Thomas Smalling, PhD, RRT, RPFT, RPSGT, FAARC

“Why?” asked Dr Bergofsky, a venerable sage and chief of pulmonology at what was then the Northport VA Medical Center in Long Island, NY. His question was directed at me, a respiratory therapy student, during my pulmonary function rotation. The year was 1987. “Why does the flow-volume loop appear that way for this patient?” I sat nervously on the other side of an old wooden table in a conference room later named after him, contemplating my response. I was not the only one in the room. There were two other attending pulmonologists, several pulmonary fellows, two registered pulmonary function technologists, and, of course, me. So, why pick on me, I thought? Oh, right. I was there to learn. So? Was not everyone else? That is the point, I guessed. I looked around the room quickly to see if I could get a hint of the correct response, but my glance was only met with a “We’ve-all-been-through-this-so-it’s-your-turn-expression.” Why? I asked myself. Why does it matter? It seemed so trivial a question at the time. I knew that if I did not answer soon and answer correctly, he would move on to a technologist or a fellow. That would not be in my best interest, I thought.

It was not until years later, after having become a respiratory care educator at Stony Brook University, that I realized why it mattered and why it was important to ask “why.” Along the “path to enlightenment,” I transitioned from student to therapist, to supervisor of (ironically) the pulmonary function lab at that VA medical center, and finally to educator. As an educator teaching pulmonary function testing, I often found myself asking my students the same questions that my mentors asked me, including the most prominent one, “why.” Was I reliving those experiences at the VA for merely nostalgic reasons or was there more to it, I wondered? After careful deliberation, I have come to the conclusion that it has been a mixture of both. The more I taught pulmonary function testing and its broader term, pulmonary diagnostics, the more I realized the important role of physiology in what and how I taught. You must realize that you cannot answer the question “why?” without a knowledge and understanding of physiology. My mentors at the VA and elsewhere were physiologists. Yes, they were also pulmonologists and pulmonary function technologists, but they considered themselves physiologists. As physiologists, they understood the importance of asking, “why?”—because answering such a question not only provides an explanation for the possible reasons test results appear the way they do, but by answering such a question, the student provides insight into their thought process and problem-solving abilities. All this, of course, fosters what we educators commonly refer to today as critical thinking. Few would debate that physiology is the foundation for all the other basic and clinical sciences. Clinical respiratory care, pharmacology, pathology, and many others all have their foundation embedded in physiology. That is often why anatomy and physiology are among the first courses we learn in our profession. Anatomy teaches us the “what,” and physiology teaches us the “how and why.”

Two of my mentors, Dr Bergofsky and Ken Belgrave, RPFT, taught me not only to understand what pulmonary function testing was and how it worked, but more important, why things were the way they were. Dr Bergofsky taught me why pulmonary function test results presented in a certain way for a particular type of patient. Ken Belgrave taught me why I needed to perform the test a certain way and also why the test errors I encountered occurred. Both of them were true physiologists. Both of them are no longer living. Over the years, I have come across fewer and fewer educators that I would consider physiologists. I surmise there are others who have experienced similar circumstances. Upon reflection, I asked myself, why (sorry, I couldn’t resist) is this happening?

For one, teaching physiology is challenging and time-consuming. It is also an art form. Many who integrate physiology into their teaching strategies have done so not based on formal training in teaching physiology but by the increasingly uncommon method of an apprenticeship. Someone who knew physiology and knew it well had to not just teach it to you, but inculcate its value to you as an educator and clinician. Those who know physiology well enough to have apprentices are fading into the annals of history. As such, educators are increasingly bereft of the skills and/or value of teaching physiology that was impressed upon them by their mentors.

The recurrent discourse in academia regarding the need to increase critical thinking skills in our students is due, in some way, to the diminished emphasis we educators (both program and clinical faculty) place on physiology. It may seem antithetical to suggest this, but I believe that we have to recognize that the present day respiratory therapy student cannot be expected to learn as much physiology as was the case 20 years ago. The reasons are mainly that the field is so technology-driven, advances in how respiratory care is provided, and the increasing venues for which that care is administered have each prompted greater demands on the curriculum. The respiratory care curricula (and others, I imagine) are under competing stresses by various stakeholders. Employers and the technological advances within the profession demand ever-greater skills and knowledge base from students. Faculty, on the other hand, are constrained by the limits of time, space, as well as institutional restrictions that make it difficult, if not impossible, to give in to these demands without some sacrifices to the existing curriculum. My response to stakeholders has increasingly been, “Well, if we add this, what do we cut?” The consequences of these constraints are that more emphasis is placed on passive learning of much greater material and less emphasis on critical thinking skills that rely on more active learning techniques such as problem-based or case-based learning, even when most faculty agree that the latter method is the preferred option. Quite simply, it takes much too long to properly teach the “hows” and “whys” than it does to teach the “whats.” A true understanding of physiology takes a considerable amount of time and commitment on the part of both the educator and the student.

Of course, the technological advances in our profession make it even more difficult to teach physiology effectively. Case in point: pulmonary function testing. Pulmonary function testing equipment from 2 decades ago required the technologist to routinely maintain the equipment using a number of calibration instruments, troubleshoot, and, at times, even fix (yes, fix!) the equipment when it produced errors; most significantly, it required the technologist to calculate and verify test results (before computers were an integral component of the testing system). While it took longer to produce test results, pulmonary function technologists of the past had a more comprehensive understanding of the equipment they operated and the test results they produced. They understood why the equipment worked the way it did, how the test results were produced, and why patterns in those results were expected for some patients and not others. With advances in hardware and software computer technology, modern equipment has transformed the way we perform pulmonary function testing. User-friendly interfaces, miniaturization, interpretation algorithms, and (increasingly) quality control guidelines integrated into the software allow those with far less training and education to conduct pulmonary function testing. Technologists are able to produce test results without needing a comprehensive understanding of both equipment and the significance of those results. Pulmonary function systems virtually tell the operator what to do, when to do it, and what is wrong with the results. I have joked with my students that the only thing missing is the computer voice of HAL from 2001: A Space Odyssey, but I realize more often than not that the students I now teach do not have a clue as to what I am talking about. Technological advances in our field, while unavoidable, come at a price—we trade an intuitive understanding of the “why” and “how” for time and efficiency. Is this the worst of times?

Has the decline in teaching physiology anything to do with our students’ diminishing ability to think critically? Or have the advances in our field and increasing emphasis on output simply made those who perform pulmonary function testing subservient to the technology they use? The answer may be very well be an elusive one, but I find solace in knowing that I have and will continue to carry on the traditions of my mentors: to find new and innovative ways of integrating physiology into my teaching. So, next time you interact with a student, always be sure to work in at least one “why.” It will virtually guarantee that you will make them stop and think for a minute. And if they answer incorrectly, you have still succeeded because you are teaching them to question their environment, which is the fundamental nature of education. As my son approaches 3, I will once again be bombarded with the question, “why?” Yes, these are indeed the best of times.

Thomas Smalling, PhD, RRT, RPFT, RPSGT, FAARC, is director of clinical education and clinical assistant professor, Respiratory Care Program, School of Health Technology and Management, Stony Brook University, Stony Brook, NY.