March 20, 2025 • 36 mins
With our dedication to our patients, we've gained a deeper understanding of the complexity of swallowing and dysphagia. How can we use these insights to advance SLP education and our own professional growth?
Guest: Nicole Wiksten, MS, CCC-SLP, BCS-S
Gap Education:
https://swallowthegap.com
Facebook:
https://www.facebook.com/GapEducationLLC
Instagram:
https://www.instagram.com/swallowpatho
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
As a profession, we've made great strides in our
understanding of normal anddisordered swallowing.
How can we then help to developour profession into one that
can help meet the demandsintrinsic to this complexity?
Find out more soon.
Welcome to Swallow the Gap, thepodcast that delves into the
(00:21):
critical world of dysphagia care.
I'm your host, dr Tim Stockdale, and I'm thrilled that you've
come to join us forconversations aiming to bridge
the gap in dysphagia educationand practice.
We value diversity inbackgrounds and opinions, so our
guests will not always reflectwhat we believe.
Through critical reasoning andopen minds, we serve as
catalysts for advancement inmedically focused
speech-language pathology.
Welcome back everybody.
(00:51):
I have today with me NicoleWigston.
She's a clinical supervisor atOhio State University in Ohio.
It's lovely to see you again.
We've chatted some in the past,but it's always been fun.
It's good to have you on herewith me today.
Do you mind telling the peoplelistening a little bit about
yourself?
Speaker 2 (01:10):
Sure, it's good to see you again too.
My name is Nicole Wickston andI am a clinical assistant
professor at Ohio State, and Ipractice primarily in the area
of swallowing and swallowingdisorders.
So I do some teaching, someclinical supervision.
We have a swallow clinic in ouracademic clinic as well as
working in acute care at ourmedical center.
Speaker 1 (01:32):
Very cool.
Got a few things going on there.
Speaker 2 (01:35):
Just a few.
Speaker 1 (01:36):
Yeah, what do you think you like the most about
your job?
Speaker 2 (01:40):
I really love inspiring speech pathology
colleagues to be to loveswallowing as much as I do,
because I really find it veryinteresting, and even the ones
that think they're not going tolike it once they work with me
and we do the thing.
We see a few patients, I teachthem a little bit.
It's kind of catchy.
(02:00):
So I love that when somebodyfinds their niche in this area.
Speaker 1 (02:05):
You're sharing your positive energy.
You're passing it along.
That's super cool.
Speaker 2 (02:08):
I can't help it.
Speaker 1 (02:10):
I love it.
I love it.
Well, one of the things we weregoing to discuss here today are
some of the changes in speechpathology over the past 20 years
you've been practicing and howwe're adapting to those changes,
how we're making thingsdifferent.
So question for you what do youthink are some of the biggest
things that have changed overdysphagia, at least within the
(02:31):
past 20 years?
2025, let's shoot it back to2005-ish.
Speaker 2 (02:39):
I know and I can't believe it's been 20 years that
I've been practicing.
But when I think back to theeducation that I received in
grad school, to what we're doingnow, it's just such a huge
difference and the time flew by,but so much has changed.
So one of the biggestdifferences I see is our
clinical exam.
So you know, when I learned toassess swallowing disorders, I
(03:01):
was basically learning to countcoughs right.
Swallowing disorders I wasbasically learning to count
coughs right.
Like I'm just wondering if thepatient is coughing, and if they
are, then I'm going to try tomake them not cough.
So can I maybe have them trytucking their chin, try some
thickened liquids?
If that makes them not cough,great, I'm going to interpret
that as I did something to helpthem feel better and I'm going
(03:23):
to keep assessing whether or notthey still use that chin tuck
and whether or not it stillmakes them cough and again feel
like maybe I'm helping them getbetter somehow, but really not
having good direction about whatexactly is wrong with their
swallow, and so that has justchanged so much.
Now.
What we know about swallowingand what we don't know at the
(03:44):
bedside is such a big difference.
So when I think about how Ilearned about modified barium
swallows.
Even then it was stillassessing what the bolus is
doing.
So I remember learning that ifthere was residue in the
molecular, that meant it couldbe a tongue-based retraction,
and so that's what I shouldtreat and not really watching
(04:06):
the physiology.
So that's just such a differentway to have learned swallowing
and what's actually happeningwith the physiology versus
what's happening with thebullets.
Speaker 1 (04:17):
I'm glad you mentioned that.
And man, I could go on off onthat for a while.
I was taught the same thing.
I was taught there's residue inthe molecular, it's base of
tongue retraction.
That's what it is.
It's like a formula, a cookbook.
You see this, you do that, thatsort of a thing, Not
necessarily thoroughlyevidence-based, although a lot
of times it is reduced base oftongue retraction.
(04:39):
But it's like that's not theonly thing it could be.
So there's more nuance to it.
As with counting coughs, theCSE, what's wrong with counting
coughs?
You're talking about dissonantcounting coughs.
Your people cough, I stillcount.
I don't count coughs, but I payattention to coughs in my
clinical eval.
What are some limitations ofthat?
Speaker 2 (04:58):
Yeah, so you know, initially, like as I was talking
about, I would even try tothink in my mind as an early
clinician okay, well, if theywere coughing on their thin
liquids and I had them tucktheir chin and that made them
not cough anymore, I wouldhypothesize that maybe they have
a delayed swallow, or maybethey have impaired bolus
(05:20):
formation in their mouth and sothey're aspirating before the
swallow and so the chin tuckworked right.
So I'm going to choose to maybetry to treat one of those
things.
I still don't exactly know why,and so cow cough really didn't
tell me anything for sure.
Speaker 1 (05:36):
So would the rationale have been that, in
your mind, the chin tuck is goodfor a delayed swallow and so
because the chin tuck got rid ofthe cough, that their swallow
might be delayed?
Okay, I mean, there'sdefinitely a string of logic
there too.
There's just again, the nuance.
There's so much more nuance inwhat the chin tuck does or does
(05:57):
not treat, what a cough may ormay not mean, and that sort of
thing.
But it sounded like you'redoing the best you could with
what you had.
Speaker 2 (06:05):
Right, and now that you know instrumental evals are
more available than they wereback then, I could know for sure
that I'm actually treating adysphagia and not treating a
cough that a patient has becausethey have a respiratory
infection and they're justcoughing in accordance with the
moment after I gave themsomething to drink.
Speaker 1 (06:23):
Yeah, it's almost like there's some common
recurrent laryngeal nerveinnervation too in the cervical
esophagus that might, in somepatients, trigger a cough when
they swallow.
Who knows, who knows.
Yeah, I've been very convinced,very convinced, and kind of
looked silly in front of doctorsbecause I was so sure that this
patient with Parkinson's I mean, I can almost see their room
(06:45):
still in my mind Sure that theywere aspirating and whatever
that meant to me at the time itwas a pretty big deal.
But I was wrong, it was verywrong, and sometimes we're wrong
, sometimes we're right.
Definitely a place for clinicalevaluation.
There's a lot that it can tellus, but there's a lot that it
can't tell us.
Speaker 2 (07:05):
So a couple of big changes, a couple of big changes
, yeah, and also even justknowing the difference between
normal swallowing and abnormalswallowing.
Right, that's not something Ilearned, or you know.
We really included in our, inour education, but now we
recognize that it's just asimportant to understand normal
swallowing as it is tounderstand normal language
development, for example and sothat's a change that I think has
(07:31):
happened over the past 20 yearsis we better understand what is
normal and how that compares towhat is abnormal or disordered.
Speaker 1 (07:36):
Yeah, no, that helps, that makes sense.
One of the patterns that I seewith what you're saying is the
level of simplicity versus thelevel of complexity.
When you learn a little, it'seasy to go by rules of thumb and
kind of oversimplify.
(07:56):
So we got into working withpatients with dysphagia.
I mean we study that anatomyand so let's give it a go Right,
(08:21):
and we learn more now that it'sa lot more complex, and this is
something that I've probablysaid a thousand times.
So people are probably hittingstop.
You know, next episode you'rehearing me say that again.
But we, you know, there's a lotmore nuance, there's a lot more
complexity than we realizedoriginally, and to our credit.
That's a good thing.
That's a good thing.
That means we're not stayingwhere we were, it means we're
getting better, we're pushingforward, we're pioneers in this
field and we're really trying toget better, and so we're
following the science.
And the science is not as easyor not as simple as we thought
it was before, and so I think itrequires a greater level of
(08:44):
complexity in what we're beingtaught and in what we're
learning and so on.
So I mean, as you're saying,with the clinical evaluation,
like there's more to that thanjust counting coughs.
With the modified barium swallowstudy.
It's more than just a formula.
You see residue in the piriformso it's reduced hyaluronidryl
elevation.
You see it in the vlecula.
(09:04):
It's reduced base of tongueretraction.
There's other stuff you got tolook for If you're seeing
residue in the piriform sinuses.
What's the mechanism?
So, normal swallowing you saidnormal swallowing.
You need to learn about that,okay.
So what's the mechanism?
How does that happen?
With normal swallowing, cranialnerves nine and 10, pharyngeal
plexus get this signal and it'sheld the ues, which is tight at
(09:24):
rest, to relax, settle down,which probably a lot of people
are saying to me right now, tosettle down.
Way, way too enthusiastic aboutthe freaking ues.
But yeah, so you've got that.
And then you've got thecricopharyngeal attacks.
Attaches to the cricoidcartilage, goes around the
pharynx and so when the larynxmoves it helps to stretch that
open and so, but then you havepressure from above that helps
(09:45):
to move it through.
So when you're looking atpiriform sinus residue I mean
there are just so many differentthings that are that can go
through your mind Is it theduration of the opening of the
UES?
Is it the extent of it?
Is it not getting enoughpressure from above?
And if it is any of thosethings, how do we get specific
in being able to diagnose that?
And that's just like one thing,one thing, and we don't get all
(10:06):
of this in one dysphagia class.
So what I think is cool isyou're doing some things, you're
making some changes within yoursphere of influence.
I'd love to hear more aboutthat.
What are you doing?
Speaker 2 (10:16):
Yeah.
So as part of our curriculumwe've really developed a robust
program where we can helpstudents learn more about these
instrumental exams and how todiagnose dysphagia and how to
make a more specific treatmentplan, and so we've added a
normal swallowing course, whichhas been a great addition to the
(10:40):
dysphagia course that alreadyexisted, and then we're also
adding some electives.
So you know, our scope ofpractice is huge as an SLP
program, but for those thatreally want to practice in this
area, they have the opportunityto take some extra coursework
that helps them develop theskills they need for going into
their placements.
(11:00):
So previously we send studentsto their placements and they
don't have experience withmodified barium swallows or fees
, and so now they have someobservation opportunities with
fees in the hospital, being ableto go and participate alongside
a practicing SLP.
They help set up, they helpfeed the patient, they help
(11:21):
clean up, they learn all aboutthe process and then when they
go into their clinicals they canhave some experience with this
exam.
We also have a course formodified barium swallow and
endoscopy interpretation, and sothe students have the
opportunity to review somestudies, some case studies, and
they also have the opportunityto do some normal passes with
(11:44):
their scopes and so that thenwhen they go in their placement
they have the opportunity topractice swallowing on abnormal
patients if that's a possibilitywithin the placement.
So we're really trying to setthem up to be more competent in
the area of dysphagia assessmentthan previous.
You know, previously we weregetting them to the point where
(12:04):
they could do a clinical bedside, but those skills of being able
to do a fees or interpret afees or do a modified or really
interpret that thoroughly camelater in the job during their CF
.
But now we're trying to getthem that experience sooner,
especially those that want to bein acute care.
If you want an acute care job,those are skills that are
absolutely necessary to be ableto practice in that area.
(12:28):
So the opportunity to learnmore about the diagnostic
process as well as utilize itfor therapy planning, because
certainly now we know which wedidn't before how much we really
need those exams to guide agood plan of care for a
patient's treatment.
Speaker 1 (12:44):
Yeah, yeah, for real, because of the complexity of it
, clinical eval or bedside evalisn't good enough most of the
time.
I mean, sometimes that's allyou can get and clinicians would
love to be able to have accessto an instrumental and maybe
they can't I realize there arelots of circumstances like that
(13:09):
want to disparage them andthinking through, like what
you're talking about.
So I'm sure that there are agreat number of listeners who
work with students, but I alsowould suspect there are a great
number of students who don't.
So, in making this applicableto everybody, you think we're
all trying to do better, we'reall trying to learn more, and so
I think it helps to kind ofunderstand the layers of how we
(13:31):
got to where we are right now,because that helps us to
understand the influences ofwhat we think right now, the
biases that led to that, thethings we may have mislearned or
the things that are great andthat we've learned and we need
to continue passing along.
And, from like an educationperspective, if you are working
with students, think of where doI want them to get and you
(13:51):
reverse engineer that.
So, with our learning in this,looking at the complexity of
things, like you know, we'rethinking we want the big picture
, that we want to improve theswallow, right, but even beyond
that, like, why do we want toimprove the swallow?
Well, nutrition, hydration,quality of life, we won't want
(14:11):
them to get pneumonia, we don'twant them to choke and
asphyxiate, not be able tobreathe.
Those types of things are likethe functional outcomes and then
work backwards from there tothe swallow.
You know efficiency and safety,the physiological processes that
are disordered or functional ordysfunctional, and that type of
thing that are disordered orfunctional or dysfunctional and
that type of thing, and thenlayering on top of that, I guess
(14:38):
what, the innervation, likewhat I'm getting lost in my
thoughts because there's a lotto it and I just get lost in my
thoughts a lot, but anyway, butyou're working backwards.
You see the physiology, you knowwhy does that happen, why is it
important, and so, like, thenormal is your baseline.
So you, we see the value tounderstanding how to evaluate
and treat swallowing and knowingwhat's typical or atypical, and
(15:01):
so that necessitates that we weput more time into learning,
that we put more time intounderstanding that, in addition
to these mechanisms ofassessment, like knowing how to
pass a scope, practicing on manypeople like it's not.
It's the mechanical skill too,or the technical skill of being
able to pass the scope andmanipulate the device and
(15:22):
interpreting it, knowing kind ofwhich trial to go to next, how
to adapt which compensatorystrategies to try, and so
there's that, and there's justso much more, and I know there
was a point to where I was goingMaybe you were following my
train of thought and you know it.
What's my point?
Speaker 2 (15:42):
We considered making this applicable to everyone
right Like thinking about thoseof us who maybe graduated at a
time where we didn't, like I,didn't, learn about fees in
graduate school.
That's not something that wasincluded in my, even in my class
, like I did watch modifiedbarium swallows on the computer
screen, right, but I these,these wasn't a topic in my class
(16:04):
and then even in my first jobthese was not an option.
It wasn't available until mynext job.
So I was, you know, three yearsinto my career before I even
had the option to practice infees and be able to be trained
in that, and so it isn'tavailable to everybody.
But being able to understandwhat you're looking at or what
you're reading when you receivethe reports of an instrumental
(16:27):
exam, you know, as I practice asan outpatient clinician right
now, I don't have theopportunity to do fees and
modifies on my outpatients andtherefore I get the reports from
the other modified bariumswallows and fees and I need to
be able to interpret them.
So even as an outpatientclinician, if I'm not completing
the exams, I need to use theinformation from those exams to
(16:48):
guide my plan of care.
But I do think for anybody whowants to be able to learn these
skills that maybe didn't in gradschool.
You know there are opportunitiesgrowing out there to be able to
learn it.
So continuing educationopportunities to be able to
learn the skill to eventuallyeither provide the exam or be
(17:09):
able to interpret better, usethat in your plan of care,
whatever it might be.
It's not as readily availablejust yet, but I think that could
be coming and maybe that's evenjust kind of like had a little
idea in my brain that maybe thatwould be something that, as we
develop a course on the academicside where we're teaching
graduate students how to do fees, why couldn't we teach, you
(17:29):
know, a community SOP who wantsto be able to learn this and
grow a program at their facility?
So I think this is somethingthat we can eventually develop,
just like we did for theclinical swallow valve and the
AMBS and even things like thehigh resolution pharyngeal
manometry.
Right, that's really the onlyway that we can detect pressure
(17:49):
in the pharynx, and so it wouldbe great if I knew how to do
that, but I don't, and I don'tknow anybody who's doing it.
So when I need that information, that's not something that's
readily available at myfingertips, but I have a feeling
that if you were interviewingan SLP in 20 years.
They're going to say I rememberwhen we didn't have high
resolution pharyngeal manometryavailable and it was really hard
.
But now we have it and I can doit and it's great.
(18:11):
So in another 20 years ourswallow practice is going to
look a lot different than itdoes now, I'm sure.
Speaker 1 (18:18):
Yeah, yeah, I think it will.
Speaker 2 (18:20):
I think it will, I might've just gone off on my own
tangent there, so hopefully no,I don't, I don't think so.
Speaker 1 (18:25):
I think that really was in line with what I was
saying and, even if it was atangent, it made sense, it was
helpful.
I mean the complexity, becausewe're pushing forward, we're
learning more, we're doingbetter.
We realize the complexity ishigher.
Therefore, the standard oflearning is higher because we
have to learn more, we have tolearn about all these different
(18:48):
things, and so the questionbecomes how do we get to this
standard?
And we know that it's not easyand it's not universal right now
, or not?
Well, it would be really hardto make universal changes in
education to speech pathologists, and so, for everyone listening
here, I think it comes back tous what can we do, what can we
(19:10):
contribute?
Whether it's developing aprogram for teaching, whether
it's thinking specifically aboutthe students that we get an
externship in and where we wantthem to be, and how we reverse,
engineer and help them to meetthose expectations within our
setting, or maybe it's in ourpersonal development.
There is a lot more that I needto know, and so, as I'm trying
to figure this out, I'm lookingfor resources and opportunities
(19:32):
to be able to do that.
So, really, if we're talkingabout a problem, an issue, a gap
.
It's through the lens of likewell, how do we help?
How do we help and make itbetter?
And so it sounds like you'redoing some stuff and that's
really cool.
I'm wondering what person A,person B, whoever else is
listening to this.
(19:53):
I'm going to say some names andmaybe people will be like
that's me, no, anyway.
But yeah, for us all to thinkabout, like within our setting,
within whatever our sphere ofinfluence, how we can make this
better, because it really is thepurpose.
Our patients deserve it.
Think of the credibility thatit lends when you can talk to a
(20:16):
physician and provide a solidrationale, not just this
person's aspirating and I needto make them stop aspirating but
maybe this person's aspirating.
They have recurrent pneumoniaand readmissions costing the
hospital thousands and thousandsof dollars, and that's not the
most important thing.
Of course, the patient is themost important thing.
That's just anotherconsideration.
And sometimes how we canleverage things to get what the
(20:38):
patients need.
But the patient is dependent onothers for oral hygiene, they
have a very weak cough and allof these different things, and I
know that from you know.
A while back they had abrainstem stroke and it affected
cranial nerves nine and 10 orwhatever, and so you can explain
the rationale in a way thatmakes sense and it lends your
credibility more likely to getpatients.
(21:00):
They're more likely to trustyour recommendations, and I mean
as providers, we want to beable to be out there and hold
our own in conversation, not forthe sake of looking cool but
for the sake of like.
It's a reflection of what's onthe inside and it allows us the
ability to better help ourpatients and in turn it gets us
a lot of credibility.
(21:20):
That's my soapbox again.
Speaker 2 (21:24):
Well, and I think you touched on something important,
which is you know personallyhow we feel about our practice,
and one of the things that canbe hardest is change right,
especially 20 years in.
You know, I tell my students allthe time, you're never going to
know it all, especially whenpracticing in medicine.
There's constant changehappening, and so it's really
(21:46):
important that the SLP keep upwith the newest information,
evidence-based practice.
You know how the world ischanging and that can be really
hard, because you go from aplace where you know things and
you know as much as you canpossibly know, and things change
and you don't know as much asyou could know, and so that's a
(22:06):
constant battle.
And it can be difficult to bethe person who maybe doesn't
know or learn, could know, andso that's a constant battle, and
it can be difficult to be theperson who maybe doesn't know or
learn something new, and so wehave to be willing to change
with the field and with medicineas it's changing.
So if I didn't learn fees, thenI might not have another
perspective that I can give mypatient or a different
(22:26):
opportunity to look at theirdeficit when the MBS doesn't
give me the information I need,and vice versa.
So if we only had one test, wewould be very limited, but I
have to be willing to change andlearn and grow with that.
So I just think that's reallyimportant to be open to change
and recognizing that you willnever know everything.
Speaker 1 (22:46):
Yeah, for sure, and one of the things I love is and
I'm not putting you on the spot,don't take it this way- but,
when people come on here who arelike really well known and
they'll talk about like, oh,listen to this stupid thing I
did, because it shows thetransparency that they're
willing to give up.
They're not willing to give upthis pretense, this idea that,
oh, this person's perfect.
No, like, the one of the thingsthat makes so many of these
(23:20):
clinicians and researchers andand, and instructors, and
whoever out there, great istheir willingness to change,
their willingness to learn,their willingness to reflect and
say like, well, this is whatI'm doing, great, this is what I
want to improve and movingforward with it, and it's the
direction that you're going.
It's like so, so important, Ithink.
(23:43):
Sometimes I lean on the side andthen people have told me this
I've had students get on my casebecause of it.
I self-deprecate so muchbecause I guess I don't take
myself that seriously orseriously enough or something.
And it's like you can learnsome stuff and you can know some
things, but you don't have tohave an inflated ego, right?
That's not what it's about.
(24:04):
And so, different perspective,different perspective.
Speaker 2 (24:08):
For sure yeah.
Speaker 1 (24:09):
Cool.
Well, is there anything elsethat's really sticking out?
Any things that you've reallyseen clinicians in the community
doing?
Maybe some of the externshipsupervisors you work with, or
just clinicians that you haveseen that are doing a great job?
Anything else out there youwanted to go into?
Speaker 2 (24:27):
Yeah, go into.
Yeah, I think that when youknow, part of my role is I send
students out to their placementsin the second year of the
program, and there are certainlysome preceptors that are very
much interested in teaching thestudent as much as they can
about all of the differentmodalities that are out there
(24:48):
for assessment treatment, and soclinicians are having to push
themselves not only to learn thenew things but then to be able
to teach the new things, and onething we didn't learn in SLP
school is how to be a teacher,and so I appreciate when a
community SLP is willing to takethe time to teach a graduate
(25:09):
clinician the skills that theyhave encountered, or going along
with them to learn the time toteach a graduate clinician the
skills that they haveencountered, or going along with
them to learn the thing.
So as, for example, maybe afacility is rolling out EMST and
they are learning how toincorporate EMST into their
dysphagia management program andthey bring the student along
(25:29):
and have them do projectsrelated to that treatment
modality and the student's ableto learn along with the
clinician, and vice versa, youknow that the clinician is
learning along with the student,and so, um, I find that really
inspiring.
And again, to have cliniciansthat are teaching students while
they are learning at the sametime is challenging but so
(25:50):
absolutely rewarding, becausethat helps the clinician be able
to understand what they'redoing well enough to teach it,
and so that's always promising.
But being able to do things likeyou know let a student run your
MBS or handle the scope on yourpatient is certainly a new area
(26:13):
for clinician supervisors.
To be able to allow thestudents that kind of
independence in that area andnot feel like but I own this
patient and I feel veryresponsible for them.
So being able to collaboratewith your student is an amazing
skill.
And then also including them in, just like you said, being able
to talk to physicians, talk tonurses, talk to other
(26:36):
professionals about what we knowis also helpful experience for
students.
To be able to let them havethose conversations is
beneficial for them as they gointo their careers too.
They can go in a little moreconfident than they were before,
where their supervisor was theone to have all those
conversations.
Speaker 1 (26:54):
You talked about learning while your students are
learning, so like if you'reattending a course, kind of
inviting a student along andyou're learning these things
simultaneously.
And one thing I really tookaway from that is you're
modeling ongoing learning,You're modeling continuing
learning, lifelong learning.
You're not just teaching themwith your words, You're setting
an example of the things thatthey should do, and that's great
(27:15):
, and that also because you'relearning about the same things,
it opens up conversation aboutthose types of things too, which
is great.
There was one other thing.
Oh yeah, so sometimes, ifyou're a supervisor, you know
you're working at a communityhospital or skilled nursing
facility or wherever, and youhave a student with you the
difficulty in handing nothanding over, but giving the
(27:38):
students more independence,working with your patient.
And I think the balance in that,too is we're thinking like.
For me, I'm thinking, or I'mtempted to think I want to make
sure this patient has the bestcare right.
So on one hand, and in my mind,I'm thinking well, I'm probably
(27:59):
, hopefully, better equippedthan the student to do that.
On the other hand, though, ifyou, if we hog it all to
ourselves and don't give someliberty to the students, how are
they going to learn, and sowhen we retire, who's going to
take our place?
So there has to be some growingpains.
I think there has to be this alittle more independence.
(28:20):
You know, scaffold, teach, dowhat you need to do.
But there has to be some sortof release of control within
that, it seems.
Speaker 2 (28:29):
Yes, definitely.
It's hard for me to sometimeslet my students do it their way
because you know I like my way.
My way is the way I've done itfor so long and I think it's the
best way.
And maybe the way the studentdoes it is not wrong, just
different.
You know, not all SLPs doeverything the same either.
There are some things Irecognize that we do, you know,
(28:53):
that are very similar, buteverybody has kind of their,
their order, they like to dothem in, but everybody
eventually gets to the same.
You know, we did all of thesethings.
Everybody does a cranial nerveexam, for example, but we might
all do it a little bit out oforder, but we're all looking at
the same thing.
The way my student gives theinstruction might not be the way
that I do it, but as long asthey come to the same
(29:13):
realization I did, that's okay.
Speaker 1 (29:16):
I think that's a really good point and it's a
point that I've disagreed withpeople on in the past is, well,
if you're training a student orif you're working with somebody
else, there is not necessarilyonly one right way to do it, and
in certain cases there might beand I am not saying that there
might be something that'sclearly empirically better,
(29:38):
based upon evidence and what weknow about the patient
population.
But a lot of times there mightbe different options, and so if
somebody a colleague or astudent comes to a different
conclusion, but there's a solidrationale there, like why does
my way have to be the only wayto do it?
And in most cases it's not.
And so I think it's reallyimportant that students and
(30:01):
clinicians and everyone cancritically think through these
things and understand whythey're doing, not just come to
the same conclusion that you door I do and I think that takes a
lot of humility as well, too toadmit like well, yeah, that's
not maybe what I would have done, but that's a really strong
rationale.
I see what you're saying.
Let's try it, see if it works.
Speaker 2 (30:22):
Yep, yep.
And sometimes patients orstudents have the ability to
experiment a little bit morebecause the way they're thinking
about it isn't the way I do,and so they come up with a
solution or an idea that maybe Ididn't I didn't have, and so
it's.
It's really cool when thathappens I'm like, hey, I didn't
even think of that.
Speaker 1 (30:41):
That is really cool and that shows what students
teach us and not just studentsteach us.
Again, this is not just aconversation for SLPs or
supervising students, but theimportance of talking to other
people, to talking to otherclinicians, to getting insight
from other individuals.
It's not a reflectionnecessarily that you're not
confident in what you do, butgetting another perspective.
There might be something youcan refine, there might be
(31:03):
something that can be better,and I think we get a lot of that
from students.
We get an outside perspective,Like if we've been doing the
same thing 40 hours a week for20 years.
It can cause us sometimes toget stuck in a rut or one way of
thinking, whereas just gettingan outside perspective, even if
somebody has a lot lessexperience, they're going to
(31:26):
bring something new to it, andso I think that's important to
remember that with our students,but also to remember that and
the importance of collaboratingwith other therapists and
physicians and whatnot, and withthat, that actually is probably
a good way to tie this up,because there unless sorry, is
there anything else that is justburning that you really wanted
(31:48):
to get out there, and if so,that is fine.
Speaker 2 (31:52):
You know there is, as I was thinking about, things
that have changed over thecourse of, you know, my 20 years
is that the other thing thatwe're doing is we are having
patients swallow food, you know,for therapy, and back then it
was kind of like, oh, they'reaspirating, we need to, they
should swallow nothing.
And so I think we've learned alot in 20 years about how much
(32:15):
exercise actually swallowing isand that it's not really going
to affect them in a negative wayif we let them keep swallowing,
that it's actually a morepositive thing.
So I feel like that is one bigchange I've seen in how we treat
dysphagia.
Speaker 1 (32:30):
So I feel like that is one big change I've seen in
how we, how we treat dysphagia.
So as far as that goes likethere, there are a couple of
things that I that I'm getting,but I want to make sure that I'm
understanding, like one, thespecificity of treatment that
it's important to continuallyfor, for motor learning, for
neuroplasticity, to keepswallowing.
You know best, you've heard itsaid that the best exercise for
swallowing is swallowing.
(32:50):
You know best, you've heard itsaid that the best exercise for
swallowing is swallowing.
So it's important to swallowfood, different textures,
different weights, so that ourbody can kind of adapt and learn
how to do that, learn how torespond to different bolus sizes
and bolus weights, that type ofthing.
So I'm getting that from it.
Is that, is that that part?
That's part of what you'resaying, right?
Yes, okay.
And the other part is it doesit have to do with maybe not
(33:14):
being quite as afraid ofaspiration or other differences
in swallowing than we used to be?
Speaker 2 (33:21):
Definitely Cause we are, you know, not as, not as
afraid.
We just aren't as afraid to letpeople swallow and to let
people be uncomfortable, becausewe recognize that the more we
learn about exercise science,for example, that it's it's in
that exercise that you knowpatients are going to see the
(33:42):
benefit, and so if we're afraidto let them try, they aren't
going to see the benefit totheir muscles if they're not
actually using them.
So yes, yeah, thank you forputting professional words to
what I'm saying.
Speaker 1 (33:54):
No, no, I was, I was make.
I wanted to make sure that Iwas getting the takeaway.
That was intended, that wasintended there, that was, that
was part of it.
Yeah, and there's.
I mean, there's a bigdifference between being
reckless and not being afraid,like if I did an MBS or a fees
and I.
This happened once I was doing afees and this lady had dementia
(34:17):
and I'm trying to think of whatelse we did prior to this point
, but she swallowed a crackerand she swallowed a cracker.
She didn't chew it very well,there was a big piece of cracker
in her throat and I was alittle scared, and I probably
had reason to be scared too atthat point.
And so that's not to say like,yeah, give this lady all the
crack.
I mean, throw crackers at her,right, you know, give her all
(34:40):
the crackers and that sort ofthing too.
But on the other side ispatient aspirates some thin
liquid and you know, yeah, goodoral hygiene, their cough is
strong.
You consider these othervariables and other parameters
rather than just being deathlyafraid of laryngeal penetration
or all sorts of, you know, anykind of aspiration, that type of
thing too.
So, yeah, some middle groundthere, I think is really
(35:01):
predicated on what we've learnedand how we've developed in our
understanding of you know howthese negative outcomes like
pneumonia or asphyxiationdevelop.
Speaker 2 (35:12):
Right Learning how to challenge the system, but
within limits of safety, forsure.
Speaker 1 (35:17):
Yes, yeah, yeah, very cool, very cool.
Well, it was great to chat withyou again.
Some take home messages and ifyou think of anything else that
you want to just put out there,let me know.
But some take home messages forthis, I think, the importance
of we have a higher level ofknowledge now, so we need to
(35:37):
really raise our standards.
So how do we do that?
And that's going to depend onwho you are, where you are, who
you're working with yourresources whether it's readings,
articles, people, that type ofa thing but reflect on what you
know, even maybe keep track ofit.
Keep track of things thatyou've learned.
It's kind of cliche and corny,as that sounds Like you know.
(35:57):
These are some things I'velearned this year.
These are some ways I'vechanged in my thinking, so you
can go back and look throughthat.
But continue to reflect,continue learning.
Share resources, like if youfind courses that are good, if
you find whatever types ofresources that are good, like,
share those with people.
Spread the good news.
Spread the information that'sgoing to help your patients.
(36:18):
Talk to people.
Talk to students.
Talk to other speechpathologists.
Get their perspectives.
Being part of a community, Ithink, is not just beneficial in
knowledge sharing and maybe I'man odd one out in this, but it
gets me excited, like when Italk to other people, when I'm
just by myself all the time.
I mean, I'm not really classicintrovert, so I'm kind of taking
(36:41):
that into mind.
My, you know how my brain works, yeah, but we there's a lot we
can do to encourage each othertoo.
Like if you're holding theseconversations, you're not just
learning or at least I'm not itjust gets me excited to.
It makes me want to do more,makes me want to do better and
talk about ideas and that sortof thing too.
So I think those are some takehomes that that everybody you
know can can walk away with, anddefinitely, definitely I will.
Speaker 2 (37:05):
Great Thank you.
Thanks so much for the chat.
Speaker 1 (37:08):
Yeah, yeah, thank you for coming on, appreciate it
and hopefully see you around.
Thank you.
Before you go, a quick reminderof two courses coming up soon.
This Sunday, march 23rd, drKendrae Grand is doing a
three-hour webinar teaching oncranial nerve exam for
(37:30):
assessment of bulbar functioning, for the medical
speech-language pathologist, theclinical specialty course.
So that's this Sunday, march23rd, with Dr Kendra Grant and
on April 5th, saturday,respiratory muscle strength
training foundations andevidence with Dr Chris Sapienza,
the co-inventor of the EMST 150.
The co-inventor of the EMST 150.
As a thank you for being alistener, please use the code
(37:52):
POD1, or P-O-D in all lowercaseand the number one at checkout
and that'll give you 10% off.
To find these courses, go toswallowthegapcom slash
livecourses or medslpgapcomslash livecourses.
As a profession, we've made great strides in our
understanding of normal anddisordered swallowing.
How can we then help to developour profession into one that
can help meet the demandsintrinsic to this complexity?
Find out more soon.
Welcome to Swallow the Gap, thepodcast that delves into the
(00:21):
critical world of dysphagia care.
I'm your host, dr Tim Stockdale, and I'm thrilled that you've
come to join us forconversations aiming to bridge
the gap in dysphagia educationand practice.
We value diversity inbackgrounds and opinions, so our
guests will not always reflectwhat we believe.
Through critical reasoning andopen minds, we serve as
catalysts for advancement inmedically focused
speech-language pathology.
Welcome back everybody.
(00:51):
I have today with me NicoleWigston.
She's a clinical supervisor atOhio State University in Ohio.
It's lovely to see you again.
We've chatted some in the past,but it's always been fun.
It's good to have you on herewith me today.
Do you mind telling the peoplelistening a little bit about
yourself?
Speaker 2 (01:10):
Sure, it's good to see you again too.
My name is Nicole Wickston andI am a clinical assistant
professor at Ohio State, and Ipractice primarily in the area
of swallowing and swallowingdisorders.
So I do some teaching, someclinical supervision.
We have a swallow clinic in ouracademic clinic as well as
working in acute care at ourmedical center.
Speaker 1 (01:32):
Very cool.
Got a few things going on there.
Speaker 2 (01:35):
Just a few.
Speaker 1 (01:36):
Yeah, what do you think you like the most about
your job?
Speaker 2 (01:40):
I really love inspiring speech pathology
colleagues to be to loveswallowing as much as I do,
because I really find it veryinteresting, and even the ones
that think they're not going tolike it once they work with me
and we do the thing.
We see a few patients, I teachthem a little bit.
It's kind of catchy.
(02:00):
So I love that when somebodyfinds their niche in this area.
Speaker 1 (02:05):
You're sharing your positive energy.
You're passing it along.
That's super cool.
Speaker 2 (02:08):
I can't help it.
Speaker 1 (02:10):
I love it.
I love it.
Well, one of the things we weregoing to discuss here today are
some of the changes in speechpathology over the past 20 years
you've been practicing and howwe're adapting to those changes,
how we're making thingsdifferent.
So question for you what do youthink are some of the biggest
things that have changed overdysphagia, at least within the
(02:31):
past 20 years?
2025, let's shoot it back to2005-ish.
Speaker 2 (02:39):
I know and I can't believe it's been 20 years that
I've been practicing.
But when I think back to theeducation that I received in
grad school, to what we're doingnow, it's just such a huge
difference and the time flew by,but so much has changed.
So one of the biggestdifferences I see is our
clinical exam.
So you know, when I learned toassess swallowing disorders, I
(03:01):
was basically learning to countcoughs right.
Swallowing disorders I wasbasically learning to count
coughs right.
Like I'm just wondering if thepatient is coughing, and if they
are, then I'm going to try tomake them not cough.
So can I maybe have them trytucking their chin, try some
thickened liquids?
If that makes them not cough,great, I'm going to interpret
that as I did something to helpthem feel better and I'm going
(03:23):
to keep assessing whether or notthey still use that chin tuck
and whether or not it stillmakes them cough and again feel
like maybe I'm helping them getbetter somehow, but really not
having good direction about whatexactly is wrong with their
swallow, and so that has justchanged so much.
Now.
What we know about swallowingand what we don't know at the
(03:44):
bedside is such a big difference.
So when I think about how Ilearned about modified barium
swallows.
Even then it was stillassessing what the bolus is
doing.
So I remember learning that ifthere was residue in the
molecular, that meant it couldbe a tongue-based retraction,
and so that's what I shouldtreat and not really watching
(04:06):
the physiology.
So that's just such a differentway to have learned swallowing
and what's actually happeningwith the physiology versus
what's happening with thebullets.
Speaker 1 (04:17):
I'm glad you mentioned that.
And man, I could go on off onthat for a while.
I was taught the same thing.
I was taught there's residue inthe molecular, it's base of
tongue retraction.
That's what it is.
It's like a formula, a cookbook.
You see this, you do that, thatsort of a thing, Not
necessarily thoroughlyevidence-based, although a lot
of times it is reduced base oftongue retraction.
(04:39):
But it's like that's not theonly thing it could be.
So there's more nuance to it.
As with counting coughs, theCSE, what's wrong with counting
coughs?
You're talking about dissonantcounting coughs.
Your people cough, I stillcount.
I don't count coughs, but I payattention to coughs in my
clinical eval.
What are some limitations ofthat?
Speaker 2 (04:58):
Yeah, so you know, initially, like as I was talking
about, I would even try tothink in my mind as an early
clinician okay, well, if theywere coughing on their thin
liquids and I had them tucktheir chin and that made them
not cough anymore, I wouldhypothesize that maybe they have
a delayed swallow, or maybethey have impaired bolus
(05:20):
formation in their mouth and sothey're aspirating before the
swallow and so the chin tuckworked right.
So I'm going to choose to maybetry to treat one of those
things.
I still don't exactly know why,and so cow cough really didn't
tell me anything for sure.
Speaker 1 (05:36):
So would the rationale have been that, in
your mind, the chin tuck is goodfor a delayed swallow and so
because the chin tuck got rid ofthe cough, that their swallow
might be delayed?
Okay, I mean, there'sdefinitely a string of logic
there too.
There's just again, the nuance.
There's so much more nuance inwhat the chin tuck does or does
(05:57):
not treat, what a cough may ormay not mean, and that sort of
thing.
But it sounded like you'redoing the best you could with
what you had.
Speaker 2 (06:05):
Right, and now that you know instrumental evals are
more available than they wereback then, I could know for sure
that I'm actually treating adysphagia and not treating a
cough that a patient has becausethey have a respiratory
infection and they're justcoughing in accordance with the
moment after I gave themsomething to drink.
Speaker 1 (06:23):
Yeah, it's almost like there's some common
recurrent laryngeal nerveinnervation too in the cervical
esophagus that might, in somepatients, trigger a cough when
they swallow.
Who knows, who knows.
Yeah, I've been very convinced,very convinced, and kind of
looked silly in front of doctorsbecause I was so sure that this
patient with Parkinson's I mean, I can almost see their room
(06:45):
still in my mind Sure that theywere aspirating and whatever
that meant to me at the time itwas a pretty big deal.
But I was wrong, it was verywrong, and sometimes we're wrong
, sometimes we're right.
Definitely a place for clinicalevaluation.
There's a lot that it can tellus, but there's a lot that it
can't tell us.
Speaker 2 (07:05):
So a couple of big changes, a couple of big changes
, yeah, and also even justknowing the difference between
normal swallowing and abnormalswallowing.
Right, that's not something Ilearned, or you know.
We really included in our, inour education, but now we
recognize that it's just asimportant to understand normal
swallowing as it is tounderstand normal language
development, for example and sothat's a change that I think has
(07:31):
happened over the past 20 yearsis we better understand what is
normal and how that compares towhat is abnormal or disordered.
Speaker 1 (07:36):
Yeah, no, that helps, that makes sense.
One of the patterns that I seewith what you're saying is the
level of simplicity versus thelevel of complexity.
When you learn a little, it'seasy to go by rules of thumb and
kind of oversimplify.
(07:56):
So we got into working withpatients with dysphagia.
I mean we study that anatomyand so let's give it a go Right,
(08:21):
and we learn more now that it'sa lot more complex, and this is
something that I've probablysaid a thousand times.
So people are probably hittingstop.
You know, next episode you'rehearing me say that again.
But we, you know, there's a lotmore nuance, there's a lot more
complexity than we realizedoriginally, and to our credit.
That's a good thing.
That's a good thing.
That means we're not stayingwhere we were, it means we're
getting better, we're pushingforward, we're pioneers in this
field and we're really trying toget better, and so we're
following the science.
And the science is not as easyor not as simple as we thought
it was before, and so I think itrequires a greater level of
(08:44):
complexity in what we're beingtaught and in what we're
learning and so on.
So I mean, as you're saying,with the clinical evaluation,
like there's more to that thanjust counting coughs.
With the modified barium swallowstudy.
It's more than just a formula.
You see residue in the piriformso it's reduced hyaluronidryl
elevation.
You see it in the vlecula.
(09:04):
It's reduced base of tongueretraction.
There's other stuff you got tolook for If you're seeing
residue in the piriform sinuses.
What's the mechanism?
So, normal swallowing you saidnormal swallowing.
You need to learn about that,okay.
So what's the mechanism?
How does that happen?
With normal swallowing, cranialnerves nine and 10, pharyngeal
plexus get this signal and it'sheld the ues, which is tight at
(09:24):
rest, to relax, settle down,which probably a lot of people
are saying to me right now, tosettle down.
Way, way too enthusiastic aboutthe freaking ues.
But yeah, so you've got that.
And then you've got thecricopharyngeal attacks.
Attaches to the cricoidcartilage, goes around the
pharynx and so when the larynxmoves it helps to stretch that
open and so, but then you havepressure from above that helps
(09:45):
to move it through.
So when you're looking atpiriform sinus residue I mean
there are just so many differentthings that are that can go
through your mind Is it theduration of the opening of the
UES?
Is it the extent of it?
Is it not getting enoughpressure from above?
And if it is any of thosethings, how do we get specific
in being able to diagnose that?
And that's just like one thing,one thing, and we don't get all
(10:06):
of this in one dysphagia class.
So what I think is cool isyou're doing some things, you're
making some changes within yoursphere of influence.
I'd love to hear more aboutthat.
What are you doing?
Speaker 2 (10:16):
Yeah.
So as part of our curriculumwe've really developed a robust
program where we can helpstudents learn more about these
instrumental exams and how todiagnose dysphagia and how to
make a more specific treatmentplan, and so we've added a
normal swallowing course, whichhas been a great addition to the
(10:40):
dysphagia course that alreadyexisted, and then we're also
adding some electives.
So you know, our scope ofpractice is huge as an SLP
program, but for those thatreally want to practice in this
area, they have the opportunityto take some extra coursework
that helps them develop theskills they need for going into
their placements.
(11:00):
So previously we send studentsto their placements and they
don't have experience withmodified barium swallows or fees
, and so now they have someobservation opportunities with
fees in the hospital, being ableto go and participate alongside
a practicing SLP.
They help set up, they helpfeed the patient, they help
(11:21):
clean up, they learn all aboutthe process and then when they
go into their clinicals they canhave some experience with this
exam.
We also have a course formodified barium swallow and
endoscopy interpretation, and sothe students have the
opportunity to review somestudies, some case studies, and
they also have the opportunityto do some normal passes with
(11:44):
their scopes and so that thenwhen they go in their placement
they have the opportunity topractice swallowing on abnormal
patients if that's a possibilitywithin the placement.
So we're really trying to setthem up to be more competent in
the area of dysphagia assessmentthan previous.
You know, previously we weregetting them to the point where
(12:04):
they could do a clinical bedside, but those skills of being able
to do a fees or interpret afees or do a modified or really
interpret that thoroughly camelater in the job during their CF
.
But now we're trying to getthem that experience sooner,
especially those that want to bein acute care.
If you want an acute care job,those are skills that are
absolutely necessary to be ableto practice in that area.
(12:28):
So the opportunity to learnmore about the diagnostic
process as well as utilize itfor therapy planning, because
certainly now we know which wedidn't before how much we really
need those exams to guide agood plan of care for a
patient's treatment.
Speaker 1 (12:44):
Yeah, yeah, for real, because of the complexity of it
, clinical eval or bedside evalisn't good enough most of the
time.
I mean, sometimes that's allyou can get and clinicians would
love to be able to have accessto an instrumental and maybe
they can't I realize there arelots of circumstances like that
(13:09):
want to disparage them andthinking through, like what
you're talking about.
So I'm sure that there are agreat number of listeners who
work with students, but I alsowould suspect there are a great
number of students who don't.
So, in making this applicableto everybody, you think we're
all trying to do better, we'reall trying to learn more, and so
I think it helps to kind ofunderstand the layers of how we
(13:31):
got to where we are right now,because that helps us to
understand the influences ofwhat we think right now, the
biases that led to that, thethings we may have mislearned or
the things that are great andthat we've learned and we need
to continue passing along.
And, from like an educationperspective, if you are working
with students, think of where doI want them to get and you
(13:51):
reverse engineer that.
So, with our learning in this,looking at the complexity of
things, like you know, we'rethinking we want the big picture
, that we want to improve theswallow, right, but even beyond
that, like, why do we want toimprove the swallow?
Well, nutrition, hydration,quality of life, we won't want
(14:11):
them to get pneumonia, we don'twant them to choke and
asphyxiate, not be able tobreathe.
Those types of things are likethe functional outcomes and then
work backwards from there tothe swallow.
You know efficiency and safety,the physiological processes that
are disordered or functional ordysfunctional, and that type of
thing that are disordered orfunctional or dysfunctional and
that type of thing, and thenlayering on top of that, I guess
(14:38):
what, the innervation, likewhat I'm getting lost in my
thoughts because there's a lotto it and I just get lost in my
thoughts a lot, but anyway, butyou're working backwards.
You see the physiology, you knowwhy does that happen, why is it
important, and so, like, thenormal is your baseline.
So you, we see the value tounderstanding how to evaluate
and treat swallowing and knowingwhat's typical or atypical, and
(15:01):
so that necessitates that we weput more time into learning,
that we put more time intounderstanding that, in addition
to these mechanisms ofassessment, like knowing how to
pass a scope, practicing on manypeople like it's not.
It's the mechanical skill too,or the technical skill of being
able to pass the scope andmanipulate the device and
(15:22):
interpreting it, knowing kind ofwhich trial to go to next, how
to adapt which compensatorystrategies to try, and so
there's that, and there's justso much more, and I know there
was a point to where I was goingMaybe you were following my
train of thought and you know it.
What's my point?
Speaker 2 (15:42):
We considered making this applicable to everyone
right Like thinking about thoseof us who maybe graduated at a
time where we didn't, like I,didn't, learn about fees in
graduate school.
That's not something that wasincluded in my, even in my class
, like I did watch modifiedbarium swallows on the computer
screen, right, but I these,these wasn't a topic in my class
(16:04):
and then even in my first jobthese was not an option.
It wasn't available until mynext job.
So I was, you know, three yearsinto my career before I even
had the option to practice infees and be able to be trained
in that, and so it isn'tavailable to everybody.
But being able to understandwhat you're looking at or what
you're reading when you receivethe reports of an instrumental
(16:27):
exam, you know, as I practice asan outpatient clinician right
now, I don't have theopportunity to do fees and
modifies on my outpatients andtherefore I get the reports from
the other modified bariumswallows and fees and I need to
be able to interpret them.
So even as an outpatientclinician, if I'm not completing
the exams, I need to use theinformation from those exams to
(16:48):
guide my plan of care.
But I do think for anybody whowants to be able to learn these
skills that maybe didn't in gradschool.
You know there are opportunitiesgrowing out there to be able to
learn it.
So continuing educationopportunities to be able to
learn the skill to eventuallyeither provide the exam or be
(17:09):
able to interpret better, usethat in your plan of care,
whatever it might be.
It's not as readily availablejust yet, but I think that could
be coming and maybe that's evenjust kind of like had a little
idea in my brain that maybe thatwould be something that, as we
develop a course on the academicside where we're teaching
graduate students how to do fees, why couldn't we teach, you
(17:29):
know, a community SOP who wantsto be able to learn this and
grow a program at their facility?
So I think this is somethingthat we can eventually develop,
just like we did for theclinical swallow valve and the
AMBS and even things like thehigh resolution pharyngeal
manometry.
Right, that's really the onlyway that we can detect pressure
(17:49):
in the pharynx, and so it wouldbe great if I knew how to do
that, but I don't, and I don'tknow anybody who's doing it.
So when I need that information, that's not something that's
readily available at myfingertips, but I have a feeling
that if you were interviewingan SLP in 20 years.
They're going to say I rememberwhen we didn't have high
resolution pharyngeal manometryavailable and it was really hard
.
But now we have it and I can doit and it's great.
(18:11):
So in another 20 years ourswallow practice is going to
look a lot different than itdoes now, I'm sure.
Speaker 1 (18:18):
Yeah, yeah, I think it will.
Speaker 2 (18:20):
I think it will, I might've just gone off on my own
tangent there, so hopefully no,I don't, I don't think so.
Speaker 1 (18:25):
I think that really was in line with what I was
saying and, even if it was atangent, it made sense, it was
helpful.
I mean the complexity, becausewe're pushing forward, we're
learning more, we're doingbetter.
We realize the complexity ishigher.
Therefore, the standard oflearning is higher because we
have to learn more, we have tolearn about all these different
(18:48):
things, and so the questionbecomes how do we get to this
standard?
And we know that it's not easyand it's not universal right now
, or not?
Well, it would be really hardto make universal changes in
education to speech pathologists, and so, for everyone listening
here, I think it comes back tous what can we do, what can we
(19:10):
contribute?
Whether it's developing aprogram for teaching, whether
it's thinking specifically aboutthe students that we get an
externship in and where we wantthem to be, and how we reverse,
engineer and help them to meetthose expectations within our
setting, or maybe it's in ourpersonal development.
There is a lot more that I needto know, and so, as I'm trying
to figure this out, I'm lookingfor resources and opportunities
(19:32):
to be able to do that.
So, really, if we're talkingabout a problem, an issue, a gap
.
It's through the lens of likewell, how do we help?
How do we help and make itbetter?
And so it sounds like you'redoing some stuff and that's
really cool.
I'm wondering what person A,person B, whoever else is
listening to this.
(19:53):
I'm going to say some names andmaybe people will be like
that's me, no, anyway.
But yeah, for us all to thinkabout, like within our setting,
within whatever our sphere ofinfluence, how we can make this
better, because it really is thepurpose.
Our patients deserve it.
Think of the credibility thatit lends when you can talk to a
(20:16):
physician and provide a solidrationale, not just this
person's aspirating and I needto make them stop aspirating but
maybe this person's aspirating.
They have recurrent pneumoniaand readmissions costing the
hospital thousands and thousandsof dollars, and that's not the
most important thing.
Of course, the patient is themost important thing.
That's just anotherconsideration.
And sometimes how we canleverage things to get what the
(20:38):
patients need.
But the patient is dependent onothers for oral hygiene, they
have a very weak cough and allof these different things, and I
know that from you know.
A while back they had abrainstem stroke and it affected
cranial nerves nine and 10 orwhatever, and so you can explain
the rationale in a way thatmakes sense and it lends your
credibility more likely to getpatients.
(21:00):
They're more likely to trustyour recommendations, and I mean
as providers, we want to beable to be out there and hold
our own in conversation, not forthe sake of looking cool but
for the sake of like.
It's a reflection of what's onthe inside and it allows us the
ability to better help ourpatients and in turn it gets us
a lot of credibility.
(21:20):
That's my soapbox again.
Speaker 2 (21:24):
Well, and I think you touched on something important,
which is you know personallyhow we feel about our practice,
and one of the things that canbe hardest is change right,
especially 20 years in.
You know, I tell my students allthe time, you're never going to
know it all, especially whenpracticing in medicine.
There's constant changehappening, and so it's really
(21:46):
important that the SLP keep upwith the newest information,
evidence-based practice.
You know how the world ischanging and that can be really
hard, because you go from aplace where you know things and
you know as much as you canpossibly know, and things change
and you don't know as much asyou could know, and so that's a
(22:06):
constant battle.
And it can be difficult to bethe person who maybe doesn't
know or learn, could know, andso that's a constant battle, and
it can be difficult to be theperson who maybe doesn't know or
learn something new, and so wehave to be willing to change
with the field and with medicineas it's changing.
So if I didn't learn fees, thenI might not have another
perspective that I can give mypatient or a different
(22:26):
opportunity to look at theirdeficit when the MBS doesn't
give me the information I need,and vice versa.
So if we only had one test, wewould be very limited, but I
have to be willing to change andlearn and grow with that.
So I just think that's reallyimportant to be open to change
and recognizing that you willnever know everything.
Speaker 1 (22:46):
Yeah, for sure, and one of the things I love is and
I'm not putting you on the spot,don't take it this way- but,
when people come on here who arelike really well known and
they'll talk about like, oh,listen to this stupid thing I
did, because it shows thetransparency that they're
willing to give up.
They're not willing to give upthis pretense, this idea that,
oh, this person's perfect.
No, like, the one of the thingsthat makes so many of these
(23:20):
clinicians and researchers andand, and instructors, and
whoever out there, great istheir willingness to change,
their willingness to learn,their willingness to reflect and
say like, well, this is whatI'm doing, great, this is what I
want to improve and movingforward with it, and it's the
direction that you're going.
It's like so, so important, Ithink.
(23:43):
Sometimes I lean on the side andthen people have told me this
I've had students get on my casebecause of it.
I self-deprecate so muchbecause I guess I don't take
myself that seriously orseriously enough or something.
And it's like you can learnsome stuff and you can know some
things, but you don't have tohave an inflated ego, right?
That's not what it's about.
(24:04):
And so, different perspective,different perspective.
Speaker 2 (24:08):
For sure yeah.
Speaker 1 (24:09):
Cool.
Well, is there anything elsethat's really sticking out?
Any things that you've reallyseen clinicians in the community
doing?
Maybe some of the externshipsupervisors you work with, or
just clinicians that you haveseen that are doing a great job?
Anything else out there youwanted to go into?
Speaker 2 (24:27):
Yeah, go into.
Yeah, I think that when youknow, part of my role is I send
students out to their placementsin the second year of the
program, and there are certainlysome preceptors that are very
much interested in teaching thestudent as much as they can
about all of the differentmodalities that are out there
(24:48):
for assessment treatment, and soclinicians are having to push
themselves not only to learn thenew things but then to be able
to teach the new things, and onething we didn't learn in SLP
school is how to be a teacher,and so I appreciate when a
community SLP is willing to takethe time to teach a graduate
(25:09):
clinician the skills that theyhave encountered, or going along
with them to learn the time toteach a graduate clinician the
skills that they haveencountered, or going along with
them to learn the thing.
So as, for example, maybe afacility is rolling out EMST and
they are learning how toincorporate EMST into their
dysphagia management program andthey bring the student along
(25:29):
and have them do projectsrelated to that treatment
modality and the student's ableto learn along with the
clinician, and vice versa, youknow that the clinician is
learning along with the student,and so, um, I find that really
inspiring.
And again, to have cliniciansthat are teaching students while
they are learning at the sametime is challenging but so
(25:50):
absolutely rewarding, becausethat helps the clinician be able
to understand what they'redoing well enough to teach it,
and so that's always promising.
But being able to do things likeyou know let a student run your
MBS or handle the scope on yourpatient is certainly a new area
(26:13):
for clinician supervisors.
To be able to allow thestudents that kind of
independence in that area andnot feel like but I own this
patient and I feel veryresponsible for them.
So being able to collaboratewith your student is an amazing
skill.
And then also including them in, just like you said, being able
to talk to physicians, talk tonurses, talk to other
(26:36):
professionals about what we knowis also helpful experience for
students.
To be able to let them havethose conversations is
beneficial for them as they gointo their careers too.
They can go in a little moreconfident than they were before,
where their supervisor was theone to have all those
conversations.
Speaker 1 (26:54):
You talked about learning while your students are
learning, so like if you'reattending a course, kind of
inviting a student along andyou're learning these things
simultaneously.
And one thing I really tookaway from that is you're
modeling ongoing learning,You're modeling continuing
learning, lifelong learning.
You're not just teaching themwith your words, You're setting
an example of the things thatthey should do, and that's great
(27:15):
, and that also because you'relearning about the same things,
it opens up conversation aboutthose types of things too, which
is great.
There was one other thing.
Oh yeah, so sometimes, ifyou're a supervisor, you know
you're working at a communityhospital or skilled nursing
facility or wherever, and youhave a student with you the
difficulty in handing nothanding over, but giving the
(27:38):
students more independence,working with your patient.
And I think the balance in that,too is we're thinking like.
For me, I'm thinking, or I'mtempted to think I want to make
sure this patient has the bestcare right.
So on one hand, and in my mind,I'm thinking well, I'm probably
(27:59):
, hopefully, better equippedthan the student to do that.
On the other hand, though, ifyou, if we hog it all to
ourselves and don't give someliberty to the students, how are
they going to learn, and sowhen we retire, who's going to
take our place?
So there has to be some growingpains.
I think there has to be this alittle more independence.
(28:20):
You know, scaffold, teach, dowhat you need to do.
But there has to be some sortof release of control within
that, it seems.
Speaker 2 (28:29):
Yes, definitely.
It's hard for me to sometimeslet my students do it their way
because you know I like my way.
My way is the way I've done itfor so long and I think it's the
best way.
And maybe the way the studentdoes it is not wrong, just
different.
You know, not all SLPs doeverything the same either.
There are some things Irecognize that we do, you know,
(28:53):
that are very similar, buteverybody has kind of their,
their order, they like to dothem in, but everybody
eventually gets to the same.
You know, we did all of thesethings.
Everybody does a cranial nerveexam, for example, but we might
all do it a little bit out oforder, but we're all looking at
the same thing.
The way my student gives theinstruction might not be the way
that I do it, but as long asthey come to the same
(29:13):
realization I did, that's okay.
Speaker 1 (29:16):
I think that's a really good point and it's a
point that I've disagreed withpeople on in the past is, well,
if you're training a student orif you're working with somebody
else, there is not necessarilyonly one right way to do it, and
in certain cases there might beand I am not saying that there
might be something that'sclearly empirically better,
(29:38):
based upon evidence and what weknow about the patient
population.
But a lot of times there mightbe different options, and so if
somebody a colleague or astudent comes to a different
conclusion, but there's a solidrationale there, like why does
my way have to be the only wayto do it?
And in most cases it's not.
And so I think it's reallyimportant that students and
(30:01):
clinicians and everyone cancritically think through these
things and understand whythey're doing, not just come to
the same conclusion that you door I do and I think that takes a
lot of humility as well, too toadmit like well, yeah, that's
not maybe what I would have done, but that's a really strong
rationale.
I see what you're saying.
Let's try it, see if it works.
Speaker 2 (30:22):
Yep, yep.
And sometimes patients orstudents have the ability to
experiment a little bit morebecause the way they're thinking
about it isn't the way I do,and so they come up with a
solution or an idea that maybe Ididn't I didn't have, and so
it's.
It's really cool when thathappens I'm like, hey, I didn't
even think of that.
Speaker 1 (30:41):
That is really cool and that shows what students
teach us and not just studentsteach us.
Again, this is not just aconversation for SLPs or
supervising students, but theimportance of talking to other
people, to talking to otherclinicians, to getting insight
from other individuals.
It's not a reflectionnecessarily that you're not
confident in what you do, butgetting another perspective.
There might be something youcan refine, there might be
(31:03):
something that can be better,and I think we get a lot of that
from students.
We get an outside perspective,Like if we've been doing the
same thing 40 hours a week for20 years.
It can cause us sometimes toget stuck in a rut or one way of
thinking, whereas just gettingan outside perspective, even if
somebody has a lot lessexperience, they're going to
(31:26):
bring something new to it, andso I think that's important to
remember that with our students,but also to remember that and
the importance of collaboratingwith other therapists and
physicians and whatnot, and withthat, that actually is probably
a good way to tie this up,because there unless sorry, is
there anything else that is justburning that you really wanted
(31:48):
to get out there, and if so,that is fine.
Speaker 2 (31:52):
You know there is, as I was thinking about, things
that have changed over thecourse of, you know, my 20 years
is that the other thing thatwe're doing is we are having
patients swallow food, you know,for therapy, and back then it
was kind of like, oh, they'reaspirating, we need to, they
should swallow nothing.
And so I think we've learned alot in 20 years about how much
(32:15):
exercise actually swallowing isand that it's not really going
to affect them in a negative wayif we let them keep swallowing,
that it's actually a morepositive thing.
So I feel like that is one bigchange I've seen in how we treat
dysphagia.
Speaker 1 (32:30):
So I feel like that is one big change I've seen in
how we, how we treat dysphagia.
So as far as that goes likethere, there are a couple of
things that I that I'm getting,but I want to make sure that I'm
understanding, like one, thespecificity of treatment that
it's important to continuallyfor, for motor learning, for
neuroplasticity, to keepswallowing.
You know best, you've heard itsaid that the best exercise for
swallowing is swallowing.
(32:50):
You know best, you've heard itsaid that the best exercise for
swallowing is swallowing.
So it's important to swallowfood, different textures,
different weights, so that ourbody can kind of adapt and learn
how to do that, learn how torespond to different bolus sizes
and bolus weights, that type ofthing.
So I'm getting that from it.
Is that, is that that part?
That's part of what you'resaying, right?
Yes, okay.
And the other part is it doesit have to do with maybe not
(33:14):
being quite as afraid ofaspiration or other differences
in swallowing than we used to be?
Speaker 2 (33:21):
Definitely Cause we are, you know, not as, not as
afraid.
We just aren't as afraid to letpeople swallow and to let
people be uncomfortable, becausewe recognize that the more we
learn about exercise science,for example, that it's it's in
that exercise that you knowpatients are going to see the
(33:42):
benefit, and so if we're afraidto let them try, they aren't
going to see the benefit totheir muscles if they're not
actually using them.
So yes, yeah, thank you forputting professional words to
what I'm saying.
Speaker 1 (33:54):
No, no, I was, I was make.
I wanted to make sure that Iwas getting the takeaway.
That was intended, that wasintended there, that was, that
was part of it.
Yeah, and there's.
I mean, there's a bigdifference between being
reckless and not being afraid,like if I did an MBS or a fees
and I.
This happened once I was doing afees and this lady had dementia
(34:17):
and I'm trying to think of whatelse we did prior to this point
, but she swallowed a crackerand she swallowed a cracker.
She didn't chew it very well,there was a big piece of cracker
in her throat and I was alittle scared, and I probably
had reason to be scared too atthat point.
And so that's not to say like,yeah, give this lady all the
crack.
I mean, throw crackers at her,right, you know, give her all
(34:40):
the crackers and that sort ofthing too.
But on the other side ispatient aspirates some thin
liquid and you know, yeah, goodoral hygiene, their cough is
strong.
You consider these othervariables and other parameters
rather than just being deathlyafraid of laryngeal penetration
or all sorts of, you know, anykind of aspiration, that type of
thing too.
So, yeah, some middle groundthere, I think is really
(35:01):
predicated on what we've learnedand how we've developed in our
understanding of you know howthese negative outcomes like
pneumonia or asphyxiationdevelop.
Speaker 2 (35:12):
Right Learning how to challenge the system, but
within limits of safety, forsure.
Speaker 1 (35:17):
Yes, yeah, yeah, very cool, very cool.
Well, it was great to chat withyou again.
Some take home messages and ifyou think of anything else that
you want to just put out there,let me know.
But some take home messages forthis, I think, the importance
of we have a higher level ofknowledge now, so we need to
(35:37):
really raise our standards.
So how do we do that?
And that's going to depend onwho you are, where you are, who
you're working with yourresources whether it's readings,
articles, people, that type ofa thing but reflect on what you
know, even maybe keep track ofit.
Keep track of things thatyou've learned.
It's kind of cliche and corny,as that sounds Like you know.
(35:57):
These are some things I'velearned this year.
These are some ways I'vechanged in my thinking, so you
can go back and look throughthat.
But continue to reflect,continue learning.
Share resources, like if youfind courses that are good, if
you find whatever types ofresources that are good, like,
share those with people.
Spread the good news.
Spread the information that'sgoing to help your patients.
(36:18):
Talk to people.
Talk to students.
Talk to other speechpathologists.
Get their perspectives.
Being part of a community, Ithink, is not just beneficial in
knowledge sharing and maybe I'man odd one out in this, but it
gets me excited, like when Italk to other people, when I'm
just by myself all the time.
I mean, I'm not really classicintrovert, so I'm kind of taking
(36:41):
that into mind.
My, you know how my brain works, yeah, but we there's a lot we
can do to encourage each othertoo.
Like if you're holding theseconversations, you're not just
learning or at least I'm not itjust gets me excited to.
It makes me want to do more,makes me want to do better and
talk about ideas and that sortof thing too.
So I think those are some takehomes that that everybody you
know can can walk away with, anddefinitely, definitely I will.
Speaker 2 (37:05):
Great Thank you.
Thanks so much for the chat.
Speaker 1 (37:08):
Yeah, yeah, thank you for coming on, appreciate it
and hopefully see you around.
Thank you.
Before you go, a quick reminderof two courses coming up soon.
This Sunday, march 23rd, drKendrae Grand is doing a
three-hour webinar teaching oncranial nerve exam for
(37:30):
assessment of bulbar functioning, for the medical
speech-language pathologist, theclinical specialty course.
So that's this Sunday, march23rd, with Dr Kendra Grant and
on April 5th, saturday,respiratory muscle strength
training foundations andevidence with Dr Chris Sapienza,
the co-inventor of the EMST 150.
The co-inventor of the EMST 150.
As a thank you for being alistener, please use the code
(37:52):
POD1, or P-O-D in all lowercaseand the number one at checkout
and that'll give you 10% off.
To find these courses, go toswallowthegapcom slash
livecourses or medslpgapcomslash livecourses.
Popular Podcasts
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
24/7 News: The Latest
The latest news in 4 minutes updated every hour, every day.
Therapy Gecko
An unlicensed lizard psychologist travels the universe talking to strangers about absolutely nothing. TO CALL THE GECKO: follow me on https://www.twitch.tv/lyleforever to get a notification for when I am taking calls. I am usually live Mondays, Wednesdays, and Fridays but lately a lot of other times too. I am a gecko.