Op-Ed: Has the Time Come to Standardize Wilderness Medicine Education and Training?

There is no shortage of wilderness medicine education providers in this country. From organizations that offer education and training for Wilderness First Responder (WFR) and Wilderness First Aid (WFA) certifications to those that offer train-the-trainer programs, a simple online search reveals a ton of options — especially when the search is focused on a specific geographical region.

What’s striking about all the wilderness medicine training and certification taking place is that none of it is nationally regulated. None of it adheres to commonly accepted industry standards that govern what’s being taught or how wilderness medicine education and training are being delivered. On the other hand, the training and certification EMTs receive is regulated on a state-by-state level and must meet minimum requirements as set by the National Highway Traffic Safety Administration (NHTSA).

Wilderness medicine training, while loosely adhering to a similar curriculum, is officially overseen by, well, no one. That being said, standardization and oversight aren’t completely absent. Several organizations have attempted to fill the void with a variety of education programs, courses, guidelines, accreditations, and oversight committees.

A Mismash in the Making

Historically speaking, first on the list is the Wilderness Medical Society (WMS) — a nonprofit founded in the early 1980s to encourage, foster, support, and conduct activities that improve the scientific knowledge of human health activities in a wilderness environment. WMS offers three types of advanced wilderness medicine-related certification that have a “continuing education” focus and accreditation connection. The organization’s Fellowship in the Academy of Wilderness Medicine (FAWM), Diploma in Mountain Medicine (DiMM), and Diploma in Diving and Marine Medicine (DiDMM) are all provided in accordance with standards set in part by the Accreditation Council for Continuing Medical Education (ACCME).

There’s also the fledgling Wilderness Medicine Education Collaborative (WMEC) — an ad hoc group of medical educators whose interest in providing guidance on content for wilderness medicine courses has resulted in the creation of minimum guidelines and scope of practice (SOP) documentation for Wilderness First Aid (WFA), Wilderness Advanced First Aid / Advanced Wilderness First Aid(WAFA/AWFA), and Wilderness First Responder (WFR) training. While the work of the collaborative (whose members include leaders from SOLO Wilderness Medicine, Wilderness Medical Associates International, and NOLS Wilderness Medicine, among others) has resulted in a robust set of SOPs, its influence is nonexistent outside those of us who actively choose to look beyond ourselves for best practices. In other words, without accreditation, there’s no real motivation for anyone offering wilderness medicine education to seek out the WMEC. And without a formal structure and an administrative arm, the WMEC has no enforceable authority or meaningful influence.

Speaking of accreditation, closer to home for those us in outdoor and experiential education, following a rapid increase in the number of adventure programs in the late 1980s and early 1990s, it became imperative that outdoor experiential education programs develop standards of program quality, professional behavior, and appropriate risk management. Enter the Association for Experiential Education (AEE), which responded to that need in the early 1990s by developing comprehensive standards for common practices in the adventure education industry, becoming the nation’s first recognized accreditation provider focused on outdoor and adventure-based experiential education programming.

Since then, the AEE Accreditation Program’s standards-based evaluation process — conducted by objective, independent reviewers — has become the industry-accepted level of professional evaluation for outdoor and adventure-based experiential education programs, with AEE recently adding an accreditation focusing on outdoor behavioral healthcare.

Similarly, since the late-1940s, the American Camp Association (ACA) has offered an external professional peer-reviewed accreditation program for camps. According to ACA, to become accredited, camps must meet up to 300 health and safety standards, now considered best practices throughout the industry. The accreditation process is voluntary, and ACA currently accredits more than 2,500 camps nationwide.

The big difference between AEE’s and ACA’s accreditation offerings and WMS’s certifications is that the former are focused on organizations, while the latter is focused squarely on the individual. And while individual certification certainly advances the field of wilderness medicine, it stops short of ensuring that wilderness medicine education providers are teaching from a curriculum that’s commonly recognized as the industry standard by way of peer review, evaluation, and ultimately accreditation.

What’s clear from the currently available hodgepodge of education, certification, and guidelines is that standardization and regulation as codified through an accreditation scheme would be helpful and may be necessary to both ensure the quality and reputation of the industry and fend off state-by-state and/or federal regulation. What’s not so clear is how it would be implemented and the impact it would have on the wilderness medicine education sector.

What Standardization and Regulation Might Look Like

An effective system for establishing and enforcing standards would almost certainly require a close collaboration among the industry, employers, and perhaps state government:

• Industry/internal standardization: An institution such as the Wilderness Medical Society, the Association for Experiential Education, or an operationally funded Wilderness Medicine Education Collaborative could publish standards and institute an accreditation program to ensure their standards are being met. This is similar to what’s already offered by AEE and ACA but don’t include wilderness medicine education.
• Employer requirements: Employers would require that staff members be educated and certified at an accredited organization.
• State government regulation: Laws and regulations could be instated at the state level to regulate what a WFA or WFR would be permitted to do and be prohibited from doing, but this is something we should seek to avoid. State governing bodies could standardize testing and curriculum. This is how emergency medical services (EMS) are currently regulated.

Examining the Potential Benefits of Standardization and Regulation

Industry regulation would provide standardization to curriculum and potentially establish minimal competency levels. A Wilderness First Responder (WFR) trained at one institution could be expected to have learned the same material and developed the same skills as one trained elsewhere. Industry standards would adapt faster and be more flexible than governmental regulation and could be fine-tuned to address the differences in the qualifications required. Industry standards would be closer to national standards than state regulation could achieve.

Employer Benefits: Employers would be aware of the minimum level of medical knowledge and the skill sets required for job applicants to be considered qualified candidates. In addition, employers would serve as regulators at a grass-roots level by requiring proof of certification. Finally, when offering training to their staff — often onsite through a third-party vendor, employers would be compelled to work with an accredited wilderness medicine education provider.

Insurance: Another employer benefit would be in the realm of insurance. Presumably, reputable insurance companies (e.g., admitted insurance companies) would seek to offer coverage only to those organizations meeting the industry standard, as shown by an active accreditation. And while discounts on premiums aren’t permissible within the insurance sector, premium credits would likely be offered to those organizations meeting the accreditation standard.

Government’s Role: State regulation, which I am not an advocate of, would guarantee minimum competency and knowledge standards. It would elevate WFR certification in the eyes of other medical providers, specifically those working in emergency medical services. Professionalization could also lead to expanded career paths or increased salary/benefits for certified providers. Governmental regulation might also help insulate providers/educators from potential legal liability. To be clear, however, internal industry regulation — as has been the case in the outdoor and adventure-based experiential education programming sector and the camp industry — also helps with this.

Considering the Potential Drawbacks of Standardization and Regulation

Rarely is any single solution to a complex challenge ideal.

Industry regulation would be voluntary. Currently, advanced medical training and education received through the Wilderness Medical Society are regarded as “the standard,” but competing agencies would most likely arise, leading to confusion. Moreover, internal self-regulation is not likely to elevate the status of a Wilderness First Responder in the eyes of an EMS professional or other medical provider.

Employer Drawbacks: Employers would have a greater responsibility in screening job applicants to ensure they have proper certification. At the same time, employers would face the prospect of having to increase compensation (both salary and benefits) to compete for qualified candidates.

State Regulation is Rigid and Slow to Adapt: New ideas and innovations often take years to make it into curriculum and standards. Standards tend to be set very low to avoid resistance and pushback. Much like EMS, if providers are trained in one state, their certification may not be valid or transfer to another. State regulation and standards tend to be influenced most heavily by a few well-funded entities. State (and to a lesser extent industry) regulation would also limit what can be taught in a WFA/WFR course, and instructors/institutions would be legally obligated to teach only the approved material.

Limits the Number of Providers: Wilderness medicine education margins are thin to being with, and the cost of accreditation would only eat into those margins. It’s possible that fewer — not more — providers would be left standing as the cost of education increases, which could result in a scarcity of qualified instructors and certified educators, guides, and field guides.

Increases the Cost of Becoming an Outdoor Educator: Any increase in the cost of wilderness medicine education would likely be passed onto those seeking training and certification. That means instructors, educators, and guides would take on an increasing burden of qualifying to work in the adventure-based experiential education programming sector, which could lead to fewer — not more — people entering the industry in both FTE and part-time roles.

The Choice We Face

As an organization that offers wilderness medicine education and certification, we look forward to the day when our industry’s training and certification providers stand on common ground, ensuring that someone who receives their Wilderness First Responder or Wilderness First Aid training and certification from an organization in California has the same education and training as someone who participates in a course offered by different provider in North Carolina.

Common standards will make it easier to evaluate job candidates. Such standards would also go a long way toward ensuring that quality and scope of care being provided in remote and wilderness settings are in the best interests of those who entrust us with their safety and wellbeing.

But the question remains, who is going to carry the burden of setting and administering the standards? By adopting and maintaining the minimum guidelines and scope of practice documentation created by the Wilderness Medicine Education Collaborative, an organization like the Association for Experiential Education or the Wilderness Medicine Society — both of which have robust administrative, education, and credentialing experience — would be the ideal entities to take this one. Accreditation is already within their wheelhouse, and leading and fledgling organizations alike already look to them for guidance, networking, education, and more.

Regardless of which organization chooses to take this on, one thing is very clear to me and other industry leaders with whom I regularly speak. If we don’t start self-policing, states will step in, and government regulation is not the answer. By self-regulating, as the Association for Experiential Education has done within the outdoor and experiential education field and as the American Camp Association has done in the camp sector, we stand a better chance of establishing standards we all can live with, while simultaneously strengthening multiple sectors that rely on Wilderness First Aid, Wilderness Advanced First Aid / Advanced Wilderness First Aid, and Wilderness First Responder training and certification.