I’ll start this post off by acknowledging that I’m likely stirring the pot here, as I attempt to delve into a sensitive subject.
I once read a comment on a Reddit board, claiming our entire profession was a “farce” and I had to fight back the urge to type up a 10 page APA response to said Reddit user, explaining why what we do is valuable, necessary, and evidence-based.
During my time as a Speech Therapist, I have come to understand that my professional value will come into question from time to time; be it from a patient, family member, or collaborating professional.
At times, I have over explained myself to patients, in an ongoing fight to be known for all that we do; the breadth and depth of our profession being much greater than fixing lisps. Other times, I offer education and a strong rationale, and I don’t really put up much fight at all. Instead, I leave it be.
I cannot convince everyone. It’s my responsibility to educate others enough to make an informed decision, but I am certainly not responsible, nor is it appropriate for me to attempt to be responsible for, the beliefs of others. So I leave it be, at times, too.
I am a Speech Therapist who provides optional services. I have learned there is little to be gained from servicing a patient who has no buy-in or personal investment in their progress. I educate, educate, educate, and then, I respect my patients decision to either decline or discontinue speech services.
But what if the doubters weren’t entirely wrong? What if they were on to something, even?
The misunderstanding of our profession extends far beyond a sole Reddit user, or a few patients/family members/team members who do not see value in what we do.
The question of true value, scary as it is, is also coming from those within our profession. How terrifying is it, that SLPs are asking themselves if our profession is pseudoscience, or science?
How do we know that we are helping? How can we assess true value?
I remember asking my SLP supervisor, as a graduate student, how we can be certain that the improvement we were seeing in an aphasic patient on caseload was the product of treatment vs. spontaneous recovery?
My SLP supervisor informed me that there was no good way to know. It would be inhumane to not offer speech therapy following a stroke; therefore, research with proper control groups did not exist. She offered that as speech therapists, we were often facilitators of progress. There was a correlative relationship between our services and outcomes, not casual.
I liked that concept; I was facilitating progress. I was a facilitator. But it’s still messy, and not enough to instill full confidence, is it?
To be honest, I applaud my colleagues who have doubts. Thank you for not just drinking the facilitated communication Koolaid. Thank you for critically thinking about why you are doing what you are doing. Thank you for being skeptical about the problematic subjectivity with many measures of progress being used by novice and seasoned therapists alike.
It’s easy to lie with statistics, but it is even easier to lie when we don’t even know we are lying. To elaborate on this notion of accidental lying, lets dissect a short-term goal I continue to see via Casamba builds.
Exhibit A: “Pt will improve short-term recall to 75% accuracy given mod verbal cues”.
WHAT DOES THIS EVEN MEAN?
When we assign a random percentage to a vast and complicated cognitive domain with vague cues and call it a short-term goal, we have problems.
Where is the research that states that short-term recall, in itself, can even be improved? Perhaps with the use of compensatory strategies, a memory deficit can be mitigated, but we aren’t really diminishing the deficit in itself here.
Suddenly, within a week, come progress report period, the short-term goal is updated to reflect the “progress” a patient has made. A patients short-term recall has been improved by 10%. This percentage was accomplished by blocked recall trials of novel stimuli items. Or, the less fancy way of describing this: a therapist asked a patient to remember 5 random items (e.g. block, can, dog, boot, green) after a 5 minute delay during 30 minute sessions, several times during a session, 5 times a week.
The problem is this: if there even is any improvement to be made by doing this, it is not necessarily true that we are improving a patients short-term recall, but rather, we are improving a patients ability to recall 5 novel objects after a 5 minute delay.
We get better through deliberate practice, so why are we practicing crossword puzzles?
Imagine explaining to a medical doctor that the patient’s problem-solving has improved to 80% accuracy I.
Imagine explaining, literally saying to the doctor, “I have determined this patient has adequate problem solving abilities as evidenced by their ability to put puzzle pieces together to form a cohesive puzzle picture”.
Excuse me, but what?
What exactly is problem-solving, anyway?
Perhaps we decide that it is the patients ability to use a call light when needed, to respond appropriately to an unsafe event, to don their nasal cannula at all times, to know what to do when their nasal cannula falls off and onto the floor, to use their walker to walk when ambulating as recommended by their PT. How do these functional tasks translate to what the patient needs to do, and how does putting puzzles together fit into this messy picture? And is someone who is 80% I at problem-solving 80% accurate at all of these things individually, or accurate at 8 of 10 of these things, or just 80% accurate at one of these things and we are hoping this accuracy level is representative of all problem-solving tasks at large?
Imagine telling a neuroscientist that you are having patients play a game of cards in order to improve their cognition for “safe return to their prior living environment”. Sure, areas of cognition are utilized in such a game, but is card playing what skilled speech therapy treatment should look like?
Life as a Medical SLP, especially in a SNF, can be challenging. Not only must we deal with meeting the challenge of SNF logistics which include (but are not limited to!) excessive documentation and the push for productivity (90% – are you kidding me?), but we often lack the necessary resources to provide EBP treatment in a timely manner (who else has to wait multiple weeks before their patients finally have their MBS completed?!).
What are we doing when we are treating cognition, a highly complicated area that many of us received little training in? And, what are we doing when we are treating a patient 5 times a week for 4 weeks, and it is now week 3 and the patient still hasn’t completed instrumental assessment, despite the MBS order you placed at time of evaluation?
Treating cognitive deficits and swallowing deficits should not be our best guesswork. Just because we see a technique being used by a colleague, does not mean we should blindly use it as well. The belief that things work without evidence of their effectiveness is pseudoscience.
How many of us are delivering pseudoscience, and what can we do to reduce that number?