For most of us the answer is grad school, maybe the clinical fellowship year if we were lucky. And then we got li…

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She was working with a three-year-old who still wasn’t chewing, but before she told us much about the child, she explained everything that had gotten in the way. Mom canceled often. He’d been on her caseload since March. She knew she probably should have referred him out by then.

By the time we got to the child himself, we had about two minutes left. We didn’t know much about his feeding history or what he actually did with different textures. We hadn’t talked about sleep, breathing, tongue posture, or much of anything that might have helped us understand what was happening.

She left the call feeling encouraged.

But encouraged and helped aren’t always the same thing.

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The version you rehearse in the car

If you’ve ever presented a case to a mentor or colleague, you know how easy it is to edit the story before you even get there. You think about the parts that might make you look less competent and figure out how to explain them first.

Four months without much progress becomes, “We’ve been working on this for a while.” The thing you tried that didn’t work gets a much softer description. And if you’re not really sure what’s going on, you might bury that somewhere in the middle of a very clinical explanation.

I don’t think that’s dishonest. I think it’s self-protection.

Most of us have been in situations where admitting we didn’t know something felt uncomfortable, so we learned how to make uncertainty sound a little more polished.

The problem is that when you spend your time defending the case, you don’t leave much room for someone to actually help you with it. They’re hearing your explanation of why things haven’t worked instead of getting enough information to help you figure out what to do next.

You’re not asking for a verdict

A lot of the time, there’s a second question underneath the case we’re presenting: Am I doing a good job?

We don’t necessarily say it, but we’re hoping the person listening will tell us that we’re on the right track.

And usually, they do. They’ll say, “That sounds like a tough case,” or “I think you’re doing the right things.” It feels good to hear, especially when you’ve been questioning yourself.

But you can walk away feeling reassured and still have no idea what to do differently when you see that child again.

If you want useful feedback, give the person something specific to respond to. “Any thoughts?” is pretty broad. A question like, “I’m having trouble understanding why he can chew on one side but won’t move food across midline. What would you look at next?” gives someone a much better place to start.

Give them the child, not the whole chart

When you present a case, start with the basics. Who is this child, and why are they seeing you? A three-year-old with a limited diet who is down to eight foods and gags when offered texture gives me plenty to work with at first. I don’t need the entire intake before I can start thinking.

From there, tell me what you actually observed. This is where I think clinicians sometimes get stuck because we’re so used to summarizing our findings.

“Poor oral motor skills” might be what you wrote in your note, but it doesn’t tell another clinician very much. Tell me what the child did. Maybe he bit the cracker, kept it on the right side, didn’t move it across midline, and swallowed it in pieces with his head tipped back. Now I have something I can picture.

Once we know what you’re seeing, give me the history that might change how we interpret it. How did feeding go as an infant? Breast, bottle, or both? What happened when solids were introduced? How does the child sleep? Does he snore or mouth breathe? Is there a history of a tongue tie or release? Who performed it, and what changed afterward? Has anything changed recently?

You also don’t need to give me a play-by-play of every therapy session. Tell me what you’ve actually tried and what happened. If something worked, tell me. If something didn’t work, tell me that too. Honestly, the thing that didn’t work may be more useful to me.

And then tell me where you’re stuck. Give me one question you want help answering.

You don’t have to explain yourself first

One of the easiest things to leave out is everything you were planning to say about the family’s attendance. You don’t need to spend the first few minutes explaining how many appointments Mom canceled or why you haven’t tried a particular approach yet.

That information might matter at some point, but it probably isn’t the reason you’re bringing the case to someone.

The same goes for the theory you’ve already decided on. If you open with, “I think this is sensory,” you’ve already framed the case for the person listening. They’re now reacting to your interpretation instead of looking at the child with fresh eyes.

You might be right. But you might not be.

Give them the observations first. Let them tell you what they see in the information you’ve shared. If they notice something you completely missed, that’s exactly what you wanted from the consultation.

It’s okay to say you don’t know

You can say, “I don’t know what’s going on here.” That’s not a bad thing to admit.

The problem is when that’s all you give someone.

Compare, “I’m not sure. I feel like I’m missing something,” with this: “He’s had six months of therapy. He chews on the right but doesn’t move food across midline. He snores and mouth breathes at rest. I tried texture grading and didn’t see it carry over. I expected more change by this point, and I’m not sure what I’m missing.”

Now I know where you’re stuck. I can start asking better questions.

“I don’t know” is a sentence about the case. It only becomes a sentence about you when you say it without showing your work.

Pay attention to the questions they ask you

You can present a case well and still walk away without much help. Sometimes the person you’re asking simply isn’t the right person for that case.

One thing I pay attention to is what happens next. Does the person immediately tell you what they think, or do they start asking questions?

“What does his tongue do at rest?”

“What happens when Mom feeds him at home?”

“What is his sleep like?”

“Has anyone looked at his airway?”

Those questions matter. They tell you the person is trying to build a picture of the child instead of just reacting to the summary you gave them.

And ideally, you leave with something you can actually take into your next session. Not just “keep working on chewing,” but something more specific: “Try placing the cracker on the left and see whether he can move it. If he can’t initiate lateral tongue movement on that side, that may tell you something about what needs to be addressed first.”

That’s the kind of feedback that changes what you do.

There’s nothing wrong with hearing, “That’s a hard case,” or “I think you’re doing a good job.” Sometimes you need that, too. But if you leave feeling better without feeling any clearer about the case, you received support. You didn’t necessarily receive consultation.

Both are valuable. They just serve different purposes.

This matters beyond the one case

There’s another reason I think learning how to present a case well matters. Over time, people notice the clinicians who can talk through a complicated case without pretending they have everything figured out.

They’re the ones colleagues start calling when they have a difficult patient. They’re the ones other professionals remember because they ask thoughtful questions and can explain what they’re seeing. You don’t build that reputation by having an answer for everything. You build it by being able to say, “Here’s what I’m seeing, here’s what I’ve tried, and here’s the part I can’t figure out.”

That takes practice. So does knowing what information actually matters and being comfortable enough with your own uncertainty to let someone else challenge your thinking.

Try this with one case.

Think about the case you’ve been sitting on. The one you keep meaning to bring to a mentor or colleague but haven’t because you’re worried about how it will sound.

Bring that one.

Don’t spend the first few minutes explaining why the case is difficult or why things haven’t gone the way you hoped. Give them a quick picture of the child, tell them what you’ve actually observed, share the history that matters, explain what you’ve tried, and tell them exactly where you’re stuck.

You might be surprised by how much more useful the conversation becomes when you stop trying to prove that you’ve done everything right.

And you may learn something else, too: sometimes the most valuable part of consultation isn’t getting the answer. It’s having someone ask the question you didn’t think to ask.

So tell me: what case are you sitting on right now? Give me the one-sentence version. The version you’d normally clean up before anyone else sees it.

The biggest shift in my clinical practice wasn’t that I suddenly knew more about airway. It was that I stopped asking what should I try next and started asking what is keeping this child from responding to good therapy. Those questions sound similar but they take you in a completely different direction.

In this episode, I share what changed in my evaluations after that shift, and why it made my referrals fewer, clearer, and more specific.

In this episode:

• Why the clinicians we think of as highly experienced are usually asking better questions, not carrying a bigger toolbox

• How training in silos leaves us fluent in individual parts but unprepared for the child whose presentation doesn’t stay in one box

• The order Hallie now uses in every evaluation: breathing and sleep first, state regulation second, structure third, function fourth, presenting concern last

• The 18-month-old whose parents came in expecting a tongue tie referral and what a broader look actually revealed

• Why restriction present does not automatically mean release indicated, and how that one distinction changed her referral patterns

• What a strong referral looks like versus a vague one, and why the difference matters for collaboration

• How to talk to families about uncertainty in a way that builds trust instead of eroding it

• What to do when you identify an upstream concern but the family can’t get an appointment for months or the medical exam comes back unremarkable

• Why integration doesn’t feel like more information piled on top of what you already know

What has stayed with me is this: every clinician in that binder did good work.

The ENT completed a thorough airway evaluation and documented the findings. The reflux concerns were properly assessed. The allergist ordered the right tests and interpreted the results correctly. The feeding therapist who saw him before me had done solid work on food textures. I would have been comfortable putting my name on that treatment plan.

No one was careless. Every provider answered the question they were asked to answer and documented it well. If someone reviewed that chart for quality of care, each note would meet the standard.

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She told me she had already tried the usual ways of getting her name out there. She visited pediatric offices, dropped off business cards, and shared posts about her services on social media. But nothing really changed.

Instead of talking about marketing, I asked her a clinical question.

“When a child comes in with feeding difficulties, poor sleep, an open-mouth posture, and limited tongue movement, what goes through your mind?”

She paused for a moment before answering.

“I know something else could be going on,” she said. “I’m just not sure what it is yet. So I work on feeding and hope things improve.”

That was the real issue.

She didn’t need to spend more time promoting herself. She needed more confidence in understanding what she was seeing so she could manage those cases with confidence.

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In this episode I walk through what fall does to nasal breathing, what changes downstream when the nose stops working well, and why an open mouth is information to interpret rather than a habit to correct. If you’ve ever hit October and quietly wondered whether you lost your edge, this one is for you.

In this episode:

• The seasonal pattern Hallie missed for years and what finally made it visible

• Why an open mouth is an accommodation, not a behavior, and what changes when you start treating it that way

• What reduced nasal breathing can do to tongue posture, chewing efficiency, speech carryover, and sleep

• The three-year-old articulation case that made Hallie start asking about sleep when she had run out of ideas

• What belongs in your documentation when you’re observing a breathing pattern but not diagnosing it

• How to write a referral that is specific enough to actually be useful to the provider receiving it

• What to do during sessions while a family is waiting on a referral

• Why a normal medical exam does not mean you stop documenting what you see functionally

• How to know when several stalled cases are a clinical pattern and not a verdict on your skill

Before you go: Add a nasal breathing and sleep check to your next five sessions, including the straightforward ones. Watch the child at rest for 30 seconds. Ask how often they snore and whether they sleep with their mouth open. Come back here and tell me what you noticed. I have a feeling at least one of those five will change how you write the plan.

Resources:

Free screening training at feedthepeds.com/training

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Thursday at 4:30 p.m.

Her fall schedule was already full.

A few days later, a relative of one of my current clients called. Her child had been on the waitlist since spring. The same pediatrician had referred her child to both of us.

You could hear how tired she was.

When I offered her the spot, she said yes right away and didn’t even check her calendar.

She was surprised by how quickly her fall schedule had filled up. It was only the middle of August.

But August gets busy. Families want appointments before school starts so referrals start coming in. Everyone starts figuring out their fall schedules at the same time.

Then suddenly, it’s November.

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And you’re looking at your calendar wondering how you got so booked.

I did the same thing for years.

I treated every open hour like lost money when I was still seeing clients because full hour meant I was working and earning.

So I kept filling the calendar because I thought that meant I was running my practice well.

Boy, was I wrong.

A full calendar doesn’t always mean you have a good schedule.

There’s a difference between being fully booked and having a schedule that actually works for you.

Every decision feels like the right one when you’re making it. Which is why this is so easy to overlook.

Think about this, my friends: A family reaches out because they need your help. They were referred by a doctor you trust, so naturally you say yes.

Another child is only available on Thursdays at 4:30 p.m., and you happen to have that time open, so you book it.

Then a colleague asks if you can cover for them while they’re away for a few weeks, and you agree.

You see, none of those decisions are wrong. In fact, they’re all reasonable.

The main challenge is that they add up over time. And before you know it, your schedule is built around everyone else’s availability instead of your own.

One day, you look at your calendar and realize it’s not the schedule you would have chosen for yourself. (I know. How did we even get here? 🤯)

Because the truth is… a calendar can be filled with good decisions and still not support the way you want to work.

Plan your week before you start filling it

One huge mistake we make a lot (yes, me included) is opening the calendar too soon.

We see an open spot, so we fill it.

Makes sense, right?

Then fill another one.

…and another.

Before we know it, the whole week is already booked, and there’s barely any time left for notes, meetings, or anything outside of work.

So try planning your week before you start filling it.

First, decide how many hours you actually want to see clients each week. And I mean actually.

But don’t use your busiest week as the goal. Think about what you can handle without feeling drained, while still having time for your notes, meetings, and/or life. (Having time to do things outside of work is very important too, friends!)

Now I want you to look at each day.

When do you want to start seeing clients?

When will you take lunch?

When will you finish your notes?

What time do you want to be done for the day?

If you have school pickup or a few hours you want to keep open, block those off first.

THIS part really matters.

Now that you know what your week should look like, then you can start filling in the clients.

You’re not looking at every open spot and thinking, “Well, I guess I could put someone here.”

You already know what fits.

And what doesn’t.

It takes a few extra minutes at the beginning.

Honestly…I’d rather spend five minutes planning my week than spend the next four months wondering why I agreed to that 4:30 p.m. Thursday slot.

When to say no

In my experience, the hardest people to say “no” to are usually the ones you really want to help.

When a family calls because their child needs therapy or when someone you trust referred them.

You know you can help.

The only problem is…you’re already FULL.

I still hate these conversations and I wish I could say yes to everyone, but I can’t.

And yes, I feel bad about it.

But I’ve learned that feeling bad isn’t a good reason to squeeze someone into a schedule that’s already full.

If I don’t have an opening, I just tell them.

I’d rather be honest than give them a time that I already know I can’t keep up with. Especially if I know another clinician who might be a good fit. So I’ll just send that clinician their information.

If I don’t, I’ll offer to add the family to my waitlist.

But is that what they want to hear? Most probably not.

But it’s better than saying yes today and realizing a few months later that I can’t give that child the time and attention they need.

Sometimes saying “no” is the more responsible choice.

The financial side we don’t always think about

Here’s a little fun fact: the schedule you build this fall will affect your income for the next few months.

Because for a lot of us, August is when it starts filling up.

It’s really easy to look at an open spot and think to yourself, “Sure, why not?”

But then you do it again…and again.

Until you look at your calendar and think, “Wait a minute. When did I agree to all of this?” 😅

My friends, the problem is not saying yes to one appointment. It’s saying yes over and over without stopping to look at your whole week.

Because not every hour you work has the same value.

It’s easy to end up with a schedule full of appointments that push you into working late, rush your notes, or eat into time you could’ve used for something else.

And at the end of the month, you may be working more hours without actually making more money.

That’s the part we don’t always think about.

So I suggest, before you fill every open spot, take a step back.

Look at your fall schedule and decide how many hours you want to work.

Then think about which hours work best for you.

Leave enough time for notes and admin work.

And leave time for the other things that help keep your business running, (Yes, even the boring stuff.) and your personal life too.

Once you look at it this way, saying yes or no gets so much easier.

Here’s what you can do this week…

Look at your fall calendar. Is there one appointment you wish you hadn’t said yes to?

Pick one.

Now ask yourself: If this appointment came up today, would I still take it?

And don’t just look at what you make from that one session. Look at how much time it takes from your week, too.

If you wouldn’t take it today, that tells you something.

You don’t have to change your whole schedule overnight. Start with one appointment and go from there.

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Initially, nothing about his eating pattern seems particularly noteworthy. His jaw is moving, he demonstrates rotary chewing, and his lateralization look…

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In this episode I walk through the airway connection I wasn’t routinely a…

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More often, the challenge is that we were trained to evaluate connected systems separately, even though the child is presenting as one whole, connected story.

In this live, I explored what changes when we stop treating feeding, oral function, airway, tethered tissues, posture, regulation, sensory needs, and speech as isolated concerns and begin asking better questions through an integrated clinical lens.

Inside this conversation, we cover:

• Why treatment plans can make sense on paper but still fail to create progress
• How relationships between systems can reveal what isolated strategies miss
• Why collecting more information is different from strengthening clinical reasoning
• What it means to read a complex case as one connected story
• How mentorship, application, and community help integrated thinking become second nature

You may not be missing a piece. You may simply need a more integrated way to read the pieces already in front of you.

If you’re ready to move beyond siloed clinical thinking, watch the replay and learn more about The Integrated Therapist™.

Doors close July 31 at midnight.

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He came to me for speech and feeding. The family was doing everything we worked on in our sessions consistently but he wasn’t hitting his goals the way I had hoped. So I kept switching things up. I kept taking a new approach but I always asked myself the same question over and over: Is it the approach, or is it me?

I kept my focus on speech and didn’t really look into his feeding patterns because that’s what I’d been trained to do. And I couldn’t figure out why a kiddo doing everything we practiced still wasn’t progressing.

Then one day I realized I should stop looking at his speech and his feeding as two separate things. So I looked at his whole mouth and the answer was sitting right there.

The same tongue that couldn’t move food side to side, also couldn’t lift to produce sounds. The same muscle pattern that made it hard to form a bolus was driving his articulation errors too.

I hadn’t missed a finding, I had missed the connection between the findings because nobody had ever taught me to look for it.

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A child came in and their tongue tip couldn’t touch the roof of their mouth, so I evaluated their tongue posture, the resting position of their tongue and the strength of their lip muscles to ensure it was adequately sealing around a cup. A child struggled with transitioning to table foods…

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People assume I’ve always lived this way, that I’ve always read ingredient labels, reached for a homeopathic remedy first, or thought about health through the lens of the whole body. Not even close. I wasn’t raised this wa…

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The girl would mouth a new food, hold it, and then it would just sit there, or fall back out, or get parked in a …

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I was sitting across from someone on my team who was struggling, and it hit me with a sinking clarity that I had no idea how to help her. I knew how to assess a child. I knew how to build a treatment plan, run a session, counsel a parent through a hard diagnosis, and I had years of training in all of it.

But the thing in front of me wasn’t a clinical problem, it was a human one. How do you grow a person, hold a standard, have a hard conversation without crushing someone, and build a team that actually holds together? On all of that, my graduate program and my clinical fellowship and my stack of CEUs had handed me precisely nothing. I was an expert clinician and a complete beginner at the actual job I now had.

If you’ve crossed from doing the work to overseeing the people who do the work, you know this disorientation. You were excellent at the thing, so you assumed you’d be at least competent at running the people who do the thing, and then you discovered they’re not the same skill at all.

Nobody warned you, and you’ve been quietly improvising ever since, hoping it’s working. I want to name that gap honestly today and start filling it, because it’s the one almost nobody in our field will say out loud.

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That reflex ran my life for a long stretch, and I see it …

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