to contact a physician for formal orders for each intervention that they performed. Some specialists believed this was the only safe approach to providing care in this fashion. In some early cases, 'paramedics' operated blindly, providing medications from numbered or colour-coded syringes as they were directed by the physician, with no real understanding of the actions they were performing. Control was absolute and immediate; there were examples of paramedics being trained, but not legally permitted to perform their skills, or in other cases, they could take action only with a physician or nurse present, much like the existing Franco-German model. In the earliest stages of paramedicine, the paramedics were not yet formally licensed and often served as an extension of the physician's medical license. The Canadian province of Ontario continues to have such a system, as of 2008. As the training, knowledge and skill level of paramedics increased, licensing and certification were formalized, and physicians became more comfortable in working with this new profession; then paramedics were permitted greater degrees of independent practice. In the 21st century, most paramedics function based on complex written protocols or standing orders committed to memory, often numerous pages in length, and contact a physician only when standing orders have been exhausted. In such systems, the medical director's role takes on several aspects. To begin with, the medical director is much more a leader of paramedics than of other physicians. They generally perform a leadership role among the small group of physicians tasked with providing delegation to paramedics in the field. The medical director plays a key role in the professional development of paramedics as well. In almost all cases, the medical director will have, at a minimum, input into the curriculum of paramedic training at a local level. In a great many cases, they will also teach some portions of the program, supervise clinical rotations of paramedics, and in some cases, precept their initial field practice, prior to formal certification or licensing. In almost all cases, the medical director will be charged with the creation of all protocols and standing orders, and with any research that goes into their creation. The medical director will also, assisted by others, be responsible for the creation and development of the Standards of Practice for their EMS system. Throughout the paramedic's career, the medical director will provide the mechanism for medical quality control, conducting chart audits and reviewing