ASHA 2016

Where did the time go?   I can’t even believe that next week is the ASHA convention!  After a long week it is time to start packing because if you’re like me packing early is a must!!!

Now it’s time to make my packing list!  

Comfy clothes (I’m not presenting and have no intention of dressing up! Long sessions and much learning calls for comfort!)
Comfy shoes (There’s A LOT of walking!)

Light bag (To carry my iPad and chargers. Nothing heavy because it is a long day and did I mention a lot of walking?)

Hygiene supplies (Shampoo, soap, the works. Don’t forget the deodorant…..long days, miles of walking!!)

Sweater or light jacket (Some rooms are hot and some rooms are cold.)

My list of sessions. (There is nothing worse than arriving at the conference and having no clue where to go. There are computers to create and print your agenda, however they can be very crowded.). I also try to double-book sessions in case one might be full or let’s face it, I just might change my mind.

Portable charger (I use a New Trent which will charge my phone and iPad fully at least once if not more.  I always go for a charger with a high mA output.)

Power strip or multi USB charger. (Let’s face it, hotels often don’t have enough outlets for all your electronics and if you have a roommate or 3, you will definitely need the extra charging space.  

A small first-aid kit. (You never know when a headache will come on or you need a band aid for blisters from SO MUCH walking!)

An open mind. (There are so many sessions to attend and so much information to learn!! Be ready to learn, not only in your sessions but in the exhibit hall.)

Pajamas (There is very little time to sleep, however it’s nice to be comfy during those brief periods of rest.)

Be prepared to learn, have fun, meet new friends, visit with old friends and enjoy the atmosphere!
Follow @dysphagiarmblng for live tweeting of ASHA 16 dysphagia sessions!

5 Considerations for Continuing Education

If you are like me, you are inundated with social media advertisements for various certification or continuing education courses.

The question is…..which do you choose?

We most certainly can’t afford to attend every course or obtain every certification.  So how do we figure out which courses are worth our time and money?

  1.  The course is ASHA approved for CEUs-Be aware.  Just because the course provides you with ASHA CEUs doesn’t necessarily mean that it is a good course.  While courses are required to be peer-reviewed for ASHA, that doesn’t mean the course is the cream of the crop.  ASHA also does not endorse any specific treatment or tools.  We still have to be conscientious learners.
  2. The course offers “fast” results-I have had the very few patients that met their goals in a short amount of time.   When we work with patients with dysphagia, we are typically working on changing muscles.  This involves strength, coordination and timing.  I can’t go to the gym and strengthen my arms in “just a few sessions”.
  3. Watch the evidence base-A new course can have 150 different references to “support” it’s use.  Read the evidence.  Some may not even be related to the technique you are learning.
  4. Does it really make sense?-The presenter may have you convinced by the end of a course or even through the advertisement that this new technique works wonders because of x, y, z.  Sit down and think about this.  (This is where our critical thinking caps must be ready to go!)  Does this technique make sense?  If I have a patient concentrate on working their knee, is that really going to change the swallowing system?
  5. Use your social media-Post in Facebook groups, use Twitter, Pinterest or even the ASHA SIG groups to question new courses and techniques.  You shouldn’t have to shell out thousands of dollars on a technique that doesn’t work.  You can absolutely keep an open mind to new techniques but maybe others in these forums can help you problem-solve why these techniques may or may not work.

We all work hard for our money and time is a precious commodity.  Choose continuing education and new techniques with care and always hold the welfare of your patients paramount.

What are some courses you have really enjoyed or wish you would have skipped?

What do you think would be the best resource to use to share and look up quality, evidence-based continuing education courses?

Quick Pocket Reference for Tracheostomy Tubes and Speaking Valves

I would first like to thank Northern Speech Services for sending me this wonderful reference to review!

If you haven’t yet had a chance to take a look at the new Pocket Reference from Northern Speech Services, you should!  This is a great reference tool for working with patients with trachs.
First, the guide is not much bigger than my iPhone 6.  It very easily fits in my scrub top pocket.  The pictures are large and very visually appealing.  Each page consists of some text but is not too much to read.  It is truly a reference tool.

The book consists of the following sections:  Basic Tube Anatomy, Selection, Cuffs, Brand Identification, Code on Neck Plate, Sizes, Speech, Talking Trach Tubes, Speaking Valve Identification.  Each section consists of pictures and texts to aid in the identification and decision making for Trach tubes and speaking valves.  

Whether a seasoned or new clinician working with patients with trachs, this is definitely a guide worth the money!

Find the Quick Pocket Reference for Tracheostomy Tubes and Speaking Valves here.  

The Cost of Thickened Liquids



Thickened liquids have had a lot of publicity lately in social media.  They’ve been a large part of dysphagia management.  Sometimes, it can be argued that the use of thickened liquids occurs more frequently than other compensation or management techniques.

  • “Texture modification has become one of the most common forms of intervention for dysphagia and is widely considered important for promoting safe and efficient swallowing.”  (Steele and Miller 2010)

Often, products or research is aimed at reducing the use or need of thickening liquids.  The Provale cup is one such product that only allows the patient 5-10 ml per drink, which may or may not be a safer amount of thin or nectar thick liquids.

There is a lot to look at when looking into thickened liquids.  The physical cost is definitely an issue.  Thickener is not cheap.  My friend Vince Clark calculated the cost of pre-thickened liquids and posted the following on Facebook:

When we look at the cost of Thickened liquids:

  • Per Day: 9 x .34 = $3.06
  • Week: $21.42
  • Month: $85.68
  • Year: $1116.90

These are the costs of a single organization.   An individual purchasing thickener may pay double.

We also need to look at how thick we’re recommending for our patients.  Many times and research back that maybe nectar thick is enough.   Dr. Leder looked at patients that aspirated thin liquids and found that these same patients had 100% successful swallows with both nectar and honey thick liquids indicating that nectar thick may be adequate to promote safe swallowing.  (Leder et al 2012)

There has been research leading to the fact that maybe we shouldn’t thicken liquids.  Dr. Logemann et al found honey thick liquids were the most effective in eliminating aspiration when compared to nectar thick liquids and a chin tuck.However, when aspirated, honey thick liquids had the most significant impact causing pneumonia, longer hospital stays or death.  (Protocol 201).

There are times patients are seen for a Modified Barium Swallow Study (MBSS), they penetrate with both thin and nectar so they are placed on honey thick liquids.  Perhaps the debate should not be an all or nothing, thickened liquids or no thickened liquids, but look at the whole patient and make the decision with them.  Always consider those patients that aspirate thin liquids during the MBSS, return home, continue to drink thin liquids and never die from aspiration pneumonia like we sometimes teach them will happen when they aspirate.

My interpretation of this research into my very real daily job is that I need to consider the whole patient and that some patients just need those thickened liquids.  They’re not going anywhere anytime soon.

In fact, thickened liquids can be great therapeutically.  Dr. Bonnie Martin-Harris has done quite a bit of research while developing the Modified Barium Swallow Impairment Profile (MBSImP) and has found that using a nectar consistency during the Modified Barium Swallow Study (MBSS) there is more significant pharyngeal movement during the swallow.  There are also studies looking at how adding “weight” to the bolus can be an effective therapeutic strategy.

We need to be careful in interpretation of research.  Just because an article came out that says not to use thickened liquids at all, don’t go and throw out all your thickener.  (Wallace, this article, 2016).

The cost is not only monetary, but also in our patient’s health, satisfaction and quality of life.  We all have or have had that patient that just really doesn’t mind thickened liquids.  They drink the liquids, they may not be turning cartwheels with thickened liquids but they tolerate them.  Some patients know it’s short-term and once they rehabilitate their swallowing function they may be able to resume thins.

We also have or have had those patients that just outright refuse thickened liquids.  They don’t like the texture or the consistency.  This may be the patient that says, “I know I need them but they taste like snot.”  (A former patient on thickened liquids circa 2011.)  This may also be the patient that refuses to follow your recommendations or just stops drinking all-together.

There always has to be a balance and a consideration for hydration, overall health, respiratory health and patient satisfaction.  I’m not talking the survey the patient gets and rates you on a scale from 1-whatever.  I’m talking about their everyday, I’m happy with my life satisfaction.

Always look at your patient as a whole.  Look at their respiratory system, their overall health, history, cognition and if able create a plan with that patient.

I have completed many MBSS’s with many patients over my years.  “Remember, the person is here because they have been having difficulty with their swallow.  I’m guessing this isn’t the first or last time they have or will aspirate.”  (Wallace at every MBSS when the radiologist is ready to quit because the patient aspirated.)

Remember those elders at the SNF that are put on thickened liquids and remain on honey thick liquids for the rest of their days.  These may be the same people you say wandering the halls, stealing drinks at the water cooler, stealing drinks from the tables in the dining room or sneaking drinks from the bathroom sink.

Steele, C. M., & Miller, A. J. (2010). Sensory input pathways and mechanisms in swallowing: a review. Dysphagia, 25(4), 323-333.

Robbins, J., Hind, J., & Logemann, J. (2004). An ongoing randomized clinical trial in dysphagia. Journal of communication disorders, 37(5), 425-435.

Leder, S. B., Judson, B. L., Sliwinski, E., & Madson, L. (2013). Promoting safe swallowing when puree is swallowed without aspiration but thin liquid is aspirated: nectar is enough. Dysphagia, 28(1), 58-62.

Dysphagia Awareness


June is Dysphagia Awareness Month.  A month dedicated to a disorder that most have never heard of but comprises 80% of my work.  It’s not even in my title, so what the heck is dysphagia?

What is Dysphagia?

If you Google dysphagia, you get this:


  1. difficulty or discomfort in swallowing, as a symptom of disease.
    “progressive dysphagia”

What does a Speech Language Pathologist (SLP) do?

I have worked in a number of different settings as a full-time employee, part-time employee and PRN (as needed).  I have worked in Skilled Nursing Facilities (SNF otherwise known as a nursing home), home health, outpatient (where people come to see me), schools and in the hospital.   Some people research the swallowing process, techniques we use and interventions while teaching people to become and SLP at the college level.

Now, you need to get your head out of the gutter!  When I say I’m working with swallowing, I’m talking about the ability to swallow, saliva, food, drink and pills.  You know, that thing that we do 600-1200 times per day without a second thought!  It’s after a person or a loved one actually starts having a problem that people realize swallowing can “go wrong.”

I have worked with patients with such a variety of diseases.  Thyroid issues, CVA (stroke), Parkinson’s, ALS, MS, Rhett Syndrome, Mitochrondial Myopathy, Shaken Baby Syndrome, dementia, just to name a few.

Typical Day?

So what does a typical day look like for me?  Well, there is no typical day.  I never know what I’m walking into!  In the SNF setting, I walk in the door and hope for the best!  I work with Occupational and Physical Therapy to provide the best care for each elder that I possibly can.  For some that involves working on their cognition (memory, problem solving, executive functions), some work on their speech because they may have difficulty with word-finding (aphasia) but most have some type of swallowing problem.

In the hospital is where my day varies the most.  At the hospital is where I also get to work in x-ray to actually see how the swallow is affected.   I get the chance to mix barium with food and watch, using fluoroscopy, a live feed of the swallow.  Barium is used because it is dense and shows up as a dark substance on the swallow study (Modified Barium Swallow Study or MBSS).  I watch to make sure the muscles do what they’re supposed to do (close the airway, squeeze the pharynx, block off the nose, move the food/drink (bolus) back in the mouth and open the esophagus) and that the food/drink goes where it’s supposed to go, into the esophagus and not into the airway (aspiration) or remains in the pharynx/throat (residue).  I also am called in to assess patients in their rooms and determine the safest diet consistency for them.

Is Swallowing a Problem for You?

Most of the time, I’m told “I don’t need speech, I can talk just fine.” Sometimes, I’m told “I don’t have any problems with my swallowing” as the person takes a drink of water and coughs relentlessly.  I’ve also been told that “It’s just sugar that gets me” as the person drinks water and coughs relentlessly.  If you haven’t figured it out, that relentless coughing often clues me in that the person may be having difficulty with swallowing and that water may actually be going down into their lungs.  So what are some signs of swallowing problems?  Well, here’s a list that may indicate a problem:

  • Coughing/choking with food or liquid.
  • Feeling that food is “stuck” in the throat.
  • Difficulty chewing, losing the food/drink from the front of the mouth (through the lips) or not able to move the food to the back of the mouth to swallow.
  • Avoidance of certain foods.
  • Feeling that food “balls up” in the mouth as the person chews.
  • Frequent pneumonia.
  • Weight loss.

These are just a few things that may indicate dysphagia.  If you or a loved one experiences any of these, go to your doctor who can then refer you for Speech Language Pathology (Swallowing) services.


So now, you may wonder what a Speech Language Pathologist (SLP) can do for you.  A Speech Language Pathologist will determine the cause of the dysphagia or swallowing problem and create a treatment plan to rehabilitate the swallow.  Swallowing is mediated by 55 muscles and cranial nerves.  These muscles can be exercised to improve their function.  Now, we can’t necessarily set you up on a treadmill or a weight machine and let you go to town, sometimes these exercises are a little creative and may seem a little silly at first, but your SLP should describe the exercises to you and explain why each exercise is needed.

Sometimes, the SLP will recommend a different consistency of food for you to eat.  It may be recommended that you eat a mechanical soft diet with your meat ground (no crunchy, hard foods) or you may be advised to eat only pureed foods (mashed potato consistency).  It may be recommended that your liquids be thickened using a commercially available thickening agent.  You may be advised to use a compensatory strategy to increase the safety of your swallow such as turning your head to one side or the other or looking down at your lap as you swallow.  Some people have a better swallow if they eat a bite of lemon ice before their food or if they take a drink of water after each bite of food.  Some people even have difficulty with pills and need help in how they take their pills.

Why an SLP?

You may wonder, what makes me, an SLP, the person to help you or your loved one because all of this sounds extremely complicated!  It is very complicated!!  There is no cookbook approach to swallowing disorders and each person has to be treated and evaluated individually.  The SLP holds a Master’s degree.  Why yes, that may mean SIX years of college.  I’m also responsible, after all that school to continue my education through courses taught be other SLPs or professionals.  This is called Continuing Education.  I am required by the state of Indiana to have at least 36 hours of continuing education every 2 years.  I go well above and beyond that because there is always so much to learn!!  I also read research about swallowing.  A lot of research.

Some of us even go a bit beyond that and obtain Board Certified Specialty in Swallowing and Swallowing Disorders (BCS-S).  The SLP will then sign all their paperwork with that BCS-S to demonstrate this specialty.  Holding the BCS-S means that I have participated in 72 hours or more of continuing education specifically in the area of dysphagia, I have demonstrated competency through a test in dysphagia and have demonstrated more advanced work such as educating the public in the area of dysphagia.

My “Job”

My job is not a fleeting/passing moment with people.  I work with people in a variety of settings with something that is very important to them.  Eating/drinking is our staple for social interactions.  We often go out for drinks or go out to eat.  The most rewarding part of my job is when my patient reaches their goal and eats/drinks that item that they have been longing for, but was not deemed safe for them.  It is that time that the patient no longer experiences discomfort or difficulty with one of life’s main functions.  We need nutrition, right?  I work closely with these patients and we develop a connection.  It’s absolutely the best part of my job!  I don’t aim for perfection with my patients, I aim for functional!

Some other cool things about my job?  I get to write this blog!!  I love writing my thoughts out and sharing them with the world.  I never in a million years dreamed that people would actually read what I write!  I have collaborated with other professionals and app developers to create apps for Apple regarding dysphagia.  I have had the opportunity to teach webinars and to travel and teach classes about dysphagia.

National Dysphagia Awareness Month

Our field has, in recent years, lost 2 people integral to the world of dysphagia.  Dr. Jeri Logemann passed away on June 19, 2014.  She was the mother of the field of dysphagia.  I owe her so much for delving into this world of swallowing, assessing and treating that I love so much!  Dr. Steven Leder recently passed away.  He was a major researcher in our profession who brought passion to our field and made us all use our brains!  We will forever be grateful for the work that both of these influential souls have given us and leave to us!

Let’s “celebrate” National Dysphagia Month by spreading awareness!   May all your swallows be functional swallows!

Better Hearing, Speech (and Swallowing) Month


(I love this picture from Simply Thick!)

Often, I am asked what I do for a living.  If I say Speech Pathologist I get that look of “what?”  If I say I work in a school, it’s assumed that I’m a teacher and if I say I work in a hospital, it’s assumed that I’m a nurse.  When I say I work in both setting, there’s mass confusion.

This month kicks off Better Hearing and Speech Month for Speech Language Pathologists (SLPs).   If you’re not sure what an SLP does, well, we do A LOT!  If you are looking for a job with a great deal of variety, plenty of learning opportunities and flexibility, well, this is a pretty good start.  **Disclaimer:  This post is information an SLP will already know and was intended for a variety of readers.**

An SLP can work with people from newborn to elderly.  We work with people that were born with cerebral palsy, developmental delays, autism, Down Syndrome (along with a number of other syndromes) and with acquired speech, language and swallowing problems due to stroke, Parkinson’s, brain injury, cancer, and a variety of other diseases or traumas.

We work with articulation (production of speech sounds), language, voice, cognition (memory, problem solving, attention), reading, social language, executive functioning, motor speech and swallowing.

An SLP goes to school for 6 years, as a Masters Degree is required.  Many SLPs go on to get a Doctorate.  SLPs work in school systems, nursing homes, rehab facilities, home health, First Steps, hospitals, NICU and universities as well as private clinics.  Some SLPs will even go on to research certain areas such as swallowing to help SLPs better understand the physiology, anatomy, assessment and treatment techniques.

Swallowing and Swallowing Disorders is my area of expertise.  I even took the extra step(s) to obtain my Board Certification in Swallowing and Swallowing Disorders (BCS-S).   During the process I had to demonstrate that I not only understand swallowing and swallowing disorders, but also go above and beyond to educate others.

Dysphagia (swallowing disorder) seems to be an area in our field that has very little understanding and even less recognition.  Dysphagia is becoming one of the primary assessment and treatment diagnoses in the medical field.  Some schools even offer dysphagia therapy for school-aged students.

You may wonder what an SLP can possibly do with a swallowing problem.  The SLP is the person that assesses the swallowing difficulty.  Assessment may be completed through (most commonly) a clinical evaluation, Modified Barium Swallow Study (MBSS or also known as a Videofluorographic Swallow Study VFSS) and/or Flexible Endoscopic Evaluation of Swallowing (FEES).

Treatment may happen in the form of diet consistency alterations, compensatory strategies or rehabilitative exercise.

I often ask myself, “What am I doing for my profession?  How am I helping?’  Part of my job has been education.  I have developed webinars and taught live seminars to help further the knowledge of others through evidence-based practice.  I keep current in evidence and continuing education.  I use this blog for education, not only for clinicians but also for the general public.  I use Facebook groups and Twitter to share information.  I have authored/co-authored 3 apps with Tactus Therapy and SmartyEars.

What do you plan to do to share knowledge regarding our wonderful field??

Educating others is a huge part of what we need to be doing.  Let everyone know what we do and why we do it!!


advocacy paint

Picture from:


If you are on Facebook in any of the SLP medical-based groups, you know the word of everyday is advocacy.  There are too many stories of Speech Language Pathologists not able to get instrumental examinations for their patients with dysphagia because of the cost.  People are losing their jobs for not maintaining 90% productivity.

We all talk about advocating for the needs of our patients.  At the end of the day, the patient is the one who is not receiving the service they were promised.  At the end of the day it’s the patient’s life that we’re playing with.

How many times have you been in a facility and heard “Oh, you’re just speech.”  I have.  Yes, I’m just speech.  Yes, I have a very important job of making sure that a patient is safe with a diet, rehabilitating the patient’s swallow to make them safe with the consistency they desire, setting up a cognitive program so that person can function as independently as possible, making sure oral care is complete and appropriate to reduce the risk of pneumonia.  Just because I’m not the person that is going to come in and put your patient back into the bed doesn’t mean my job is not important.

It is true.  We do need to advocate for instrumental assessment.  Otherwise it’s a guessing game.  At ASHA 2015, there was a great session on instrumental assessment vs. bedside assessment by Coyle, Leder and McCaullaugh.  One of my take-away messages:  “Once the mouth is closed, everything is inferred.”  “The clinical bedside exam is a series of pass-fail screens.”  “We need more than a cough to determine that a patient might aspirate.”  “No part of bolus flow or the pharyngeal phase can be assessed without instrumentation.”

I wish that every professional with which I work could have attended this course.  I feel like 80% of my job in the acute care hospital is education.  I take many opportunities to educate staff that I, in fact, cannot determine if the patient is aspirating or has aspiration pneumonia during a clinical assessment.  I may have a good idea that they are, but there is no way to say for sure.

I educate staff that a chin tuck, may indeed be the contributing factor to aspiration and may not help the patient after all.  Instrumentation is required to determine if the chin tuck may or may not be an appropriate strategy for the patient.

I educate staff that the gag reflex is NOT present in every person and that it is not a reliable predictor of the ability or inability to swallow.

Sometimes we advocate just for the use of instrumentation.  My friend Shareka lives in Barbados.  She had the equipment available for a modified barium swallow study, however she had to advocate to use it and FINALLY was able to complete her first MBSS.

Here in the United States many of us advocate for FEES assessments with and without success.  We have to prove outcomes, cost effectiveness, etc while sometimes our therapy counterparts are able to purchase large equipment without the same hassle.

We have to stand up at some point and let other medical professionals know that what we do matters.  We’re not “just the speech therapist” and that we’re more than a few service-based codes.  This will not change if we all sit back and hope ASHA or our state organizations do this for us.

Do you need some inspiration in advocating for instrumental assessment?  This post was put together by Vince Clark and Kate Krival and approved by members of the Dysphagia Therapy Group Advisory Board.

“Often SLPs comment on this page about how testing (both Modified Barium Swallow Studies – MBSS and Flexible Endoscopic Examination of Swallowing – FEES) is openly discouraged or “not permitted” by administration. While this occurs in all settings, it seems that skilled nursing facilities tend to be the setting where this occurs most often. The topic comes up so frequently that the admins on this board feel we need to address it. It is worrying that this trend seems to be so pprevalent throughout our work environments and it is particularly troubling when it is discussed here that the leadership often encouraging “no testing” or making inaccurate claims about what ASHA considers “best practices” are SLPs themselves. In order to give those in the field easy access to ASHA policies and guidelines, we present the following statement and resources.

Speech-language pathologists (SLPs) practicing in all the United States settings are obliged to follow American Speech-Language-Hearing Association (ASHA) guidelines for best practice [1]. SLPs are mandated to perform all clinical tasks competently [1], which requires them to develop and maintain the knowledge and skills consistent with prevailing scientific information regarding clinical practice. Best practice for SLPs engaged in the diagnosis and determination of management approaches for adults with oropharyngeal dysphagia requires consideration of both clinical and instrumental examinations where needed [2, 3]. The American Speech Language Hearing Association (ASHA) [3] recommends that clinical evaluation of patients presenting with probable swallowing difficulty include an interview, medical chart review, observation of eating and drinking, and oral mechanism examination [3]. Instrumental visualization should be added to the clinical exam in order to identify anatomical and physiological aspects of swallowing that cannot otherwise be discerned [3].

1. American Speech-Language Hearing Association. Code of ethics [Ethics]. 2015.
2.Splaingard, M.L., et al., Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical assessment. Arch Phys Med Rehabil, 1988. 69(8): p. 637-40.
3. American Speech-Language Hearing Association. Preferred practice patterns for the profession of speech-language pathology [Preferred Practice Patterns]. 2004.

While all patients are not appropriate for testing, the vast majority of them are appropriate for testing. Consider what you are doing when you recommend diets, compensatory strategies, exercises or maneuvers WITHOUT testing. Evidence based practice would indicate that we are most likely doing inappropriate things and ultimately causing harm when we treat without the use of MBSS or FEES.

Best of luck as we all try to change the system in a positive manner.

Sincerely, The Admins of The Dysphagia Therapy Professional Page”

May begins Better Hearing and Speech Month.  Although most of the pre-made promotional materials cover communication and are aimed at pediatrics, we can still take the month and plan some educational activities at our facilities.  Some ideas?

  • 1.) Pass out educational material on dysphagia and what we as SLPs do to help.  Make sure there is evidence to support us.
  • 2.)  Create a quiz for others to complete with a gift card as a prize.  Even a $5 gift card is worth the effort!
  • 3.)  Plan a 5-10 minute in-service for staff to let them know what we do.
  • 4.)  Work with companies to host a luncheon and invite your patients with dysphagia.  Success stories are always a great boost.  (I did this with my VitalStim representative.)  Invite your rehab managers or any of the top-dogs at your company.
  • 5.)  Create a bulletin board to stay up for the entire month.
  • 6.)  Write a story for your local newspaper.

Do you have any other ideas?  Get out and let people know what we do and why we matter!!!  We are more than “just the speech person!!”