A medical director is a physician who provides guidance and leadership on the use of medicine in a healthcare organization. These include the emergency medical services, hospital departments, blood banks, clinical teaching services and others. A medical director devises the protocols and guidelines for the clinical staff and evaluates them while they are in use. Emergency medical services The role of a medical director in the emergency medical services (EMS) varies by which type of system is in use. Franco-German model The first model, arguably the oldest, is generally described as the Franco-German model. This model is physician-led, and those personnel who serve emergencies from ambulances are often place in minor, supporting roles. There is ample evidence indicating that at the turn of the 20th century, many North American hospital-based ambulances in larger centres were staffed by ambulance surgeons; physicians who responded in the ambulance and provided care in a manner which very much resembles the current Franco-German model. In the French version of the model, only physicians and nurses perform advanced care, and ambulance drivers have only minimal medical training. In the German version of the model, there are paramedics (called Rettungsassistenten). Medical control is on-line, immediate, and direct. The training of the Rettungsassistent is comparable to that of many North American paramedics, but they may be limited in their scope of practice. Paramedics may practice advanced life support skills at all times when the physician with whom they work is physically present. In some cases they are restricted in action if there is no physician present, a legal position mostly claimed by the physicians' lobby. Under German law, unless an immediately life-threatening or potentially debilitating emergency is present, such individuals may be limited to basic life support skills only, or to restricted ALS skills, which are defined in the "standing orders" of the medical director of each respective county. In 2003, there was a reform movement to expand the "standing competency", especially in the realm of pain treatment, by offering additional training to the level of "Notfallsanitaeter". This model is intended to bring physician-centred definitive care to the patient, rather than bringing the patient to the care. As a result, in addition to conventional ambulances, most communities have physicians (called Notarzt) who respond directly to every life-threatening call to provide care. This system does not recognize emergency medicine as a medical specialty, in the sense that North Americans