practices (U.K.). In some cases, the Practitioner retains the ability to summon a physician to the patient when the limits of the scope of practice are reached (U.K.) while in others, the finite limits of treatment are those within that scope of practice, and no physician 'back-up' is normally provided (South Africa). In this type of model, the role of the medical director includes the teaching of the practitioners, in both the classroom and the clinical setting. Most such training programs tend to feature very large components of hands-on clinical experience, generally conducted in the emergency room or similar environment, and usually in a one-to-one ratio with the physician. The medical director will be responsible for examination of the candidate and certification of their ability to practice safely. The medical director will have a major role in determining the permitted scope of practice, and will investigate practice-related complaints. In some jurisdictions the medical director will be responsible for medical quality assurance, although there are some where this function is performed by the practitioners themselves. Finally, the medical director (or other emergency physicians) may be responsible for providing the required medical 'back up' when the practitioner reaches the limit of their scope of practice. Crossover models There are some models, most notably the Netherlands, which use a blend of a number of these models, including the Franco-German, Anglo-American, and Autonomous Practice models. In Netherlands, for example, all paramedics are in fact registered nurses with one year of additional training, usually in anesthesia but other critical care training is also acceptable, who then complete an additional year of training in ambulance care. All such individuals are licensed by the Dutch Ambulance Institute(DIA), and are employed by one of approximately 45 private companies providing emergency ambulance service under government contract. The model looks very much Anglo-American on its surface, however, in most cases Dutch paramedics are for all practical purposes autonomous practitioners. The scope of practice and permissible procedures are determined at a national level by the Dutch Ambulance Institute, and all paramedics must function within this guidance. Within the scope of practice, however, all judgment and treatment decisions fall to the paramedic, as in the Autonomous Practitioner model. Each ambulance service is required to employ a medical manager whose role is oversight and quality assurance, and who may be contacted for directions by any paramedic who has reached the limits of their