Regulating Wilderness Medicine

Introduction
Numerous articles, podcasts, and letters have recently argued for regulating wilderness medicine certifications. At its root, regulation is about control—someone always benefits, and there are always associated costs. This article discusses the various forms of regulation that apply to wilderness medicine certifications and attempts to identify who benefits and at what cost. Once they are known, we can run a cost/benefit analysis and see where it leads us in the near and distant future. Three types of regulation apply to wilderness medicine: economic regulation, government regulation, and self-regulation. 
Economic Regulation
Economics currently regulates the field of wilderness medicine; it's a problematic market-driven, buyer-beware scenario. The Boy Scouts of America, the American Camping Association, and numerous college recreation programs require tripping staff to be certified in Wilderness First Aid. And the outdoor industry recognizes Wilderness First Responder certification as the industry standard for guides and outdoor instructors. Interestingly, course curricula, hours, format, delivery strategies, instructor training, and student assessment and evaluation for both courses vary greatly depending on the provider. Without industry-wide certification standards, potential students, sponsors, employers, and land management agencies have no easy or reliable way to evaluate course curricula or quality. 
Beneficiaries 

• Low-quality wilderness medicine schools or training companies.

Costs

• There are no industry-wide certification standards for wilderness medicine. Economic regulation does not work for government agencies tasked with protecting the recreational public, employers seeking well-trained staff, and students seeking a quality education.

Government Regulation
Governments enact laws (policies) to control the practice of medicine. In the United States, the Emergency Medical Services (EMS) act of 1973—part of the Public Health Service Act—allocated funds to develop regional EMS systems. States are responsible for training and licensing four levels of first responders: Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), Advanced Emergency Medical Technician (AEMT), and Paramedic. Other countries have similar, but not identical, EMS systems. While numerous schools teach Wilderness EMT (WEMT) or Wilderness EMS (WEMS) courses, wilderness EMS is essentially unregulated on a national or international level. If a country regulated wilderness medicine certifications, it would likely roll the curricula and standards into its existing EMS system. 
Beneficiaries 

• The general public and state EMS agencies would benefit from an expanded scope of practice, and licensure is enforceable.
• EMS practitioners would benefit from a nationally recognized wilderness medicine certification.

Costs

• Innovation would slow down due to increased bureaucracy.
• Governments would likely approve some wilderness medicine schools as training centers so they could teach the WEMS curricula and standards.

Rendering First Aid versus Practicing Medicine
Good Samaritan laws protect people who provide first aid at the scene of an accident, act in good faith for the patient's benefit, within their training, and do not receive payment for their services. First aid training addresses the specific needs of a workplace, and the course curriculum tends to vary with the organization; sometimes, this requires advanced training. Graduates of WFA, WAFA, and WFR courses work in remote environments, under challenging conditions, with minimal resources, and in places where traditional EMS is not readily available. Depending on the country and region, some treatment skills taught in wilderness medicine courses may not be considered first aid by local authorities, but practicing medicine and, as such, require a license. Again, depending on the region, a licensed medical advisor with prescribing authority may—or may not—be able to authorize trained staff to administer prescription medications or follow advanced protocols.
Self-regulation
Two potential self-regulatory options exist—accreditation or industry acceptance of scope of practice documents that set standards for WFA, WAFA, and WFR certifications.
Accreditation
Accreditation is typically the form of self-regulation that initially jumps to mind. If a wilderness medicine school is accredited, an external body has reviewed and approved its curricula, delivery strategies, topics, scope of practice, assessment requirements, instructor hiring, and instructor training guidelines according to a previously agreed-upon set of standards. Accreditation is not a panacea; it does not guarantee quality but indicates an organization has gone through an evaluation process that may improve its operations. Seeking accreditation is voluntary, and the process generally requires a rigorous, often costly, evaluation of the organization's pedagogy with a focus on educational quality. The accrediting body is typically a non-profit organization comprised of widely recognized experts in the field. At present, there is no accrediting body for wilderness medicine schools. 
Beneficiaries 

• The general public and the outdoor industry would benefit from consistent WFA, WAFA, and WFR certification standards should accreditation be widely accepted.

Costs

• Establishing an accrediting body would be expensive and time-consuming and likely encounter serious resistance from the established schools. Wilderness medicine schools would have to adopt the certification standards created by the accrediting body. In today's environment, it's unlikely that the major schools would be willing to abandon their curricula, instructor training standards, copyrighted material, etc., in favor of accreditation.
• The bureaucracy and cost associated with accreditation would create barriers to establishing new wilderness medicine schools and slow innovation.

Scope of Practice Documents
Voluntary adherence to scope of practice documents is another form of self-regulation and a reasonable alternative to accreditation. Medically, scope of practice (SOP) documents define the assessment and treatment skills graduates can perform, while curriculum refers to content, delivery, and assessment strategies. Scope of practice, curricula, and certification are related and often overlap. For example, a scope of practice document may require graduates to be able to recognize and treat _______ As a result, _______ becomes part of the course curriculum; however, the SOP generally will not specify how a school must teach _______. While SOPs may specify the minimum hours required to teach core material and in-person skill labs and simulations, they typically leave the curriculum details, delivery methods, and assessment strategies to the individual school.
The Wilderness Medicine Education Collaborative (WMEC) formed in 2010 to provide a forum for discussing trends and issues in wilderness medicine and to develop consensus-driven scope of practice documents for WFA, WAFA, and WFR certifications. In 2022, they expanded their work to include related white papers and position statements. Collectively, the WMEC schools* have over two hundred years of experience teaching wilderness medicine and have trained over 750,000 students in the past four decades. 
Decisions regarding the content of the WMEC SOPs and papers are made based on emerging research and technology, peer-reviewed articles, and best practices. The WMEC SOP documents provide a basis for certification and curriculum development and are available for public use on the WMEC website. For the WMEC SOP documents to solve the wilderness medicine regulatory problem, international outdoor education and recreation associations must formally recognize them as the industry standard. Examples of industry-wide associations include the Association of Outdoor Recreation and Education (AORE), the Association of Experiential Education (AEE), and the Wilderness Education Association (WEA). 
Beneficiaries 

• The general public and the outdoor industry would benefit from consistent WFA, WAFA, and WFR certification standards.
• Curriculum and delivery innovation remain with the provider and will increase compliance.
• Management costs are significantly lower than accreditation.
• Adopting certification standards would avoid government intervention.

Costs

• Compliance relies on signatory schools to honor their commitment to adhere to the SOPs.
• Enforcement relies on the strength of industry standards to leverage buy-in.
• Since curriculum and delivery details, student assessment, instructor qualifications, and training remain within the provider's purview, these standards will vary. 

Conclusion
The United States EMS system will likely develop a Wilderness EMS (WEMS) certification in the coming years; however, licensing WFA, WAFA, and WFR certifications appear unlikely. That said, there is the possibility that state regulators may push for standardized exams, and if that occurs, the exams will have the potential to impact WFA, WAFA, and WFR course curricula. Creating an accreditation body also seems unlikely due to the expense and resistance from established WFA, WAFA, and WFR schools. At this juncture, adopting the WMEC SOP documents as certification standards seems the most likely outcome, assuming AORE, AEE, and WEA, among others, are willing to endorse them as industry standards. The WMEC released an updated WFR SOP and numerous white papers October 2022 and is on track to release updated WFA and WAFA SOPs in the coming months.

Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.

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