Should Not Be
The Isle of Dysphagia
by Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com
In November, 2016, I ran from one end of the convention hall to another to take in over 19 hours of dysphagia education at the American Speech-Language-Hearing Association’s annual convention. I found myself asking, why don’t they put all the dysphagia courses in one spot? Once I got home, caught my breath and reviewed my notes, I then considered the potential risks of viewing dysphagia as a separate island within Speech-Language Pathology. The session called Dysphagia Education: Opportunities to Prepare Future Leaders discussed the problems with organizing information into separate silos or islands. Dysphagia has become quite a distinct specialty; however, are we doing our students a disservice by conducting dysphagia education in isolation at the graduate school level and beyond?
Dysphagia Island versus Webs of Knowledge:
Rather than looking at dysphagia as a separate island, it is more effective to connect information through webs of knowledge, per Memorie Gosa, of University of Alabama. James Coyle, of University of Pittsburgh, also suggested that these connections need to be started at the undergraduate level, tying the anatomy and physiology into clinical realities. Teaching the vocal tract, the speech mechanism, and the swallowing mechanism as separate entities leads to only rote memorization of facts. When new SLPs will be responsible for not hurting people, per Coyle, memorizing facts is not enough. Per Coyle, our undergraduate education should be like premed, including anatomy and physiology and knowledge of all organ systems and how they work to achieve homeostasis.
Students need to insist on new ways of learning to become independent self-motivated learners and critical thinkers. In order to synthesize the information, the student has to be link new information with the old.
Memorie Gosa suggested the book from Ambrose, S.A., et al (2010) called: How Learning Works: Seven Research-Based Principles for Smart Teaching, published by John Wiley & Sons. Per these theories, graduate school students must first acquire skills and develop competence, then practice the skills to integrate them, and then the student will know how and when to apply which skills to the individual patients. Early on in this process, the student may have “unconscious incompetence,” which is dangerous in dysphagia evaluation and management. This means the student or new SLP does not know what he does not know. She may not know how to advocate and find resources.
Students need to move through the learning continuum to, at least, the “conscious incompetence.” This is where they know what they don’t know and it bothers them enough to seek assistance and resources. Students need to be encouraged to constantly question. The risk here is if answers and assistance is rigid. Supervisors may say: “This is how we do it here,” or “This is how we have always done it.”
If we do not develop self-directed learners who think critically, can problem solve, and know where to go for evidence, SLPs will have difficulty eventually becoming “consciously competent.” This mindset needs to start at the undergraduate level. We need to critically analyze how dysphagia education is performed.
Do More / Read More:
Nancy Swigert, of Baptist Health, shared a list of essential professional characteristics for students before the externship:
- Solid knowledge of anatomy and physiology
- Problem solving and critical thinking skills
- Good writing skills (i.e., formulating brief summaries)
- Communication skills (i.e., the ability to code switch between the doctor, the nurse, the family and the patient)
- Organizational skills with ability to prioritize and multi-task
- Understanding Evidence-Based Practice
- Know when to ask questions and ask for help
- Ask why. Know where to go to find more evidence. Know how to read the evidence.
The following is Swigert’s list of essential dysphagia knowledge prior to the externship:
- Normal swallowing
- Typical aging swallow
- Basics of neurologically-based versus structurally-based disorders
- Timing versus movement disorders
- What we can and cannot know from a clinical swallowing examination
- Who may be appropriate for an instrumental evaluation
- Exposure to VFSS and FEES
Evidence-Based Practice in Dysphagia Education:
In the dysphagia education session, Jay Rosenbek, of University of Florida, reminded us that Evidence-Based Practice is a three-legged stool. We need to be sure to teach all three.
“Evidence is one, clinical experience is two, and what the patient and others want is the 3rd leg of that stool. All three of those contribute to the treatment of that whole person.”
When Martin Brodsky, of Johns Hopkins University, reviewed “what clinicians want” (during the session called Speak Out: Professional Advocacy Through Negotiation by Mulheren, King & Brodsky), it was identical to these three legs of evidence-based practice. Clinicians want to hear their patients’ wishes. They strive to develop sound clinical judgement. They want to efficiently find relevant and sound scientific evidence.
If it is challenging to elicit the patient’s and caregivers’ values and preferences, Rachel Mulheron, of Johns Hopkins University, suggested the following resources:
- Brief Action Planning (BAP): www.centrecmi.ca/learn/brief-action-planning/
- Motivational Interviewing: www.motivationalinterviewing.org
Bridging the gap between clinicians and researchers may be the best way to develop sound clinical judgment and move practice patterns forward. Here are some resources recommended at the advocacy session:
- CLARC program by ASHA: designed to connect clinicians and researchers for the purpose of collaborating (www.asha.org/academic/CLARC/)
- ASHA Practice Portal: trusted resource for the most current practice guidance (www.asha.org/practice-portal/)
- Research Gate: simple and free way to share your research, ask questions, read and discuss publications, and connect with researchers around the world (www.researchgate.net).
- One that was not mentioned is the new www.DysphagiaGrandRounds.com, whose main purpose is to bridge the researcher – clinician gap.
Giselle Carnaby, of University of Central Florida, further addressed research leg of EBP during her short course and warned to “sort the trash from the treasure.” She gave numerous examples of researchers using reliability and validity incorrectly. Even in published literature, “people get it wrong.” Students need to be taught to be good consumers of evidence, whether it comes from publications or from their supervisors’ clinical expertise.
Why didn’t they teach me this in school?
“Buried in all that knowledge and skill, is a depth of factual information, a depth of concept, a depth of hypothesis, and a depth of the unknown that clearly produces students of very different competence and very different preparedness to move forward,” stated Rosenbek.
According to Rosenbek, dysphagia education is not about accumulating hours and getting grades. Rosenbek suggested the following to create potentially groundbreaking dysphagia education:
- Teach a tolerance for ambiguity.
- The answers are not “known.” Often there is no right/wrong.
- There is ambiguity around every decision that we make in clinical practice.
- Teach thoughtfulness rather than being right.
Rosenbek noted that the best education will be holistic and patient-centered, encompassing human emotion as well as family/caregiver, environmental, and healthcare system influences. He urged dysphagia education to include all four points of the Healthcare Compass:
- Clinical practice
- Patient satisfaction
- Quality of life
- Cost and utilization
Three Holistic & Patient-Centered Examples From #ASHA16 Sessions:
1) Moving beyond aspiration: Example of changing practice patterns:
Years ago, aspiration used to be the sole focus of evaluation and treatment. I could call this aspiration island, as looking at issues in isolation is similarly as problematic as my dysphagia island concept above. We cannot not think of aspiration in isolation anymore.
As Bonnie Martin-Harris, of Northwestern University, noted during her session called, Integration of Respiration and Deglutition: “It is much more than penetration and aspiration, even though that is what people obsess about.” She advised to look at a videofluoroscopic image and “think backwards.”
Are students learning to think backwards? This means asking what are the underlining muscles and structures that play a role in the action and/or impairment. What is the breakdown in peripheral and/or central control? Martin-Harris reminds to ask if it is a mechanistic problem with swallowing or a respiratory/swallowing coordination impairment. Giselle Carnaby stressed to ask: “What have I got left to work with?”
James Coyle said: “Preventing aspiration is not a goal.” Our goals are to promote independence and health and/or to minimize negative sequela.
John Ashford, of SA Swallowing Services, PLLC, described the three pillars of aspiration pneumonia. Only one of these pillars is aspiration due to a high incidence of unsafe swallows. The others are severely impaired health status and poor oral health status (session: NPO & Oropharyngeal dysphagia: What the SLP Needs to Know). Sometimes we cannot fix the aspiration, but we can support the other pillars.
2) Learning from your patients:
Loni Arrese, of Ohio State University, presented with Nicole Rogus-Pulia, of University of Wisconsin-Madison, comparing and contrasting management with patients with head and neck cancer versus stroke. Arrese shared how much she learned from her patients with head and neck cancer and late-radiation induced dysphagia. She presented a case of when therapy was not improving the actual safety and efficiency of the swallow, but the person decided to continue with thin liquids and a regular diet. She realized that much of the time we cannot make the swallow perfect. She taught maintenance exercises, respiratory strengthening exercises, and ways to minimize risk of aspiration pneumonia. She counseled the patient and gave caveats of: “You’re not getting any younger, and I don’t know when medical consequences will catch up.” However, ultimately “it is not a problem until it becomes a problem.” This is appropriate from all four standpoints: clinical, quality of life, patient satisfaction, and cost and utilization.
Is this kind of thinking-outside-the-box taught in university?
3) Honoring goals of care:
During the session called: “The Practicing Dysphagia Clinician: What are we afraid of?,” we had a great discussion about the term “non-compliance” and the use of waivers. We asked:
- Do we sign off on a patient who does not want to follow our safe/restrictive swallowing recommendations?
- Do we make them sign a waiver, stating that they have been informed of the risks?
Answers: No and No.
Waivers can be looked at as a form of coercion. At the very least, they set up the pragmatics of conflict rather than cooperation. Instead, we educate, communicate, provide options and document well. Your recommendations after an instrumental examination should not be a strict list of do’s and don’ts; rather, we could pose them as options on a spectrum. The medical team is then tasked with analyzing the risks/benefits of each option and aligning the patient’s goals of care with a plan of action. The SLP can contribute to the decision-making. Rosenbek, in the dysphagia education session, suggested the phrasing of:
“Given all that we know about you and your swallowing, the potential safer (not safest) of the three options may be –.”
The SLP can help reduce negative sequela and complications as much as possible, while meeting the person’s wishes. This approach certainly includes the 4 points of the healthcare compass: patient/family education on clinical findings, a focus on patient satisfaction and quality-of-life, while potentially minimizing healthcare procedures and costs at the end of life. The SLP and medical team can seek out assistance as needed from the facility’s ethics committee and/or palliative care team. Please see also my blog on the SLP’s Role in Palliative Care.
The Practicing Dysphagia Clinician session discussed how “risk” is physical and health-based, but it may also be emotional and quality-of-life-based. The session presenters recommended the AJSLP article by Horner, et al, from November, 2016 called: “Consent, Refusal, and Waivers in Patient-Centered Dysphagia Care: Using Law, Ethics, and Evidence to Guide Clinical Practice.”
Dysphagia Education Conclusions:
“We are not preparing for a test, we are preparing for life. We are preparing to go out into a world and try not to do harm, and in fact to do good, and that requires a tremendous amount of knowledge,” per Rosenbek.
A doctor thanked me the other day for my “thoughtfulness,” which was ironic as Rosenbek focused on that same word. We may not always be right in our decisions. We need to be comfortable with some ambiguity. Rosenbek laughed as he said: “most of us stay out of trouble because we recognize the very real potential for ambiguity around every decision.”
But seriously, we are all still students of swallowing and swallowing disorders, and this ambiguity can remind us to dig deeper, ask questions, communicate thoroughly, and document well.
Citations from #ASHA16 Oral Seminars:
Arrese, L. & Rogus-Pulia, N. (2016, November). 1843: Impact of medical diagnosis on dysphagia management: Patients with head & neck cancer versus stroke. Seminar presented at the annual convention of the American Speech-Language-Hearing Association, Philadelphia, PA.
Brown, K., Ashford, J., & Skelley Ashford, M. (2016, November). 1693: NPO & Oropharyngeal dysphagia: What the SLP needs to know. Seminar presented at the annual convention of the American Speech-Language-Hearing Association, Philadelphia, PA.
Carnaby, G. (2016, November). SC23: Don’t be a “settler” – How to avoid homemade tools & treatments in dysphagia. Seminar presented at the annual convention of the American Speech-Language-Hearing Association, Philadelphia, PA.
Corbin-Lewis, K., Coyle, J., Gosa, M., Kimelman, M., Rosenbek, J., Severson, M., & Swigert, N. (2016, November). 1049: Dysphagia education: Opportunities to prepare future leaders. Seminar presented at the annual convention of the American Speech-Language-Hearing Association, Philadelphia, PA.
Martin-Harris, B. & McFarland, D. (2016, November). 1643: Integration of respiration & deglutition: Function & disorders. Seminar presented at the annual convention of the American Speech-Language-Hearing Association, Philadelphia, PA.
Mulheren, R., King, J., & Brodsky, M. (2016, November). 1767: Speak out! Professional advocacy through negotiation. Seminar presented at the annual convention of the American Speech-Language-Hearing Association, Philadelphia, PA.
Suiter, D., Smith, P., Murray, J., & Hind, J. (2016, November). 1343: The practicing dysphagia clinician: What are we afraid of? Seminar presented at the annual convention of the American Speech-Language-Hearing Association, Philadelphia, PA.
Horner, J., Modayil, M., Chapman, L.R., & Dinh, A. (2016). Consent, refusal, and waivers in patient-centered dysphagia care: Using law, ethics, and evidence to guide clinical practice. American Journal of Speech-Language Pathology, 25 (4), 453-469. https://dx.doi.org/10.1044/2016_AJSLP-15-0041
Ambrose, S.A., Bridges, M.W., Dipietro, M., Lovett, M.C., Norman, M.K., Mayer, R.E. (2010). How Learning Works: Seven Research-Based Principles for Smart Teaching. John Wiley & Sons, Inc. (I have nothing to financially or non-financially disclose in recommending this text)