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I have been pondering on and off this past week what to write in my final post on what makes me a ‘better’ clinician. Initially, I was annoyed that I was even thinking about it. I had taken a long weekend off, away from work, and so I was trying not to think about work.

And then it all became very obvious. Breaks make me a better clinician!

For three days straight, I did not think of work. Or if I did, I quickly banished it from my mind. (I admit, on the first of the four days I took off, I did do some thinking related to work, but it was very relaxed, on a subject I have a passionate interest in, and I stopped when I started to get tired.) It. Was. Glorious.

The magic of Taking a Break did not happen right away. My first day back at work was exactly like a first day back at work after a break. What am I doing here? Why is it so hard to focus on researching patient histories? Professionalism? Where did I put that…I’ve been acting goofy all weekend. Whyyyy am I soooo busyyyyy?

But then, suddenly, the second day back, my mind was filled with 10 million (exaggeration) new activity ideas for my clients! Now the only problem is to find the time to put some of them together. But it made me feel like I was an SLP again; not some robot-SLP going through the motions and drilling cards with children for eight hours a day.

Happy Better Speech and Hearing Month!  …and take a break!

There are moments in the madness that it is worthwhile to remember the joy in SLPing.

The excitement of starting a new patient and thinking of the potential he/she holds.

The excitement of being a hop, skip, and jump away from discharging a client you have had for years.

The excitement of a patient making progress on the one goal you’ve been working on forever.

The hilariousness of stuff my kids say.

Watching the wonderful, heart-warming interactions of supportive families.

The excitement of having a honest-to-God break from it all coming up.

I love SLPing.

 

 

There is a lot of variety in speech-language pathology. One can specialize by population (adults versus pediatrics; and even pediatrics can be broken down into birth to three, early childhood, and school-age), or by disorder (although jobs that focus on even one or two disorders are more difficult to come by).

I am all over the place, I work with adults, with children, with swallowing, early childhood language, phonological disorders, aphasia, cognition…and the list goes on. A question comes to me a lot: Can I do the best I can, give the best therapy and information possible, when I see so many types of patients? (The giant thought-bubble that hangs over my head during therapy where I’m not sure where I’m going with a patient: “AM I PROVIDING EBP?”)

I am undecided on this question. I do not want to accuse therapists who do work across a variety of different orders of doing a bad job. I like to think I do a good job, although I think I can do better. (This is probably because I haven’t been SLPing for very long.) And I also don’t want to deny my colleagues one of the cool things about our field: that there’s so much to learn, so many different opportunities, and one can change the course of their career to fit their interest or lifestyle.

But when I talk to other SLPs who have been focusing their energies on one area, or a much smaller area, for a long time, their knowledge on a particular subject amazes me and makes me wish I could have that much knowledge about things. (Well, let’s get real, I would love to have that kind of knowledge about All The Things SLP, but that’s probably not possible.) I don’t know if I could ever know as much as I should about all the different disorders I see now. Maybe I don’t have enough years of practice and perspective on this to know if it is possible. Sometimes I feel like there is outside pressure for me to do All The Things SLP. Again, this might be my Type A personality projecting my stress of being a new SLP onto my daily life.

What do you think? Do you think it is better for professionals and our profession as a whole to specialize? Is it better to be a sort of SLP-of-all-trades? Does anyone have advice for reconciling a Type A personality with the expectation of doing All The Things SLP? Is it even realistic to expect everyone to specialize? Is it nice in our field that some people can specialize if they choose to, while others seek out the jobs that require therapy for a variety of individual with various disorders?

Some weeks just come up to you and punch you in the face. I still don’t know what happened, but I know I have a lot of planning to do.

It’s been a wacky up/down week. The main issue I need to solve (or in Type-A-Personality-Speak: Organize, organize, organize), is how to better manage my now bulging out-patient schedule. (Which, of course, immediately defies it’s own immensity by having half of my patients no-show today. But…that’s probably a rant for another post. My fellow out-patient SLPs can relate, I’m sure.)

I have a few patients who require additional set-up and break-down time and I am struggling to work this into my schedule without throwing off other parts of my schedule that are already established.  Plus I need to find some very simple hands-on craft activities and learn All The Baby Signs. ALL OF THEM.

Did I mention this week punched me in the face? Time to spend part of the weekend brainstorm ideas. And then maybe blogging about them.

So I had been working on an entirely different post this week, but decided to opt for a completely different piece because the other one seemed unpolished and unfinished.

I might have mentioned I work at a hospital where I sometimes work in the acute setting and sometimes in out-patient care. Some days I jump back and forth between both. Some days, it’s almost as though I don’t get anything accomplished in either place. On the other hand, the idea of sitting still in either setting puts my type-A personality on edge.

I’ve been doing this over a year now, and while it has gotten easier to switch between the two (switch populations, switch ages, switch my brain), I am still searching for that balance. If I really love something (and I love SLPing) or if I really want to succeed at something (and I really, really want to be a kickass SLP) I throw myself into it. In a sometimes-kind-of unhealthy way. (In fact, I should add to my goals: take some frigging vacation even when you don’t have anywhere to go.  Ahem. Anyway.)

In that way, it’s probably a good thing, especially this early in my career, that I have to keep hopping back and forth between many very different SLP-type things. I can obsess about twenty different types things all at the same time!  I mean, I can work hard towards balancing my time among all the different things I do.

Now I realize I am not a special snowflake who spends their SLPing jumping around between adults, children, swallowing, voice, evaluations, treatment, phonological disorders, playing Simon Says  to giving families the facts about NPO versus signing a waiver given the risks of aspiration. What do you guys do for balance? Does it get easier? Does it get harder? Do you think you provide the best care possible to so many different types of patients? (I know this is something I worry about all the time. I can’t be an expert at everything, can I?) Do you ever feel like banging your head against the wall? Oh, wait. I guess that’s all of us.

(Full title of this post redacted for brevity and pithy-ness: “This post might be cheating as a real post with substance, but it’s true.”)

While reading a book by Steven Pinker, I came across this fantastic quote.

This should pretty much be every grad student’s mantra when making lesson plans and remind us all on bad days that our patients are, above all, human.

“…the Harvard Law of Animal Behavior: ‘Under controlled experimental conditions of temperature, time, lighting, feeding, and training, the organism will behave as it damn well pleases.'”

Word.

Lately with various kids I have been working with, I have been thinking less about what I am teaching, and rather how I am teaching it.

First off, before I jump on my soap box, this is not to say that what you are teaching is not important.  I have suggested in earlier posts that I do think there are better ways of teaching a child the sounds in the English sound system that others (e.g., teach later developing sounds rather than earlier developing sounds).

On the other hand, there are somethings like colors or basic concepts where I think, Wait, what am I doing? Not as in, Why am I teaching this? But rather, Why am I sitting here drilling them on this stuff? Isn’t this how they are being taught in the classroom?  The point is, I have the luxury of sitting down with him or her one-on-one. Shouldn’t I take advantage of that? Shouldn’t I be looking at how my patient learns best and try to teach them, if at all possible, through the method that works best for them?

Too often lately, I’m finding myself strapping them into a chair and showing them flashcard after flashcard. While increased number of repetitions of a skill is obviously part of how they learn (since they haven’t learned whatever skill after the same number of repetitions a typical child is exposed to), but shouldn’t I be incorporating how they learn into my skilled intervention as well? Where’s the creativity I had in grad school? (Or maybe that’s just the graduation goggles talking.)

A lot of my kids now seem to be tactile/motor learners. Time to bring out the scavenger hunts! The manipulatives! The crafts!  This giant mess for me to clean up between patients somehow…. (Sounds like a future blog post for how I will manage the chaos.)

Well, at least in baby steps. I can’t get all that together in one night. But it is something I need to be mindful of and begin to incorporate into my therapy.

What about you guys? How do you incorporate your patients’ learning styles into your therapy? How do you figure out their learning style? What type of activities do you do to incorporate these different learning styles?

So, I was doing some continuing education in FEES this past weekend. (Finding fun in sticking a small camera up your colleagues’ noses for two days.  Not sure what that says about me as a person.) It was a mix of speech-language pathologists working across of variety of (mostly) medical settings.

Nerd that I am, I liked to hear what it was like for each of them working across different settings. (Especially those working in long-term care facilities with trachs and vents! I mean, PEOPLE EATING AND SPEAKING ON VENTS???  I had an entire class on trachs and vents and my mind still  boggles.)

Anyway, in reflecting on the interesting information I had gathered about various clinicians’ job settings, I suddenly had a questions.

Q: Did I just miss an opportunity to network?

A: Yes.

Not necessarily in the job crawling sense (although if I were looking for a job, it would have been a good place to do it), but rather in a, Let Me Make Contact With People Who Know More About Certain Stuff Than I Do. Maybe the opportunity for me to do that was not particularly obvious to me because I already work with a good group of clinicians with whom I can ask questions. But that’s not true for everyone! And it’s also not true that everyone I work with happens to be an expert/have a lot of knowledge in a particular area that I have questions in. Not to mention if there comes a time in my life where I am looking for a new job. Wouldn’t it be nice to have some contacts in my back pocket?

The question is, how do I make that leap from chatting about my/their job/s to, “So can I call you sometime.” “Can I have your email address in case I ever have questions about X?”

Of course, not all of these SLPs were doing work that related to my current interests and activities in my own job (see also: people talking on vents.) But it got me thinking about future workshops or conferences I attend. Guess networking falls under one of my Top Goals of All Time: Being Assertive.

Does anyone else have thoughts on networking? Do you use it? How do you make (and keep) contacts? What do you use it for or have you used it for? How do you work exchanging contact information into the conversation?  Or is that last question an obvious sign that I am insecure and un-assertive? Guess I have a lot of work to do.

So.

The SLPing SLP’s (very own, very personal, heavily influenced by her graduate training) Definition of Articulation:

So, looking back at my definition of phonology, that…pretty much covers everything.

Basically, when I think of articulation, I think of a strictly motor or placement problem.  For example, I think of a lisp as an articulation problem. Also, if I child is still having difficulty producing sounds after around the age of five or five in a half (when phonological growth plateaus [see Shriberg & Kwiatkowski, 1994; Shriberg et al., 2994-a, -b]), I begin to see it as pretty much a motor issue.  The child has been mis-pronouncing a sound or sounds for so long that is has become a learned motor pattern.

This does affect my approach to treatment, because then I do treat initial, medial, and final position, and I do teach to sentence and/or conversation level. That’s because I am less changing a cognitive system, and more a (long-suffering) motor pattern.  Much harder to do!

(Where does that leave childhood apraxia of speech? Well, I guess that’s something to write about in the future.)

I think the importance in distinguishing articulation from phonology is how it affects treatment. Since I treat (most) my kids as having a phonology problem (how I define phonology), I only spend time teaching them the initial sound in words. (And yes, there is evidence to show that change occurs across the phonological system, by teaching certain sounds and only in initial word position, e.g., Gierut, 2001; Geirut, 1999.) It’s only when they are older and I see it as an articulation (learned motor pattern) problem, do I spend the time teaching it across positions and practicing it in sentences. Otherwise, I would feel like I’m wasting my own and my patient’s time (and insurance) by teaching all sounds, all positions, and all “levels” of production.

The SLPing SLP’s (very own, very personal, heavily influenced by her graduate training) Definition of Phonology:

As wacky as this week is going, I basically want to say: “Whatever is on those dreadful SuperDuper articulation and phonology cards is exactly what I think phonology is NOT.”

And then go read my book club book.  But then I like to think I take this blog a little more seriously than that.  So.

I agree with the ASHA that a phonological disorder is one where a child exhibits “patterns of sound error.”  However, I do not think of these patterns as the phonological processes that have been discussed and described in some areas of literature (final consonant deletion, fronting, backing, etc.; see Khan, 1982 in Language, Speech, and Hearing Services in Schools for an overview of phonological processes).

A pattern to me is when a child is omitting or substituting a sound or set of sounds consistently. While placement (e.g., backing) might be a noticeable pattern, so might whether or not the child is using manner or voice. I then examine these missing sounds and their features and use this to determine which sound or sounds to target.

Because I view phonology (and most the kids on my caseload with a sound/speech disorder) as a problem with a cognitive representation of the English sound system, rather than a strictly motor one, my approach to treatment is different from it is with articulation. If I have a child between the ages of three and four (maybe up to four and a half) with a moderate to severe phonological disorder, I will teach later developing sounds* in an attempt to change the entire sound system (because it is a system, isn’t it?  We have charts that show how place, voice a manner overlap, remember?), and I will teach only initial word position. No painstaking, long-suffering movement through syllables, medial and final positions, and phrases and sentences. Because I’m not trying to replace a learned motor pattern, I’m trying to replace a learned cognitive pattern, or, perhaps more accurately, teach the child something about the phonological pattern of English that s/he had not previously learned from her/his environment.

My definition of articulation is to come, and is much, much shorter than this one. (Yay! I can dig into my book club book!) What do you think of my definition? (That’s right! Now’s your chance to disagree with someone on the Internet!) How do you treat kids on your caseload for articulation/phonological disorders (depending on the definition you personally use)? Does your definition affect your treatment approach?

 

*The underlying theory behind choosing later developing sounds is that a more complex sound will result in generalization to less complex sounds. A good introduction to this approach to phonological treatment is by Gierut (2001) and can be found in Language, Speech, and Hearing Services in Schools.

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