Why the debate over physician involvement in pre-hospital care in B.C. needs a reset

I work as an advanced care paramedic in British Columbia. I’m proud of our work, but I’m increasingly concerned that debate over physician involvement in pre-hospital care has lost sight of its primary goal: improving patient outcomes.

The discussion has shifted to misaligned assumptions and turf wars on both sides, rather than focusing on what benefits patients most.

Over the past year, tensions have increased following opinion pieces, interviews and public commentary by emergency and critical care physicians advocating for greater participation in pre-hospital medicine. One flashpoint was an opinion article published in the Prince George Citizen by Dr. Mike Christian and Dr. Neil McLean, which was later removed after questions were raised about conflicts of interest tied to the publisher’s relationship with Alberta’s STARS air medical program. That episode didn’t create the controversy, but it exposed it to the public in a way never seen before.

To many paramedics, the article came across less as a neutral discussion of patient care and more as a push toward physician-led emergency response models. In British Columbia, where ambulance services are delivered exclusively by BC Emergency Health Services (BCEHS), these concerns raise fundamental questions about scope, accountability and the future of paramedicine.

That unease grows because several physicians who are now publicly critical of BCEHS were once deeply embedded within it. Figures such as Christian and Ritchie previously held influential advisory or leadership roles in the service. Their advocacy for their own organizations is not illegitimate, but it complicates the narrative. From the paramedic perspective, it can feel less like external innovation and more like an internal rift played out in public, with frontline providers caught in the middle.

Union leadership has been explicit that it views several of these physicians not simply as critics, but as contributors to the problem, citing conflicts of interest, misleading public comparisons and attempts to advance change outside established provincial processes as factors that have intensified mistrust and hardened positions.

That said, focusing only on personalities or past affiliations risks overlooking the deeper issue: how the system has handled – or failed to handle – collaboration.

It is important to acknowledge physician involvement in pre-hospital care is not new. Paramedicine in B.C. was built in close partnership with physicians, from education and protocol development to ongoing medical oversight. The current debate is not about whether doctors belong in pre-hospital care – they always have – but about how that involvement evolves as paramedicine matures and systems change.

In many parts of the world, doctors and paramedics share the pre-hospital workspace in structured, regulated ways, with degrees of success. B.C is unusual in how completely it has centralized pre-hospital care under a single ambulance service and professional identity.

Organized paramedicine in B.C. has often responded to increased physician interest with a consistent refrain: doctors should stay in hospitals, especially given chronic staffing shortages. In a public response to the Prince George Citizen article, Ambulance Paramedics of BC president Jason Jackson described physician involvement in pre-hospital care as “outright reckless” given emergency department closures and physician shortages. But this position has consequences. By framing physician involvement solely as a workforce problem, it can diminish the role of doctors who want to contribute outside hospital walls. It can feel dismissive or even insulting to those passionate about pre-hospital work.

Across the province, physician-affiliated or physician-led groups are increasingly active in spaces traditionally occupied by paramedics. Private medical response organizations have signalled interest in expanding into critical care and interfacility transport. In some regions, search-and-rescue organizations transport patients. In others, physician response teams attend calls alongside paramedics. Each initiative may be defensible in isolation. Taken together, they create a sense that the boundaries of pre-hospital care are being quietly redrawn, often without a coordinated provincial framework.

These developments have raised serious concerns within organized paramedicine. In recent communications related to potential job action, the Ambulance Paramedics of British Columbia (APBC) explicitly identified “contracting out” as a significant point of contention, signalling that physician-associated or parallel response models are viewed as a threat on par with wages, staffing and working conditions. In this context, the union’s argument is not that BCEHS dollars are being transferred to physician-led groups, as “contracting out” is commonly understood, but that the public ambulance service and external response organizations are ultimately competing for the same limited pool of public health funding. From APBC’s perspective, any government investment directed toward parallel models risks displacing funding that could otherwise be used to expand Advanced Care Paramedic (ACP) and Critical Care Paramedic (CCP) resources within the public ambulance system.

Many of the physician-involved or community-based response models that have sparked controversy dispute this framing. Search-and-rescue organizations, regional physician response teams and similar groups argue they are funded primarily through community donations, volunteer support and non-BCEHS sources rather than through direct public ambulance funding. They contend that their existence reflects persistent service gaps, particularly in rural, remote or highly specialized contexts.

The question, then, is whether new models strengthen the public system or risk displacing future investment in ACP and CCP capacity. Until that question is addressed transparently, debates about “contracting out” will continue to obscure the real issue: how best to allocate finite resources to improve care for the sickest patients without weakening the foundation of public paramedic services.

It is also worth acknowledging that physicians are not the only ones building alternatives.

Paramedic-led initiatives also have emerged to address unmet needs. This is not a story of one profession encroaching on another. It is a system responding imperfectly to pressure points it has not formally addressed.

Paramedicine also needs some self-reflection. Have we, at times, become overly isolated?

Have we been so focused on protecting hard-won professional ground that we’ve been hesitant to engage with ideas that challenge our model – even when those ideas may benefit patients? Paramedics in B.C. already work in highly skilled, high-performing teams and physician involvement is not a prerequisite for excellence.

However, in other jurisdictions, physician-integrated pre-hospital systems have shown how doctors can add value not by replacing paramedics, but by supporting complex decision-making for the sickest and most resource-intensive patients. These models are not about expanding scope for its own sake; they are about concentrating additional expertise where uncertainty is highest.

This is the same rationale that underpins advanced and critical care paramedic programs. While these international systems do not always translate neatly to B.C., it is difficult to claim a commitment to evidence-informed practice while largely excluding internationally recognized pre-hospital experts from leadership and system design discussions.

The real risk, then, is not collaboration, but unstructured evolution. When neither BCEHS nor organized paramedicine meaningfully engages with physician participation, the vacuum does not remain empty. It becomes filled by ad hoc arrangements, community-funded workarounds and parallel models that operate outside a coordinated provincial framework.

Over time, this weakens coherence and makes accountability less clear – even if no public dollars are being diverted.

Many paramedics fear that physicians want to diminish them to little more than drivers or assistants. Many physicians, in turn, view paramedicine’s resistance as insular and defensive. The truth is somewhere in between. Physicians are not trying to take over pre-hospital care; they want to participate in it. Paramedics are not hoarding power; they are protecting a profession they have worked hard to build. Both instincts are understandable.

But without an intentional framework for collaboration, both lose.

The implications for patient outcomes are significant: without a deliberate approach to collaboration, uncoordinated service delivery may lead to inconsistent care quality, delays in critical interventions or transport and reduced access to specialized expertise when it is most needed.

If this debate needs anything right now, it is less defensiveness and more honesty. We need to talk about our motivations, our fears and the shared goal we all claim to hold: better care for patients before they ever reach a hospital.