I was sitting and thinking today. There are so many therapists that I have seen that are sub-par, (none of my friends of course!) It made me stop and think that every patient, client and student deserves to have the best of the best as far as therapy goes. I don’t want to take my children to a sub-par doctor, why shouldn’t I expect expertise from my therapist???
Dysphagia, in that respect, is no different than any other specialty. In fact, dysphagia may be a little more so in needing expertise. Dysphagia is life and death most of the time. I’ve actually seen patients die from poor choices in diet and from upgrading too soon to an inappropriate diet. Residents in nursing homes have died from uneducated staff. This is not acceptable. This is my own personal list of what it takes to be a GOOD therapist, from a dysphagia perspective, of course.
1. You need a therapist that is knowledgeable, to the point that the therapist can make any and all patients, client, etc. understand dysphagia. Every patient/client is entitled to understand their diagnosis and to understand the therapy you are providing. I can’t count how many patients have come to me for therapy, after having previous dysphagia therapy and never understood what the actual problem is!
2. The dysphagia therapist should very much understand the process of the swallow. It’s not enough to know that people aspirate or penetrate and then give them a cookbook sheet of oral-motor exercises to complete every day 10 times, 3 times a day. The dysphagia therapist needs to know the muscles, the structures, the nerves and their functions.
3. Don’t underestimate all the new treatments that are available. So many people will absolutely not touch VitalStim because “it’s not researched enough.” VitalStim and NMES is one of the most researched areas in our field. If you are able, go to these courses and learn what they are about. Read the literature. Make your own educated opinions. I always find that taking a little from each and every course that I go to, and putting it together to create my own therapy plan is more successful than the cookbook sheet of oral motor exercises.
4. Do a COMPLETE assessment of each and every patient. It is not enough to simply sit with the patient at a meal and watch for them to cough or choke. You need to assess all the cranial nerves, do a complete chart review, palpate the structures and functions during the swallow. The 3 ounce water swallow challenge is a new assessment procedure that can give some valuable assessment data. Not so sure I completely believe in it yet, however am using it before all my MBS’s to test the validity on my own terms.
5. When you complete an MBSS, don’t focus on aspiration, penetration, premature spillage, etc. Those are merely symptoms of a bigger dysfunction. You need to look at all the functions of all the structures and report on those. Yes, the person may aspirate, but why and what are you going to treat?? Bonnie Martin-Harris is publishing and providing CE courses next year on the MBSImP, which will be a standardized manner, in which to assess swallowing function during the MBS.
6. NEVER, ever, ever upgrade a patient diet on a Friday, leave for the weekend, and come back on Monday to check how they are doing?? Doctors do not start a new medication then leave the person hanging for days on end. How can you functionally assess a person’s ability to manage the diet upgrade if you are not there to monitor??
7. I so very often see therapists treat, by sitting with a patient at a meal, watching them eat, assisting with compensations and strategies and then doing the cookbook oral motor exercises with the patient. Don’t get me wrong, oral motor exercises can be functional, as a home exercise program in addition to ACTUAL swallowing therapy and compensations/strategies have their place, but they are not therapy. These compensations/strategies and OME do not promote the muscle changes required to constitute rehabilitation, which is what we do. You cannot improve the swallow without having the patient complete swallowing tasks.
It is often debated, what do we, as SLP’s call ourselves?? Some demand Speech Pathologists, Speech Language Pathologists, Speech Therapists, etc. I prefer Speech Therapist, because I rehabilitate people.
My challenge to everyone is to examine yourself and your therapy. Look at how you assess patients, how you complete the instrumental exam, how you treat patients with dysphagia. Ask yourself, what am I doing for my patient, what SHOULD I be doing for my patient and how can I do better for my patients, to rehabilitate their swallowing mechanism and therefore do my job and make my patient better??