Are SLP Graduates Ready for Careers in Dysphagia

by Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com

There has been quite a buzz in social media, or should I say quite a tweet, wondering: Are we preparing our graduate students well enough for careers as medical speech-language pathologists, who may spend the majority of their day evaluating and treating dysphagia?

I have been discussing this important issue with #SLPeeps, like Yvette McCoy, MS, CCC-SLP, BCS-S and Rinki Varindani Desai, MS, CCC-SLP (see bios below).

Rinki shared with me: “ASHA does not mandate a specific curriculum for dysphagia,” referring to the last paragraph of this document below. This is the model created by ASHA for universities to follow for dysphagia training.

Dysphagia Graduate Curriculum https://www.asha.org/policy/TR2007-00280/

Schooling versus Training. What’s the difference?

Schooling, per Merriam-Webster.com, means: “teaching that is done in a school.”

Training, per the same dictionary means: “a process by which someone is taught the skills that are needed for an art, profession, or job.”

Hitting the books versus hands-on clinical experience.

ASHA defines this practical training experience as an Externship. (www.ASHA.org/Students/Externships/), stating:

“Students are expected to gain the necessary knowledge and skills to work with a variety of populations and disorders in various settings.”

I have enjoyed training graduate students during their externships. I took students at my hospital non-stop for 12 years. I felt it was my way of volunteering for ASHA to make sure students obtained this crucial on-the-job training. I have to say, working with students was one of the most rewarding things I have done in my career! They teach you as much as you teach them. I could not have joined the blogosphere if it weren’t for the guidance of my student!

However, in this day-in-age of staffing cut-backs, staff shortages, and the use of per diem SLPs, many medical-based SLPs cannot take students or are not allowed to take students per their employers.

Luis F. Riquelme, PhD, CCC-SLP, BCS-S (Chairperson of the American Board of Swallowing and Swallowing Disorders) shared this on a recent DysphagiaCafe post. 

“It is a reality that there is only so much that can be taught in a 15-week dysphagia course, and that where “it all comes together” for the graduate student is during completion of their externships. However, many hospitals are not taking graduate students (as per already big workload) and many are not hiring CFs either. Everyone wants SLPs “with experience” but won’t provide such experience.”

A Dangerous Issue:

Yvette McCoy, MS, CCC-SLP, BCS-S shared:“One would not expect a medical student to be knowledgeable in any given area of medicine after 4 years of med school.  That is not logical.  They are required to do an internship and residency before they are specialists.  Why should we be any different?  Dysphagia clinicians can potentially put someone’s life in danger if they are not adequately prepared.  This must change.”

Per Rinki Varindani Desai, MS, CCC-SLP: “This is what made us question the adequacy of dysphagia preparation at the graduate level. Most dysphagia courses are not core courses/mandatory. Most schools have one dysphagia course dedicated to learning EVERYTHING a clinician is supposed to know before they graduate. Medical/adult-based rotations are not mandatory either. How can we change this? That is essentially what motivated us to prepare this very preliminary survey and to share results with ASHA’s Academic Affairs Board.” 

Yvette and Rinki teamed up to create a survey to ask SLPs if they felt prepared to be dysphagia specialists after graduation. 715 Speech-Language Pathologists took this survey!

This survey has now ended, but they are sending the results to ASHA’s Academic Affairs Board.

Sneak-peak at the survey results:

• Over 60% of respondents did NOT feel adequately prepared in dysphagia after completing their graduate program.
• Only 5.5 % of respondents report that they felt “very competent” in dysphagia after graduation from their Masters program.

Quite a dilemma for ASHA, our field, our universities and their external placement coordinators.

It can be really tough for placement coordinators to find stellar placements for every student. However, it takes good externships to really absorb skills and build confidence.

All SLPs, who are able, need to offer placements as often as they can. Seriously, no guilt here, but it takes a village!. Here is a great resource from ASHA on Medicare policies for students:

Medicare Coverage of Students & Clinical Fellows: Speech-Language Pathology.

https://www.asha.org/practice/reimbursement/medicare/student_participation_slp.htm

I can recall that deer-in-the-headlights look on my students during their first day. By the half-way point, some students would doubt themselves or even break down with tears. (Tears are good, by the way, especially as you are being introduced to end-of-life issues and medically fragile patients.) Eventually, I would see my students soaring high with confidence and being able to teach the incoming students by the end of their placements. During the second half of a placement, students really can be such a tremendous help. However, many students may require more than a 3-month placement to reach the point of carryover and synthesis. Many hospitals have switched to 6-month placements; therefore, less students are served.

How can we cut down on the basic-training that is often needed at the beginning of an externship?

Can universities better prepare students for these placements?

Dr Ianessa Humbert, PhD, CCC-SLP (@dr_deglutition on Twitter) answered questions on her Live Chat on July 27, 2015, hosted by the National Foundation of Swallowing Disorders (@NFOSD on facebook and Twitter). The chat was called “Critical Thinking in Dysphagia Management,” and she covered the issue of graduate students’ readiness for their medical externships.

Many SLPs working in hospitals find that the students come to them completely unprepared, per a caller. Humbert noted that ASHA mandates “some swallowing experience,” but not the “extent” or quality of the experience. Per Humbert, if you do not have a good clinical practicum, how can you move from the book to the bedside? She commented that dysphagia courses at some universities may not even be taught by swallowing specialists.

Dr Humbert encouraged SLPs from the medical facilities to develop partnerships with the universities to let them know what you expect out of a student.

Give them a list: “Here is what the student needs to know.”

What if the student cannot obtain a good externship?

Can we do more for our graduate students while they are still on campus?

Here are two interesting ideas from poster sessions at the Dysphagia Research Society‘s annual meeting, March, 2015, Chicago, IL:

1. Dysphagia Labs

Graville, et al (2015, March) from Oregon Health & Science University asked: Can we “better prepare graduate students in Speech Pathology for their off-campus medical placements?”

The dysphagia training program that they created was mandatory for the entire cohort of graduate students prior to an off-campus placement. No additional tuition fees were charged, and the training gave them one lab credit. Graville and team created 10 individual one-hour dysphagia lab modules with assessment tools. Each lab had about 8 students and was taught by practicing SLPs with at least 5 years of experience in dysphagia. 95% of the students found the labs to be “very” or “extremely” helpful. The best part about this is the name: Camp Swallow!

The labs covered the following topics, and utilized endoscopic and flouroscopic views (5 pediatric-based and 5 adult-based):

1. Normal Anatomy & Physiology
2. Clinical Swallow Evaluation
3. Abnormal Swallowing
4. Management & Treatment techniques
5. Comprehensive Review of Dysphagia (case studies/scenarios)

Graville, et al. (2015, March) discussed how there is an abundance of literature in the medical field on role-playing as a method of teaching clinical skills; therefore, simulations or actors playing typical patients could be implemented in the Speech Pathology world as well. 

The above dysphagia-lab model seems to require a significant time commitment by the teachers (with an 8:1 student:teacher ratio), so what about video simulations?

2. Simulation

Ewing & Ferguson (2015, March) shared a poster at the same DRS annual meeting on training graduate students via video simulation versus in vivo simulation. Their aim was to train the clinical judgment skills needed to interpret feeding behaviors in preterm infants. They compared two methods of dysphagia training:

1. A 30 minute lecture plus video simulation training, versus

2. A 20 minute lecture followed by a hands-on (in vivo) simulation experience.

They found that graduate students from both groups benefited from the training and both improved accuracy in making clinical decisions.

Interestingly, though, the video simulation group did better on the post-test. The authors speculated that this was due to the following:

• Less stress during a video simulation versus an “in vivo” simulation; therefore, the novel information may have transferred to long-term memory better. (They cited Schwabe, et al., 2009.)
• In early learning stages of learning, a student relies heavily on working memory and has not integrated the new skills. (They cited Beilock, et al., 2002.)
• The “in vivo” simulation group was taught in an active manner, but tested in a passive way. The authors stated: “Knowledge is better retained and recalled when testing environments resemble learning environments.” (They cited Schwabe, et al., 2009; Smith & Vela, 2001.)

Therefore, I hope that the future research by this group adds in vivo testing, rather than just passive testing. Ultimately, it is the hands-on carryover to the bedside that is needed. We may need to first train with video simulation, enhance generalization with in vivo simulation, and then test with in vivo simulations across various patient populations.

Additionally, the time and content of each lecture should be exactly the same. I’m not sure if the In Vivo/hand-on group’s class equalled 30 minutes total. Ensuring that the content and time are equal will help to focus on the benefits of video simulation versus in vivo simulation.

If video simulations are just as effective as in vivo simulations, then more graduate schools could have access to this form of teaching. Not every school can hire extra staff to teach dysphagia labs and/or provide real-life scenarios.

Wait, why all this focus on dysphagia training?

What about cognition, speech, language, voice, fluency, AAC, and more?

Again, thank you to Yvette McCoy, MS, CCC-SLP, BCS-S and Rinki Varindani Desai, MS, CCC-SLP for the following information and links:

They have reviewed ASHA surveys, called: SLP Health Care Survey Report: Patient Caseload Characteristics Trends, from 2005 to 2013.

• Link to the 2013 Survey Report: https://www.asha.org/uploadedFiles/2013-SLP-Health-Care-Survey.pdf
  

• Link to the comparisons of caseloads from 2005-2013: https://www.asha.org/uploadedFiles/2005-2013-SLP-Survey-Caseload-Characteristics-Trends.pdf

ASHA’s 2013 Survey Results on Caseload Characteristics in Healthcare:

• 60% of clinical services provided in health care were to adults.
• “More adult service time was in the area of swallowing (42%) than in any other area of intervention.”  (page 4)
• “Time spent on swallowing was highest in general medical and LTAC hospitals (59%).” (page 4)

• In 2013, only 12% on average indicated that another professional other than SLPs provides the primary swallowing services at their facility.
  • Out of the SLPs who work for Skilled Nursing Facilities (SNFs), only 2% of the responses indicated that another professional evaluates and treats swallowing.

• Since the survey began in 2005, about 90% of respondents indicated that no professional other than SLPs provided primary swallowing services in their health care facility.

Conclusions:

Rinki ties it all together with: “If we, as Speech Language Pathologists, are going to represent ourselves as ‘dysphagia specialists’, we need to back that up with the necessary skills and competence. Academic programs are the starting point for this training.We (Yvette and Rinki) believe that the current preparation and training in dysphagia at the graduate level in U.S graduate SLP programs is inconsistent across schools and predominantly inadequate. We were interested in finding out if other practicing clinicians felt there was a problem too; and if yes, come up with solutions we could propose collectively. This is what motivated us to create this survey and to share the results with ASHA’s Academic Affairs Board.” 

As stressed by Rinki and Yvette,

• If SLPs are going to truly lead the field of swallowing and swallowing disorders, and
• If the majority of your day in the hospital will be focused on dysphagia,
• Then more extensive dysphagia training at the graduate level is needed.

Of course, no one expects a student to be an expert after graduation. However, what if the graduate cannot get a good first job in healthcare for the Clinical Fellowship Year (CFY)? See previous blog on barriers to hiring CFYs.

Overall, graduate schools can instill the concept of life-long-learning. Professors can provide resources, names of researchers to follow, journals to subscribe to, groups to join (i.e., ASHA’s SIG 13 and DRS), websites to follow, articles, and connections. The students should expect to continue training long after they have tossed their caps into the air. Social media provides global connections (i.e., follow Twitter hashtags: #slpeeps, #dysphagia, #DysphagiaAwareness, and #slp2b).

Think outside the box! This is going to take a lot of brainstorming in the coming years.

Was your dysphagia training sufficient?

Were you prepared for a career in the medical world?

What should we all do about it?

Keep the conversation going!

Bios:

Rinki Varindani Desai, M.S.CCC-SLP is a Medical Speech-Language Pathologist, specializing in the rehabilitation of speech, language, cognition and swallowing disorders in adults. She obtained a Bachelor of Science degree in Audiology and Speech-Language Pathology from AYJNIHH in Mumbai, India in 2009. In 2011, she earned a Master of Science Degree in Communication Disorders from the Callier Center at the University Of Texas at Dallas, ranked among the top 5% of graduate programs in the United States. She is now a Vitalstim® certified dysphagia therapist, currently pursuing Board Certification as a Specialist in Swallowing Disorders as well as a Brain Injury Specialist. Rinki is the creator and administrator of the Medical SLP Forum, a professional SLP group on Facebook with over 8,000 members. She is a member of ASHA’s SIG 13 and an ACE Awardee. She has served as an ASHA S.T.E.P Mentor, reviewer for ASHA’s Minority Student Leadership Program, NSSLHA officer, TSHA Chair and a Research Assistant in the Aging and Aphasia Lab at UTD. She has written articles for The ASHA Leader, Dysphagia Café and was recently interviewed for a podcast Conversations in Speech Pathology. Follow her for Medical SLP related updates on Facebook (https://www.facebook.com/Rinki.SLP), Twitter (@rinkislp).

And

Yvette McCoy, MS, CCC-SLP, BCS-S is a Speech-Language Pathologist with over 22 years experience, specializing in adult-neurological rehabilitation with a special interest in dysphagia and stroke rehabilitation. She is a Board Certified Specialist in Swallowing and Swallowing Disorders.  She owns Speak Well Solutions, LLC, a thriving practice started in 2005 that now has four employees.  She is certified by the American Speech-Language-Hearing Association, and a four time ACE Awardee.  She is also a member of the Dysphagia Research Society and is an MBSimP registered clinician.  She currently serves on the Adult Services Committee for the Maryland Speech-Language and Hearing Association, as well as on the Website, Communications and Public Relations Committee for The Dysphagia Research Society.  She obtained a Bachelor of Science Degree in Speech Pathology from Northeast Missouri State University in 1990 (now Truman State University). In 1991, she earned a Master of Science in Speech Pathology from Southern Illinois University at Edwardsville. Follow her on Twitter https://twitter.com/yjohnsonmccoy. Connect with her on LinkedIN or visit her website at www.SpeakWellSolutions.com

References

Council on Academic Accreditation in Audiology and Speech-Language Pathology. (2014).

Standards for accreditation of graduate education programs in audiology and speech-language pathology (2008, revised 2014). Retrieved 7/28/15 from https://www.asha.org/uploadedFiles/Accreditation-Standards-Graduate-Programs.pdf

Medicare Coverage of Students & Clinical Fellows: Speech-Language Pathology. Retrieved 7/28/15 from ASHA website:

https://www.asha.org/practice/reimbursement/medicare/student_participation_slp.htm

Ewing, J & Ferguson, N.F. (2015, March). Training clinical judgment skills for interpreting feeding behavior in preterm infants: A comparison of video and in vivo simulation training. Poster Presented at the 23^rd Annual Meeting of the Dysphagia Research Society, Chicago, IL.

Graville, D.J., Palmer, A.D. & Gorsek, S. (2015, March). Teaching Dysphagia Skills to Graduate Students: Experiences with a Competency-Based Program. Poster Presented at the 23^rd Annual Meeting of the Dysphagia Research Society, Chicago, IL.

Schwabe, L., Bohringer, A., Wolf, O. (2009). Stress disrupts context dependent memory. Learning & Memory, 16, 110-113.

Smith, S., & Vela, E.(2001). Environmental context-dependent memory: A review and meta-analysis. Psychonomic Bulletin & Review, 8(2), 203-220.