need to reflect on what the impacts of our practice might be. In this regard, and aligned with the insights we put forward in our article, educators and program directors could ask themselves these questions:

Who teaches sociological content in your program and how is it taught? How is this content integrated with other elements of the curriculum, including practicums/clinical placements?

How does your program challenge race-based medicine in curricula or incorporate the biosocial complex in your discussions of anatomy, physiology, pathophysiology, etc.?

How does your program challenge sexism, patriarchy, and white supremacy in course content? How does your program move beyond binary understandings of patients and bodies or are these binaries reinforced inside (and perhaps outside) of the classroom?

Is the sociological content taught in your program in the form of one-off courses or integrated throughout the entire curriculum? If the former is the case, how might the social sciences and humanities be incorporated throughout all or at least more elements of curricula?

Does your program support (and perhaps challenge) students (and instructors) to develop a sociological imagination? What training do you or could you provide to your instructors that supports this endeavour?

How do you know if the sociological content in your program ‘sticks’? How does your program make sociology relevant to clinical practice and beyond, including understanding structural forces central to the well-being of both patients and paramedics?

If your program ‘strive[s] to deliver holistic education’, what does this actually mean and look like? How is this actually accomplished?

Overall, how can we bring sociological knowledge and hopefully knowledge from other disciplines in the social sciences and humanities to equal status to that of the bio-psycho-medico? To deny that there is an imbalance between the bio-psycho-medico and more sociological content, which Hill and Campbell seem to suggest, for us at least, does not reflect the actualities of paramedic education and training. Of course we can find out broadly what is taught and assessed in curricula from module descriptors, handbooks, or national standards, but as we explicitly point out in our article, the incorporation of sociological elements in curricular does not necessarily correlate with student uptake or parity with bio-psycho-medico elements, and this is what we refer to as part of the tyranny. For example, the 6^th edition of the ‘Paramedic Curriculum’, as Hill and Campbell mention in their letter, only discusses sociological content briefly on one page of a 43-page document and this page says nothing of what content is actually taught or how it is taught in practice.

What we are arguing here is that to assume the teaching and uptake of a critical sociology, particularly within paramedicine, which we view as a field dominated by the bio-psycho-medico, where sociological and corollary content can get constructed as ‘the fluff’ as one paramedic educator put it in Corman's research on Becoming a Paramedic, is simplistic, problematic, and completely contrary to the research we refer to in our article and our experience in paramedicine. Similarly, saying that a program strives to deliver ‘holistic’ education, while a worthy goal, does not account for the overt and often hidden messaging, the language, behaviour, and role modelling that may subtly undermine the sociological element in favour of the bio-psycho-medico. To the contrary, it might do the opposite by leaving the tyranny that we speak of in our article in abeyance. And to be clear, this tyranny likely begins before a paramedic student ever enters the classroom; just look at the public-facing marketing materials (e.g. websites) of paramedic programmes, not to mention other popular culture representations, ³ to see how images, language, and other discursive constructs of paramedics and their work privilege stereotypical and historical views of paramedicine that centre trauma, major incidents, the ambulance, and other medical technologies.

As stated in our article: ‘Our argument in this short Scholarly Perspective is that paramedic education, for all its expansion and change in recent decades, still has room to progress’ (p. 210). We do not feel this is too radical of a statement. While we are happy to see our Scholarly Perspective taken up by Hill and Campbell, we feel as though they have missed the ‘so what’ we proffer. To be clear, we argue for the need to double down on how ‘the social’ is incorporated into paramedic education, training, and practice, and in this light, we invite readers to reflect on whether curricula go far enough to advance the professionalisation of the profession. Furthermore, how might this important work be accomplished in light of the intensifying pressures facing higher education, in which many academics find their autonomy constrained by creeping bureaucratisation, and their teaching and research challenged by resource cutbacks and marketisation (see Martin, 2017)? ⁴

We end with what we agree about in Hill and Campbell's letter, mainly their call for future research on the education and training of paramedics. This is a call that is more timely than ever and one that we support fully; in fact as stated in our Scholarly Perspective, we rely on some of our own research on the education and training of paramedics to situate our arguments in the article. And as we point out, ‘A fuller analysis of the nature of paramedic education needs to consider both the visible and the hidden, the seen and the unseen, the abstract and the real’ (p. 209). We also agree more focus is needed on different ‘pedagogical approaches, interdisciplinary teaching teams, and longitudinal studies exploring its impact on paramedic understanding of sociological aspects of practice’. Yes, let's do this important work. But without a critical lens on the current paradigm that dominates paramedicine (and other health professions education for that matter), and perhaps a critique of it, to paraphrase Elizabeth Townsend (1998), ⁵ we are concerned such good intensions will be overruled.