As a university instructor for more than 10 years, I've exposed my students to a fair share of techniques, programs, and exam preparation materials for the CRT, RRT, and Clinical Simulation exams. For the longest time, one company dominated the market-- Kettering National Seminars. Consequently, up until recently, the university has facilitated the use of Kettering. A few years ago, however, my colleagues began to report an increase in the number of their students using a company called LindseyJones. Because the school has historically chosen what provider to use, there began to be growing unrest among the student body about being forced to use one over the other. Many students would insist that they did better with LindseyJones, having bought the material independently. Before long, raging debates about which company was better would spark among students. Finally, I decided to embark on a study with my students to determine which was most effective, if any: LindseyJones or Kettering National Seminars. I've tried to be unbiased since my role as an instructor dictates it. Here are my findings and opinions.

For the purpose of this analysis, so as to not breach my contractual relationship with the university, I will not disclose my employer or myself. I have a deep obligation not to recommend any particular program and I don't want to come across as representing the university's opinion on the matter. With that being said, while I found pros and cons to each program, I did come to the conclusion that there was one clear leader. I provide this information only as a reference for decision makers (Instructors) who find themselves in the dilemma of choosing between LindseyJones and Kettering. What I found most difficult was to provide some sort of point system for specific attributes. Thus, with each point tally, I have also provided as much explanation as I could. Generally, I looked at materials provided in each company's home study courses and looked at their effectiveness so far as I could gain that information. In most cases, obtaining statistical information from each company was difficult to say the least. Kettering simply does not publish their pass rates. The closest they come to transparency is their pass rates, which is informally given when you call the company. LindseyJones DOES publish a variety of statistics, but they will not make available their statistical analysis methods. As anyone knows, statistics can be massaged favorably by anyone

Both companies produce a Study Guide of several hundred pages. Most students I spoke with favored the format of the LindseyJones guide. Predominately, they indicated that it was just easier to read and the order of the information made sense. As for my own opinion, I did not feel that format made that much of a difference, but I did think the order of subjects in the book was a bit more logical with the LindseyJones study guide. It seemed to build on knowledge a bit more methodically. I was surprised to find that the Kettering manual had no index or method to look up specific subjects. I found myself literally thumbing through the book to find specific details. The LindseyJones manual has a fairly detailed index, though it does not cover everything in the book. For the index, LindseyJones receives several points. The reason the final tally was so close for me had to do with editorial accuracy. The LindseyJones guide had a few more typos than did the Kettering manual, though both had their fair share. One of the reasons for this may be the fact that the LindseyJones manual is an ever-changing document. While Kettering appears to publish the study guide every few years (and makes very few changes), LindseyJones indicates that they publish several times a year, quickly responding to new or previously unknown topics on the exam. In that since, the LindseyJones guide seemed to be more up-to-date. I checked the copyright of my student's brand new Kettering manuals at the end of 2013 and found they were still distributing the 2010 edition.

Kettering was the only company of the two that produced a robust workbook. LindseyJones does not even attempt it. However, upon inspecting the workbook, and from speaking to students over the years, I have come to feel that student's who diligently completed the workbook (which is merely transferring information from the study guide) had somewhat of a disappointing outcome. Several students I spoke with indicated that when they finished the workbook, it gave them the sense that they were ready for the exam. Many expressed that the activity did not really help them. I also discovered that only 1 out of 10 students actually completes the workbook. Many start off doing it but become disillusioned after a few pages. As for me, a workbook like that would only work if it was diligently studied and memorized after completion. All in all, that may be asking the student to participate in too much redundancy. Generally, I found the workbook ineffective and in some cases misleading as to its helpfulness. However, LindseyJones receives 0 points because they have no such tool.

In the years I've been teaching, I believe the single most effective activity in preparing for the NBRC exams is practice, practice, practice. For that, LindseyJones towered over its competition. Kettering has a fraction of the number of questions compared to LindseyJones. For instance: for the 2015 exam, Kettering offers only ONE (that's right, just ONE) practice exam. If one desires more practice, they may use 1 of the included 40 tokens to do extra questions. I like that they include addition tokens but one can gain access to only 15 questions per token. And, as a far as I could tell, there are only about 250 or so questions available. Thus, the 250 questions, if added to the ONE full-length exam, total about 400 questions. The LindseyJones program, in contrast, includes 8 full-length exams totaling 1,120 questions (actually, my students are currently reporting 12 full exams for a total of 1,680 questions, but the product advertisement shows 8 exams). I did like that Kettering's online questions, though few in number, offered audio explanations. Whereas LindseyJones explanations were just text, although they were much more explanatory. Overall, I felt the low number of practice questions offered by Kettering is a great downfall. Because practice questions are key in determining pass rates, I felt Kettering was missing the ball on this one. And although you can use your tokens to buy up to 250 more questions, what they don't tell you is that the same set of tokens has to be used to do their simulations. When I do the math, it looks like one MUST buy more tokens to do all the exercises that Kettering offers. Additionally, one can only repeat exercises for a limited time (two weeks). Beyond that, the user must use more tokens to repeat exercises. I won't endeavor to go into the cost of tokens, but the base price of the Kettering program is $360. LindseyJones offers 6 months of unlimited use of all questions and clinical simulations for quite a bit less (around $275). I favor unlimited access because I've come to believe that if students have to repeatedly get out their credit card to buy more practice, they will very quickly decide that they have had enough practice as their decision may be driven by their budget. As for the quality of the questions, I generally felt that both companies produce high quality board-type questions. LindseyJones questions might be a bit harder, which I like because it increases critical thinking. But both company's questions are sufficiently difficult - in fact you'll be tempted to use profanity a few times. You may even be upset at the company that provided them - until you take the actual exam and realize the same tricks and deceit tactics are used by the NBRC. Although there are other programs and exam preparation books, including Sills, Persing, and others, I have developed the opinion that those authors do not repeatedly take the real NBRC exam. And if they do, they are not good at replicating similar conditions in their own written questions.

As far as access to the audio lectures go, the 2015 audio access for both companies has been upgraded to streaming audio online. However, in this area, there was one very important distinction between LindseyJones and Kettering. Kettering offers access that appears to be limited to online streaming audio only. I found this to be very disturbing. It means that to listen to the Kettering audio, one must be connected to the Internet by desktop computer or mobile device during the entire course of the lecture. That may be fine when connected to a wireless Internet source, but when using a mobile device on a restricted data plan, data charges could apply. I thought this was very restrictive of Kettering and I believe this will lead to a colossal failure if they do not change this delivery system quickly. In contrast, LindseyJones provides 6-12 months access to online audio, similar to Kettering, but the company also includes over 21 hours of audio on CDs, which is shipped with the study guide and flashcards. This allows for installation on mp3 devices, such as iPhone, IPod, and Android mobile devices. Once installed, an Internet connection is not required, no data charges are incurred, and audio may be used indefinitely (no expiration).

Generally, both companies offer high quality, exam-like clinical simulations. For Kettering the same token method is used from the 40 tokens included in their basic package, while LindseyJones offers unlimited use for the entire period. Both programs use a few special (instructional) simulations but Kettering indicates that the instructional Sims can be used only ONCE. True to form, LindseyJones offers unlimited use. Most of the tokens offered by Kettering would be required to complete all their simulations, requiring the user to purchase more tokens to complete practice questions and other simulations. Between the two companies, there is one fundamental difference in the way the clinical simulations operate. For Kettering, a simulation must be completed before any review can be done. The review consists of viewing each screen and identifying what was correct and incorrect by color codes. I like they way Kettering handles that. LindseyJones simulations do not have a review at the end. They have two modes - teaching and testing. In teaching mode, the user receives immediate rational as selections are made. While I'm not sure which one I like better, I do feel my students learned more with LindseyJones. This, I believe, was primarily because they had to run through the LindseyJones simulations several times, picking each answer, in order to learn what was was correct or incorrect and why. I believe this led to greater understanding in the long run. With Kettering, students mostly completed a simulation, read the final review, and then were done with the simulation forever. Technically they could repeat that simulation for two weeks, but must utilize another token beyond that. In speaking with my students, I believe that few students did a Kettering simulation more than once. Student's certainly liked the Kettering simulations because they presented answers clearly in color codes. However, an analysis of student scores showed that the LindseyJones simulations had by far the greatest affect on pass rates and clinical simulations scores. At our own institution, improvement was remarkable with the LindseyJones simulations. This is likely due to the fact that each student was forced to struggle through the simulation multiple times to learn what was correct and incorrect and why. I've observed over the years that any method that causes a student to struggle, to think deeper, and come to a conclusion (although uncomfortable to the student) will have a much greater impact on the student's understanding in the long run. Finally, I will say that our own university witnessed a huge jump in clinical simulation scores with LindseyJones. Although we had used Kettering for years, the data was undeniable and we switched providers.

Both companies have flashcards. 200 flashcards are included in the basic package with LindseyJones. 160 Flashcards can be purchase for an extra $20-40 from Kettering. Kettering covers normal values and calculations. LindseyJones' flashcards cover pharmacology, word associations, and calculations. Kettering's cards are black and white, while LindseyJones cards are color. Beyond explaining what is offered on each product, I had no clear evidence indicating which company was more effective with the use of flashcards. I did lean slightly toward LindseyJones because they offered pharmacology, an area that requires rote memorization and lends itself to the flashcard approach to study.

Kettering wins in this area because they technically offer toll free tutoring while LindseyJones makes no attempt at tutoring students who purchase a home study. That being said, I could only give Kettering 2 points because when one reads the fine print, one discovers that the tutoring call schedule is quite restrictive, almost non-existent. In fact, according to Kettering's own published tutoring schedule, only 6-8 days a month are available for call in. On their website, they indicate that if you get a busy signal, try again later. Most every student I spoke with suggested they had extreme difficulty connecting with a tutor. Several indicated that they had to hover over for the phone for the better part of a day to get through. They also indicated that the tutor did not really engage in teaching; rather they simply regurgitated information in the book, which my students reported as not very helpful. To see for myself, I attempted to call every 15 minutes for 7 hours on one of their available days. I never got through. I always got a busy signal. For that reason, I have given Kettering only 2 points for tutoring.

Although the 2015 Kettering site remains to be seen, the LindseyJones online practice comes with a custom dashboard that accumulates scores and gives advice on areas of weakness and strengths. I love this feature. The reason I know about his is the LindseyJones offers a 4-day live demo with a free full length exam and several clinical simulations as well as audio lectures. With LindseyJones, the more practice the student completes, the more information they receive about areas on which they need to focus. They even graphically display other test taking tendencies, such as the tendency to choose too many selections or not enough in a clinical simulations (omission vs. commission scores). Kettering offers no such thing.

I don't like to comment about cost all that much because cost does not dictate quality. I won't give exact quotations here, but among students that I've spoken with, the average amount spent on Kettering was $450. That number was shocking to me. But considering the base price of the program ($360) and then add flashcards ($20-40) and purchase of additional tokens to complete all the practice available ($50-$100), one can see how the bill climbs quite drastically. And at that whopping price, access to simulations was still limited to two weeks and only one use of each instructional simulation. For those using the LindseyJones, the total price of $275 seemed to include everything, unlimited use during a 6-12 month period. Consequently, pass rates, in my experience, were markedly higher with the LindseyJones program.

When I set out to study and compare these two companies, I resolved to be as unbiased as possible. However, the very purpose of the study was to determine if any bias was warranted. Although Kettering offers a few items that LindseyJones does not, my logical finding was that LindseyJones is generally more inline with student preferences, cost less, and results in higher NBRC examination scores. Keep in mind that this study was not scientific in that I could not study the thousands of students required to make it statistically valid. However, I did study hundreds of students by survey and have spoken personally to my own and several other program’s students. These conclusions are based upon those interactions.

Final Note:
I do not endeavor to say which is the best exam preparation program for any particular individual or group. I leave all to their own conclusions. I hope the information provided is helpful. If I appear biased, it is because I am. I became so as I collected this information. Although I cannot be reached directly, editorial comments can be emailed to the RESPIRATORY REVEW EDITOR.

In January 2015, the NBRC CRT and RRT Written exams will spontaneously combust and disappear. That does not suggest that the CRT (Certified Respiratory Therapist) credential will be gone. Both the CRT and RRT credentials will live through the change but the method of achievement will have undergo a significant change. The CRT and RRT Written exam will be replaced by one unified examination. The National Board of Respiratory Care (NBRC) is referring to the new exam as the Therapist Multiple Choice Exam, or the TMC (sometimes called the TMCE). When challenging this new exam, prospective RTs will receive one of three status designations. 1) Failed. 2) Passed at the CRT level or 3) Passed at the RRT level and eligible to challenge the Clinical Simulation exam. Let's explore the implication of these three outcomes.

FAILED This level suggests that not enough questions were answered correctly to obtain the minimum CRT designation. The exam must be retaken.

PASSED at the CRT level When a minimum threshold is achieved (a certain number of answers are correct), the test taker becomes a CRT and receives a license to practice as such. However, he or she is ineligible to challenge the Clinical Simulation exam and is therefore barred from RRT status. To remove that barrier, the candidate may retake the TMC exam and attempt to achieve the higher cut score to obtain eligibility for the Clinical Simulation exam and the potential to become to an RRT.

PASSED at the RRT level The test-taker is immediately licensed as a CRT and can schedule the Clinical Simulation exam at will. If they pass the Clinical Simulation exam, they become an RRT.

Most who are reading this are probably wondering what scores the NBRC requires to become a CRT and what cut score is required to pass at the RRT level? I'm afraid no one has those exact numbers. The NBRC has not yet published the cut scores for each level (as of the date of this article). But statistical deduction by a few big players in the game suggest that the minimum passing rate (to achieve CRT status) is about 60-65% and the RRT pass level is most likely around 74-81%. Again, these numbers are not known for sure, but evidence suggests that they are in the ball park.

What is the purpose of the change in the exams? Many pontificate about this but generally most authoritative entities believe the move will help candidates save money by taking less exams (2 rather than 3). That supposition, of course, will become true only for test-takers who pass on the first try. In addition to changing the format of the exams, the NBRC suggests that new information on the exam will alter (likely increase) the cognitive value (difficulty) of the exams.

In addition to the support for this change by the NRBC, the American Association of Respiratory Care (AARC) also pledges its support. That's no wonder. If one examines the faculties of each entity and the commonality among their governing and advisory boards, it's fairly easy to assume that the NBRC and AARC are bedfellows. It's interesting to note that in 2013, when the AARC threw its support toward the new change, it also decided to begin selling an examination preparatory course.

While the AARC supported the change to the new TMC exam, they also expressed opposition with many academic entities that the CRT designation should be discontinued. They site a lack of evidence indicating that the current entry level designation of CRT is insufficient. More specifically, they cannot find evidence that CRT level therapists pose any particular threat to patient welfare, compared to RRT level therapists.

Both the AARC and NBRC have indicated that they feel the move to the new testing format will encourage a greater number of therapists to obtain the RRT status. The truth remains to be seen. Even AARC president, George Gaebler, has tasked the board of directors to monitor the results and to take other measures to encourage increased RRT matriculation if the change does not materialize as they expected.

Other central concerns related to the combing of the CRT and RRT written examinations, as well as the underlying influence to move CRTs to RRTs, relates to the future of those therapists who have the CRT designation and do not intend to move toward the RRT status. What will happen to their future prospects for employment? Will they be able to maintain licenses? What will happen to CRT licensed professionals if the RRT designation becomes the entry level credential?

These are valid questions that have no solid answer at this point. But the AARC generally expresses that CRTs will likely be grandfathered in most cases, though the AARC is also quick to point out that States have the right to manage licensure independently. Currently, states that are leaning heavily toward creating an environment where only RRTs are welcome include California and Ohio but others appear to be moving that way.