Research vs. Clinical skills

One thing that has become completely apparent through social media is that there seems to be a great divide amongst researchers and clinicians.  

There are the people that swear if one more person asks them to present the article providing the research to the technique they are recommending……….

The truth is we live in a world of Evidence-Based Practice (EBP).  Somewhere along the line, EBP became peer-reviewed research articles published in a relevant journal.  

ASHA defines EBP as:  

Evidence-Based Practice (EBP)

The goal of EBP is the integration of: (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve. Conceptually, the trilateral principles forming the bases for EBP can be represented through a simple figure: Read more about EBP.

EBP_Logo

We do need published research to support what we do.  The trouble is, techniques we try using our general knowledge and clinical expertise may be something we try during a session.  It may be something that comes to us as we sit and work with a patient or client, however we really don’t have the time to sit and wait for the research to be funded, proposed, completed, peer reviewed and published.

Listening to our patients can be very revealing in what works and doesn’t work for them.  Not sitting and listening to the patient and saying, “Well, the research said this would work.”  It may not work for the particular patient.

Honing in on our clinical skills is pertinent to our profession.  You may read an article and think, that might work for my patient if I change x, y, and or z factor.  

Research is a part of EBP.  The studies are great to have and the studies definitely support what we do as a Speech Language Pathologist (SLP).  I, personally, deeply admire those that complete research in our field.

One obstacle I find with research is that I can’t always exactly replicate a study.  Does that mean, if I use a substitution that I’m not following the peer-reviewed published research?

We need to let research guide us in our decision-making skills when assessing and formulating that ever-evolving treatment plan for a patient.  

We also need to use our hard-earned clinical skills that we all worked so hard to earn!

Where Can I Go for Questions Regarding Dysphagia?

You work with dysphagia everyday.  Well, maybe not everyday for some, but you work with patients with dysphagia at least some days.  You have the books, you have paper resources.  Does anyone else keep a binder with information for dysphagia??  I’m working on putting mine on Dropbox so that I can use mine on my iPad.  Where else can you go for information/help with dysphagia?

 First, there is a group on Facebook.  You may have seen it, may even be a member.  The Dysphagia Therapy group has grown more than I could have ever hoped.  This group has been such a great resource for swallowing specialists.  This group has served as a great place for professionals to ask and answer questions and to vent about issues we experience everyday.  We are also getting a number of students who utilize this forum as a means of gaining real world experience by asking professionals questions.  This has also been a great forum to share continuing education experiences, courses and information regarding dysphagia products.  You can join this group at our Facebook site.

 Twitter has become a great resource for all things SLP.  If you belong to Twitter, all you have to do is add the hashtag #dysphagia or #dysphagiapeeps.  Twitter has been such a great resource to ask/answer questions.

 There is a dysphagia maillist.  You email your questions/information to the listserv and will usually get at least one response if not more.  The only downside to this listserv is that it can, at times flood your email.   One complaint of this maillist is that often times the responses to questions can be very negative and often times you feel that you are being told what not to do, but never really what to do.  It also seems to be very heavily geared towards the pediatric population.

 By the same token, ASHA Special Interest Group (SIG) 13 for Swallowing and Swallowing Disorders also offers a mail listserv.  Again, the downside of this is flooding of your email and you have to be a member of SIG 13 (an extra $35 in addition to your dues for ASHA).  The good part of this listserv is the responses are often very positive and informative.  You also tend to hear from some of the “big names” in dysphagia such as James Coyle.  SIG 13 also has their own webpage on the ASHA site and with your membership, you get access to the Perspectives for Swallowing and Swallowing Disorders journal, which is a great resource.  You also, for a fee, can utilize this journal for CEU’s.

The National Foundation of Swallowing Disorders (NFOSD) provides free educational webinars as well as connects patients with qualified speech pathologists.  They publish articles on their site about patients with dysphagia.

 The Dysphagia Research Society is a great resource to therapists.  You can join via a research track or a clinical track.  There are three tracks of membership:  full member is $220 a year and you have to have published research; associate membership requires interest in deglutition and costs $170 a year, however you have full access to the Dysphagia journal; student/trainee membership is $50 a year and requires a letter from the head of the department.  In addition to their website, access to the Dysphagia journal, the DRS also has a conference once a year.  The 2012 conference will be held in Ontario Canada.  I believe that the conference is available for CEU’s.

 The VitalStim website offers great resources, whether you are a certified clinician or not.  The website offers resources, a list of VitalStim certified clinicians and free webinars.  Some of the webinars are for VitalStim certified clinicians only and some are free for all clinicians.

 That Mayo Clinic website offers resources for Dysphagia that would be more appropriate for families/patients.  This would be a great site for clinicians looking for resources for family/patient education handouts.  It might be good for students/new clinicians to start adding to their toolbox.  

 Clinicians that want to specialize in Dysphagia are encouraged to get their Board Recognized Specialty in Swallowing (BRS-S).  The BRS-S website offers CEU’s in Dysphagia.  You can also print the application to obtain your BRS-S with a list of the requirements.  You can obtain this via a research or clinical track.  The clinical track requires evidence of skills in Leadership, Education and Research, along with 75 hours of CE in Dysphagia courses within the last 3 years.  You also have to have 350 clinical hours within the last 3 years.  Once you submit your paperwork with $75 (you can request a mentor to assist you with your paperwork, help you determine if you are ready for BRS-S and set you on track to obtain your BRS-S within 3-5 years.) Once your application is accepted, you can take the examination for an additional $300.  You have 2 chances to take the test without having to pay again.  After the first 2 tries, you have to pay $75 per re-take and can only attempt to pass the exam for the next 12 months.

 The American Dysphagia Network offers CEU’s for clinicians, information on swallowing and swallowing disorders for clinicians and patients and a self-test for Dysphagia that can be completed online or printed and given to the public.  

 Swallow Safely is an amazing book written by Roya Sayadi, Ph.D., CCC-SLP and Joel Herskowitz, M.D. It is a great resource for family, patients, potential patients and clinicians. The book is easy to read, not terribly long and inexpensive. The book runs anywhere from $9.99 to $14.99. It is also available in ebook format, so it provides easy reading on your iPad or Nook.

 Last, but not least, if you own an iOS device (iPad, iPhone, iPod) or an Android system, there are apps available for you to use for Dysphagia therapy. There are not many yet mind you. If you own an Apple device, you can look for: Oral Motor from SmartyEars which is geared mainly towards pediatrics; Lingraphica offers an oral motor app geared more towards adults; Lingraphica also offers a Dysphagia app (Smalltalk) with icons which can be utilized by patients to “speak” words/phrases regarding their swallowing/dysphagia and also videos demonstrating maneuvers such as the supraglottic swallow; iSwallow offers a means of setting up a program for your patient, adding exercises, schedule, instructions and a journal for patients to use for their swallowing therapy; NeuroToolkit includes the NIH Stroke Scale, Coma Scales, SAH/AVM Scales, TIA/Stroke/ICH Scales, Anticonvulsants and Outcomes/UPDRS/Eye/EDSS/MIDAS. This is about it for the Dysphagia apps I have found for iOS. For Android, there are even less. Android offers the MiniMental app which may be helpful in determining cognitive status for you patient, Rancho Los Amigos app which basically just tells you what to expect at each level, and I sometimes use the stopwatch app for my assessment.

Journey to BRS-S

It’s official!  I finally did it and am so extremely happy and excited!!

 I finally, not only had my application accepted by the BRS-S (Board Recognized Specialty in Swallowing and Swallowing Disorders) and passed the exam.  I can officially put the title BRS-S after my credentials!

 I wish that I could say that it was an easy process, but it really wasn’t.  I will say though that I have learned so much along the way and have met so many new and wonderful process through this amazing journey.

 The main reason for writing this post is to, hopefully encourage others to do the same.  This was something to me that several years ago seemed completely unreachable.  I mean really, I’ll never compare to the Jeri Logemanns of the world!

 Many people have asked me about applying for and taking the exam for the BRS-S.  Here is post about my experience.

 I had went to many conferences and saw speakers with BRS-S after their names.  I went to the website, www.swallowingdisorders.org, and started looking into what it would take to become BRS-S.  WOW!  Not only do you have to prove that you have gone over and beyond in the area of swallowing and dysphagia, but you have to have 75 CEU’s in dysphagia, 3 years experience post graduation and letters of recommendation.

 The BRS-S does offer the opportunity to utilize a mentor during the entire process.  I decided that it wouldn’t hurt to look into a mentor to even see if this is something possible for me.  I actually did, 2 years ago, I applied for a mentor.  I ended up with Nancy Swigert, who I truly can never thank enough for not only giving me the courage and the confidence to believe that I could do this, but also endlessly reviewed and helped my revise my very very very long application.

 If you are looking into applying for BRS-S, the website has the following listed as requirements:

 

Requirements for all applicants      

 

 

1. ASHA Certification.

All applicants must currently hold the ASHA Certificate of Clinical Competence in Speech-Language Pathology (CCC/SLP).

 

2. Continuing Education.

All applicants must document receipt of at least 7.5 CEUs that relate to dysphagia within the last 3 years. A minimum of 4.5 of the CEUs need to be ASHA sponsored courses and up to 3.0 of the CEUs may be non-ASHA sponsored continuing education activities.

Individuals attending workshops which do not give ASHA CEUs may apply for independent study through ASHA to receive ASHA CEUs. Please provide evidence of attendance at other educational activities in closely related fields. Detailed descriptions of all non-ASHA sponsored CEU activities is required. Continuing education activities may include

  • Workshops, meetings or courses in swallowing and swallowing disorders, video and audio courses, telemedicine, and other electronic media)
  • Independent study (e.g., course development, research projects, publications, internships)
  • Self-study (e.g., videotapes, audiotapes, journals).

Continuing education courses must be directly related to dysphagia. If the title of the course is unclear (as it relates to dysphagia), an applicant should submit a program or brochure to provide substantiation for its inclusion.

When applying CEUs from the ASHA National convention or other multi-offering events, applicants must list specific course/workshop titles and corresponding CEUs in the application table. CEUs will be applied for only those courses/workshop relative to dysphagia.

College Courses.  If an applicant has completed a college level course in dysphagia, accrued credits can be applied to continuing education requirements. Graduate university coursework must be accompanied by a syllabus or transcript. One college credit is equivalent to 1 CEU (as it relates to application for BRS-S). The applicant must submit a transcript or other document verifying completion of those credits.

Instructor or Invited Lecturer. If an applicant teaches a dysphagia course at an approved university/college or provides dysphagia-related lectures at a conference which provides ASHA CEUs, a maximum of 3.5 CEUs may be applied to the 7.5 CEU requirement for BRS-S. One college credit is equivalent to 1 CEU. Each course may only be applied only one time within an application (even though the same course/conference may be taught several times during an academic year or in consecutive years). The applicant must submit appropriate evidence and documentation of the lectures that were related to dysphagia.

 
 

3. Post-Certification Clinical Experience.

All applicants must have completed a minimum of 3 years post certification (CCC/SLP) clinical work that has a focus in dysphagia. BRS-S has established two tracks to meet the diversity of clinical service environments for professionals at all levels of advancement within the profession:Clinical Track and Academic/Administrative Track.  The Clinical Track looks to identify professionals who demonstrate strong advanced clinical skills through direct provision of services to patients/clients. The Academic/Administrative Track looks to identify researchers, instructors and administrators who have advanced in different employment environments. These individuals maintain clinical skills through ongoing patient/client contact, while promoting improved patient care through research and teaching/training of clinicians within this specialized area of practice.

a. Clinical Track: a minimum of 350 clock hours of evaluation and/or treatment of swallowing disorders completed within a year for each of 3 years prior to applying for BRS-S. Supervision of speech-language pathology staff members and students providing evaluation and treatment to infants, children or adults with feeding and swallowing disorders can account for 100 of the required 350 hours/year. Supervisors must submit a statement affirming that all of the 100 hours of supervision were for dysphagia cases. The balance of the hours must be obtained from direct face-to-face clinical service to patients.

b. Academic/Administrative Track: a minimum of 100 clock hours of clinical evaluation and/or treatment of persons with swallowing disorders completed within a year for each of 3 years prior to applying for BRS-S. These hours must all be direct patient contact hours.

In place of the higher number of clock hours required of those in the Clinical track, applicants in the Academic/Administrative tract shall hold either:

a. an academic position in a degree-granting institution with a combination of teaching, and research, and academic advising with a focus on swallowing and swallowing disorders. Evidence of student advising, teaching, and research must be included in the narrative section of this application. Evidence of teaching should include a syllabus of the dysphagia course taught. Research must include clinical research in normal or disordered swallowing with direct contact with human subjects as part of the methodology. OR

b. an official administrative or supervisory position in a setting that provides clinical services to persons with swallowing disorders. Responsibilities will include training and supervision of clinical staff, program development, and leadership in the institution directly related to swallowing and swallowing disorders. Multiple examples and evidence of these areas of leadership must be included in the narrative section of the application (e.g. policy/protocol development regarding swallowing program, development and implementation of dysphagia quality improvement program).

 

4. Advanced Skill Documentation

Through the documentation of advanced level skills in swallowing and swallowing disorders, candidates must demonstrate that they have applied the highest level of ethical standards in their practice (i.e. service delivery and in the conduct of scholarship, research, and training). The expectation is that applicants can demonstrate “advanced” clinical and professional skills over the past 3 years. In other words, the applicant has achieved the highest standard of excellence, displays professionalism, is committed to continuous advanced learning, and displays characteristics that reflect achievements that go above and beyond expectations. Applicants may indicate a clinical preference or advanced level of experience in either pediatrics or adults but this is optional as applicants will have knowledge of swallowing and its disorders regardless of age.

There are distinctly different requirements for each track.

a. Applicants in the Clinical Track must evidence advanced skills either by satisfying at a minimum: two activity types within one category or one activity in two different category types. In other words, the applicant can choose to provide documentation in just one of 3 advanced areas.

b. Applicants in the Academic/Administrative Track must evidence advanced skills in at least two different category types.

 

 

       

 Yes, Yikes!!! I knew I had the ASHA credentials, I actually did have the continuing ed requirements, the hours of experience (thank you to all my SNF experience and the hospital). My area that I was lacking was my advanced experiences. Nancy gave me some wonderful ideas such as presenting poster presentations at my state convention, at ASHA, presenting within the community. I also added things like my Facebook groups, my Twitter experiences, online journal club. I live and work in a very rural area (25 bed hospital), so some of these advanced skills took some creativity. I also was very fortunate in that at the time I started my application process, I had the opportunity to supervise 2 CF’s and a student. Everything just seemed to come together at the perfect time!

I did end up doing a poster session at my state convention in 2011, then a poster presentation that same year at ASHA. I had the Facebook groups, CF supervision and several experiences with education of nursing staff etc. I felt that I was ready at that point. After sending in four copies of my very lengthy application, submitting my payment for application and several long weeks of waiting, I received a letter in the mail. I wasn’t accepted at that point.

The nicest part of the rejection letter, was that the board didn’t just tell me it wasn’t good enough at that point. They highlighted my areas of weakness and strength with suggestions for improving those weak areas and improving them for future application.

I’ll admit, that I spend a couple of days feeling sorry for myself. I cried a little. After encouragement and support from Nancy, my family and several friends, I decided to get back on it.

After another year of presenting to the community, speaking to a nursing class, reworking my application and basically doing all the things that were suggested by the board, i resubmitted my application. 4 more copies, $75 more, MANY revisions of the application, 4 letters of recommendation and letters from former patients.  After an agonizing 8 weeks, I was sitting on the couch one evening, checking my email. I had an email from the BRS-S. MY APPLICATION WAS ACCEPTED!!! I had to email and text everybody I knew!! It was like an absolute dream!

Then came the scary part. I had to pass the exam. What is on the exam?? That is what every person that has not taken the exam would like to know!!! There is a study guide that is submitted with your acceptance email, however, basically, you need to know a little bit of everything about swallowing and dysphagia. I have spent about the last month and a half studying everything I could get my hands on regarding swallowing and dysphagia, pediatrics, Dr. Logemann’s book, journal articles, everything!

I signed up to take my exam on Oct 2. I was a nervous wreck. I couldn’t eat and was just anxious. The time came to take the exam. I signed in (you have 2 hours to take the 110 question exam). I do remember several times thinking, why didn’t I study that more or what in the heck is that?? I actually finished the exam in less than an hour, thinking I would review my answers. I then decided that if I went back over my answers, I would change them and do worse.

I very quickly decided to then click on submit, which I did and waited. My score appeared within seconds, 92%!!!!! I needed an 80% to pass. I could barely believe that I passed!!! I actually obtained Board Recognized Specialty in Swallowing!!

I do believe that anyone who wants to achieve this great honor, should! It is a tough process, it is very taxing, but it is so very rewarding in the end. It is an amazing feeling to know that you have done something that very few people have accomplished at this point.

It is so important in the time of changing health care and the need to “prove” our services, that we have something that we can “prove” the worth of our services and that we are the ones that specialize in the area of swallowing!