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. Patients that are on a restricted diet that develop dehydration, malnutrition, sepsis from refusing the altered 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.
So what are 7 things you can do to be a better therapist?
1. You need a therapist that is knowledgeable.
Knowledgeable to the point that the therapist can make any and all patients, clients, families and other professionals 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!
Education on oral care, what can happen with or without following recommendations, why they are doing specific exercises.
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.
They also need to understand the physiology of the swallow from the assessment and know which exercises, compensations, maneuvers or strategies to employ to assist that patient with a more functional swallow.
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.” If you are able, go to these courses and learn what they are about. Read the literature. Research the various companies that utilize NMES such as Ampcare or Guardian. 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.
Keep up with the new courses. MDTP has been out forever and is really gaining popularity. I still have spoken with SLPs that have never even heard of MDTP.
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, vies the structures and functions during the swallow through instrumental assessment. The Yale Swallow Protocol is a screen that can give some valuable insight to your patient’s swallow.
Instrumental assessment is as vital to swallowing therapy as a CT Scan or MRI is to a doctor diagnosing and treating a new CVA.
5. When you complete an MBSS (Modified Barium Swallow Study) or FEES (Flexible Endoscopic Evaluation of Swallowing), don’t focus on aspiration, penetration, premature spillage, etc.
Those are merely symptoms of a bigger dysfunction. You need to look at the physiology of the structures and report the dysfunctions that are observed. Yes, the person may aspirate, but why and what are you going to treat??
The MBSImP is a great way to learn to identify dysfunction and to report those dysfunctions during the MBSS.
6. Be cognizant of the diet level you recommend for the patient.
You are not the diet police. You may recommend that a certain consistency is better for that patient, however they may disagree and not follow your recommendations. That does not mean they will die.
There have been times that patients have aspirated every single consistency during an MBSS, declined the NPO status and started eating by mouth. No consequences at all. Never forget that some patients are functional aspirators.
7. If you are going to work with a patient, actually TREAT the patient and choose exercises that are functional in rehabilitating the swallow.
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.
When prescribing exercises for a patient, you must utilize exercise physiology principles. Exercise needs to have certain aspects to actually do what it is supposed to do.
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??