Respiratory Care, Back to Our Roots
Pre-edited version of an article published in Adv Resp Care Prac, Oct 16, 2000, vol 13, No 21.
Desmond Allen, PhD, MBA, RCP
A PhD in health administration and a credentialed Respiratory Care Practitioner with 35 years experience. The author of A CURE IS NOT WELCOME: America’s Successful Failing Health System, as well as several other articles and books.
My mother still calls me an Inhalation Therapist. That was our title when I entered the field in 1973. It has changed a couple of times since then. We became Respiratory Therapy, then Respiratory Care Practitioners. Other, more significant changes have also taken place. Our scope of practice has expanded to the limitless boundaries of diversification and a fierce internal battle is being waged over credentials.
The changing title, the focus upon diversification and the incessant internal bickering is centered upon one objective--to establish professional respect within the healthcare community. It is painfully obvious that we have not accomplished the goal. Beyond struggling for the respect of our peers, now we struggle even to respect ourselves. The decline in AARC membership is a prime example.
I hear the same questions we asked some thirty-years ago. “What is the future of the field? Will it survive? How do we gain the respect of our peers?” Curiously, and I suspect few will remember, I published articles on these subjects many years ago. Although my opinion has not changed, I have an even clearer picture now than I did then. My advice was not headed then—nor, I suspect, will it be now. Nevertheless, I am convinced that my assessment is accurate.
For many years the strategy for survival and respect has been “diversity.” Herein, I challenge this strategy. The second issue that weighs heavily on our survival and our respect among peers, is the ever present internal strife. It must come to an end.
The ability of respiratory therapy to diversify has long been touted as our primary marketing feature. Indeed, I have made the most of this characteristic--spreading my wings into any number of services. Certainly diversification is a benefit, even a necessary asset in many situations. But it is not the vehicle that will withstand the rough terrain ahead. It is not the strategy that will secure the future of the profession or achieve the much desired peer respect.
Administration is Unclear as to RT’s Role
In this ever changing climate of cutbacks and downsizing, there are inherent dangers to being known as diversified. Aside from the infamous stigma, “Jack of all trades and master of none,” diversification leads to obscurity and necessitates an ambiguous definition of the profession. To this day administration has little idea what respiratory therapy does or who we are. I recall a meeting with the VP of human resources, in which I contented for salary increases for the department. Although involved in healthcare human resources for more than twenty-five years, he virtually had no idea of respiratory’s responsibilities or to what level of patient care we are involved. Sadly, he is not alone. As a PhD in health administration, let me assure you, administration at large does not have a clear understanding of the clinical necessity or fiscal value of their respiratory therapy departments.
I remember--in my younger days--strutting around the hospital, proud of being an Inhalation Therapist. Daily, I was involved in saving lives, intubating people, maintaining ventilatory and hemodynamic matters that even the physicians had trouble understanding, reading x-rays, caring for A-lines and ABG machines, performing cardiac outputs, doing cardiac stress tests and PFTs. I even studied with a cardiologist to master science 12-lead cardiogram interpretation. I also recall encounters with the hospital’s office personnel. I sported a sense of pride as a clinical person on the front lines, saving lives, doing something that not everyone could do. It was not until years later--when I became a suit myself--that I realized what administrative personnel actually thought of us respiratory therapists. RRT, CRTT, OJT, it makes no difference to them. As best they can figure, we administer oxygen and watch people take nebulizer treatments--four at a time. What skill does this take? They have parents that do this for themselves at home.
Nursing is Unclear as to RT’s Role
In general, nursing doesn’t really understand our role either. I recall working in the ICU with an elderly gentleman who had very compromised ventilatory and hemodynamics issues. I had been a critical player in his care for several days. I had intubated him, selected and maintained his ventilator setting. I had recognized some serious issues and suggested critical changes in his care that were very pertinent to his survival. When the lab technologist and the nurse were unable to collect blood samples, I did it for them. I had even helped change his soiled bed.
One Sunday afternoon, his daughter--an instructor at the local nursing college--was visiting. As I entered the room the gentleman gestured to me. By know we had developed a relationship. His daughter saw the jester and responded, “Oh, its OK Dad, he is just here to check the machine. Some of us deal with patients and others deal with machines.”
The patient’s ICU nurse was in the room as well. We looked at each other. Realizing the remark was vicious and demeaning, she was mortified. It was all she could do to hold her tongue. Outside the room, she apologized for the nursing instructor’s comments. Although I hade earned the respect of these particular ICU nurses with whom I worked, the fact remains, that this nursing instructor’s impression is exactly the impression that much of nursing has toward respiratory therapy. Too many of them do not realize that we too know anatomy and physiology and have just as good a grasp on medicine as they do.
Respiratory Therapists are Unclear as to RT’s
“How,” you may ask, “does this relate to diversification?”
Diversification paints an obscure picture. It necessitates an ambiguous definition of the profession. I would venture to wager that the majority of new respiratory therapists don’t even know why the field exists. I suspect few realize that respiratory therapy and the intensive care unit are twins–specifically bred to manage patients in need of ventilatory assistance. This is our roots. And I content, this must be our future.
Essential Care Givers in the ICU/CCU
Not that we should avoid diversity, but that we should tout the ICU. The ICU and critical cardiopulmonary illnesses are the heart and soul of respiratory therapy. If the field is to survive, we must reclaim this territory. It is imperative that we focus our activities and re-establish our link to the past. This means more than Q2 hour vent checks and responsive ventilatory changes upon demand. It means the mastery of ventilation and hemodynamic issues. It means the mastery of ventilation and hemodynamic equipment. It means knowing more about cardiopulmonary diseases and their treatment than do the physicians. It means being the vital clinical resource sought by physicians for advice and care of their critically ill cardiopulmonary patients.
It was a mistake to relinquish a focused involvement in cardiopulmonary medicine for the ambiguity of diversity. Today, in far too many institutions respiratory therapy does little more than deliver small volume nebulizers, IS, and CPT. Oh yes, and they change the vent settings as directed. Two of which, patients can do themselves, one–is generally a classic example of mis-allocated resources and the other nurses can do. Is their any wonder why administration is continually seeking to cut the department? The acquisition of EKGs, sleep diagnostics, ABGs, echocardiograms, MDIs, home care, phlebotomy, or even patient education is not going to secure the future of the profession. Each of these functions can be and are performed by any number of disciplines.
Touting such diversity as our major marketing characteristic has relegated the profession to a catch-all “orderly” category in many minds. But it is our relationship to the ICU that identifies us as necessary entities in critical care medicine. This invaluable link to the ICU must be our focal point. From here we may diversify as needed, but we must always focus upon our role in the ICU.
Coupled to this intimate reunion with the ICU, must be the implementation of Patient-Driven-Protocols. As is being proven throughout the country, such protocols insure a uniform and consistent patient care; and they save a considerable amount of money for the hospital. Eventually, both the medical staff and administration will begin to take note.
When administration asks, “What do Respiratory Care Practitioners do?” The answer must be clear and concise, and it must roll off the lips of nurses, physicians and therapists with ease. “Respiratory Care Practitioners are the essential care givers who maintain the cardiopulmonary status of our most critically ill patients.”
The second issue that we must be settled is the incessant internal strife. This constant bickering about credentials serves no useful purpose. It only harms the profession. It is imperative that the bickering cease and that the profession unite. We must mend our fences . . . No, we must take down the fences and move forward in unison.
A Few Observations
I’ve made a few observations about this bickering. First, it is understandable, but it is uncalled for. It is an immature response to a desperate sense of professional insecurity. This insecurity is due to the perceived and even realized lack of professional respect within the healthcare community. Curiously, as noted above, I believe this lack of respect is fostered by the strategy of diversification and the subsequent lack of focus upon the ICU/CCU. (Please note, I realize that many therapists work in critical care units and are deemed vital members of the clinical team. Unfortunately, I do not believe this is the case in general, and here I am painting with a broad brush). The strategy to diversify has resulted in an ambiguous definition of the profession that has not gained or earned respect.
Secondly, this bickering only serves to create a sick atmosphere within the profession. The irony is that the rest of the healthcare community, in general, doesn’t even understand the distinction between the two credentials. Many of them don’t even know it exists. Indeed, they struggle even to understand what we do, much less what credentials we hold.
The VP of human resources, whom I sited earlier, had no idea of the difference. Nor did he have concern once informed. In response to the AS and even BS degrees, he said, “Are they necessary to perform the job?” Credentials do not gain respect. They never have and they never will. This reality transcends healthcare. It holds true throughout life. In a hierarchical system, credentials or position will demand obedience, but they do not generate respect. Respect is something that we earn. But before we can earn the respect of others, we must respect ourselves. We must unite as one, with a common objective and a common regard for the profession. Only then will other healthcare providers view us as their peers. Beating up on each other only pushes the goal further a further away.
Aside from not generating respect, there is something else that credentials do not do. They do not equal ability. Sometime ago, I published an article bemoaning the obvious inept design of minimal competency exams for MDs, RNs, RRTs, CRTs, LPNs, etc. Obviously inept I say, because we have all worked with individuals who have passed these exams, achieved their credentials, and yet have no clear understanding of their discipline, much less a mastery of it. Some of them are out right dangerous, making you wonder, “How did they ever pass the test?” The answer is obvious. The test is inept. The acquisition of a particular credential does not equal ability any more than much reading equals intelligence. Needless to say, credentials have never impressed me too much, not even my own.
I am thinking of the most competent Respiratory Therapist with whom I have ever worked. He was an OJT. Educated? No, at least not by an accredited school. But yes, he was educated. His education was thorough, driven by interest, self determination and a genuine ability to comprehend medicine. He had read and mastered every major work on the subject of cardiopulmonary care. He had years of clinical experience and he could instruct even the instructors. In contrast, I think of one of the most incompetent therapist with whom I have ever worked. An RRT, with several years in the field who struggled to understand even the basics of ABG interpretation and certainly never had a clear grasp of the dynamics of pressure/volume association.
What is my point? Am I advocating that we abandon formal education? No! Of course not. But I am advocating a change in the system. I suggest the following.
1. The NBRC abandons the CRT exam and offers only the RRT.
2. The NBRC raises the bar on the RRT exam, making it more difficult and thereby weeding out those who do not have the ability to comprehend the mechanics of medicine.
3. As is the precedent under grand-fathering, let those presently holding credentials sit for the new exam.
4. The NBRC devices a prerequisite exam specifically designed to screen-out would be RT students who do not have the mechanical aptitude to comprehend cardiopulmonary medicine. Thereby assuring the quality of future students, their ability to pass the more difficult exam and their ability to function in the critical care arena.
These changes would benefit both fronts. The internal squabbling would cease. At first, the egotists who picture themselves as purist will complain about the grand-fathering, but they will get over it. Also, great progress would be made toward gaining the respect of our healthcare peers. Not because of the credentials, but by assuring qualified individuals who could master the cardiopulmonary issues of the ICU.
I also have a project for the AARC. Spend the next few years sending speakers to every medical and health executive convention in the country. Their task is to proclaim the importance of Respiratory Care Practitioners in the ICU and to inform of the importance of Patient-Driven-Protocols. I dare say, such a proactive strategy would increase membership.
Finally, I have a charge for each therapist and each department. Healthcare is changing. Reimbursements are shrinking and the baby-boomers are getting older, sicker. Soon, hospitals will be overwhelmed with cardiopulmonary patients. Already they are seeking creative, effective and inexpensive ways to care for these people. To secure the future of the profession, we must go out of our way to prove our value. It must be proved to both clinical professionals and administration. Credentials alone will not prove value. What will prove value is a direct effect upon clinical outcome and the wallet--the cost of providing quality care for each patient.
This means that patient by patient we must: (1) decrease the length-of-stay by providing appropriate and aggressive care, giving constant feedback to nurses and physicians, even if and especially when unsolicited; (2) decrease over-utilization of respiratory care services and medications by instructing the nurses and the physicians as to proper and appropriate therapy, and working to implement Patient-Driven-Protocols; (3) decrease re-admission violations by assuring our patients are properly educated as to the care of their particular disease process before discharge; and lastly (4) make certain that we implement a process to make administration aware of the money we are saving them. As ignoble as it may sound, healthcare is still a business and money is the driving force.
Of one thing I am certain; the battle for the survival of our field must be waged in the critical care arena. There, we are assured victory. This is our turf. The terrain is specifically suited to our skills. In all other battle grounds the field is level–with our skills no better suited for the terrain than are the skills of others.
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