Posts by talkspeechietome

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The pseudoscience of Speech Pathology; SNF edition.

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?

hint: *terrifying*

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”.


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?




“But I talk fine!” They say

While no two patients are the same, it would seem as though much of my caseload has been cohesive in their gross misunderstanding of Speech Therapy.

I have grown accustomed to those outside the therapy discipline having a very narrow concept of Speech-Language Pathology. No, we do not *just* work on lisps. No, we do not *just* “fix” speech.

To this day, some of my closest friends still don’t understand exactly what I do. Which is fine, because, to be honest, I was already a few semesters into my graduate program before I began to truly comprehend the full scope of practice. That’s just it though. The breadth and depth of Speech Therapy is so vast that someone (like me!) can be halfway to completing their Masters degree, still learning of unique sectors SLPs play a key role in.

Unfortunately, this lack of familiarity with my chosen profession would cause me trouble as I began my first year out of school, now gainfully employed in a Skilled Nursing Facility (SNF).

Having never worked in a Skilled Nursing Facility prior to my Clinical Fellowship Year (CFY), I was ill-prepared for the amount of resistance I would receive from patients who were unfamiliar with my profession. I would begin my evaluation of a new admit with an introduction. Subsequently, my innocent attempt to establish rapport was often met with push-back. The conversation would go as follows:

Me: Hi, My Name is X, and I’m a Speech Therapist. I’m going to be taking a look at –

Patient (interrupting, flat affect now quickly transforming to a stern, slightly frightening, look of aggressive disapproval): Speech Therapy? Why would I need that? I talk fine!

Me: Yes, I know you talk fine. I’m actually here to look at your cognition, language, and swallowing.

Patient: But, I talk fine! I don’t need Speech Therapy! I’m here to walk!

Some patients were more open-minded than others when it came to allowing me the time to explain why I was seeing them. Most patients permitted me to progress with the evaluation given a little persuasion and firmness on my behalf.

Despite this; however, the disheartening fact remained that some of my patients were utterly disinterested in the service I offered, solely due to the semantics of my job title. I desperately needed my patients to shift their focus away from my job title and instead focus on the value I could add to their rehabilitation process.

Albeit, admittedly, they might “be here to walk”. Fine. Walking was important to them. But, did they understand I could help them safely consume liquid without aspirating? Did they know I could help them improve their ability to express themselves and understand others? We could work together on their cognitive-communication skills in order to augment their progress in other therapies, where they’d have to accurately sequence and recall functional information during wheel-chair transfers and sit to stands.

I was a resource who could help them with things they likely found important. Did they understand that, though?

I suspected they did not.

After tiring of the same song and dance that perpetually proceeded my (now dreaded) introduction, I set out to establish a shared understanding with patients before receiving resistance. This was no easy feat.

I experimented with a new introduction approach. My goal was to conjure up a miracle recipe powerful enough to elicit consistent, favorable responses.

I collected research, which took the form of case studies. Modifying my introduction execution with each new admit, I’d carefully observe the exchange. I’d then draw conclusions about the effectiveness of a modification based on patient reactions and willingness to participate.

I tried everything. First, I tried avoiding my specific job title and opting for the more general title of “therapist”, but that felt dishonest. I then tried avoiding my introduction entirely, but that felt awkward and rude. I tried switching out “Speech Therapist” for “Speech-Language Pathologist”, but that felt, well, equally unproductive and also proved to be, equally unproductive. My patients still developed less buy-in than I’d hoped to facilitate.

I tried leading with an explanation of what I did and then slyly “‘confessing” my job title. Unsurprisingly, this approach still ended with that same push-back and a baffled look on my patient’s face who’d then gripe, “But I talk fine!”.

Finally, something clicked. My patients could not relate to understanding my discipline, because they never needed to before. They did not understand my role, and as much as I wanted them to, I could not make them understand in a thirty-second introductory time span.

I had to work with what they did understand. And they definitely, absolutely, unquestionably, understood that they talked fine. 

So, I began to introduce myself and then carefully (and quickly) follow my job title by validating their reservations. I’d say, “I know it might seem weird that I’m seeing you, because there’s nothing wrong with your speech. I’m actually here to-”. Or, “You might be wondering why you’re seeing a Speech Therapist, but I actually rarely work on someones speech in this setting. The main things I work on with patients here are-”

My patients responded favorably to having their reservations validated. They moved past their own biases associated with my job title. This way of introducing myself allowed us to waste less time. We were able to efficiently focus our attention on their rehabilitation. This small change in my introduction worked.

It worked like the love child of Van Riper’s Hierarchy and Super Duper articulation cards in remediating a lisp. It worked like my fiscally irresponsible ex boyfriend, after returning from a Vegas with only 7 dollars to his name. It worked like Beyonce at a club.

Ok, I think we’re done here.

Rapport Building Matters

I once had a supervisor, in an attempt to help me polish my beside manner, provide me with the example of a high school counselor. She asked me to imagine my own high school counselor. Then, she asked me if I would feel compelled to open up to that counselor if I did not like her (no!).

Unfortunately for me, my supervisor was not just interested in soliciting my opinion on high-school staff members. In her example, I happened to be the unapproachable counselor that high-school students avoided at all costs (say what?!).

She explained: “If you don’t like someone, you’re probably not going to want to share stuff with them, right?”

Being the lousy high-school counselor was not a role I had any desire to play. In fact, my entire life, I had prided myself on being highly personable.

I was, and am, the obnoxious type of person that makes best friends with the grocery store clerk in a twelve second time span over our love for grapefruit. I stop and talk to the neighbors. I exchange life experiences with my Uber drivers. I genuinely like people!

So, how could this be? If I felt I was innately personable, then why was I receiving constructive criticism on my bedside manner?

My supervisor had to be misunderstanding the situation, right?


My supervisors comparison was not without reason. I had skipped over a critical aspect of the initial evaluation. I neglected to establish rapport.

As a student, I feared my execution of an assessment would be riddled with “rookie” mistakes. That I’d expose myself for the novice I was. Because of this, I hyper-focused on accurately administering the assessment and obtaining relevant data.

I worried I’d forget to complete an important step during the evaluation process, or that I’d accidentally veer off from a diagnostic script. I was concerned I wouldn’t remember to ask an important question necessary to yield clinically significant information.

My fears guiding me, I entered the patients room, ready to implement what I’d been taught with precision. I then proceeded to evaluate the patient with precision and thoroughness, but also with robotic-like fidelity of implementation.

In my robotic execution, I had removed myself from the fact that my patient was a human being, and therefore, desired to be treated as such.

My evaluation process allowed me only to know the deficits my patient presented with. I didn’t really know my patient, as a person, at all. Not knowing the patient as a person meant that I couldn’t know how his deficits would impede his daily life. I didn’t know what he wanted to gain from therapy.

How could I write a plan of care without knowing what we would be working to achieve?

Moreover, my lack of bedside manner undermined my ability to recruit buy-in from the patient. This was highly problematic because I needed my patient to want to work with me and see value in therapy in order to maximize treatment benefit.

My supervisor taught me many things over the period of time I was fortunate to have her guidance, but the importance of establishing rapport is one of the greatest lessons she bestowed upon me.

Establishing rapport begins the minute you step into a patients room. It is your presence; this includes the professionalism, compassion, and positivity you communicate both verbally and non-verbally. It is asking the right questions, in the right way, in order to better understand the patient and their individual needs, desires, and preferences.

The process of establishing rapport is fluid. You are challenged to modify your behavior, objectives, and presentation style as you continue to gather information and gain insight into what is important to the patient. What worked for one patient will often not work for another. Good treatment is evidence-based, but great treatment is evidence-based and individualized. Only after understanding the patients unique story are you able to progress with developing the treatment plan.


8 Steps to Scoring a Medical CFY

Scoring a job as a new graduate can be difficult. In the field of Speech-Language Pathology, this can be especially true for recent graduates of an accredited program hoping to secure full-time employment in a hospital-based setting.

In fact, even the seasoned speech-language pathologist may find competition to be fierce for hospital positions.  This is, in part, because job opportunities in schools and private practice settings usually exceed those in healthcare.

For the clinical fellow, things get a little bit trickier. In accordance to the American Speech and Hearing Association (ASHA) requirements, clinical fellows must complete 9 months of supervised experience before becoming eligible for a Certificate of Clinical Competency (CCC).

In order to hire a clinical fellow, then, hiring managers must secure and provide adequate supervision to the new graduate.

In some cases, clinical fellows may be competing at a disadvantage to applicants who have similar, or even less experience, but have obtained their CCC’s. Whether or not the clinical fellow is able to score their dream job over other applicants may depend on many factors. It is likely, however, that the availability and expense of providing supervision is a weighted factor in the employers candidate selection.

Fellows aspiring to complete their supervised professional experience (SPE) in a hospital, then, should plan to demonstrate value to their prospective employer that will exceed the cost of mentorship and training.

The following are suggestions serving as a guide to gaining employment as a clinical fellow in the hospital setting.

“I want a Medical CFY,” – me, to me, as a recent graduate

1. Have Relevant Graduate Externships 

This one is probably a no brainer. An ideal candidate is a candidate who is qualified for the job they are applying for.

Fortunately, most SLP graduate programs prepare students as well-rounded generalists rather than specialists. Unfortunately, this can be a double-edged sword.

On one hand, new graduates prepared as generalists are enabled the adequate skills and experience for careers in a variety of settings. On the other hand, new graduates prepared as generalists will be doning similar resumes to every other new graduate applying for the same job. In other words, a resume that reads “jack-of-all trades generalist” is not a stand-out application for a job requiring a narrow set of skills.

Students aspiring to work in the medical setting may benefit from expressing their interest in health-care to academic counselors and externship-site coordinators as early on in the program as possible. Doing so may increase the likelihood of gaining relevant opportunities where technical skills can be honed and polished.

Professional experience administering Modified Barium Swallow Studies (MBS), Fiberoptic Endoscopic Evaluation of Swallowing (FEES), and/or working with low incidence and highly complex populations may prove to be useful, qualifying experience that can help candidates stand out.

In particular, the ability to administer whilst interpreting a Modified Barium Swallow Study (MBS) is a high-level skill fundamental to acute-care hospital work. It is also a rare skill not all speech-language pathologists have mastered.

2. Be Willing to Relocate

Smaller towns tend to have greater difficulty recruiting qualified health-care professionals. This can result in open positions remaining unfilled for extended periods of time. While it may not initially sound attractive to relocate to a place called Hazard, KY, where the population sits at around 4 thousand people, it may benefit your career to do so. Of course, this one might be tough for new graduates firmly rooted in a city or with families.

3. Be Flexible with Pay 

Employers who are willing to pay top dollars for new graduates are typically those who expect new hires to hit the floor running. While being paid less than others from your cohort may be discouraging, it is important to consider that your employment package is greater than the value of salary alone.

Opportunities to learn and further develop skills should be considered as part of the whole offer.  Think of it as another year of learning and gaining valuable professional expertise, except, this time, instead of paying to learn, you are paid to do the learning (Don’t worry, your graduate student loans will probably be paid off before you die).

4. Apply Directly To Hospital Sites 

This is an important one that not every new graduate is aware of. Often times, the career opportunities advertised on job boards like Indeed are only a small percentage of available jobs.

In some cases, sites require companies pay in order to post open positions. Additional costs can deter employers from using third parties to augment their recruitment efforts.

Job boards may also prove to be unreliable. Just because a job is advertised does not mean it is available. Some third party sites may continue to advertise a job long after the position has been filled.

By scouring hospital sites and directly applying to their job postings, you may become aware of opportunities that are less heavily advertised. This may work to your benefit, as fewer candidates may applying for a single job because fewer people are aware the job exists. This ultimately means less competition for you.

Bonus points for visiting each hospital site frequently. In doing so, you are increasing the likelihood of being one of the first to know when a new job has been posted.

5. Further Your Qualifications  

Okay, so you remember what I said about being a generalist? While you may not be able to control which externships you complete while enrolled in a graduate program, you  can control how much continuing education and extra training you obtain after you complete your program (or while enrolled!).

Some viable options to help build your resume include taking extra courses during graduate school (e.g. elective courses in dysphagia, traumatic brain injury, trach/vent care, aphasia, etc.) and obtaining certifications through the MBSImP training or LSVT training.

6. Network 

Never underestimate the power of becoming a familiar face. A hirable person is often someone who is easy to work with. Generally speaking, recruiters want to hire someone who is likable and has integrity; the kind of person you would let hold your baby for a hot minute if you were in a bind and had to use both your hands simultaneously.

Your resume doesn’t exactly scream “top pick for baby-holding”, and lets be honest, it shouldn’t. This is why putting a face and personality to your resume is so incredibly important.

What is more is that by networking, you may learn of job opportunities that are not yet openly advertised.  Through networking, you increase the likelihood of becoming a memorable contact for when an opportunity does present itself later.

7. Demonstrate Academic Excellence 

This was a suggestion I found when researching for this article on one of the SLP Facebook groups I belong to. I won’t touch too much on this one, because if you were one of the lucky ones able to secure a spot in a graduate program, I will also presume you have a track record of obtaining above mediocre grades.

Go to class, learn, develop competencies. Having a 4.0 might set you a part from other candidates, but also, maybe not. This will depend on what is important to those hiring you.

If anything, I promise your future will not be completely ruined by receiving an A-.

8. Wait It Out 

This is one a previous supervisor suggested to me when I expressed my interest to her in obtaining a medical position following graduation. She explained that the process of gaining a medical CFY might be difficult, but would not be impossible, lest I was willing to “wait it out”.

In her opinion, it was better to continue to do steps 1-7 until securing my dream position, than to take a CFY in an alternative setting and attempt to transition into my dream job following completion of my fellowship year.

Keep in mind, like many of these points, this was only one supervisors opinion and therefore is not the ultimate truth. While obtaining a medical CFY may be the easiest and most comfortable routes to a medical career, it absolutely is not the only one. Transitioning after your CFY can be done.

If you do chose to wait it out until you obtain a medical position, I recommend setting a clear timeline for yourself. If your situation is anything like mine, your family will tire of always obligingly buying your popcorn at the movie theatre and, after so much time, you will tire of living in your parents basement. Figure out how much time it will take until you anticipate reaching that ‘tire’ point and plan to diligently work towards your goal until then.