Branson:

I've worked in the department of surgery since 1985. I don't work in the respiratory therapy department, and I don't supervise respiratory therapists [RTs] at the bedside, but I like everything you said. At present, where are we falling down? Is it the abilities of students and getting good applicants to the schools? Is it at the schools? Is it at the hospitals? Where is the next generation of RTs who will lead the science and the profession coming from?

Kacmarek:

I don't know if that's true. You know, the older we get, the more we think we know and the less we think new graduates know. The reality is that the new graduate today knows a lot more than we did when we entered the profession. And 20 or 30 years ago, when a similar group sat here, they probably said the same thing: “There's nobody coming after us to take our place, and where are all the young people?” There are people out there, but I don't think there are enough of them. I don't think we always attract the right individuals into respiratory care, and that's partly because of the entry-level academic credential of the profession.

When you talk to your children about their future profession, is respiratory therapy ever a part of the discussion? When I talk to my children, my expectation is that they will get at least a baccalaureate degree. With a profession that has as its entry level an associate degree, it eliminates a lot of students whose goal is a profession that requires a baccalaureate degree. You don't see school guidance counselors even talking about respiratory care, because it does not require a baccalaureate at the entry level.

I believe we have problems at the respiratory therapy department level, and I'll say it, since I'm one of that group, many respiratory therapy department directors are not as interested in improving the quality of care as they are in maintaining the fiscal viability of their departments. They're not focused on quality; they're only focused on financial issues. Now, obviously, that's a generalization that doesn't fit across the board, but only 27% of the directors of respiratory therapy programs provided input into a very important survey that will help determine the future of respiratory care. What happened to the other 73% who chose not to even participate in that process?

I think we have problems at multiple levels. I think we have problemswith the educational entry level that eliminates good people, and we clearly have problems in our current leadership at the hospital level, and that needs to be improved.

Branson:

Chris Blakeman has worked with me now in the department of surgery for the past 5 years, but up until Chris, all the people I worked with closely—and I would consider some people I mentored—all of them either work for industry, went into medical school, or became PAs [physician assistants], perfusionists, or CRNAs [certified registered nurse anesthetists]. That's part of what the educators seem to be fighting: how important it is to have a bachelor's degree and create an advanced degree, because we lose a lot of the best people due to just financial reasons. There are just so many academic jobs that provide a reasonable living, and I think that's really important and gets lost. We lose so many people from the profession because the only upward career pathway is into administration. There are no advanced practice RTs.

Kacmarek:

One of the problems with salaries is those we are compared to! I'm frequently sitting next to physical therapists with PhDs at entry level, occupational therapists with master's degrees at entry level, or speech/language pathologists with master's degrees or PhDs at entry level. All those people have a much higher academic entry point than RTs. As a result, we're at the end of the line.

MacIntyre:

Let me switch from the entry level to the top. I think that the profession as it's constructed right now has a ceiling above which you can't go without leaving the profession and doing something else. But at Duke we've built a huge new bed tower with a bunch of new ICU beds and we're running around like chickens with our heads cut off trying to figure out how to staff it.

An obvious staffing model would be a PA-RRT. I can think of no better entry level for a PA than the RRT to move into an ICU and be an independent practitioner. It seems to me the next step for the respiratory care profession is to create independent practitioner licensure by the states, just like the physical therapists, occupational therapists, PAs, and CRNAs to provide independent care. Rather than count somebody who goes to school for PA as lost to the profession, instead somehow make it possible that they're still within the profession. I know there are a bunch of RTs who would love to see independent licensure for advanced level RTs.

I think it's a terrific idea, but it's going to be a huge uphill battle to get state legislatures and all the things that need to go into place to get licensure for independent practice. Why not somehow partner with the PA system that's already in place, already grants a master's degree, and in all 50 states can get a license? Rather than consider them lost RTs, consider them RTs who have broken through the ceiling and can provide independent expertise. In my ICUs I have about 10 RTs who'd be terrific if I could get them to be independent practitioners.

Kacmarek:

You could retire!

MacIntyre:

With a PA licensure they could damn near run my ICUs.

Kacmarek:

The problem is that too few individuals are entering the profession with the capability of moving in the direction Rich described, because our entry-level requirement immediately makes them choose another profession.

MacIntyre:

Oh, I realize it will be few.

Kacmarek:

Because of the current entry-level criteria. One of the arguments against requiring a baccalaureate degree is that we'll have nobody applying to respiratory therapy programs. I disagree with that entirely; a baccalaureate entry opens up a broad spectrum of high school graduates who would never have considered respiratory care because of its associate's degree entry, as opposed to a baccalaureate. Today we have 54 baccalaureate level respiratory care programs and 3 quasi-master's respiratory care programs. They're master's programs that provide a degree, but they're not clinically oriented.

MacIntyre:

I'm not arguing with you on the entry-level part of it. It just seems to me that the respiratory care profession would have more attraction if our superstars had an avenue to proceed through that ceiling.

Kacmarek:

No question. We can even look at the fact that if we had baccalaureate entry, why couldn't we have advanced level RTs with master's degrees, like nurses do? They're your PAs by virtue of their educational level. It opens up the opportunity for upward mobility to a much greater extent. I agree with Rich that, unless you move into education or management, the profession doesn't have a mechanism for upward advancement.

MacIntyre:

One last pitch for the American Respiratory Care Foundation here. One of the topics on their agenda is focusing the scholarship program away from associate level scholarships and consolidating them into really meaningful advanced degree scholarships. I think the advanced degree scholarships should have licensure attached, to allow breaking through that ceiling and into a clinical leadership role.

Kacmarek:

Agreed.

Kallet:

I would like to offer a counter viewpoint or a cautionary viewpoint on this. These discussions are extremely important, and I have a tremendous amount of sympathy for what's been said. However, in the context of a shrinking middle class, I think back to my own roots. I entered respiratory therapy as a teenager in Syracuse, New York, during the deep economic recession of the 1970s, when my dad was unemployed. An associate's degree was something doable and attainable. The model at Upstate Medical Center was extremely good: it was a “two-plus-two” program. You got in, you got great associate's degree level training, and then the upper division course work was advanced respiratory care. There was the option of supporting yourself while working towards a bachelor's degree.

Parenthetically, in northern California, the RT graduates we've hired from our community college programs have been great. They're bright, well prepared, and a joy to work with. They're ready for us to train them into the much more advanced role we need them to take on. But a lot of them do not have the economic means to go through 4 years of college in one bite. They're not from upper middle class or solid middle class families. They're kids, a lot of them from immigrant families, working to get into the middle class.

While I totally understand where the profession needs to go, and if we try we can get the profession to where it needs to be, but to move it to a baccalaureate program where all you're doing is saying the kids need 2 years of basic college education, then they get the associate's program core courses in the last 2 years …

Kacmarek:

You said that: I didn't say that.

Kallet:

OK, but in a lot of the baccalaureate programs I'm aware of it's not really advanced respiratory care. The training I went through when I went back and got a baccalaureate was advanced respiratory care, advanced biology and chemistry—subjects that made me a better professional: education, management, and research. If it goes that way, fine, but I think if the idea is to get this up to a level where all we're really doing is saying, “Go to a community college for 2 years and do the basic science and liberal arts, and then do 2 years of core respiratory care curriculum that's basically an associate's level degree,” we're going to limit a lot of very bright young people who could enter the middle class and the profession without appreciably advancing their knowledge base.

Kacmarek:

We are going to change the demographics of who enters the profession, there's no question. But the creativity associated with developing a baccalaureate program is unlimited. Nobody is proposing a restriction that will make it all private 4-year colleges that offer baccalaureate programs at $50,000 a year. Many states will allow associate-degree-granting community colleges to develop a baccalaureate degree.

Florida has several schools that are in the process of moving from associate programs to baccalaureate programs. You can structure it any way you want. But we need to “bite the bullet” and accept that by some date we must start requiring baccalaureate degrees. And that at some later date all the associate degree programs have to become baccalaureate programs. Nobody is saying this is going to be done overnight; it has to be a reasonable transition. I have sympathy for what you're saying, but I also agree with Rich Branson that we need a better quality individual who is motivated to the levels he referred to; otherwise, the profession will not grow and develop: it will eventually die.

Kallet:

I agree with that. I think it's a matter of how it's done. And I think the idea of still allowing people to come into respiratory therapy with an associate's degree, but with a contract expectation that, once they can earn money, they will continue their education and get a bachelor's degree …

Kacmarek:

There has to be a point in time where we have to “bite the bullet.” We have to grow as a profession. Eventually, we have to say it has to change and everybody entering respiratory care has to be educated at a higher level.

Turner:

Another issue is the importance of collaborative interdisciplinary education. I think that more and more we're moving towards trying to get all trainees to learn together earlier in their training. As an example, we have our pediatric critical care fellows shadow the RTs and the nurses early in their fellowships, to foster an interdisciplinary approach to their education. With improved collaboration, both education and patient care are enhanced, which is particularly important in the ICU environment, where teamwork is crucial.

Kacmarek:

I agree. I think the ICU does it better than any other aspect of in-patient care, because of the nature of the work and the type of professionals who are there. There's a more collaborative attitude in most ICUs, so we can be the model for collaborative education in other parts of the institution.

Branson:

I understand that the real issue is that we need to develop these educational constructs for people to grow within the system. Is there any advantage in funding internships? An internship at Massachusetts General Hospital for 6 months or a year? An internship at San Francisco General for a year? The question is, what kind of piece of paper do you get when you're done? Ideally, you'd get this wealth of experience and we'd be pushing these people out of the nest to hopefully fly to other places and create similar programs at other hospitals.

Kacmarek:

You could do that. But it takes a long time for somebody to get acclimated to an insane asylum like our place. By the time you're acclimated, you're half way through the internship. I would be more in favor of funding other institutions who have the capability of moving to the level that we, and Duke, and the Mayo Clinic, and other places are, to assist them so that their departments become what our departments are.

Marini:

Bob, do you agree with this historical perspective? One of the big reasons people aren't considering respiratory care is not only that energy has been sapped out of it by the business interests of the hospitals, but also that the doctors are no longer at the bedside. The mentors I learned from, Hudson and Pierson, were excited about physiology, which is no longer very well taught to our medical students.

The physiological intrigue of being an RT seems to have dissipated some, too. A lot of our RTs seem to have limited interest or encounter trouble with the waveforms, the interpretations, the reasons behind why the patient fails. They'll have an opinion as to why a patient failed a weaning trial or need support, but the physiological understanding has eroded because the medical profession has allowed physiology to take a back seat to statistics and evidence-based medicine. And doctors are more interested in getting on with their next patient than in mentoring someone who is not really well prepared to receive the information.

The whole field of medicine has changed radically, and not always for the better, in my opinion. You still have to use physiology to extricate the information and unravel the knot that most patients present. I think we have a great and dedicated group of RTs at my hospital, but even our RTs are often too busy applying treatments and documenting observations to ponder what might be happening underneath it all, and their high workload makes them eager to move on to the next patient. They cannot be with us on rounds much of the time. We try to educate them, but the culture has changed.

Kacmarek:

A certain culture in the respiratory therapy department has to be promoted to allow that to happen. If I went into any ICU and asked the RTs if they are on rounds 100% of the time, the answer would be no, because they may have 6 or 7 patients, and this patient's tube needs to be re-taped, this is happening here, and that's happening there, so they get pulled away from rounds. They're not 100% on rounds because it's impossible, because of critical problems. But I agree that physiology is not taught to the level it should be. And the kids coming out of respiratory care schools do not understand physiology to the level they should.

But it's also important to remember the difference in our expectations of an associate degree graduate 20 years ago, compared to today. We expect that person to know a lot more than we did 20 years ago, but we haven't expanded the time and opportunity for them to learn it, so I can't expect them to come as prepared as I would like. We spend 3 months with them. Dean and I do one-on-one lecturing; Dean does workshops with them on how to start NIV. We do a lot of one-on-one education to train them to be the RTs we want at the bedside.

Branson:

I agree with both of you. I grow tired of bedside caregivers telling me they made a change because they felt like the patient would do better—with no physiologic evidence or basis in the literature. I hear things such as, “I felt like ATC [automatic tube compensation] was a good idea on this patient during the spontaneous breathing trial, because he has a smaller tube.” I don't know where the problems reside, and so I don't know how to fix them. I think this is a great opportunity for the profession, but I'm not sure how we move forward.

Giordano:*

I agree with everything that's been said, but eventually we have to put our feet on the ground and not be floating 30 feet in the air. I offer a couple things to think about. First, I think there's an inevitable move toward requiring RTs to get at least a baccalaureate degree. We already have over 50% of our members with at least a bachelor's degree. Could this be because they found that with an associate's degree their education was wanting?

I think a critical event that will shift this paradigm is the bill¹ we're pushing to get RRTs who have baccalaureate degrees to work under Medicare Part B, as employees of physician practices. They will not bill independently; they'll be salaried by the practice. But they'll be able to see patients with chronic lung diseases and provide disease management in the physician's office without having to make an appointment with the physician. That will push even more people to acquire those grounding communication skills. It will happen, and it will drive change.

Regarding capacity, the RT profession has a burn rate of approximately 8,000 people per year, so we have to graduate that many per year. As you mentioned, we have approximately 55 baccalaureate degree programs and 3 graduate programs, but they're not filling up their classes. Another survey we conducted as part of the 2015 and Beyond initiative was to ask allied health teams whether they have what they need to develop respiratory care baccalaureate programs. We had only one positive response. That survey will be repeated with a predicate of this baccalaureate requirement to work in offices, and I think that will change then.

What it comes down to is the market. Bob mentioned this in regards to Florida, which I believe a couple of years ago changed its laws to allow community colleges to offer baccalaureate degrees. This was done not because the educators and professions got together: it was because, across all occupations and professions, the employers said to the education system that the graduates are not adequately educated and you need to step it up. Everything is market-driven. Until every department head has a baccalaureate degree as a prerequisite, you will not necessarily have everybody with a baccalaureate degree.

Case in point: nursing has been advocating for baccalaureate-trained nurses for at least 3 decades, but over 50% of nurses in the workforce are associate-degree prepared, because that's what the marketplace accepts. When we change the marketplace—and many of the things that were discussed at this conference will feed into that—we will see this change, this evolution. We'll then be able to show that it's a sound business model for educators and universities to create baccalaureate programs.

One final point: a bit of a caution is indicated from the experience of our friends the physical therapists. A funny thing happened on the way to doctoral degrees, which is that all of a sudden there developed a physical therapy assistant, and guess where they're getting educated? At community colleges, and getting associate's degrees. So, whereas once there was, especially in hospitals, a team of, say, 20 physical therapists, now there may be 5 physical therapists and 15 physical therapist assistants. I don't know whether this will boomerang on us in a similar way, just because of the higher critical thinking that's going to be demanded in the future, but I would not necessarily hold that up as a road we want to go down. Certainly it's a design we've learned from.

Kacmarek:

We're not asking for PhD entry, we're asking for baccalaureate entry. And if you allow the market to drive itself, we will all be dead before any change is made. It seems to me that we can do what's necessary to make change occur without damaging the workforce or entry into the workforce. Nobody has asked for this to happen tomorrow; what we are asking for is to start setting solid deadlines for things to change.

In Massachusetts we're working with 2 community colleges, and we believe we'll be able to go to baccalaureate degrees in community colleges in Massachusetts, like they have in Florida. Increasingly, I think we'll see that same thing happening in multiple states, because, as you said, it seems to be the right thing to do to properly educate people for various professions. Why can't we say that, 10 years from now, you can't develop a new respiratory therapy program unless it's at the baccalaureate level, and 20 years from now that all associate degree programs have to change to baccalaureate? That's easily enough time for the profession to acclimate to the changes that are being demanded of us to survive.

Giordano:

I agree, but we have to make sure there's enough education capacity out there. We've got some university deans to talk to.

Kacmarek:

Sure, but I also think that we make a bigger deal about the manpower issues than is real. In the northeast we have many RTs who don't have jobs. This year's graduates from respiratory therapy programs in Massachusetts, Rhode Island, Vermont, New Hampshire, Connecticut, and Maine can't find jobs. I've had 50-70 applicants for just a couple openings. We have lists of people who cannot find work in respiratory care in the northeast. I realize there are pockets throughout the United States where there are deficiencies, but I'll bet that, globally, recently that's changed a lot and that we have an excess of RTs.