As pulmonary, critical care, and sleep clinicians, we collaborate with multiple health care specialties daily. One of our most important relationships is with respiratory therapists (RTs). RTs are critical to our ability to provide care in the ICU, sleep lab, pulmonary function test (PFT) laboratory, pulmonary rehabilitation program, and outpatient setting. Pulmonary medicine has been closely linked to the RT profession from its beginnings as “inhalational therapists” in 1940s to the current complex, high-tech practice that includes extracorporeal membrane oxygenation, advanced mechanical ventilation, protocol management, and, now, the advanced practice respiratory therapist (APRT). At the center of our relationship with RTs is the Medical Director position.
The Medical Director of Respiratory Care role is critical to the functioning of modern hospitals. For hospitals that accept Medicare, appointing a “director of respiratory care services who is a doctor of medicine or osteopathy with the knowledge experience, and capabilities to supervise and adminster the service properly” is a requirement for participation in Medicare.
Many states have similar requirements. In my state, North Carolina, the Respiratory Care Practice Act mandates appointment of a Medical Director and defines them as “an appointed physician… and a member of the entity’s medical staff, and who is granted the authority and responsibility for assuring and establishing policies and procedures and that the provision of such is provided to the quality, safety and appropriateness standards as recognized within the defined scope of practice for the entity.”
The Medical Director role is also reognized as critical to respiratory therapy education. The Commission on Accreditation for Respiratory Care (CoARC) mandates that “A Medical Director (MD) must be appointed to provide competent medical guidance… ensuring that didactic, laboratory and supervised clinical instruction meet current practice guidelines. The MD must be a licensed physician and Board certified (as recognized by the American Board of Medical Specialties (ABMS) or American Osteopathic Association [AOA]) in a specialty relevant to respiratory care.”
Despite the importance of this position, most of us who fill these roles in our facilities have little or no formal training. While some aspects of the role (pulmonary function laboratory supervision, for example) receive attention in training programs, most of what is needed to effectively provide medical oversight to a respiratory care department is never addressed in a pulmonary fellowship. There is also surprisingly little information in the published medical literature. The most recent comprehensive statement that I am familiar with was published as a position statement by the American Thoracic Society in November 1987.
This educational void was partially filled for over 30 years by the National Association for Medical Directors for Respiratory Care (NAMDRC). In March 2020, NAMDRC and CHEST announced a merger, ultimately finalized in 2023. While the advocacy part of the NAMDRC mission was continued, their educational role was dropped. Recognizing the vacuum, a group of senior respiratory therapists and physicians from the Americal Association for Respirtory Care (AARC) began working on an outline for an educational program to fill the gap. The project never progressed, but the outline provided a starting point for the first major project for the CHEST Respiratory Care Interest Group, the recently completed Guide for Medical Directors of Respiratory Care.
The project—completed with the leadership of David Vines, FAARC, PhD, FCCP, Chair of the Respiratory Care Interest Group Steering Committee, and CHEST staff—represents the combined efforts of the Interest Group Steering Committee, all with extensive educational and leadership experience in respiratory care. Both physican and RT perspectives are represented.
The guide addresses the Medical Director role in six settings:
- The acute care facility
- Pulmonary rehabilitation
- The PFT lab
- The sleep lab
- Respiratory care educational programs
- The ICU
Guidance on core responsibilities, standards, staffing, process improvement, and billing/finances is provided where appropriate. The guide is by no means comprehensive but does represent a great first step in consolidating information needed by RT medical directors. Hopefully, it will serve as a repository that can grow and evolve with the changing responsibilities of the position.
The guide is located on the CHEST website, and printed copies will be available at the Cultures and Communities Reception on Monday, October 19. All conference attendees are welcome to join.
Feedback on the content and suggestions for new projects are also encouraged. To receive updates on the Respiratory Care Interest Group, log in to your CHEST account and join the interest group.
References
1. Centers for Medicare and Medicaid Services. Condition of participation: Respiratory care services. 42 CFR §482.57.
2. North Carolina General Assembly. Respiratory Care Practice Act: §90-648. Definitions.
3. Medical Director of Respiratory Care. Accepted as an Official Position Paper by the ATS Board of Directors, November 1987. Am Rev Respir Dis. 1988;138(4):1082-1083. doi:10.1164/ajrccm/138.4.1082
