We’ve all been there.

You start a new job, and the first thing they tell you is when to show up in the dining room so you can “do therapy during meals.” Easy, right? You sit with 8 patients, remind Mr. A to use a chin tuck, and politely ask Mrs. B to slow down between bites.

Except that’s not therapy. That’s supervision with a side of coffee refills—and no tips.

From Waitress to Rehab Specialist

Let’s break this down. The way many of us were taught dysphagia therapy was to observe patients during meals and provide cues. And sure, that may feel productive, but what’s really happening?

You’re likely being interrupted to help with tasks that aren’t part of your clinical role, and more importantly, you’re not challenging the swallow. Rehab is about change. Change comes from progressive overload and skill-based repetition—not status quo. Sitting in the dining room while your patient chews pureed meat is not strengthening their swallow.

Swallowing is a submaximal muscle activity—meaning unless we push the system, it doesn’t grow stronger (Logemann, 1998). Watching a patient eat applesauce three times a week doesn’t push anything except your patience.

We Can’t Treat What We Can’t See

We must stop skipping the instrumental evaluations. The truth? Once the mouth closes, we’re guessing. You cannot palpate the epiglottis. You cannot “feel” if the bolus was aspirated. Instrumentals like MBSS and FEES aren’t luxuries; they’re critical to identifying the physiology behind the problem—not just the symptom (Martin-Harris et al., 2008; Leder, 2015).

Would a neurologist guess the location of a stroke without imaging? Then why are we still trying to treat pharyngeal dysphagia without visualizing the swallow?

And no—instrumentals are not just to “see if they aspirate.” A radiologist can do that. Your job is to figure out why, trial strategies, assess physiology, and build a treatment plan.

Let’s get one thing straight: if we’re basing our treatment on assumptions, bedside guesses, or just the classic “Let’s try pudding,” we’re missing the mark. Instrumental assessments are not optional—they’re essential. FEES and MBSS provide the information we need to see what’s really happening during the swallow (Langmore et al., 1998; Martin-Harris et al., 2008). Clinical swallowing evaluations (CSEs) are valuable for identifying risk and guiding referrals, but they’re not definitive.

We’re not fortune tellers—we’re clinicians. And our patients deserve more than guesswork.

Three Things to Stop Doing in Dysphagia Care

1. Stop skipping the instrumental.

No, it’s not “just a formality.” It’s the gold standard. You wouldn’t diagnose a heart condition without an EKG. Don’t try to treat dysphagia without visualization.

2. Stop choosing treatment based on “what we’ve always done.”

The field has evolved. We know now that exercises like effortful swallow, Mendelsohn, and Masako have specific indications and mechanisms (Burkhead et al., 2007). They’re not one-size-fits-all.

3. Stop assuming modified diets are always the answer.

“Thick and pureed” does not equal safety. If anything, overly restrictive diets without evidence of need can lead to malnutrition, dehydration, and reduced quality of life (Robbins et al., 2008).

The Myth of Usual Care

Giselle Carnaby and Lindsay Harenberg (2013) showed us the truth: there’s no standardization in dysphagia therapy. None. More than 47 different techniques were recommended for the same case scenario, and only 13% were exercise-based. Fewer than 20% of patients returned to their previous diet.

Let that sink in.

We talk a lot about best practices, but as a field, we’re all over the map. And that’s hurting our patients.

Protocols like MDTP and EMST (click here to download your free guide to RMST) offer structured, evidence-based frameworks that use exercise science and neuroplasticity to actually improve the swallow (Burkhead et al., 2007). We can’t keep handing out tongue wagging exercises and calling it a day.

Let’s face it: many facilities are doing the bare minimum. A CSE, a diet change, and “monitor for signs and symptoms” is not a rehab plan. That’s a risk mitigation strategy. That risk mitigation strategy is often driven by unrealistic expectations and ridiculous productivity standards. If we want to rehabilitate swallowing—actually improve physiology—we need to stop being afraid of “rehabilitation” and start using principles of neuroplasticity, exercise science, and targeted intervention (Clark, 2003).

The Buy-In: Making Patients Care About Swallowing Therapy

Here’s another reality check: patients don’t always understand why they’re seeing us. They swallow “just fine,” even though they cough with every sip of water.

We’ve done ourselves a disservice with 10-page handouts of confusing exercises and zero explanation.

It’s our job to explain the “why.” Swallowing therapy is neuromuscular retraining. These are muscles—and if you don’t use them right, they don’t work right. Just like limping after a sprained ankle can throw off your gait for months, inefficient swallowing compensations can create secondary problems.

Your therapy room should look like a gym, not a tongue circus. Stop having your patient say “cook” 30 times. Have them swallow.

Let them know there’s homework. Let them know it takes time. Ask for 4–8 weeks. Show progress. Build trust.

Here’s the truth: no one cares about your FEES skills or your perfect SOAP notes if they don’t understand the value. And unfortunately, “SLP” doesn’t always scream “swallowing expert” to the average nurse or family member.

So what do we do? We market. Not in a sleazy, used-car way, but in a human, empathetic way. We build trust. We communicate our role clearly and often. We provide wins—those little moments where your strategies make a difference. Because those moments build momentum.

When you show people that your work means fewer choking incidents, fewer hospitalizations, and more mealtime joy, they start to listen.

Time to Step Out of the Dining Room

Let’s be real: no patient wants their PT doing quad exercises at dinner. So why do we think it’s appropriate for SLPs to do dysphagia therapy at the dining table? Observation is not therapy. If the PT watched a patient walk down the hallway with no intervention and no intention. is that therapy? If the OT simply sat and watched the patient bring a spoon or fork to their mouth with no intervention or an occasional cue, is that therapy?

Observation has a place—initial assessment, spot checks, and generalization. But it is not therapy. Your therapy should be active, targeted, and individualized. As Carnaby taught us at the Florida Dysphagia Institute, therapy should include:

• No chit-chat
• No compensations
• Aggressive intervention
• Feedback
• Repetitions
• Control
• Effort

Let’s raise the bar. Let’s stop “supervising” and start rehabilitating.

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Final Thoughts

There is no “usual care” in dysphagia right now—but there can be. You can be the SLP who raises the standard at your facility. You can be the one who advocates for instrumentals, educates your team, and transforms your therapy sessions into rehab sessions.

You are not a “feeding therapist.” You are a dysphagia specialist. You have the training to assess, treat, and rehabilitate the swallow. But if we accept “usual care” as enough—or if we wait for others to give us permission—we’ll keep spinning our wheels.

You didn’t go to grad school to be a waitress. Let’s do what we’re trained to do.

Happy swallowing. And no, you can’t bill for that applesauce.

Are you ready for a deeper dive with even more resources available? Join the Dysphagia Skills Accelerator today. You will get so many great tools with new tools being added all the time! Click here to join now!

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References

Burkhead, L. M., Sapienza, C. M., & Rosenbek, J. C. (2007). Strength-training exercise in dysphagia rehabilitation: Principles, procedures, and directions for future research. Dysphagia, 22(3), 251–265. https://doi.org/10.1007/s00455-006-9074-z

Carnaby, G. D., & Harenberg, L. (2013). What is “usual care” in dysphagia rehabilitation: A survey of USA dysphagia practice patterns. Dysphagia, 28(4), 567–574. https://doi.org/10.1007/s00455-013-9467-8

Daniels, S. K., McAdam, C. P., Brailey, K., & Foundas, A. L. (1997). Clinical assessment of swallowing and prediction of dysphagia severity. American Journal of Speech-Language Pathology, 6(4), 17–24.

Lazarus, C. L., Husaini, H., Jacobson, A. S., Mojica, J. K., Buchbinder, D., Okay, D., & Urken, M. L. (2014). Development of a new lingual range-of-motion assessment scale: Normative data in surgically treated oral cancer patients. Dysphagia, 29(4), 489–499. https://doi.org/10.1007/s00455-014-9533-0

Leder, S. B. (2015). Comparing simultaneous clinical swallow evaluations and fiberoptic endoscopic evaluations of swallowing: Findings and consequences. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 24(1), 12–17.

Logemann, J. A. (1998). Evaluation and treatment of swallowing disorders (2nd ed.). PRO-ED.

Martin-Harris, B., Brodsky, M. B., Michel, Y., Castell, D. O., Schleicher, M., Sandidge, J., … & Blair, J. (2008). MBS measurement tool for swallow impairment—MBSImp: Establishing a standard. Dysphagia, 23(4), 392–405. https://doi.org/10.1007/s00455-008-9185-9