I started working in the summer of 2011, right before a lot of the ACA changes started rolling out where there were new Medicare rules each October. A lot has changed since then but a lot of things ring true today.
My first job was in a skilled nursing facility that, like many, had a subacute portion, assisted living portion, and long term care portion. There was an outpatient gym and it was also affiliated with an affiliated assisted living facility that I was expected to travel to on an as needed basis. It was regarded as having a good reputation in the area that I worked. I had some difficulty getting a medical-based job in the Chicagoland area so I moved away to practice in a different city.
I went to interview at this facility and really liked it but was on the fence about accepting the job. Afterwards, the SLP at that facility called me one weekend and spoke to me. I really liked her on the phone and related to her. She was going to be my CFY supervisor and we would be the two speech therapists covering this building.
On the first day that I showed up (a Tuesday), she let me know that she would be working there the remainder of the week and that Friday was her last day but that she would still be my supervisor. She decided to take a travel position in the schools instead.
I’ve carried a lot of anger with me about that and felt somehow cheated out of a good experience and a lot of learning. I had chosen to work there over other places because I wanted my supervisor to be on-site. I have since realized that, while she probably could have helped me reach a few goals a lot faster and this facility could have had better SLP retention overall if I had a better experience (I left after 13 months with the intention of sticking it out), I can’t be too upset about it. I had to be my own supervisor and I probably grew a lot as a result of it. If I could go back in time with the experience I have now (5 1/2 years), this is what I would tell my CF-self.
1. Don’t overthink it.
I would spend so much time at work agonizing over if this goal was just right or if my evaluation or treatment summary was just perfect. Just stop. With the exception of your supervisor, it is very unlikely another speech therapist is reading your paperwork or even going to know what you’re talking about. Being direct and a concise is key and let’s face it, brevity is not something that is valued in grad school.
I’ve worked an assessment summary out to a “formula” in general (of course all evaluations are individualized so if someone is actually there for aphasia or dysarthria it will look a little different) because for many of the types of patients I have (80+ and medically complex), I test for a lot of the same things. Here is my formula:
Patient presents with [mild/moderate/severely] impaired cognitive-communicative deficits characterized by [mild/moderate/severely] impaired [cognitive domains (delayed short term memory/safety awareness/problem solving/thought organization/sustained attention/etc.) Repeat the impaired domain description as needed] impacting patient’s ability to [complete IADLs/make appropriate health and safety decisions/return to PLOF]. Expressive and receptive communication are grossly WNL.
Patient also presents with [mild/moderate/severely] impaired oral phase and [mild/moderate/severely] impaired pharyngeal phase dysphagia characterized by [suspected reduced oral bolus control, (m/m/s) reduced hyolaryngeal elevation, 3-4 second pharyngeal swallow trigger, etc.] leading to s/s distress on [regular/soft/puree] solids and [thin/nectar/honey thick] liquids putting patient at risk for aspiration pneumonia and reduced intake.
2. Don’t overplan it.
I think this is useful regardless of setting. Have a vague idea in mind for what you want to do in your session, but if you have just one thing planned and no alternate activity, you’re going to be disappointed. Your patient isn’t going to want to do it or something else will come up and it just won’t happen. Have a variety of options in your arsenal. In fact, have a treatment binder or folder with some of your favorite materials. Make sure you have both visual items (e.g. worksheets with large-ish print) as well as auditory items (for those who can’t see or don’t want to sit up in bed and do a worksheet).
3. Co-treat with other disciplines.
While about 99% of the time I don’t co-treat (because I feel like it takes more time away from activities we would otherwise do) there are times when it is necessary because of time restraints and patient cooperativeness. Instead of getting upset, look at it for what it is: an opportunity. Let’s not kid ourselves: the patient are there for physical therapy and they will outright tell you. But are there barriers that are presenting that patient from showing up and being their best selves and getting the most from physical therapy or occupational therapy? Work collaboratively and you might find out…in fact, some of my most functional treatment sessions have been either a suggestion of PT/OT or something that I observed during a session. I will never forget the time, shortly into my CFY, that a PT with 40+ years of experience suggested that I work on safety awareness with a patient we shared. I stared at her blankly and asked how I would do that because I had no idea. My student experience was in a hospital (acute/rehab floors) and this is just something we didn’t address. Fortunately, she was so kind and gave me great ideas.
Some things that I will frequently work on with patients is sequencing for hand placement with transfers, locating/remembering the brakes on their wheelchairs, hand placement for wheelchair to toilet transfers, or safety while ambulating (in other words, either working on left neglect while ambulating or self-propelling in a wheelchair OR, rarely, if someone is able to ambulate with a walker or cane, searching and reaching for items that I have taped in the hallway while avoiding obstacles).
4. Don’t be afraid to
try trial new things.
When I was brand new, I was terrified to give someone on nectar thick liquids trials of thin liquids. If they coughed once, that was a deal breaker. Even more than this, if someone was NPO, I was too afraid to give them ANYTHING without a video. Realistically, I’ve learned throughout the years that it takes a little more than we think for someone to develop pneumonia from aspiration. We are somehow led to believe that if someone on nectar thick liquids drinks a cup of thin liquids, they will have pneumonia the next day. This simply isn’t true. There are so many factors that go into developing pneumonia including someone’s overall medical status and immune status, oral hygiene, saliva quality, activity level, etc. I have had multiple patients that were known aspirators based on videofluoroscopic studies that were noncompliant with my recommendations and regularly drank thin liquids and would perhaps develop pneumonia once a year (the individuals that come to mind were more physically mobile and able to walk around and skewed a bit younger, in their 60’s). I had one patient that silently aspirated following a cervical fusion surgery that silently aspirated everything and the video recommended NPO. I later met his daughter approximately a year later and found out that he decided to continue to eat and drink everything as before and never had any complications (he was otherwise healthy and very active).
This is why, when able, I like to really discuss things with patients and family members and let them know about their risk and tell them what might mitigate the risk rather than tell them that they entirely should not have x, y, or z. Do I really want a 92-year-old to go home on thickened liquids when he coughs occasionally with thin liquids but has otherwise not had pneumonia? No!
You will find all differing opinions and there is a spectrum of liberal to conservative therapists but a lot of continuing education courses are really trying to move away from altered consistencies and PEG tubes being long term fixes. There is much more of an emphasis about these being acute fixes. There are plenty of presentations of articles about this topic so I won’t go into too much detail but really get out there and take some CEU courses about this. In the meantime, I will leave you with this quote from this article:
The best predictors, in one or more groups of subjects, were dependent for feeding, dependent for oral care, number of decayed teeth, tube feeding, more than one medical diagnosis, number of medications, and smoking. The role that each of the significant predictors might play was described in relation to the pathogenesis of aspiration pneumonia. Dysphagia was concluded to be an important risk for aspiration pneumonia, but generally not sufficient to cause pneumonia unless other risk factors are present as well.
tl;dr: to summarize, as my co-worker/former CF said when I asked her what she wished she knew when she first graduated: “That nobody is going to die [if they cough with thin liquids]”.
5. You might be depressed.
When I first started working, I cried every day. I have to believe this is normal for a lot of us. It is overwhelming and you feel like you suck and are the worst SLP to grace this earth. There is a huge learning curve right out of school.
Here is the truth, though: I would look at my schedule each morning and become automatically overwhelmed with all the names of the people for whom I was responsible, have a panic attack and cry. I called my supervisor crying maybe twice. There were months that I would lock myself in the therapy bathroom and cry for a good ten minutes. I would startle awake multiple times each night. I had so much shoulder pain from tension that it hurt to move. I once had a patient to whom I was showing pictures of my niece (because duhhhh octogenarian ladies, in general, love baby pictures) and I just broke down crying. She was so sweet about it but, hello, super embarrassing. Fortunately, she had no short term memory so I was able to recover gracefully the next day but how could I function as a professional like that? I couldn’t.
Finally, one day the rehab director said to me, “Maybe you’re depressed and should talk to a doctor.” I didn’t have the best relationship with the director at the time but I am so thankful that she told me this because I went to the doctor and was an absolute mess with the medical student there. But the doctor prescribed medication for me and it made all the difference.
My situation was a little rough: I didn’t have enough guidance or supervision and I had to call the regional director nearly every day explaining why my productivity wasn’t exactly 85%. But you know what? I shouldn’t be crying absolutely every day, unable to sleep or do anything outside of get up, go to work, and go home and sit on the couch each day…for 8 months. I would expect that for maybe a month at the most while adjusting.
Depression can sneak up on you and sometimes you can no longer have the insight and introspection necessary to realize you are there. Depression alters the activation of your prefrontal cortex and makes cognitive tasks much harder. You can’t do your best job when you are depressed and you need help. I am so glad I had someone in my life to suggest this to me when I couldn’t exercise that self-awareness and so I don’t ever regret gently suggesting the same to some of my patients and educating them about how depression, particularly in the elderly, can affect cognitive function.
Everyone is different, but I was first diagnosed with clinical depression when I was eleven years old and have had CBT for various periods throughout my life. Having that background made it easier for me to take action. If you need help, it’s as easy as starting with talking to your primary care physician at a regular check-up.
6. Not every session needs to be structured. Relax.
I went into each session with the grad school mindset that everything needed to be planned out and structured. Sometimes when you do this, you can’t see the forest for the trees. Sometimes, it’s ok to just sit and talk; not chit-chat, but conversation with a purpose.
One example (although there are countless), I had a patient a few weeks ago that was a low fall risk but a fall risk nonetheless. God bless him, he had a lot of energy for his age but no short term memory so he constantly forgot that he shouldn’t be up and walking around. The nurses are busy and it is really hard to watch everyone while you are trying to focus to make sure you are delivering the appropriate dose of a medication and will often yell over to a patient, “Sit down!”
Well wait a minute! If I’m that man, I’m thinking, “I need X, though,” without having the insight or self-monitoring to be able to say, “Okay, I’m not supposed to walk, but I need this, so what should I do?” Most of the time, patients aren’t walking or trying to stand up for the hell of it: they need something and either don’t think to ask (because they are an adult and can do it themselves, why should they?) or don’t actually know what they need to ask for it– they just know they are uncomfortable and are being reactive.
So I took him by the arm and said, “Hi, sir, can I help you with something?” He told me he wasn’t sure what he was supposed to be doing. I guided him to his room and we referred to the visual aids I had made for him to remind him of safety awareness and redirected him to the activity/daily schedule in his book. We discussed that he had a fall and went to the hospital and isn’t safe to walk around on his own, but that if he would like something to do, these are his options. I try to only provide 2 choices to not overwhelm someone. He chose to attend activities and I helped spatially orient him to the location of the activities room in relation to his room and the activities kept him engaged for some time. Did that solve the problem of him trying to walk around? No. He has no functional short term memory. But I educated him, reminded him about where he could go for a reference if he needed something, and at least redirected him in a friendly and helpful way to reduce his risk for falls. Occasionally, if a patient is there long enough and is frequently redirected to the visual cues, they may use them. This doesn’t happen 100% of the time but at the very least I know I’m doing my best to provide an intervention that is accessible not only to the patient but to other staff members and family members.
Was that entire session structured? No. I based my therapy that day on what I saw my patient needed at that very moment and what could fit into my plan of care and be reiterated moving forward.
7. You may need to refocus for compensation and not restoration.
For someone at that level in my above example, sitting down and doing a generative naming task is not going to functionally benefit him. He will never be appropriate for anything but 24-hour supervision. He will never be in charge of medication or money again. My goals therefore switch from returning him to being independent and focusing on home tasks (we know that tasks learned sometimes do not carryover from one environment to the next) to focusing on what will benefit him here, at the subacute level, and ensure he is safe, happy, and supporting gains in other therapies. For the longest time I felt like a fraud taking this approach: after all, shouldn’t I be able to say we are working toward more independence? But after seeing countless times how patients have benefited, I feel so good about the “now” focus for dementia patients because I am able to see firsthand and get more of an immediate return on how it has benefited them. Again, this will be a miss for a lot of people and may not work, but certain personalities like those that are inquisitive and were likely “busybodies” in their lifetime (e.g. got up at 5am to go to work, always had to be up and moving and doing housework, always active with social groups such as church), this is a successful approach and has benefitted their wellbeing (or I like to think so!). I honestly would have never thought about doing this in my first year. I was blindsided by a restorative approach and for some people, because of medical diagnoses, restoration isn’t possible.
This view really changed for me when I left that first job and took a job at what was primarily a residential-based facility for people with psychiatric diagnoses or substance abuse issues (most of these people were senior citizens with medical complexities including dementia– it wasn’t a group home or psychiatric facility, to clarify). Obviously, cognitively, I was working with a certain set-point. There are many with mental illnesses that, with appropriate intervention, can be very successful within the confines of what we define as “success” and “functioning” in our society for the neurotypical. There are others that have more challenges. So, I might have a person that needs to live in a 24-hour supervision environment because they cannot make appropriate health decisions. I’m not going to focus on medication management clearly! But I know that within that particular building, they have activities, behavioral incentives, and various systems to create a community. Many times, I liked to help newer residents to acclimate to the environment and use resources (folders, etc.) to help them organize and remember. There were a lot of pop machines and vending machines for the residents so many times, I would help them relearn how to use a vending machine and identify which coins will work for which written amounts (super motivating task, by the way haha).
8. You need to treat the whole person.
We always say this, right? In grad school, that meant making sure we were focusing on goals that addressed them functionally at home…like if they were an electrician, we would work on equations involving ohm’s law, etc. I’ve come to expand that view further.
When I first started working, I would go right into the session and set down the materials and basically be like, “Okay, we’re going to do this today.” Overall, this was not well received. That might work in an outpatient setting, but people in an inpatient setting are a lot more vulnerable and have more needs.
You have to chat people up. Especially at the evaluation. Ask them how they are, talk about why they went to the hospital, talk about their family and what they used to do. Sometimes just from this part alone, I get a sense of who this person is and can already anticipate what I need their goals to be. This gives me information about if they even have insight into their current situation, how their short term memory and topic maintenance is, and what kind of supports they have at home or in the community. That person then gets a sense of who you are by how you respond, (“I don’t have any children.” “I don’t either. Just a cat.” “I have two cats.” “Who is taking care of your cat while you are here?” “My neighbor is checking in on them everyday. My neighbor checks in on me sometimes, too.” That way they know I care about something as small as a cat that probably is a very important significant other to them!).
When I start a session, I always begin with asking someone 1) how are you today? and almost always 2) is now a good time to do some therapy? Because it’s just polite and I want someone to be respectful of me and my time. Sometimes I have someone that I know likes coffee and I will bring them coffee each time I see them to make the session a little more enjoyable (and I tell them it’s “Coffee Talk with Kristen” because I am cheesy). Before I leave, I always ask if they need anything (usually it is as simple as water) because I might be the last person they can get a hold of for the next thirty minutes. It’s just good customer service for anybody. And it increases someone’s compliance with therapy when 1) they can trust me with something as personal as swallowing or cognition and 2) their needs are met before we begin a session. Recall Maslow’s Hierarchy of Needs. I am a big believer that I cannot sufficiently do my job and access their brain if someone is distracted by discomfort or worry or whatever– that is a session that I might as well throw out the window. And that is also why, sometimes, a lot of the session might just kind of be an unstructured counseling session with a focus on assisting someone to communicate something or problem-solve them through a situation that is bothering them.
About three years into being a speech therapist, I was seeing a psychologist for counseling to deal with anxiety. I expressed to her my concerns about not feeling like I was able to help people progress (you aren’t going to have a 100% success rate, friends). She asked me if I knew what clients (of psychologists) self-reported as being the most important intervention in therapy. I told her that I believed it was Cognitive Behavioral Therapy. She told me that she would have thought so, too, but that the study (she didn’t send it to me so I don’t know what the study is to link to it here) indicated that people reported “liking their therapist” as being the most important to meeting their goals. Say what? Granted, you can’t directly compare the two disciplines, but there can be a lot of overlap in terms of cognitive therapy. We both focus on changing behavior through the plastic nature of the brain. That made such a big difference to me and I have since hung my hat on, you know, I wasn’t able to meet my goals but I tried and I was kind to them along the way. We are all stretched for time and resources in healthcare and a lot of the time that manifests in healthcare workers as being not so gentle or helpful.
9. Ask people if they want to do speech therapy.
This seems so simple but for some reason I did not do this (I think this was partly because in my CFY I was taught to pretty much pick up every evaluation and was questioned if someone was an eval only).
For those with moderate to mild cognitive deficits, I always ask if they would like to do speech therapy and give them examples of what they would do. Some people say no and I respect that. I don’t want to fight with someone everyday about why therapy is important. How am I supposed to help someone learn compensatory strategies if they don’t want to learn in the first place? If someone doesn’t want an intervention, that is their choice. Self-determination, guys.
I make exceptions if someone has severe deficits and is grossly unsafe and I talk with family and they would like to pursue therapy.
Seriously. Ask people. To this day, it feels weird and like I am giving people a sales pitch, but I make sure they understand that whether they participate or not has no effect on when they will discharge home and that it is entirely their choice to participate and if they change their mind, they know where to find me.
10. People that have modified their brains with drugs and alcohol are not less deserving of therapy.
It pains me to type that. The only reason I even got that idea in my head was because during my hospital internship we did not choose to evaluate people with drug or alcohol induced encephalopathy. I was resistant to picking up one man because of this and because I didn’t trust my boss at my first job (see above, where I mention I was kind of pressured into picking up everyone). But when I heard that the man himself and his children were requesting therapy (and not the facility), I was of course in the room right away. I was immediately chastened by this experience and I felt that I had been prejudiced in a way because of his past medical history. I will always remember that man for that lesson and also because he looked at the Symbol Cancellation subtest of the CLQT and chuckled wistfully to himself and said, “It looks like the universe” (it’s better if you know that he was totally an old hippie). But I loved that…and it was such a great new and beautiful perspective on a plain old test that makes me love it more.
11. Your identity cannot hinge on being a speech-language pathologist.
This is a newer realization that I am working on. You need to have additional interests outside of work. You need to view yourself as a person and not just an SLP. You have to do this for not only yourself, but for your patients, especially if you are a Highly Sensitive Person/Empath. You will burn out and you will burn out quickly if you don’t step away from work. Something my therapist suggested was having a symbolic way of transitioning from work to home and to leave all the worries at work. Taking off my scrubs alone wasn’t enough. I have found that my new symbolic item are my glasses. I wear them for a number of reasons (including, pro-tip: shielding my eyes when working with trachs or near someone’s mouth), but the truth is, I don’t really need them to see. They do help me with eye fatigue but the fact is that they are only for astigmatism. I could see just fine at work without them. I do use glasses at home (like when I will be on the computer for an extended period of time) but my dark-framed glasses are for when I am the speech therapist version of myself: Kristen from speech therapy. I put them on right before going into work and take them off before I get in my car.
The problem with focusing your identity on being an SLP is that you are measuring your success by others’ success, essentially. I think we should hold ourselves accountable for helping patients’ meet their goals, but there are so many variables involved in their care that they may not always perform as anticipated or hoped. I was stuck in this area for a long time because the other two speech therapists that I talked to on a daily basis were my experience level or less: I didn’t know any older SLPs to be a mentor to guide me in the right direction.
It is really hard at first because grad school brainwashes you. It really does. I remember that for the longest time, I could not read fiction. I could only read nonfiction books with a medical focus.
You will become a better, more effective, and well-rounded therapist if you pursue interests outside of speech therapy.
12. There will always be more work to do.
Don’t stay until 11 pm finishing all your paper work or organizing or being your Type A self. The work will be there tomorrow. Create boundaries for yourself to exist separately from speech. All of those times that I stayed late to make sure my paperwork was perfect or to make sure all of it was done THAT DAY…what difference did it make, honestly? We should all strive for that ideal, to make sure our notes are all done at the end of the day, but things happen. Sometimes I have to spend the 15 minutes I would have spent working on a note, looking for a patient’s nurse. Whatever. I was still doing work. Do you know how many times I have received an award, recognition, or pat on the back for working extra hours or making sure my paperwork didn’t contain superfluous commas? Never. I never have. No one cares. While you are new and getting the hang of things, you need to take extra time to get good at your things. But don’t consistently clock out to catch up on paperwork. This is essentially you telling yourself that you don’t respect your own time and, instead of being a “hard worker” and perfectionist like you think you are being, you are actually being self-limiting. You aren’t allowing yourself to grow in a space where you can becoming more efficient with the use of your time or multitasking/delegating ability. In year 5+, this and #11 are new things that I have been working on lately. I feel very late to the game and wonder what I could have gained if someone told me this sooner. I am also trying to remind myself that what I perceive as my 80% is someone else’s 100%. Really. So I’m trying to function in this space of 80% capacity to dial back my anxiety and perfectionism and rigidity because they will only cloud my judgment and my ability to focus.
13. It’s okay not to have rabid love for speech-language pathology.
I think because grad school was ALL SPEECH ALL THE TIME, I thought I had to be in love with speech therapy and worship at the alter of ASHA. It’s ok to not like it sometimes. It’s hard and a lot of days suck. We won’t all go home with smiles on our faces. Sometimes you encounter some messed up, sad stuff. Sometimes you evaluate someone and you realize they just won’t get better. Sometimes you have all low-level dementia patients that don’t remember any thing from day to day or you have a swallowing patient that literally screams at you because they are mad about their diet. It is not shiny happy kisses on the hand and “Oh, you have helped me so much!” Very likely, no one will thank you. People (even family members and your patients’ social worker) will outright tell you that speech therapy isn’t really on their radar. You will spend time on a Provale cup inservice for the kitchen that you give to managers who then never pass it on to staff. But you know what? I did my best and that is all any of us can do. For all the misses in a day, sometimes I will get a few hits and for that 1 person out of 100, they are glad that I was there in some capacity…even if it was just to write their discharge date on their calendar.
I’ve thought about writing this post for a while and I think…I think this about covers it although I’m sure there are more. After I completed writing this post, I asked some other SLP friends and coworkers along the way what they would tell their CF selves and here is what they said:
“Let me think about it so I can make sure it sounds good.”
I’m not kidding!!! Every. Single. One.
And then once they perfected their thoughts:
Michele: “It’s all gonna be ok. I was so worried (and still am) that everyone knows what they’re doing and has it figured out. I think we all leave grad school with different skills and figure the rest out as we go. Other people just seem more confident and competent because they don’t have crippling anxiety like I do at times. Trust your gut. I think I thought that was a stupid adage. But often my guy tells me something and then it takes a while for my brain to catch up. But ultimately, when I have time to logic it out, my gut was right 95% of the time. We take the “skilled” part of what we do for granted sometimes because it seems so obvious. But it’s good to check in with the larger population and realize that they really do have no idea and teaching basics IS skilled most of the time. Find a mentor. Especially if you’re all alone. I think we get feral sometimes if we don’t have anyone to talk to.”
Linnea: “Try to relax and take every experience as a learning experience. Sometimes things are going to suck and you won’t know what you’re doing because you don’t learn everything you need to know in grad school. And that is ok. And sometimes when you’re angry, keep your thoughts to yourself and don’t say them out loud.”
Grisel: “I would tell my CF self that: you will never have all of the answers nor be the most perfect therapist. You will eventually find your groove but this job will always required continued learning, questioning, and trying. That’s what makes a good therapist. So, don’t be so hard on yourself!!”
I will add more responses as I hear back! Thanks to all who contributed!
What would YOU tell your little baby CF self???