The Respiratory Therapy Profession Is at a Crossroads

In 2007, the American Association for Respiratory Care(AARC) commissioned a task force to provide recommen-dations for the future direction of respiratory therapy in2015 and beyond.1 After 3 years of study, conferences,and discussions with a wide range of individuals and or-ganizations considered primary stakeholders in respiratorycare and after defining the competencies needed by respi-ratory therapists in 2015,2 the task force made 9 recom-mendations regarding changes needed to position the pro-fession of respiratory therapy in 2015 and beyond forcontinued success. It is now more than 6 years since thoserecommendations were presented.

The third recommendation presented was that, by 2020,all respiratory therapy educational programs award a bac-calaureate or higher degree to all graduates. This recom-mendation was considered by the AARC Board of Direc-tors in December 2012 but was rejected because of aninsufficient number of baccalaureate programs (49 of atotal of 433). Progress has been slow, but now 61 of 438programs offer baccalaureate or graduate degrees. In thesummer of 2015, the AARC Board of Directors estab-lished the goal that, by 2020, 80% of respiratory therapistswould have at least a baccalaureate degree or be in activepursuit of an advanced degree.3 On January 19, 2016, theAARC website called for all new respiratory care educa-tional programs to award, at a minimum, a baccalaureatedegree in respiratory care but did not mandate this change.4

However, the Commission on Accreditation for Respira-tory Care (CoARC) has revised their policy so that as ofJanuary 1, 2018, it is mandated that all new respiratorycare programs must award graduates of the program abaccalaureate or graduate degree upon completion of theprogram.5 Although we applaud the CoARC for steppingup to encourage the development of baccalaureate andgraduate programs, this policy change does little to change

the pace of conversion of the currently accredited associ-ate degree programs.

The recommendation to require a baccalaureate degreefor entry level was the primary recommendation of the2007 task force. A mandate rather than a recommendation

SEE THE ORIGINAL STUDY ON PAGE 279

is necessary for this change to occur, since this was sup-ported by the 37 stakeholder organizations attending thetask force meetings and by surveys of directors of respiratorytherapy educational programs6 and managers of respiratorytherapy departments.7 However, in fairness, there was notunanimous support by respondents to these surveys in favorof a baccalaureate entry requirement to practice respiratorytherapy, but the vast majority recognized the need for a bac-calaureate degree for continued practice in the profession.

Under the leadership of past president Frank Salvatorein 2016, the AARC Board of Directors partnered with theCoalition for Baccalaureate and Graduate Respiratory Ther-apy Education and CoARC to identify the associate levelrespiratory care programs that would be easiest to convertto baccalaureate level.8 Once identified, contact was made,and assistance was offered to help facilitate a transition. Inaddition, a wonderful web-based tool was created by theAARC Executive Office to provide assistance.9

In this issue of RESPIRATORY CARE, additional support forthe movement to a baccalaureate entry level is provided.Smith et al10 report the results of a survey of 2,170 respi-ratory therapists in the state of New York regarding thefuture of respiratory care. The primary finding from the415 respondents was that the respiratory care profession isat risk of losing practitioners to other health-care fields.The reasons given for this attrition were limited manpowerin their institutions, limited professional growth, and lim-ited scope of clinical practice. In addition, the respondentscited salary levels and an inability to bill for services asreasons why individuals are leaving the profession. Mostimportantly, 60% of the respondents strongly agreed thatthe minimum academic standard for respiratory therapistsshould be a baccalaureate degree.

Smith et al10 go on to discuss their opinion that theMedicare Telehealth Parity Act will do a lot to expand therole of the respiratory therapist outside of acute care. Theyindicate that the Act includes respiratory therapists as qual-

Dr Kacmarek has disclosed relationships with Orange Medical, Teleflex,Coviden, and Venner Medical. Dr Walsh has disclosed relationships withGE Healthcare, Vapotherm, Dräger Medical, and Maquet Getinge Group.

Correspondence: Robert M Kacmarek PhD RRT FAARC, MassachusettsGeneral Hospital, 55 Fruit Street, Boston, MA 02114. E-mail:[email protected].

DOI: 10.4187/respcare.05484

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ified telehealth practitioners and adds respiratory thera-pists to the Medicare statutes allowing coverage for patientcare services provided in remote settings.11 However, onemust remember that respiratory therapists as a group arenot considered professionals by the United States Depart-ment of Labor, since our entry level remains at the asso-ciate degree and does not meet the criterion of “prolongedcourse of specialized intellectual instruction.”12 Therefore,only those with a minimum of a baccalaureate entry leveleducation are considered professionals and able to receivereimbursement for services provided. Nurses also do nothave a baccalaureate degree as their minimal entry leveleducation, but nursing negotiated an exception at the timethe current labor laws were written. Unfortunately, respi-ratory therapy was not in existence in the 1930s whenthese laws went into effect. Thus, only those respiratorytherapists with a baccalaureate degree will be eligible forreimbursement under the Medicare Telehealth Parity Act.

Respiratory therapist salary was a concern identified bySmith et al,10 and this is a concern of every respiratorytherapist. In the health professions, the entry level aca-demic credential and the ability to independently bill forservices are directly related to salary. Physical therapy andpharmacy require a doctorate as their entry-level creden-tial, speech and language pathology requires a master’s de-gree, and social services and occupational therapy requirebaccalaureate degrees but are moving to master’s degree en-try-level requirements. Of note, all of these professionals re-ceive higher salaries than respiratory therapists.

Respiratory therapists’ lack of autonomy was a concernidentified by Smith et al10 as well. It is clear to us thatautonomy is explicitly linked to educational level. Manyrespiratory therapists with advanced degrees practice inroles (eg, highest clinical ladder, educators, clinical coor-dinators, researchers, informatics, public health, case man-agers, administrators) that are essential to the advancementof the profession. However, because a minimum of a bac-calaureate degree is inconsistent, there is no solid founda-tion in which to clearly build these career pathways.

It is becoming increasing clear that if we expect respi-ratory care to continue to be a relevant and valued healthprofession, we must make some difficult decisions on fu-ture entry-level academic credentials. Wishing and encour-aging all respiratory therapists to obtain a baccalaureatedegree will not work. Consider the number of respiratorytherapists with sufficient interest in their future to com-plete the New York State survey, only 415 out of 2,170(22%): This demonstrates that wishing and encouragingalone will not work. This response rate was similar to thatof directors of respiratory therapy departments who com-pleted the task force survey in 2010.7 Surveys were sent to2,368 managers of respiratory care departments who weremembers of the AARC, asking questions about the futureof respiratory care in 2015 and beyond, and only 28%

responded. The professional apathy of many respiratorytherapists has a profoundly negative effect on the contin-ued development of the profession. We are clearly at acrossroads. Either we change radically and rapidly, or thereis the real possibility that our profession will regress ratherthan progress. The status quo is not acceptable. The reg-istered respiratory therapist academic requirements are es-sentially the same today as they were 40 years ago, whereasevery health profession around us has changed!

From our personal knowledge of individuals practicingrespiratory care throughout the world, we are the onlygroup that does not require at least a baccalaureate degreeas the minimum academic credential to enter practice. Ca-nadian respiratory therapists have the baccalaureate degreeas their minimum academic level to enter practice. Respi-ratory therapists or their equivalent trained in Saudi Ara-bia, Central and South America, Europe, and Asia all re-quire a baccalaureate degree to enter practice.

We do not expect a mandate that by 2020 every respi-ratory therapy program provide a baccalaureate degree toall graduates, but we do ask for specific dates that mandatechange; for example, that by 2020, all programs have aviable plan to offer a baccalaureate degree and that, by2027 (10 years from now), only respiratory therapy pro-grams that offer a baccalaureate degrees or higher will remainaccredited. Without specific pressure on the schools to changetheir curriculums, we are afraid there will be no movement toa baccalaureate degree minimum entry level into the profes-sion. Very little change has occurred over the last 6 years, andwe cannot see change occurring without a specific mandate,with deadlines set to achieve substantial change.

Combined, we have more than 70 years of respiratorytherapist experience. We are very proud to be respiratorytherapists and actively serve our profession and commu-nity. But we fear extinction of our profession. Time is ofthe essence. We are at a crossroads; change is occurring allaround us, and the status quo is no longer acceptable. Ifyou share our same concern, we encourage you to conducta study similar to that of Smith et al10 or, better yet, act. If youhave not completed your degree, please do so. In addition,contact your local AARC affiliate, educational programs, andlicensure board to ask that they mandate higher educationalstandards for our patients and our profession.

Robert M Kacmarek PhD RRT FAARCMassachusetts General Hospital

Harvard Medical SchoolBoston, Massachusetts

Brian K Walsh PhD RRT-NPS FAARCAmerican Association for Respiratory Care

Irving, TexasHarvard Medical School

Boston Children’s HospitalBoston, Massachusetts

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REFERENCES

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2. Barnes TA, Gale DD, Kacmarek RM, Kageler WV. Competenciesneeded by graduate respiratory therapists in 2015 and beyond. RespirCare 2010;55(5):601-616.

3. American Association for Respiratory Care. AARC membership up-date: 2015 and beyond. 2016; http://www.aarc.org//app/uploads/2013/07/december_2012.pdf. Accessed December 30, 2016.

4. American Association for Respiratory Care. Position statement: respiratorytherapist education. 2012; https://c.aarc.org/resources/position_statements/documents/rt_education.pdf. Accessed January 13, 2017.

5. Commission on Accreditation for Respiratory Care. Proposed finalrevision to standard 1.01. 2016; http://www.coarc.com/29.html. Ac-cessed December 30, 2016.

6. Barnes TA, Kacmarek RM, Durbin CG Jr. Survey of respiratorytherapy education program directors in the United States. RespirCare 2011;56(12):1906-1915.

7. Kacmarek RM, Barnes TA, Durbin CG Jr. Survey of directors ofrespiratory therapy departments regarding the future education andcredentialing of respiratory care students and staff. Respir Care 2012;57(5):710-720.

8. Frank S. AARC BOD work, meeting and public meetings.9. American Association for Respiratory Care. Transitioning for

an associate degree program to a baccalaureate degree program.2016; http://www.aarc.org/education/educator-resources/transitioning-associate-to-baccalaureate-degree-program/. Accessed December30, 2016.

10. Smith SG, Endee, LM, Benz Scott L, Linden PL. The future ofrespiratory care: results of a New York State survey of respiratorycare professionals. Respir Care 2017;62(3):279-287.

11. American Association for Respiratory Care. PACT day efforts pro-mote telehealth bill. 2015; http://www.aarc.org/pact-day-efforts-promote-telehealth-bill/. Accessed January 13, 2017.

12. United States Department of Labor. Wage and Hour Division (WHD)FLSA2006-26. 2006; https://www.dol.gov/whd/opinion/FLSA/2006/2006_07_24_26_FLSA.htm. Accessed January 13, 2017.

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