An Open Letter to Candidates Running for ASHA Board of Directors from a Medical SLP:

My name is Theresa Richard. I am a board certified specialist in Swallowing and Swallowing Disorders. I have a podcast about swallowing that has reached almost 1,000,000 (yes, that’s 1 million) downloads, I have a membership site that educates 2,200 medical SLPs weekly, and I perform mobile fiberoptic endoscopic evaluations of swallowing (FEES), an instrumental assessment that is CRUCIAL in the management of dysphagia, to several nursing homes and rural hospitals. I don’t say this for any self-righteous reasons other than to show that I talk to fellow medical SLPs ALL DAY EVERY DAY. I hear them. I see them. And I sympathize with them.

I am here to tell you that the reason I wake up in the morning and do what I do so loudly, passionately, and unapologetically, is because of the poor education and mis-diagnosing of dysphagia by my colleagues.

However, most of this is not about them. It is about a system that has failed us, and continues to turn a blind eye instead of supporting and respecting us.

I have seen the PROFOUND impact that our profession can have on patients with dysphagia when they have proper training and access to instrumentation, so it is crucial that ASHA support us in these endeavors.

There are 2 main issues at the very bottom of this catastrophe.

1.  Poor education – very few medical SLPs have had any training in pre-med courses including nutrition, exercise physiology, microbiology, dentistry (oral care) counseling, biochemistry, (to name a few) Yet we are expected to walk alongside physicians and give THEM recommendations about THEIR patients.

Some SLPs have reported only having 4 classes during a summer offering (NOT 4 credit hours, like 12 hours worth total! Like only 4 classes out of an entire semester!!) of dysphagia in an entire grad school curriculum, then do not get any medical placements for externship, or as in my area, most facilities will no longer take students from certain universities because they are so poorly trained, but are then handed a job and a caseload of acutely ill patients for which they are responsible for making life altering decisions.

The bottom line is that I do not claim to have any answers to this horrific problem, as I know this would be a long and arduous beast to tackle, but I’m in it for the long haul, and I really hope the next ASHA Board of Directors is too.

1.  We’ll call this issue 1a. Along with the poor education we are receiving at the graduate level, most SLPs have no formal training in NORMAL swallowing, therefore every patient they encounter with a cough or a throat clear must have severe dysphagia and sentenced to a lifetime of thickened liquids (sarcasm).

Quite frankly, if I had to guess I would probably say that only 10% of the patients I scope ACTUALLY HAVE DYSPHAGIA. Yes it pains me to type that, and some days I’m honestly just bored picking up the same pieces over and over and over, but we have a very poor foundational education of normal swallowing, and instead we’re thrown right into a dysphagia (disordered swallowing) course, where if we think we see something, we must fix it, whether it’s in our wheel house or not…

Which leads me to 3 cases that I saw just this past week in which patients were mis-diagnosed and being treated for dysphagia by SLPs when they didn’t in fact have dysphagia and just needed medical intervention. True story! Three patients received “bedside swallowing exams” and all were recommended to have a modified diet and thickened liquids due to coughing and “instrumental not recommended” was documented. After being transferred to their next level of care, and following the plan of care from the previous SLP, these 3 different patients were seen for therapy and have been doing dysphagia exercises for anywhere from 3-5 weeks. After scoping them, NONE OF THEM HAD DYSPHAGIA, they all had medical conditions that required medical intervention, not dysphagia exercises.

Now, I do NOT blame these SLPs as they were doing the best they could with the information they were given and got a swallow study as fast as their facility allowed, but we need to have this information from the onset, without hesitation, from educated SLPs, without kicking and screaming with administration to get it done so that the patients are treated appropriately from the beginning and not for several weeks for no reason while disrupting their quality of life with thickened liquids and modified diets.

2.  Which leads me to the next gigantic elephant in the room… how do we know if someone’s swallow is normal or impaired at the bedside? Correct, we don’t. We MUST use instrumental assessments. ASHA has tiptoed around this topic for years, saying it’s necessary, but not for some, issuing position statements, then they quietly go away. No one will stand up and say: “Our profession does NOT have X-ray vision, we can NOT ACCURATELY diagnose and treat dysphagia without it.”

I was also asked this weekend to guesstimate how many SLPs have access to instrumentation TODAY. Here was my response:

Today? Maybe 1%

Within a week after battling logistics with radiology, getting a doctors order signed to comply with the payor sources, or scheduling with mobile FEES/MBSS? 25%

Within 2 weeks after pleading to administration that it’s medically necessary, we can’t do our job without it, and legally they are obligated to pay for the test that they’ve already received a lump sum payment for? About 40%

And the other part is made up of either having to wait 2-3 MONTHS for a study, or SLPs who don’t order them at all because “they don’t believe in them.” <— This I find to be the most prevalent problem in our field and an issue I face DAILY! In some of the buildings that I service, the administrator or director of nursing will call me in to do the swallow study, because their SLP doesn’t find it helpful. (If you are not familiar with the dysphagia literature, we have study after study after study showing that we simply can not treat what we can not see.) There are 1,000 different reasons someone may or may not have dysphagia, so for these SLPs who say this, I find them to be a disgrace to our profession.

And then we wonder how we got in this health care financial crisis and why medical SLPs are not being respected?

We are literally treating cases that do NOT exist and we are missing patients and silent aspiration for patients that need us most. 

If we all got on the same page, were required to get instrumentation if the patient and family are on board, have a study completed by someone with formal training, get a follow up at a facility that supports follow ups, we would be respected so much more for catching conditions that exist, and not treating ones that don’t.

DOCTORS DO NOT HAVE XRAY VISION.. THEY RELY ON DIAGNOSTIC TESTS, we want to be respected by them, so let’s follow them!

So here’s where we are:

So by my calculations (disclaimer: I am not a PhD or statistician, so these numbers may not hold any real weight,) it appears that we have 4 different groups of Medical SLPs that all probably, fairly each make up 25% of the profession.

Group #1: Highly trained and competent SLPs that have the respect of their colleagues and are allowed to order and/or perform instrumentals at their own free will.

Group #2: Highly trained and competent SLPs who do NOT have the respect of their colleagues and are not able to order instrumentation freely because the “other SLP did fine without it,” “it’s not necessary,” “it costs too much money,” “it doesn’t tell us anything anyways.”

Group #3 SLPs that have very poor training and have not been trained properly to do instrumentals. Whether this is the SLPs resistance to keeping up to date or the system failing us as a whole as they just plain received poor education remains to be seen, regardless, we have SLPs doing instrumentals that are not properly trained which results in poor interpretation/recommendations which can lead to dehydration, malnutrition, aspiration, and death or just outright treating patients for conditions that do not exist. We have SLPs performing instrumentals WITH NO FORMAL TRAINING, because all ASHA says is that we have to be “competent”. Who’s holding the competency yardstick especially when employers read our scope of practice and say “yup see it’s in there! You should be doing this and no we don’t need to send you for any fancy training because ASHA doesn’t require anything specific!”

Group #4: SLPs who do not “believe” in instrumentation and they are “so experienced” that they can diagnose dysphagia at the bedside with their Xray vision, leading to overly restrictive recommendations of thickened liquids, modified diets, or missing silent aspiration all which can potentially lead to malnutrition, dehydration, pneumonia, and death.

The most dangerous of these groups are 3 and 4. And to be honest, if we didn’t have to deal with groups 3 and 4, group 2 – our highly trained and competent SLPs – wouldn’t have to go to battle every single time they needed an instrumental completed.

Perhaps if we cleaned up groups 2, 3, and 4 with actual position statements from ASHA, then we wouldn’t have to beg for respect because we were all on the same page with respect from ASHA and not the red headed step child that has to beg, plead, and cry just to do our job.

Lastly, I would like to walk you through a very TYPICAL day in my life.

 1.  I get to a facility to read a report of an SLP giving one sip of PUDDING THICK LIQUIDS on a modified barium swallow study where the patient that is so frail and weak with massive amounts of residue that they can not clear. This SLP then marks them as “failed”, the study is done, and they recommend NPO with a PEG —never even bothering to follow a protocol where the patient might do EXPONENTIALLY better on thin liquids which is many times the case. This is the most prevalent waste of health care dollars and the patient, facility, and SLP’s time, and I see it every. single. day.

2.  Now this patient is sent back to a SNF or home health on an extremely restricted diet because they got an incomplete study by someone who wasn’t trained adequately and now this SLP has to explain to their boss (whom they just fought tooth and nail to get the study done anyways) that they need ANOTHER study done, and that they wasted $2000 to send them for that study which wasn’t even worth the paper it was written on.

3.  Then in the meantime, this patient is scheduled to have a PEG tube put in place because the untrained SLP said so, even though the American Geriatric Society has a POSITION STATEMENT (wow what a nice concept) that patients with advanced dementia should NOT receive PEG tubes and in fact it shortens their life span. Yet we still have SLPs on the daily recommending NPO for these patients.

4.  But thank goodness before the PEG tube is placed, I get called in to do a FEES. The facility SLP noticed that the patient who was recommended to consume the pudding thick liquids while awaiting PEG tube placement is NOT drinking, becoming dehydrated, and has a history of malnutrition. Let’s talk about the repercussions of thickened liquids and modified diets. These can directly lead to malnutrition and dehydration. What’s worse on a frail elderly patient? Malnutrition? Dehydration? Or a teeny tiny small risk of aspiration pneumonia that destroys their quality of life but we aren’t even sure if that’s happening? Yes, clearly that’s a loaded question that should only be answered with instrumentation, patient rights, family involvement, and medical director input.

So this is just a typical day in my life, and I know so many of my colleagues can relate.

I implore you to help us.

I really truly do not know what the answers are, but I know that collectively we need to come together to acknowledge and tackle these issues. I know there are several different ways that ASHA can work together to create task forces, etc., whatever it is, we need it now.

I am not exaggerating when I say we have some SLPs that are CAUSING HARM to patients which goes against the ASHA Code of Ethics. Except it’s not intentional. It’s from not being fully educated, yet expected to work alongside colleagues with medical degrees.

There is nothing more heart wrenching than receiving messages from colleagues feeling AWFUL about what they have done because they didn’t know better. Or they have supervisors that refuse to keep up to date with our research and so the blind is leading the blind.

Please do not turn a blind eye to us any longer. I love our profession, I love our field, I love our patients, and I love the good that we are capable of doing, if our own governing body just supported us in these endeavors.

Thank you for your time.