I’m living this right now as a parent. After an insurance change I am searching for new providers for my son, and before anyone will even put us on the calendar I am expected to sit alone with a screen, type out his entire history, and then receive reminder after reminder nagging me to finish. Nobody has spoken to me. Nobody has asked what he needs. The message I receive from that experience is that this practice is more concerned with its dollars than with my child.

Now think about our patients. Someone who survived a stroke, a head and neck cancer diagnosis, a traumatic intubation, or months in the ICU is being told to relive the worst experience of their life inside a cold online form, with no clinician on the other side to listen, respond, or check on how they are doing while they write it.

This is not just my opinion. SAMHSA’s trauma-informed care guidance states that even routine practices, including intake, screening, and assessment procedures, can retraumatize a person when we implement them without considering the harm they might do, and that trauma-informed care begins at the very first contact someone has with an organization. In a practice that gates scheduling behind a completed history, that first contact is the form, and nobody from the practice is in the room for it.

The cost of getting this wrong is measurable. Retraumatization during medical encounters is associated with distrust and decreased use of health services. The same patient who abandons your form is the patient who never shows up, never calls back, and never adheres to the plan of care you worked so hard to build.

I understand the pull toward automation, because every one of us is being sold an AI intake tool right now and I know how thin our teams are stretched. But a required field is a decision about who gets care. When scheduling is locked behind a completed history, we are telling the people who need us most that their access depends on their willingness to relive that history without any support.

So the question I had to answer for the clinic I’m building was never whether to have an intake form, because we need one. It was which fields get to be required, what happens to everything else on the form, and who on our team is the human being on the other side of it. That is what the rest of this piece is.

The only fields we will ever require

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There is a specific kind of professional loneliness that comes from working in a population the research hasn’t caught up to yet. You go to the courses. You read the tutorials. You do the reasonable thing and try to apply what exists to the babies in front of you. And then it doesn’t quite fit, and you are standing there with a clinical decision to make and no evidence to hand your team.

That is the situation Karli Negrin, MA, CCC-SLP walked into, and Ep 409 is the story of what she did about it.

Karli is an SLP at Nemours Children’s Health and Co-Chair of the Cardiac Newborn Neuroprotective Network. She has spent close to twenty years in a cardiac intensive care unit with infants who have critical congenital heart disease. If you have never worked with this population, the short orientation is this: most of these babies are born at term, they receive cardiac surgery within days or weeks of birth, and their early feeding development gets interrupted by cardiac instability, surgery, sedation, intubation, and a long hospitalization.

Why the NICU literature doesn’t transfer

For years, cardiac SLPs did the sensible thing and reached for neonatal feeding research. Karli did it too. These are infants, swallowing development is swallowing development, and the NICU literature is genuinely excellent.

The trouble is the developmental trajectory. A premature infant is on a long runway. An infant with cCHD is on a short, violently interrupted one. Karli used feeding on high flow as her example, and I thought it was the clearest way to see the problem. There is thoughtful research on why feeding on high-flow respiratory support may not be safe in neonatal populations. But if this baby has four days to feed before surgery takes them out of oral intake for weeks, the calculus around offering a safe, guided feeding opportunity might look different than it does in the NICU. Same procedure, different stakes, different clock.

Infants with cCHD are also frequently excluded from neonatal feeding and dysphagia research cohorts. So the evidence base guiding infant feeding management was, in a real sense, built without them.

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What we do know is already a culture shift

Two findings from the cCHD dysphagia literature are still working their way through units:

Infants with cCHD are at risk for aspiration regardless of surgical STAT category, the score surgeons use for surgical complexity. And they are at risk even when vocal fold mobility is intact, if the surgery involved the aortic arch. For a long time the practice was to run a swallow study when ENT documented vocal fold motion impairment. Karli’s unit now studies infants who had work around the aortic arch regardless of vocal fold mobility.

More than half of infants with cCHD experience feeding difficulty in the perioperative period. Delayed prenatal brain growth, genetic influences, respiratory compromise, abnormal pharyngeal and esophageal motility, sedation, intubation, and prolonged hospitalization all contribute.

If you work in a CICU and have been arguing for more instrumental assessment than your team is used to, that is the evidence behind your argument.

The lit review that wasn’t there

Karli’s unit moved toward promoting breastfeeding, which is what we should be doing, and that created a diagnostic gap. She needed a way to evaluate breastfed infants post-operatively, and FEES does that.

Bringing any new diagnostic procedure into a cardiac ICU means going to the executive cardiac team. They asked for a literature review. Fair. She went and looked, and there was one published study on FEES in infants with congenital heart disease, done in the outpatient setting with a mean participant age around 5.4 months. Nothing about perioperative infants in a CICU.

Then there is the guidance problem. The AB-SSD Pediatric FEES Task Force put out a pediatric FEES tutorial in 2023 that is genuinely comprehensive and worth reading if you scope kids. It also identifies cardiopulmonary instability and medical fragility as contraindications or relative contraindications. Every infant in a CICU is, by definition, medically fragile and at risk for cardiopulmonary instability.

So your field’s own guidance names your entire caseload as the exclusion criteria. Karli’s response was not to abandon the question and it was not to quietly do the procedure and hope nobody asked. She went and found out what everyone else was doing.

The survey

Her team included cardiac SLPs from multiple institutions, an infant FEES content expert, the chair of her aerodigestive program, and a cardiac intensivist. They asked the field: who is doing this, on which patients, and how are you monitoring them?

58% of respondents reported performing FEES in their CICU. Of those, 71% still identified VFSS as their primary instrumental assessment. Most centers reported no lesion-specific inclusion or exclusion criteria, and most had no institutional physiologic thresholds for stopping the exam.

Sit with that middle number for a second. The majority of clinicians who have brought FEES into their CICU are still reaching for the video swallow study first. Their stated reasons were sensitivity concerns, given that dysphagia in this population involves pharyngeal and esophageal components that FEES may not fully capture. Parent and patient stress, which matters enormously in a population already receiving repeated painful procedures and in families already reporting high rates of stress, anxiety, and depression. Lack of training. And uncertainty about physiologic tolerance.

The last finding is the one with the clearest call to action. Most centers doing this procedure are doing it without written patient selection criteria or stopping parameters. Not because anyone is being careless, but because nobody has published them yet.

The workflow that might already exist

One of the more practical parts of our conversation was about the postoperative NPL. Infants who have surgery around the aortic arch, a Norwood or a BTT shunt repair, are frequently scoped by ENT as part of the standard perioperative pathway. The scope is already going in. Extending it to look at swallowing is not a leap.

The complication is timing. Those NPLs tend to happen while the infant is still somewhat sedated or in the first hours to days after extubation, which is exactly when you would want to give a swallow some grace to recover, and before the baby has had feeding experience. Pushing the scope later would give you a more meaningful swallow exam. But in Karli’s institution and plenty of others, intensivists are using NPL results to decide on enteral tube feeding, including whether to feed gastrically or post-pylorically, which is itself not firmly evidence-based. So delaying the NPL means untangling a decision chain that has nothing to do with you.

Karli also named where VFSS still wins for her. Fatigue and stamina testing. Keeping a scope in for the length of time she would normally need to assess fatigue is less tolerated in this population. And for certain cohorts, like single ventricle patients with left ventricular dysfunction, the question of how much pain and stress a baby can absorb without physiologic compromise is a real one. Her institution built a decision-making tree for FEES versus VFSS because our professional field has not given them one. They are also running a feasibility study on tolerance, hoped for publication this year. Her preview: there were physiologic changes during the procedure. That is exactly the data the field needs.

The article that rearranged her practice

I asked Karli about the research paper that most changed how she practices, and her answer knocked the wind out of me a little.

The article introduced the concept of parental role alteration. It describes what happens when a parent watches someone else do the parenting they had imagined doing. Someone else holds the baby. Someone else feeds the baby. Someone else comforts the baby when the baby cries. You are looking in from outside on the care of your own child. The study measured a range of variables, and parental role alteration was the strongest predictor of depressive symptoms in mothers of infants with CHD.

Karli read it and saw herself in it. She was the one doing the first feed. She was the one comforting the baby, in front of the mother, because the baby was critical and had dysphagia and it required skill. She said she used to approach the bedside with a version of “your baby is too sick, so I have to do this,” and she is mortified by it now.

I have my own version of this. My son was in the NICU for 15 days. My mother was a NICU nurse for 40 years, which you would think would have made it easier and did not. The thing I remember is not being allowed to touch or hold my own baby, and the answer always arriving as a flat no rather than as an explanation or an offer to help.

What Karli did with that article is the part worth copying. She emailed the first author and grilled her. Then she took it into her work. There is now an international QI project through the Cardiac Newborn Neuroprotective Network across 15 institutions looking at how to get mothers safely feeding their own babies in the CICU.

That reaches past cardiac. Any of us feeding a baby in front of a parent is standing in a role that parent expected to hold. How we hand it back, and how we explain why we are holding it in the first place, is a clinical skill. Most of us were never taught it.

“Just an SLP”

Karli called herself “just an SLP” a few times, always with the quotation marks audible. She does not have a PhD. She started by advocating hard for a pediatric medical placement in grad school when Towson wanted to send her to a school setting, landed in a CICU with good mentors, and got hired there straight out.

Her advice to anyone earlier in this than she is: do not be afraid of asking a clinical question and starting to collect data on it. That is research. You do not need a grant to begin. She describes collecting little stones and berries, noticing trends, then attaching herself to a fellow who needs a research project to graduate. That is how a clinician with no research background ends up first author on a survey of practice published in AJSLP.

The cardiac SLP community is small. Karli’s word for it was mighty. They have a listserv, they network at conferences, and they are moving practice in this population by talking to each other.

If you have been sitting on a question your unit can’t answer, this is the episode to listen to.

Reference: Negrin K, Willette S, Godsil J, LaManna S, Garcia R, Morris K, Jones C, Morrow M, Wiscount J, Meyer-Macaulay C, Aaronson N, Reynolds J. Perioperative Management of Dysphagia Within the Cardiac Intensive Care Unit Utilizing Flexible Endoscopic Evaluation of Swallowing: A Survey of Practice. Am J Speech Lang Pathol. 2026 Mar 10;35(2):763-771.

Listen to Ep 409 at SYPPodcast.com/409. Karli is on Instagram at @chd_slp and welcomes questions from SLPs.

What a FEES Competency Program Should Actually Look Like

I want to talk about something that has been bothering me for years, and this episode with Lindsay Iser, M.S., CCC-SLP finally gave me the right person to talk about it with.

Our field has a competency problem with FEES. Not a training problem. A competency problem. Those are different things, and the difference is where patients get hurt.

Training is the two day course. You show up, you hear about anatomy and scope handling and maybe scoring scales, you pass a scope on a mannequin and on a colleague, and you leave with a certificate. Competency is whether you can walk into a room in a nursing home with a patient who has dementia, no clear history, an anxious daughter, and a bed shoved against the wall, and produce a study that answers a real clinical question without hurting anyone.

Nobody gets from the first thing to the second thing in two days. And yet the way our field is structured, the two day course is often the whole runway.

What Lindsay built

Lindsay is the Director of Clinical Specialty for Powerback Swallow Solutions. The program started as conversations before 2020, driven in large part by their clinical director at the time, David Gerst, and by SLPs in the field who kept saying the same thing: we need FEES at bedside and we cannot get access to it.

They brought in external consultants who had been doing FEES for 15 or 20 years, built the thing carefully, and ran their first training in 2022. Four years later they are doing FEES at bedside across multiple states with a study count somewhere in the range of 13,000 to 15,000.

The training itself is a virtual CEU day plus five days in person. Two or three trainees at a time. That is the whole cohort. Lindsay is explicit about why: any more than that and she cannot give everyone the same attention while they learn to hold, pass, and clear a scope.

Six days sounds excessive until you list what is in it.

Policies and procedures. Disinfectant protocol. Report templates. Objective scales chosen so the entire team has inter-rater and intra-rater reliability. Scope handling and clearing. Frame by frame analysis. Body mechanics. Room setup in a space that was not designed for this. Creating conditions for a successful assessment with a patient who has dementia. A standardized protocol and, just as importantly, the clinical reasoning to know when and why to deviate from it.

None of that is padding. All of it is the difference between passing a scope and running a study.

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The body mechanics piece is the one I want people to steal

Lindsay added biomechanics and setup training because she noticed it missing at every other course she attended, and because she lived it. In the early days of the program she was doing FEES across three states, high driving volume, high study volume, and her body started to fail her. Shoulders, wrists, arms.

She figured that if she was feeling it, the trainees were too, and most of them would never mention it. So she worked with an occupational therapist to build a strength and stretching home exercise program and she introduces it on day one, before anyone touches a scope in person.

I love this for two reasons. The obvious one is career longevity. The less obvious one is patient safety, which is the point Lindsay made and I had not fully connected: a fatigued endoscopist makes worse decisions. If your shoulder is screaming and you are sweating and you are thinking about how much longer this is going to take, you are not thinking about whether that residue pattern changed between bolus three and bolus seven. You rush. You bail early. You miss things.

Comfort is not a luxury item in this skill set. It is upstream of clinical judgment.

On not controlling the outcome

This is the part of the conversation I would put in front of every FEES endoscopist in the country.

Lindsay uses a full protocol on every study, and she takes heat for it. Clinicians ask why they have to do all of this when a shorter assessment would be faster. She has not budged, and she says that 100% of the clinicians who pushed back eventually came around and looked back at their previous practice differently.

Here is the reasoning. Research suggests roughly 60% of patients aspirate on the first administration of a given bolus type. So if you give one sip of thin, see aspiration, and immediately pivot to nectar, what have you learned? You have learned that a person aspirated once. You do not know if it is a pattern. You do not know why. You have not challenged endurance. You have not seen whether it worsens or resolves across a meal. And you have no basis for choosing a compensatory strategy, because you never saw the pattern the strategy is supposed to address.

Lindsay’s framing is that a short, tightly controlled assessment lets the clinician control the outcome. We decide what goes in, in what order, in what volume, at what pace, and then we report the result as though it were the patient’s swallow rather than our own experimental design.

She raised this at a Cleveland Clinic unified care conference last year, in response to a question I hear constantly: what do you do when a patient keeps reporting dysphagia symptoms but the instrumental comes back normal? Her answer was to look at how much of that normal you manufactured.

That question deserves more attention than it gets. A normal study is not neutral. It closes doors. It ends the referral chain, it justifies discharge, and it tells the patient their experience is not real. If we produced that normal by handing someone three sips in a quiet room over four minutes, we did harm with a clean report.

The referral form as a teaching tool

Something I did not expect to find interesting: Lindsay redesigned Powerback’s FEES referral form.

She was getting referral reasons like “I want to see if my patient can tolerate regular.” Which is understandable. It is what the team is asking. It is what the family wants to know. It is also the wrong question to build an assessment around.

The reason to do a FEES is to understand the pathophysiology so we can optimize nutrition, hydration, and quality of life. Airway protection. Vocal fold closure. Residue and where it sits and why. Strength. Timing. Diet consistency is a conclusion you reach from that, not the thing you go looking for.

So she rebuilt the form to prompt the referring SLP to reflect on what they actually want to know. That is a quiet, structural piece of clinical education, delivered at the exact moment the clinician is making the decision. It is a better teaching intervention than any inservice, because it interrupts the thought while it is still forming.

If you run a program, look at your referral form. It is training your clinicians whether you meant it to or not.

Why in-house changes the feedback loop

There is a structural advantage to the in-house model that Lindsay named and that I think gets overlooked.

She sees every referral that comes through the program’s footprint. When she reads comments on those referrals, she can spot patterns: this looks like an explanation problem, this looks like a misunderstanding of what FEES can answer, this SLP thinks a FEES is a diet trial. And because everything is under one roof, she can build and deploy education about it within days.

An independent mobile FEES contractor cannot do that. They can educate the facilities they serve, but they do not get the aggregated view, and they do not have the standing to change how a company’s clinicians are trained. Lindsay has both.

That is the argument for in-house that I do not think gets made enough. It is not just access. It is a closed loop between what shows up in practice and what gets taught.

Language, again

We spent a chunk of the episode on how we describe FEES to patients, which is a hill I will die on.

Lindsay stops people in the hallway when she hears FEES compared to a COVID test. Her preferred description is a small camera gliding along the floor of your nose. It is not going up. It is not swinging around and staying there. And critically, it is not blind, we are watching the whole time.

I presented on this at the ASHA convention last year and I need to publish it, because it keeps coming up. There is literature in ENT and GI on this. The words you choose, your body language, your confidence, and your ease when you walk into that room determine whether you get a study at all. Tell someone you are sticking a camera up their nose and it might hurt but you will be quick, and you have primed them to tense up, refuse, or tolerate exactly two passes. Then you miss the lesion. You miss the backflow. You miss the thing ENT or GI referred you to find.

Powerback now has scripts for both the bedside conversation and the phone call with a POA, because Lindsay could see in the referral data that a meaningful share of patient refusals were really description failures.

That distinction matters. When a patient says no to a FEES, we tend to file it as patient preference. Sometimes it is. Often it is a clinician who described a procedure badly and a patient who reasonably declined the thing they were described.

The evidence for why any of this matters

Lindsay closed with Bice, Galek, and Ward (2023, JAMDA), Imaging Guides Dysphagia Management When Patient Status Changes in Skilled Nursing Facilities. The numbers she cited:

1. 67% of patients receiving a modified diet did not have dysphagia

2. Treatment was provided to 100% of those patients who did not have dysphagia

3. 61% of patients with feeding tubes had no dysphagia

4. Only 45% of patients who were NPO had imaging during their acute stay

Sit with the last one. More than half of NPO patients never got an instrumental during the acute stay. Those patients then transfer to subacute, post-acute, and long-term care with a diet order, a feeding tube, or an NPO status that nobody has looked at.

That is the population Lindsay’s program serves. It is also the population with the least access to imaging, the least ability to travel out for a study, and the most to lose from a wrong call about their diet.

Where I land on this

Lindsay said her dream is that families choosing a SNF for a loved one will one day ask whether the facility has access to mobile FEES. Not Powerback specifically. Anyone. Just that the question makes it onto the list next to therapy hours and staffing ratios.

I want that too. But I want the other half of it just as much, which is that whoever answers yes has clinicians who earned the scope in their hand.

Access without competency is not a win. It is a faster way to make confident, wrong decisions about people who cannot advocate for themselves. What Lindsay has built is the version where both things are true at once, and it took six day trainings, weekly report reviews, an OT-designed exercise program, and a leader who will not shorten the protocol to make it happen.

If you work for a large company and you have been wondering whether in-house mobile FEES is possible, this episode is your proof of concept and your blueprint. Send it to whoever needs to see it.

Listen to Episode 408 at SYPPodcast.com/408.

I want to tell you how this episode happened, because the origin story is the whole point.

We posted something on MedSLP Ed asking whether cognitive rehab really has a place in acute care and the ICU. It’s a fair question and one I hear constantly. The responses came in the way they usually do. These patients are too sick. There’s too much else going on. You get three days with them and then they’re gone. Cognition is a rehab thing.

Nicole Langton-Frost, CCC-SLP, BCS-S sent me a message. She’s been an SLP for 16 years, 12 of them at The Johns Hopkins Hospital, and she now manages acute care rehab therapy there across PT, OT, and SLP. She said, very kindly, that her team would like to talk about this because they’ve spent years building the opposite case. So I had her on with her colleague Carey DeWalt, CCC-SLP, who works on the stroke service and is leading their department’s cognition competency this year.

I want to give you the substance of what they shared, and then I want to talk about the thing underneath it that I’ve been chewing on since we recorded.

The research they brought

Disorders of consciousness. Nicole described a 2016 randomized controlled trial on multimodal sensory stimulation with three arms: standard care, stimulation delivered by nursing, and stimulation delivered by family. Both stimulation groups outperformed the control, and the family group did best. Her interpretation was that salience is doing the work. Generic stimulation is not the same as the smell of the coffee that person drank every morning for 30 years, or the cologne their spouse wears.

She also referenced a pre-proof paper in Archives of Rehabilitation, a retrospective observational cohort of 68 patients in a disorder of consciousness receiving PT, OT, and SLP. Of the 36 in unresponsive wakefulness syndrome, 25% emerged from a minimally conscious state before hospital discharge, and over half of all patients who emerged did so within 30 days. What makes this ours is that the defining signs of emergence are functional communication and functional object use.

And the cognitive motor dissociation research out of the New England Journal of Medicine, where patients who showed no motor response to a command were nonetheless showing brain activation on functional MRI and EEG. Up to 25% of them. People we assumed were not processing anything were processing.

Long-term cognitive impairment after critical illness. The 2013 New England Journal of Medicine study looked at surgical and medical ICU patients, not neuro. About 75% had delirium at some point. At three months, 40% had cognitive function equivalent to a moderate traumatic brain injury. That’s not delirium clearing slowly. That’s a durable deficit in a population nobody consulted us on.

And then the intervention study. A 2023 prospective RCT delivered cognitive treatment twice a week, 30 minutes a session, starting the day before ICU transfer and continuing for six months. MoCA pre and post. Statistically significant improvement over a control group that received everything else. Nicole was careful here, and I want to be careful too: these are small studies, the outcome measures aren’t perfect, and there aren’t many RCTs in this space. Her read, and mine, is that it’s suggestive and worth acting on, not settled.

Preventing delirium. She also mentioned an OT randomized controlled trial where cognitive stimulation activities, some of them delivered by nursing rather than therapy, dropped the delirium rate from around 20% in the control group to about 3% in the intervention group, and shortened duration when it did occur. Which means our contribution isn’t always a consult. Sometimes it’s telling the team what to put in the room.

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Carey’s chart review, which is the practical takeaway

This section is the one I’d go back and re-listen to.

She looks at head imaging on every patient she can, regardless of service. Not just for stroke or hemorrhage or tumor, but for cerebral small vessel disease, also written as white matter disease. It’s graded with a Fazekas score of 0 to 3, where 0 is normal, 1 is expected aging change, and 2 and 3 signal real burden. Grades 2 and 3 have been associated with a 2.6-fold increase in cognitive impairment risk and a 2.7-fold increase in frailty risk. The drivers are the same ones we already know: uncontrolled blood pressure, cholesterol, diabetes, tobacco, sleep apnea.

She looks at sodium and potassium. A patient in significant electrolyte derangement may be disoriented, irritable, foggy, and that is not the moment for a standardized assessment. Informal assessment and multimodal stimulation, sure. The RBANS, no.

Same principle with hepatic encephalopathy. Pre-transplant with high ammonia, you’re offering compensatory strategies to family and nursing. Post-transplant, as labs stabilize, if the impairment is still there, that’s when you assess formally. Nicole made the point that persistent deficits after encephalopathy clears are real and easy to write off as “just metabolic,” which means they travel with the patient to the next setting undocumented.

She looks at ejection fraction. Heart failure means poor perfusion, and poor perfusion includes the brain.

And she stacks all of it. Age, length of ICU stay, number of procedures under anesthesia, imaging findings, labs, cardiac function. She described it as tipping the scales, the same way we intuitively stack risk factors for aspiration pneumonia without needing anyone to prove each one individually.

Who is and isn’t a candidate

They were refreshingly willing to say no.

A right MCA patient who was working full time and driving before admission is a yes. Follow them, get baseline data while they’re acute, because without that baseline the next setting has nothing to measure growth against.

A patient with late-stage dementia admitted for a UTI, whose family already has education and strategies and support in place, is probably a no. Nicole said that’s a social work and care management conversation, and if the family feels supported, they don’t get involved.

But change one variable. Earlier-stage dementia, no education ever provided, admitted after a fall, and the social work note says the family is reporting caregiver fatigue. Now it’s a case. It might be a single session. It’s still worth doing.

Carey’s addition was the one that stuck with me: the patient with poorly controlled hypertension or cholesterol who isn’t taking their medications. Easy to code as baseline noncompliance. Worth asking whether it’s transportation, cost, or nobody ever explaining what the medication is for. Loop in pharmacy. Get them a pill organizer. That’s a cognitive intervention with a readmission on the other side of it.

The thing I’ve been thinking about since

Here’s what I keep coming back to.

Nicole said that when she started at Hopkins 12 years ago, SLP wasn’t treating these patients. They weren’t even doing much swallow treatment. It was eval, re-eval, move on. The practice they have now took over a decade, and it grew out of a very unglamorous habit: when a patient got readmitted within 30 days, they asked what they’d missed.

That’s not a program. That’s not a grant. That’s a question you can start asking on Monday.

I also think there’s something worth naming about why cognition specifically gets deferred in acute care. Dysphagia has a visible, immediate, scary consequence. Aspiration. Pneumonia. Somebody is watching. Cognitive impairment after critical illness has a three-month consequence, and by then the patient is somebody else’s caseload, or nobody’s. The feedback loop is broken, so the work feels optional. That 2013 study exists precisely because nobody was looking, and when somebody finally looked, 40% of ICU survivors were walking around with moderate-TBI-level cognitive function.

The other thing I’d flag: notice how much of what Nicole and Carey described isn’t billable therapy time. It’s telling nursing what activities to leave in the room. It’s calling the family and asking what perfume their mother wears. It’s a fifteen minute conversation about a pill organizer. Our field spends a lot of energy defending our value in productivity terms, and some of the highest-leverage things these two described don’t show up cleanly on a productivity sheet at all. I don’t have a tidy answer to that. I just think it’s worth saying out loud that the gap between “what helps the patient” and “what counts” is real, and departments that have figured this out, like theirs, did it by making a case over years rather than winning an argument in a meeting.

They’re also in the middle of a quality improvement project on their medical ICU, close to 600 patients, pre-post analysis, entirely unfunded and on their own time. Nicole was clear it’s not designed to show causation and probably won’t show outcomes. She’s hoping it shows feasibility and points researchers toward something worth studying prospectively. That’s what building an evidence base actually looks like from the inside, and it’s slower and less satisfying than any of us want it to be.

If cognition in acute care is something you’ve written off because your setting won’t support it, I’d listen to this one. And then pick one patient population.

We’re also running a full learning lab on cognitive therapy inside The Medical SLP Collective next month, across the lifespan and across levels of acuity, with Nicole joining us. This episode is what started it.

Full episode is here

There’s a version of this episode that’s purely about the research, and it would be a good one. Nicole Schaen-Heacock, PhD, CCC-SLP just won first place for the New Investigator Award at DRS for part of her dissertation, and the work is genuinely exciting. But the conversation took a turn I wasn’t planning, and it ended up being the part I keep thinking about.

First, the science, because it’s worth sitting with. Dr. Schaen-Heacock’s dissertation asked whether the timing of swallow-based intervention changes outcomes for patients treated for head and neck cancer. She used a rat model from Dr. John Russell’s lab at UW Madison that allows targeted chemoradiation to the tongue base plus a progressive resistance tongue training paradigm. The animal model is the thing most clinicians never see, and it’s what lets you look past the swallow study into the actual muscle and mechanism underneath.

Four groups, six months of follow-up, and a clear signal: rats who started intervention early had better bolus speed and bolus area than those who started six weeks late. That “six weeks” matters clinically, because it mirrors the patients who don’t get connected to an SLP right away. We talk a lot about proactive intervention in head and neck cancer. This is data putting weight behind the instinct.

What I appreciate about where Nicole is headed is that she isn’t staying in the model. She got into this field to be a clinician, and she’s now moving into human research with veterans and civilians, looking at proactive intervention that’s tailored to the individual and accounting for aging and frailty. That last piece is under-explored, and it’s exactly the kind of question you only think to ask if you’ve spent time with patients.

Which brings me to the part that surprised me.

Nicole went straight from her master’s into her PhD at 24, took a dedicated leave to complete her clinical fellowship year, and came back a better researcher for it. I went the other direction. I was told years ago to go work before pursuing a PhD, and I was frankly annoyed about it at the time. Both of us landed in the same place: the clinical experience is what tells you which research questions are worth asking. You can only glean so much from the literature. At some point you have to go live it.

And then there’s the twins. Nicole mentioned, almost in passing, that she’s a mom of twin toddlers who arrived right as she was starting her dissertation. Dr. Rogus-Pulia uses the phrase “work-life sway” rather than balance, and I don’t think I’ve heard it put better. Sometimes work demands everything and home is covered by the people you’ve asked for help. Sometimes a kid is sick and work can wait, and the world keeps spinning. Nicole spent one Fourth of July weekend doing 15-hour days in the wet lab because a machine broke at the worst possible moment. She doesn’t romanticize it. She just names it as the season it was.

I’ve said for years that you can do it all, just not all at once, and that support is not something to be embarrassed about. If naming your Instacart bill out loud is what lets you be fully present with your kids at bedtime, that’s not a failure of balance. That’s how the sway works.

One more thing she said that I want more early-career researchers to hear. In the middle of a PhD, the unknowns feel enormous, and right now the climate adds a few more. Her message is that there are still real opportunities and a lot of good work happening, and that it does get better. She was convinced she wouldn’t pass her defense until the day of it, even though her mentors would never have let her sit for it unprepared. If you know that feeling, you’re in good company.

You can stream this episode now!

I have a confession. For years, I have been getting messages from listeners, students, and fellow SLPs asking me to cover Phagenesis and pharyngeal electrical stimulation on the podcast. And for years, my honest answer was some version of: “I know it exists, I know people in the field are excited about it, and I don’t know enough to speak to it.”

That is not a great feeling when you run an educational platform for medical SLPs. So I finally did the thing, sat down with Cari Manypenny, MS, CCC-SLP and Alyssa Cook, MA, CCC-SLP from Phagenesis, and recorded what turned into one of the more information-dense conversations I’ve had on this podcast.

Here is what I want to share that I think deserves a little more space than the episode could give it.

The SLP Transition Story Matters

Both Cari and Alyssa are clinical medical SLPs who made the move into the medical device industry. And both of them, at different points in their careers, were skeptics about PES. Alyssa told me she came into her first conversation with the Phagenesis team firing off every question she could think of. How is this different from NMES? How do you even know the electrodes are positioned correctly? Where’s the research?

I bring this up because I think the skepticism is healthy, and it’s something our audience shares. We are a field that has been burned before by technologies that moved faster than the evidence. So I want to name that, and then also say: these are two incredibly rigorous clinicians who went in looking for holes and came out convinced. That shift happened because of the research, and the research is substantial. Thirty-plus years of it.

The Mechanism Is Genuinely Different

I think the biggest thing I got wrong before this episode was mentally filing PES in the same category as surface NMES. They are not the same. They don’t even share the same goal.

Surface NMES devices operate at 30-80 Hz to cause muscle contraction. You’re using the electrical stimulation to make muscles work against resistance. PES via Phagenyx delivers 5 Hz to the pharyngeal plexus, targeting the glossopharyngeal and vagus nerves. At 5 Hz, you’re not contracting muscle. You’re generating sensory input that increases cortical excitation and drives neuroplasticity. You’re telling the brain: something is here, reconnect the pathway, reorganize.

Dr. Shaheen Hamdi, the neurogastroenterologist who co-founded Phagenesis, was one of the first people to use brain imaging to map the cortical control of swallowing. That research started in 1996 and led directly to the development of PES. This isn’t borrowed science from another field. The mechanism was built from the swallowing literature up.

The Patient Population It Was Designed For

Here is the clinical piece I keep coming back to. Think about your most complicated acute stroke admissions. The patients with global aphasia who can’t follow commands. The patients who are too lethargic to sustain any meaningful therapeutic engagement. The patients where you’re doing everything you can think of and ultimately the honest answer is that you’re monitoring and waiting.

We know early intervention matters for dysphagia outcomes after stroke. We know the neuroplastic window is most open early. We know atrophy sets in fast. And we often have no tool that can be used on the most cognitively affected patients in that critical window.

PES doesn’t require active patient participation. The SLP personalizes the dose before every session using threshold and tolerance testing. The stimulation itself is 10 minutes. For patients who have been otherwise unreachable therapeutically, that is a meaningful option.

Alyssa said something in our conversation that I’ve been thinking about since: when stroke patients can’t participate in anything, we often give them ice chips. Not because that’s the best intervention we have, but because it’s the only thing we can do. And then the nursing team and the physicians see that and think that’s what SLPs do. We get reduced to the ice chip people. PES gives us something to actually offer in that moment, and in doing so, it changes how the rest of the team sees us.

The 2026 AHA/ASA Stroke Guidelines

I want to spend a little time on this because I think it’s easy to scroll past and not fully register what it means.

The AHA/ASA Stroke Guidelines were last updated in 2019. In 2026, they were updated again, and PES was added as a recommended early intervention modality for severe dysphagia following stroke. That inclusion was made by an independent committee. It reflects the weight of 30-plus years of research and nine randomized controlled trials in stroke populations alone.

Guidelines move slowly on purpose. That’s what makes inclusion meaningful. The committee reviewed the evidence and put PES in the guidelines because the science is there.

A Few Things to Know If You’re Thinking About Your Hospital

Phagenyx is FDA cleared for severe dysphagia post-stroke, in-hospital use in the United States. It is not currently approved for outpatient use. However, if a patient is readmitted months after their stroke for something else (UTI, hip fracture), and they still have stroke-related dysphagia, that is considered on-label use.

Bringing this into your hospital is a multidisciplinary process. It’s not a device purchase. It’s a program. Phagenesis has a team of therapy development specialists, all with acute care SLP backgrounds, who come on-site and work through implementation with you from the clinical side.

You can reach them at contact@phagenesis.com.

Over 9,000 patients treated worldwide. Zero serious adverse events related to treatment at any stimulation level.

Go listen to the full episode at SYPPodcast.com/405.

I have been thinking about this episode since before we even hit record.

I was in the middle of defending my own dissertation on FEES when we recorded this conversation—so sitting across from a researcher whose work directly mirrors what I have been studying and advocating for felt like one of those moments where everything clicks into place in real time.

Paige DiStefano, MS, CCC-SLP, is a speech-language pathologist and PhD candidate at McMaster University’s Aging Swallow Research Lab. She published a paper in the American Journal of Speech Language Pathology examining what actually happened when FEES was implemented at an acute care hospital that already had regular access to video fluoroscopy. The premise matters as much as the findings: this study was not asking “which exam is better.” It was asking what happens to instrumental assessment access when you have both tools available.

Here is what happened. VFSS volume stayed stable. Total instrumental exam volume went up 25%. ICU instrumental exam completion more than doubled, going from 7.1% to 15.1%. FEES was completed in a mean of 1.2 days for ICU patients, compared to 2.3 days for VFSS.

I want to stay with that number for a second, because I think we hear “one day” and mentally file it under “minor difference.” It is not minor. In acute care, a day is a cascade. You cannot finalize a discharge plan without knowing what a patient can eat and drink safely. If the instrumental exam that gives you that information takes two days instead of one, everything downstream shifts. Family counseling gets delayed. Therapy planning gets delayed. Nursing care decisions get delayed. The patient stays an extra day. Sometimes two. In an ICU bed. The cost, both financial and human, has nothing to do with clinical necessity and everything to do with access.

Multiply that across an entire hospital population, add in the patients who are waiting in skilled nursing facilities or stuck in longer stays because nobody could get an instrumental done on a Friday afternoon, and you are not talking about an inconvenient scheduling gap. You are talking about a systemic problem that is costing patients weeks of their lives and costing healthcare systems money that could go somewhere else.

The language that Paige’s study gives us is genuinely useful. The advocacy argument we have been making, which usually sounds like “FEES is convenient” or “FEES is portable” or “we prefer it for ICU patients,” is fine. But it is small. The argument this data supports is bigger: FEES expands diagnostic capacity. It allows clinicians to choose the right exam for the right patient at the right time. It reaches patients who cannot get down to fluoroscopy. And when it is available, total instrumental assessment volume goes up because more patients get the exams they actually need, not fewer patients getting the same exam in a different format.

This is the argument I want SLPs to be walking into administrator meetings with. Data in hand. Not anecdotes. Data.

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The “weekend effect” that Paige’s study surfaced is one of those findings that, once you see it, you cannot look away from. ICU exam delays were longer for orders placed on Mondays and Fridays, consistent with a backlog that builds over the weekend. Some of those delays are not modifiable. Patient medical status, transport limitations, equipment availability, these are real constraints. But some of them are. Staffing models, protected time for instrumental assessments, reprocessing workflows, ensuring FEES-trained coverage on weekends. These are institutional choices, and they are worth interrogating at your facility.

I want to talk about implementation for a minute, because I think there is a myth that you need a fully built-out, perfectly staffed program before you can start gathering meaningful data or seeing meaningful change. Paige’s study had three independently practicing FEES clinicians at the start. Three. By the end of five months, there were seven. That is not a complete program. And the data still showed real improvements in access and flexibility. That is important for clinicians and managers who feel like their FEES program is too small or too new to matter. It matters. You document it, you present it, and you use it to build the case for more.

On training: this came up in the episode and I have strong opinions about it. The field has developed something of a gatekeeping culture around FEES, where newer or less experienced clinicians are often told they need more dysphagia exposure before they can learn the tool. I think this is backwards. Paige started FEES training during her clinical fellowship year and was doing it independently within the first couple of months. My own conviction, backed by dissertation data, is that early FEES training accelerates dysphagia understanding. When you can see swallowing physiology happening in real time for real patients, your clinical reasoning gets sharper, faster. Withholding that experience until someone has “enough” years under their belt is not protecting patient safety. Thoughtful, mentored, graduated training does that.

Paige also mentioned an article by Paula Leslie called “Worship the Dog, Not the Larynx” on the CAFE blog. If you have not read it, the central idea is that dysphagia care cannot be evaluated only by whether the airway was safe in a controlled clinical setting. Eating and drinking are also about identity, participation, culture, and quality of life. Whether a patient can sit at a baseball game with their family and feel like themselves. That framing is important for goal-setting and for how we measure what success actually looks like in our work.

FEES, honestly, gives us more room to honor that. We can take it into different settings. We can trial a wider range of foods and liquids than we might in a fluoroscopy suite. We can meet the patient closer to how they actually live.

I keep coming back to the conversation Paige and I had about what SLPs tend to advocate for versus what we should be advocating for. We have gotten good at making the case for FEES by listing its features. Portable, bedside, no radiation, real-time secretion management. Those things matter. But when the person across the table is a hospital administrator or a facility director who is deciding whether to purchase equipment, fund training, and protect staff time, the feature list is not what moves the needle. The data does. And studies like Paige’s give us something real to bring to that table.

This is the conversation I have been waiting to have publicly for a while. I hope it lands for you the way it landed for me.

Listen at SYPPodcast.com/404.

If you have spent any time searching for continuing education on neurodiversity-affirming practice as a medical SLP, you already know how this goes.

You find a course. It looks promising. You click through, read the description, and realize it was built for school-based SLPs, or early intervention specialists, or pediatric feeding therapists. Maybe it covers some of the right concepts, but the case examples are not your patients, the settings are not your unit, and the framework was not designed with your clinical reality in mind. So you close the tab and go back to figuring it out on your own, the same way most of us have been doing it for years.

The problem is not that the content doesn’t exist. The problem is that nobody has taken it and built it specifically for us.

Until now.

On June 26th and 27th, MedSLP Ed is hosting a live two-day course called Reframing Clinical Practice: A Neurodiversity-Affirming Approach for Medical Speech-Language Pathologists, taught by Erin Forward, MSP, CCC-SLP, CLC, Expert DIR Floortime Provider, and TBRI Trained Practitioner.

And the price goes up when the course opens on the 26th, so if you want in at 50% off — $148.50 for the live course and the recording — you have three days.

But I want to back up for a second, because the “50% off” part is not the most important thing I have to tell you.

The gap we have all been navigating

Medical SLPs work with some of the most complex patients in the healthcare system. Stroke survivors. Patients with traumatic brain injuries. People with progressive neurological conditions. Premature infants. Adults who have spent weeks in an ICU and are now staring at a spoon and not responding the way anyone expected.

We were trained to assess, to treat, to document, and to move. We were not, for the most part, trained to understand what a dysregulated nervous system looks like when it’s sitting in front of us — and how often we have been calling it something else entirely.

Noncompliance. Poor motivation. Resistance. Behavioral issues. A difficult patient.

Those labels got written in chart notes by SLPs who were doing their best with the framework they had. Most of us have inherited those notes and quietly wondered what we were actually looking at. Because something was happening that the chart did not explain, and nobody gave us the language for it.

The neurodiversity-affirming lens is that language. And it has been almost entirely absent from medical SLP continuing education.

Why the existing courses were not built for you

The courses that do exist on this topic were largely developed for pediatric settings. The examples center around feeding toddlers, school IEPs, autism diagnoses in early childhood, DIR/Floortime with young kids. That content is valuable and real. But it does not translate cleanly to your ICU, your acute care floor, your outpatient dysphagia clinic, or your inpatient rehab unit without a significant amount of mental translation on your part.

And when you are already stretched thin, you do not have bandwidth to spend a full day of CE doing the translation work yourself. You need someone who has already done it.

Erin has done it.

Her course was built to follow the neurodiversity-affirming framework all the way through the lifespan, which means it does not stop at childhood. She built a full section on supporting neurodivergent adults, including late diagnosis, dual diagnoses, masking, therapy-induced trauma, and the questions of autonomy and identity that come with treating adult patients who have spent years being managed rather than understood.

She also covers the neurobiology of trauma and regulation in a way that directly applies to what medical SLPs see every day: a frightened nervous system that reads as noncompliance, a patient who tolerated the evaluation just fine and then shut down completely when real treatment started, an adult on your unit who freezes the moment you walk in and who has been labeled difficult in every note before yours.

This is not a pediatric feeding course with a few slides about adults tacked on at the end. It was built to be relevant across the lifespan because that is what medical SLPs actually need.

What the course covers

Eight hours across two days. Erin moves through the neurobiology of trauma and regulation, gestalt language processing, AAC, scripting, echolalia, feeding through a relational lens, DIR/Floortime, caregiver coaching, ethics, and supporting neurodivergent adults. She closes with case studies threaded across the lifespan so you watch the whole framework come together in real patients.

It carries 0.8 Advanced ASHA CEUs and is registered under ASHA Content Area 2, covering culturally responsive practice and interprofessional collaboration. The recording is included, so if you cannot attend live, you get full access to watch on your own time.

The introductory rate is $148.50. That is 50% off the regular price of $297. It is available until the moment the course opens on June 26th.

Why this one matters

I have been in this field long enough to know when something fills a real gap versus when something just sounds like it does. This fills a real one.

Most of us were handed a compliance-based model in school and sent into rooms with real human beings whose entire sense of safety was running the show, and we were left to figure out the mismatch on our own. Some of us got there through years of clinical experience and a lot of quiet trial and error. Some of us are still in that process. Very few of us got there through formal training, because the formal training did not exist — at least not for medical SLPs.

This course is formal training. Evidence-based, lifespan-inclusive, and built for the clinical realities that medical SLPs are actually navigating. Erin is one of the most knowledgeable people I know on this topic, and she teaches it in a way that does not make you feel ashamed of how you were trained. We were all working with the same incomplete framework. This is how you fill it in.

Register for the live course or the recording here, before the price changes on June 26th!

I did not plan to spend an episode of my podcast hosting a listening party. But here we are.

Episode 403 features Kate Hutcheson, PhD, CCC-SLP, BCS-S, Peter Belafsky, MD, M.P.H., PhD, and Andrew Tritter, MD, three heavy hitters in the swallowing world who collectively decided that the best use of a dinner at the Dysphagia Research Society was to start writing songs about the hyoid bone.

The result is “One Night at La Reserve,” a full-length AI-assisted music album that covers cricopharyngeal dysfunction, retrograde cricopharyngeal dysfunction, head and neck radiation toxicity, patient-reported outcome measures, diadochokinetics, and somehow, Dr. Shaker. The genres span country, blues, hip hop, reggae, Bollywood, and prog rock. It is a completely unhinged project and I am fully here for it.

But I want to say something beyond just “this is fun and you should listen to it.”

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The conversation we had in this episode touched on something that I think about a lot in this field. There’s a moment where Dr. Belafsky and Dr. Hutcheson are talking about one of the songs, “Rad Tox Blues,” and whether they’d share it with patients. It’s a blues track about the long-term consequences of radiation for head and neck cancer survivors. Beautiful melody. Genuinely moving lyrics. And both of them said they weren’t sure it was appropriate to share, because they didn’t know if turning someone’s medical journey into a song could ever fully honor what that person has been through.

That conversation stuck with me. These are two researchers who have spent their careers inside this population. They know the data. They know the faces behind the data. And they still paused.

That kind of care matters.

The album was built using Suno, an AI music generation tool. Dr. Tritter, who is also a lifelong musician, described the process as starting with an idea, feeding it a concept, a genre, specific phrases that had to make it in, and then iterating until it worked. Dr. Belafsky said he contributed roughly 50% of the lyrics on many tracks. The AI filled in the rest. And yes, there was a recurring problem where the AI kept mispronouncing “cricopharyngeal” until they figured out how to phonetically trick it into getting it right.

The RCDP anthem, called “The Rhythm of Release,” is a multi-act prog rock song about the lived experience of not being able to burp. Dr. Tritter, who runs one of the most active RCDP practices in the country and is reportedly one of the few physicians active on the Reddit forum for this patient community, wrote it to walk through the full arc of what those patients experience: growing up not knowing what was wrong, getting dismissed, finally getting diagnosed, getting treated, and what life feels like on the other side.

He now sends it to his RCDP patients. He said it helps them feel like someone actually gets it.

That’s not nothing.

“DIGEST” is the last track on the album and might be the one that lands hardest for SLPs specifically. It reframes the outcome measure as a metaphor for recovery, for getting back to the table, for eating soup in the fall and wine on a Friday. Dr. Hutcheson said she now grades her own days by it. Dr. Belafsky said for him it’s about grace, about what it means to have someone walk alongside you through something hard.

A swallowing outcome measure. A sad girl song. A meditation on what it means to help someone get back to their life. They are, apparently, the same thing.

The album now on Spotify, with all proceeds going to the National Foundation of Swallowing Disorders. You can find it now by searching “One Night at La Reserve,” or, per Dr. Hutcheson, just search “hyoid.” It’s currently the only result.

Full episode at SYPPodcast.com/403.

I was sitting at a bar trying to have one quiet glass of wine after weeks of navigating a hospital situation with my brother when Deb texted me.

I saw her name and thought, oh no, what now. And then I read what she sent and I thought, you have got to be kidding me.

She was going through almost exactly what I had just been through. Same pattern, different hospital, different family member. Both of us watching a system we’ve spent our careers trying to improve fail the people we love in ways that felt both completely predictable and completely unacceptable.

Debra Suiter, PhD, CCC-SLP, BCS-S, F-ASHA has spent her entire career in dysphagia. She directs the Voice and Swallow Clinic at the University of Kentucky. She’s a board-certified specialist in swallowing disorders and a Fellow of ASHA. She has taught informed consent and shared decision making to continuing education audiences for years. She knows the evidence. She’s one of the people who helped create it.

And she watched her father get placed on thickened liquids without an instrumental assessment, then a full liquid diet, then handed a waiver to sign. He signed it. Nothing changed. He signed a second waiver. Still nothing changed. And then, in order for him to have an oral diet, he was asked to declare his DNR status.

He had to sign a do-not-resuscitate order to get a cup of water.

I’ve been screaming about this stuff for fifteen years. And I still couldn’t fully believe it when I heard it.

What actually happened — and why it matters

My brother’s situation followed the same script. He was admitted to the ICU for something completely unrelated to swallowing. He coughed at a meal at the rehab facility he was transferred to. Speech was called. His diet was downgraded to puree and thickened liquids without anyone talking to him, or to my parents who were at his bedside every day. He refused to eat it. He lost ten pounds. He was back in the ICU.

Nobody had asked what his baseline was. Nobody knew he’d had chronic issues his entire life that had nothing to do with why he was in the hospital. Nobody called my family to say, hey, here’s what we’re seeing and here’s why we think this is the right move. My mom got a text at 8pm about a swallow study on his schedule for the next morning and didn’t sleep all night.

That’s the part that gets me, even more than the clinical decisions themselves. The ripple effect of not talking to people. My mom shouldn’t have been up at 3am panicking. That was completely preventable.

The research we have and the culture we don’t

The Langmore paper was published in 1998. It identified the predictors of aspiration pneumonia — and aspiration alone was not the primary driver. Oral hygiene. Mobility. Overall health status. The ability to clear bacteria from the airway. These are the variables that actually determine whether someone who aspirates develops pneumonia.

John Ashford’s three pillars of aspiration pneumonia say the same thing.

The bolus framework exists. The evidence has been there for a generation.

And yet the default response in hospitals and nursing homes across the country is still: patient coughed, restrict the diet, thicken the liquids, done. With or without assessment. With or without a conversation. With or without asking what the patient actually wants or what their prior history is.

Part of this is a training problem. Part of it is facility culture. Part of it is legal fear — SLPs worried about their license, hospitals worried about lawsuits. But the risk math being done in these situations is almost entirely one-directional. We think about what happens if the patient aspirates. We don’t ask what happens when the patient can’t eat, loses weight, becomes malnourished, declines faster, and ends up back in the ICU because of the intervention we believed was protecting them.

My brother did not need to be back in the ICU. That was a consequence of what was done to him, not of his original admission. I’m not angry about that because I want to blame someone. I’m angry because it was preventable, and because the tools to prevent it exist, and because we’re still not using them.

What SLPs can actually do

I don’t want this to just be a venting session, even though Deb and I earned one. So here’s what we actually talked about doing.

Document thoroughly. The conversation with the patient. What they understood. Their goals of care. Their prior level of function. What the family reported. If the team overrides your recommendation, document that too — not as a fight, just as a record. That documentation is what protects you and tells the story if anyone reviews the chart.

Find the committees. A lot of SLPs, especially earlier in their careers, don’t know that risk management and ethics committees exist in their facilities. These are the people whose literal job is to pay attention when clinical practice is causing harm or creating liability. They want to know about this stuff. Go find them.

Build the relationships. Deb talks about this well — forming genuine working relationships with nursing and physicians doesn’t mean showing up with a stack of research articles. It means having conversations, demonstrating that you see the whole patient, earning trust over time. That’s what gets you respected in the room.

Track your own outcomes. You don’t need a published study to make the case internally. What are the length-of-stay numbers? What are the readmission rates for patients with restrictive diet recommendations versus those managed with shared decision making? That kind of data speaks to administrators in a language they understand.

Know when to leave. Some facilities are not going to change, at least not on your timeline. If you’re working somewhere that routinely overrides your clinical judgment and ignores patient wishes, that affects you and it affects your patients. That’s not your failure. That’s a systemic problem, and you deserve better.

The part that doesn’t have a clean ending

The hardest moment in this episode is when I ask Deb to take off her SLP hat and just talk to me as a daughter. She says she felt frustrated, helpless, like things were being done to her father without the information he needed. She says part of her wishes he’d never gone to the hospital at all.

She’s going to carry that for a while.

I’m not going to tell her there’s a silver lining because I don’t think that’s helpful right now. What I will say is that she reached out, we talked about it, and this conversation is going to reach people who needed to hear it. Her father and my brother are not alone. Their situations are not unusual. And every SLP who listens to this and recognizes something in their own practice has the chance to do something differently next time.

That’s not nothing.

Stream it here, and I would love to hear your thoughts.

I recorded this episode a while back and I keep thinking about one thing Marie Jetté, PhD, CCC-SLP said. “There are pulmonologists in New York City who think there is no one in the city who does cough suppression therapy.” Not because SLPs aren’t there. Because we haven’t told anyone we do it.

This week’s episode is with a clinician-scientist and Associate Professor of Otolaryngology at the University of Colorado Anschutz, and her research sits right at the intersection of something I find endlessly fascinating: the science behind why a treatment works, and the real-world gap between that evidence and the patients who actually need it.

We are talking about behavioral cough suppression therapy — which, I want to say right upfront, is a lot simpler than it sounds.

Two to four sessions for most patients. The core technique is a quick sniff followed by a pursed lip exhale. That’s it. But the science behind why that works? That is where it gets interesting.

It is not about desensitizing receptors or dulling the nervous system. It is about interoception — your brain’s ability to sense and interpret what is happening inside your own body.

The treatment trains people to recognize their urge to cough, understand what it feels like, and respond with suppression instead of reacting automatically. When you have been coughing for ten years, that automatic reaction is deeply wired. Neuroplasticity can rewire it. But you have to be consistent.

Dr. Jetté’s team actually recommends a 48-hour suppression challenge right at the start of treatment. Hit it hard. Break the cycle fast. We also talked about what refractory chronic cough patients actually look like — people who have been tested for everything, treated for nothing, and sent home with no real answers. And about the five-year NIH-funded clinical trial her team is running right now across three sites, using fMRI to understand what is changing in the brain during treatment. Plus group therapy, which is showing better patient-reported outcomes than one-on-one. And a wearable digital therapeutic that is currently seeking FDA approval to monitor cough and coach suppression in real time through a watch.

This is the kind of episode I made this podcast for. Stream it here or wherever you listen.

I have been putting off writing this.

Not because I don’t have things to say. Anyone who has listened to this podcast for more than ten minutes knows that is not my problem. I put it off because writing something that actually captures what 400 episodes has meant, what it has cost, what it has given back, felt like a lot to sit down and do.

But here we are. And you paid for this, so let’s actually get into it.

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How this whole thing started, and why I almost didn’t do it

Before there was a podcast, there were blog posts. I was running mobile FEES in New York, servicing skilled nursing facilities, and I started writing these little newsletters for the SLPs in the buildings I worked in. Clinical tips, evidence updates, things I was seeing in the field that I thought were worth talking about. People started sharing them. SLPs I had never met were emailing me saying they had gotten forwarded something I wrote and wanted to be on the list.

And I loved writing them. I genuinely did. But keeping up with it was hard, and this was before AI existed to help with anything, so everything came straight from my brain and whatever research I had been reading. At some point I thought, what if instead of writing all of this myself, I just started a podcast and brought on the smartest people I know to share what they know?

The podcast debuted at number 11 on the Science and Medicine chart on iTunes. I had no idea that was going to happen. I also had no idea I would still be doing it more than a decade later, because I am genuinely not a planner and I do not think that far ahead about anything. I get an idea, I feel it in my gut, and I run.

That is both my greatest strength and the thing that has made certain chapters of my life significantly harder than they needed to be.

Las Vegas, a missing service, and my first real lesson in just starting

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You’re Not a Step-Down Clinician

There’s a thing that happens in our field that nobody really talks about openly, but everyone feels.

If you work in a skilled nursing facility, you’ve felt it. Maybe it was the way an acute care SLP talked about your setting at a conference. Maybe it was a professor in grad school who treated the SNF rotation like a consolation prize. Maybe it was just the general vibe that “real” medical SLP work happens in hospitals, and everything else is... less.

Dr. Sonal Pathak has worked across both worlds for 16 years. She’s practiced at UCSF Trauma 1 and in SNFs. And this week on Swallow Your Pride, she said something I want every post-acute SLP to hear: you are a primary decision-maker managing medically complex patients at their most vulnerable stage of recovery. You are not less than. You are doing the actual rehabilitation work.

The resource gap is real

Here’s the part that makes the “acute care is harder” narrative fall apart when you look at it closely.

In acute care, if a patient desats during your swallow trial, you can call a rapid response team. In a SNF, you figure it out. In acute care, you have ten SLP colleagues down the hall to bounce ideas off. In a SNF, you might be the only one in the building. In acute care, you can order a VFS or FEES this afternoon. In a SNF, you might wait weeks, or it might not happen at all.

Post-acute SLPs are doing the same level of clinical thinking with fewer guardrails. That’s not less complex. That’s a different set of challenges that requires resourcefulness, clinical confidence, and honestly, a thicker skin.

The advocacy problem

Dr. Pathak told a story that I think most SNF SLPs will recognize immediately. A patient with a fresh stroke arrived at a facility. PT and OT were already seeing them. Nobody consulted speech. When the SLP flagged it, the DOr said the patient was only there for two weeks on Kaiser, so they’d prioritized PT and OT.

A stroke patient with global aphasia. No speech evaluation. Because someone who wasn’t an SLP decided speech wasn’t the priority.

This is the kind of thing that happens when we aren’t at the table. And as I said on the episode, the answer isn’t to get offended that we weren’t invited. The answer is to go take a seat.

That means showing up to interdisciplinary meetings. It means volunteering for committees. It means learning to speak your administrator’s language about reduced hospitalizations and revenue, because that’s what gets their attention. It means educating your DOr on your scope of practice, even when they should already know it.

The continuity of care gap

One of the most important things Dr. Pathak brought up is what happens when post-acute SLPs are cut out of the care continuum. Patients arrive at SNFs on modified diets that were placed in acute care and never reassessed. Patients are on tube feeding that could potentially be weaned, but no SLP has re-evaluated them. Patients get discharged without home health SLP recommendations because nobody knew speech was even part of the picture.

40% of patients in SNFs on modified diets had never been evaluated by an SLP. Some of those patients could have been eating regular food.

That’s not a minor gap. That’s patients’ quality of life being affected by a system that doesn’t prioritize what we do.

Research that actually works at the bedside

Dr. Pathak’s doctoral research focused on spontaneous swallowing frequency as an outcome measure, specifically because she wanted something that works in settings where you don’t have ready access to instrumentals. A microphone, a defined time window, a measurable frequency. If a patient’s spontaneous swallowing rate improves after treatment, you have an objective data point that what you’re doing is working.

She designed this research for the clinician who is alone in a SNF, trying to show outcomes with limited tools. That matters.

If you’re in post-acute care

You’re not a step-down clinician. You’re the person doing the actual rehabilitation. The patient who spent three days in acute care is going to spend weeks or months with you. The goals you write, the advocacy you do, the relationships you build with the patient and the care team, that’s where real outcomes are made.

And if you’re in acute care? Get to know your local SNF SLPs. Send your documentation. Share your VFS videos when you can. Because it’s the same patient, and they deserve a team that talks to each other.

Listen to Episode 399: http://syppodcast.com/399

Over one thousand speech-language pathologists have registered for the FEES Learning Lab in the last week.

I keep coming back to that number because of what it reveals about our field.

We did not run a massive advertising campaign. We did not partner with a major institution. We announced a free, full-day event on advanced FEES interpretation, documentation, billing, and advocacy, and one thousand clinicians raised their hands within one week.

That is not a marketing win. That is a demand signal. One thousand SLPs just told us, loudly, that they have been looking for this education and could not find it in a format they could access.

The access problem is the whole point

I have written about this before, but it bears repeating one week out from the event.

The standard pathway to advanced FEES training is expensive, scattered, and gatekept by logistics. You take the basic course. You complete your supervised passes, which require finding a mentor with time to supervise you. Then, if you want to develop real interpretive skill, the kind that lets you make confident clinical recommendations and defend them in front of the care team, you go looking for advanced training that may or may not exist in your area, at a price point you may or may not be able to afford, at a time that may or may not work with your clinical schedule.

Most clinicians stop somewhere in that pathway. Not because they lack motivation. Because the pathway itself runs out on them.

The result is a field where advanced FEES interpretation lives with a small number of clinicians, and the majority of SLPs who are interested in FEES, who see the gap in care their patients are living with, who want to advocate for this tool at their facilities, are working from a foundation they have had to piece together on their own.

Over one thousand registrations in one week tells me exactly how many people have been waiting for someone to open a door.

Why free matters here

I want to be direct about this because I think the reasoning gets lost in a world where free is usually a funnel tactic.

This event is free because the first barrier to FEES adoption in our field is exposure, not willingness. My dissertation research keeps confirming this. You cannot advocate for a tool you have never seen used. You cannot make the business case to your administrator if you do not have the interpretation skills to back the conversation up. You cannot push back on a physician who defaults to VFSS if you have never watched what FEES reveals that changes the clinical picture entirely.

Charging for that first exposure would have meant one hundred registrations instead of one thousand. And the nine hundred clinicians who could not justify the cost would still be sitting in the same access gap they have been in for years.

If we want a field where every medical SLP has real exposure to advanced FEES interpretation, the financial barrier has to come down first. Everything else follows from exposure. The advocacy follows. The program builds follow. The skill development follows. But exposure has to be the first step, and it has to be accessible to everyone.

The CEU question

I also want to address something that came up almost immediately after we opened registration, because the volume of requests surprised even me.

A significant number of registrants asked about ASHA CEUs for the event. The interest in earning continuing education credit for this content was immediate and consistent. It told me that clinicians are not just looking for exposure. They want this education to count toward their professional development requirements, which makes sense given the quality of what these six presenters are teaching.

CEUs are available through MedSLP Collective Complete membership. The event is approved for 0.55 ASHA CEUs (5.5 contact hours) at the advanced level. Complete membership is $34 per month or $349 for the year, and it includes the CEU credit for this event, access to the recording for this event, 120+ on-demand courses in the full library, done-for-you clinical templates, real-patient demonstration videos, and a mentor community where you can post a clinical question and get a same-day response.

If you register free and decide after the event that you want the CEUs, you can still upgrade to a membership and earn the CEUs. You do not lose anything by starting with the free registration and changing your decision after you have seen the content for yourself.

What is happening on May 30

Six MedSLPs are teaching from the clinical settings they actually work in. Jenny Reynolds is covering NICU FEES. Gerrita Morris is teaching clinical interpretation and rating scales. Anna and Leon Daley are covering SNF and long-term care FEES, including documentation, billing, and the advocacy conversations nobody trains you for. Emily Tricarico Wilkinson is teaching acute care and ICU FEES. And I am closing the day with a session on FEES advocacy as a long-term career practice.

There is also a two-hour foundational course from Dr. Raquel Garcia available on demand starting May 26 for anyone who wants a refresher before the live day.

The full day runs 10 AM to 4 PM EST. Real case studies. Live Q&A with the presenters who will be there live. Every session is taught by a clinician who works in that setting every day.

One week out

Over one thousand SLPs are going to be in this room on Saturday, May 30. Some of them have been doing FEES for years and want to sharpen their interpretation alongside clinicians who scope differently than they do. Some of them have never seen a FEES performed in person and are walking in because they finally have access to the education they have been looking for.

Both of those clinicians belong in the same room. That has always been the point.

If you have not registered yet, the door is still open. Registration is free, takes about 30 seconds.

Register here: medslpcollective.com/learninglabsocial/

See you on the 30th.

Theresa Richard, M.A., CCC-SLP, BCS-S, PhD Candidate and Founder of The MedSLP Collective and MedSLP Education

Laura Morgan was four and a half months into her clinical fellowship when her life split into a before and after.

In December 2012, Laura was a passenger in a vehicle that crashed into a parked 18-wheeler. She sustained a moderate-severe diffuse axonal TBI, fractured her jaw, broke C1 and C2, cracked ribs from the seatbelt, and was given an initial Glasgow Coma Score of 2. She spent 72 days inpatient. She remembers none of it.

Before the accident, Laura had just graduated from the University of Tennessee with her master’s in speech-language pathology. She was running half-marathons, training for a Tough Mudder, playing cello, and building a friendship with her CF co-worker Anna during their long daily carpool. She was 23 and doing all the things.

After the accident, she had to relearn how to tie her shoes.

I wanted to have Laura on the podcast because her story isn’t just a survival story (though it is that, and it’s extraordinary). It’s a clinical education story. Laura sat in the patient chair. She received speech therapy. And then she came back to the field and started treating the same population, carrying insights that most of us can only learn secondhand.

Here are some of the things that stuck with me from our conversation:

Your patient may have just lost their primary coping mechanism.

Laura was a runner. Running was how she managed stress. After her brain injury, during arguably the hardest stretch of her life, she couldn’t run. She couldn’t access the thing that had always helped her regulate. She wants clinicians to pause before labeling a patient’s emotional responses as lability and consider whether their usual outlets have simply been taken away.

Cognitive progress and grief can increase at the same time.

Laura calls this the “double-edged sword of cognitive awareness.” As her thinking skills returned, so did her ability to fully grasp what she’d lost. That’s a pattern clinicians should anticipate. Improved cognition doesn’t always feel like improvement to the person living it.

Your office walls are saying something to your patients.

This one surprised me, but it makes so much sense. Laura remembers sitting in therapy rooms decorated with the clinician’s personal achievements, adventure photos, race medals, and feeling gutted by the contrast between those images and her own reality. She’s not saying make your office sterile. She’s saying be intentional about the atmosphere you create for someone who’s grieving their former life.

Errorless learning works in the mundane moments too.

Laura couldn’t find her car keys. Every single day, 15 to 20 minutes of searching. So she picked a spot, put up signs to reinforce the habit, repeated it until it stuck, and then faded the reminders. That’s errorless learning in real life. And it’s exactly the kind of practical, functional approach she brings to her clients now.

The journal of successes.

During recovery, Laura noticed a pattern in herself: she’d leave therapy sessions only remembering the one thing she needed to work on, not the nine things she was doing well. Sound familiar? (It should, because a lot of our patients do this.) She started a journal where she logged the small wins she might feel silly saying out loud. First time tying her shoes. First ponytail. She still recommends it to clients today.

Returning to the field was its own mountain.

Laura had to retake the Praxis. She had to redo her entire clinical fellowship, this time with acquired cognitive deficits. She volunteered hundreds of hours in speech pathology departments to keep her skills and vocabulary fresh. She earned certification as a brain injury specialist trainer. And she did all of this while still actively recovering.

She told me something I keep thinking about: she’s grateful she didn’t know all the obstacles she’d face in returning to the field, because she doubts she would have gone through with it. But she’s glad she did.

Laura now works at Metro Therapy Center in Gaithersburg, MD, where she treats brain injury survivors in individual and group settings. She’s given over 50 presentations on her experience as both a clinician and a patient. And the thing she wants her clients to know? That they’re on the same team. She brings her credentials. They bring their lived experience. Both matter.

This episode is one I’d recommend for every SLP, whether you work with brain injury or not. The lessons Laura shares about empathy, clinical humility, and functional strategy are universal.

🎧 Listen to Episode 398 of the Swallow Your Pride Podcast wherever you stream podcasts.

Learn more about Laura at www.soundmindinsights.com and on Instagram @slp_tbi and @soundmindinsights. Laura is also treasurer for TBI MedSLP, a 501(c)(3) non-profit brain injury education organization.

When you are the only SLP on your unit, the only medical SLP at your facility, the only person in your immediate professional world who actually understands what a complex dysphagia case looks like at 4pm on a Friday, something quietly happens to your imagination over time. The ceiling of what you think is possible lowers itself. The way your facility does FEES becomes, in your mind, the way FEES gets done. The productivity standard at your SNF becomes, in your mind, the productivity standard. The career trajectory of the person who held your role before you becomes, in your mind, the trajectory.

That is not a personal flaw. That is what happens to all of us when we spend most of our time in one room. Our sense of what is normal, achievable, and within reach gets shaped by the people we are physically and professionally close to. If those people are operating at a level beyond ours, we calibrate up. If those people are stuck inside the same systems we are, we calibrate to stuck.

Last week reminded me of this in a way I have not been able to stop thinking about.

Monday, I was at Ed Mylett’s house. For those who do not know him, he is one of the most well-known motivational speakers in the country, and he coaches some of the highest-performing professional athletes in the world on the mental side of their sport. Sitting in his living room, listening to him walk through the same mindset frameworks he uses with people performing at the top of their fields, I had a moment where I thought, this is the same conversation I want to be having with medical SLPs about how we approach our patients, our careers, and what we believe is achievable in this profession.

Here is what I do not want to gloss over about how I got into that room

.

I paid to be there. A lot. And I want to be honest about what that felt like, because I think it matters for anyone reading this who is considering an investment in themselves that scares them.

When I first got the opportunity, I sat with it for weeks. I felt physically sick about the number. There were stretches where I genuinely thought I was being reckless and irresponsible as a single mother, that this was the kind of decision people look back on as the moment they lost the plot, that I was a clinician at heart who had no business spending that kind of money on a room. I went back and forth more times than I can count. I almost said no, more than once.

What finally moved me was the simplest sentence I know. If nothing changes, nothing changes.

I am 41 years into a life and a career I love, but I know exactly where I want to take my career next. I know what I want for the next generation of medical SLPs coming into this field. I know what I want for my patients, my team, and the standard of care I am trying to raise. And I know, with painful clarity, that I cannot get to any of those places by repeating what I already know how to do. I have already squeezed every drop of growth out of my current way of thinking. The next chapter requires a different ceiling, which requires a different room, which requires people who have already been where I am trying to go.

Sitting in my own doom spiral about the cost of the room was not going to get me there. Reading another book was not going to get me there. Telling myself I would invest in growth “when things calm down” was not going to get me there. Things do not calm down. You either decide to stretch yourself toward the next version of your career, or you stay exactly where you are and watch the years go by. Those are the two options. There is no third one.

So I paid the money, I had a panic attack the night before, then I sat in the room.

And here is what I want to say plainly. It was worth every dollar, and it would have been worth every dollar even if I had walked out with nothing more than the lived experience of being in proximity to that level of thinking. Because that proximity is what recalibrates you. That is the entire mechanism.

Two days later, I was at my business coach Kelly Roach’s book launch. And I want to spend a minute on this one, because it was, in almost every way, the polar opposite of the room I had sat in at Ed’s house, and I needed both of them last week.

I brought my daughter with me.

Kelly is one of the few coaches I have worked with who actively encourages the women in her world to bring their children. Not tolerates. Encourages. Her position is that our daughters need to see what we do. They need to see who we surround ourselves with. They need to be in the room where their mother is being coached, celebrated, challenged, and held to a higher standard, because that is how the next generation of women learn what it looks like to build something serious without disappearing inside it.

So Mia was there. She sat through parts of the event with me. She watched me take notes. She watched me hug women I have known for years and women I had never met in person until that day. She watched her mother work, in a way that most kids do not get to see their working mothers work. She saw what it looks like when women lift each other up in a room instead of competing for the small chair we have historically been offered.

The contrast between Monday at Ed’s house and Wednesday at Kelly’s launch was not lost on me. Two days earlier, I had been in a room full of some of the highest-performing men in the country, learning frameworks built for elite athletes, in an environment that was sharp and focused and not at all designed for children. Two days later, I was in a room full of women founders, with my daughter physically next to me, in an environment that was designed from the ground up to include the fact that many of us are building businesses and raising humans at the same time and have no interest in pretending otherwise.

Both rooms were valuable. Both rooms changed something for me. And both rooms are part of the answer to a question I think about a lot, which is what kind of business owner I want my daughter to grow up watching, and what kind of clinician, and what kind of woman.

I want her to see her mother in a room with Ed Mylett, because I want her to know that the table is not closed and that you do not need to ask permission to sit at it. I want her to see her mother in a room with Kelly Roach and a hundred other women founders, because I want her to know that the table is also something you can build yourself, and that some of the most important rooms in your life will be the ones where you brought your daughter with you on purpose.

I cannot give her either of those without putting myself in both kinds of rooms. And I cannot put myself in those rooms without sometimes spending money that makes me sick, and sometimes saying yes to events where I have to figure out childcare logistics, and sometimes saying yes to events where I get to bring her along instead.

Last week, both happened in the same five-day stretch. I am still processing it.

The third room that week was the smallest. It was a meeting, just the two of us.

I sat down with the woman who is coming on as the new COO of the MedSLP Collective.

Here is the part of the story that matters. I did not find her through a job board. I did not run a hiring process and interview ten candidates. I reconnected with her last year, after her husband had a stroke and was receiving speech therapy as part of his recovery. We had known each other before that, through a mastermind I had been in years ago, but the reconnection happened in the middle of something that turned her into one of the few non-clinicians I know who deeply, viscerally understands what we do. She watched her husband fight to get his words back. She watched what it looks like when speech therapy works and what it looks like when the system around it fails. She understands, from the inside of her own family, why this work matters.

When I started thinking seriously about needing new operational leadership inside the Collective at a level beyond what I could provide, she was the first person I reached out to. Not because she was the most obvious candidate on paper. Because she was the right person, and because I already knew her well enough to know that the values would line up before the strategy ever needed to.

That meeting last week was the moment where a year of conversations turned into a real decision, with a real start date, and a real shift in what the next chapter of the MedSLP Collective is going to look like.

I want you to notice what made that meeting possible.

Read more

Like the fact that some programs include business planning and private practice courses. Or that the degree was designed specifically for people who want to stay clinical. Or that the biggest barrier to getting recognized in higher education had nothing to do with the degree itself and everything to do with an outdated accreditation rule that just got changed.

Let me introduce you to the panel first.

Dr. Erin McCarthy is the Director of Clinical Education at D’Youville University and the owner of Rochester Feeding & Swallowing Therapy. She’s Board Certified in Swallowing Disorders and got her SLPD from Northwestern. Dr. Irene Brettman is an inpatient and outpatient medical SLP at Mass General who also teaches in the SLPD program at MGH Institute. Dr. D’Anna Nowack has over 25 years in neurorehab and is now an Assistant Clinical Professor at Baylor’s online program. And Dr. Courtney V. Moore spent 15+ years in acute care before becoming the Assistant Director of the SLP program at Rocky Mountain University.

They all pursued the SLPD for slightly different reasons, but the themes were eerily similar.

They wanted to stay clinical. Every one of them said some version of “my best days are still the days I get to see patients.” The SLPD was the degree that let them keep doing that while also growing into research, teaching, or leadership.

They wanted to understand research, not just cite it. D’Anna talked about how intimidating journal articles used to feel, even after years of clinical experience. The SLPD taught her (and all of them) how to actually consume research, pick it apart, evaluate the methodology, and apply it with intention. That’s a different skill than just knowing an article exists.

They needed flexibility. Kids at home. Full-time jobs. No ability to relocate. The hybrid and remote formats of most SLPD programs made this possible for all of them.

They didn’t expect the doors that opened after. Erin never planned to open a private practice or move into higher ed. Courtney didn’t expect to end up running a program. The degree didn’t just teach them skills. It showed them career paths they hadn’t even considered before.

And then there’s the policy piece. For years, the CAA required that at least 51% of faculty in accredited programs hold terminal degrees (PhDs or EdDs). The SLPD wasn’t counted toward that percentage, which made it harder for SLPD holders to be hired in academic roles and made it harder for programs facing a faculty shortage to fill positions with qualified clinician-educators. At last week’s CAPSID conference, it was announced that this rule is being phased out. That’s a big deal for the profession.

Something Irene said really landed for me. She compared the SLPD to the concept of cultural humility, where you acknowledge that you’ll never arrive at a final destination of knowledge, and instead commit to being a lifelong learner. That’s what the degree represents. Not a finish line. A way of continuing.

If you’ve been going back and forth between PhD, EdD, and SLPD, or if you’ve been wondering whether going back to school is even feasible while you’re working full time, this episode is a really honest look at what the experience is actually like from four people who’ve done it.

Listen to the full conversation: Episode 397 of Swallow Your Pride.

I want to tell you about a woman who hadn’t seen her grandchildren.

Her esophagus was 100% closed. Completely stenosed. She’d been told there was nothing more anyone could do and that she’d be tube-fed for the rest of her life. Her husband said they couldn’t travel to see the grandkids because he didn’t want to scare them with the feeding tube. She was depressed, anxious, and ready to accept that this was just how things were going to be.

Then a surgeon and an SLP at the University of South Florida looked at her case and said, “We really think you’d be a good candidate for self-dilation.”

She didn’t believe them at first.

Now she cooks for her family. She eats what she wants. Her feeding tube is out. She dilates every other day, and it’s getting easier. She rang the gong in their clinic (yes, they have a gong for when patients get their G-tubes removed), and according to her SLP, she’s a completely different person.

On this week’s episode, I talked with a head and neck surgeon and an SLP who have built a self-dilation program at USF and Tampa General that is producing outcomes worth paying attention to. Twenty patients are currently self-dilating. Half of them came in with feeding tubes. Eighty percent of those patients have had their tubes removed.

Let me say that again: 80% of their G-tube patients no longer have G-tubes.

So what exactly is self-dilation?

The concept has been around for well over a century, but it fell out of common practice. Most patients with recurrent esophageal strictures (especially post-radiation head and neck cancer patients) end up in the OR every few months for a dilation under anesthesia. The stricture opens, they eat for a while, it closes back down, and the cycle starts over.

That cycle destroys therapeutic progress. Their SLP starts swallowing therapy, the patient makes gains, then the esophagus re-strictures and they can’t eat. By the time they get back on the OR schedule (which could be weeks or months, because airway cancers take priority), they’ve lost everything. The SLP starts from scratch. Again.

Self-dilation breaks that cycle. After an initial dilation in the OR, the surgeon sizes the patient for a dilator they take home. The team teaches the patient to pass it themselves, starting daily and gradually weaning to every other day, then a few times a week. The dilator isn’t stretching the esophagus further. It’s maintaining the opening that was created surgically so it doesn’t close back down.

The team approach is what makes this work.

These two don’t just refer to each other. They’re in the same clinic, evaluating the same patient, at the same time. The surgeon can look at the SLP and say, “There’s nothing surgical I can offer.” The SLP can look at the surgeon and say, “This patient isn’t going to be able to do therapy, so whatever you can do medically, please offer it.” That happens in real time, with the patient in the room.

For self-dilation specifically, the SLP is the recruiter. She sees head and neck cancer patients across multiple surgeons and she’s the one identifying who might benefit. She also handles the psychological coaching, because telling someone to put a dilator down their own throat every day is a big ask. One of their patients was terrified. He said absolutely not. She talked him into trying it once. Now he shows his grandkids like it’s a party trick and he dilates 2-3 times a week with ease. His feeding tube is out.

The barriers are real but solvable.

The dilator costs about $3,400. The team figured out how to order it as part of the surgical supplies so it’s billed to insurance. Storage matters because the device needs to stay straight or it won’t pass properly. And patient selection is critical. The patients who succeed are the ones who are desperate enough to be motivated: NPO, or barely eating, or stuck in the dilation-every-three-months cycle with no end in sight.

Why this matters for SLPs.

If you work with head and neck cancer patients, you’ve probably watched this exact scenario play out. You do therapy, your patient makes progress, the stricture returns, they stop eating, they lose ground, they get dilated again weeks later, and you start over. Self-dilation is a tool that keeps the esophagus open so your therapy actually has a chance to work. The swallowing muscles still need strengthening. The dilation alone doesn’t fix everything. But without maintaining that opening, the therapeutic work is constantly undermined.

This team is open to helping other clinicians learn how to set up a similar program. If this sounds like something your patients need, reach out.

🎧 Listen to the full episode wherever you get your podcasts.

And the numbers? They’re staggering.

What the Research Tells Us About Inpatient Costs

In 2018, Patel and colleagues published what was actually the first study to describe the economic and survival burden of dysphagia among all inpatients, not just stroke patients. They used five years of national hospital discharge data (2009 to 2013) from over 88 million adult admissions.

Here’s what they found:

Patients with a dysphagia diagnosis stayed in the hospital an average of 3.8 days longer than patients with similar characteristics who didn’t have dysphagia. Their inpatient care costs were 33% higher. They were 2.8 times more likely to need post-acute care services like skilled nursing or home health after discharge. And they were 1.7 times more likely to die during their hospitalization.

The authors put it plainly: dysphagia has a substantial health and cost burden on the US healthcare system.

That same year, Attrill and colleagues published a systematic review that landed in a very similar place. They found that a dysphagia diagnosis added between two and eight extra days to hospital length of stay, regardless of the reason for admission. They estimated a 40% cost increase for patients with oropharyngeal dysphagia compared to those without it. And when they zoomed out to the national level, they estimated that dysphagia was responsible for between $4 and $7 billion in additional hospital costs every single year.

And here’s the kicker: those numbers only account for inpatient care. They don’t include what happens after the patient leaves the hospital.

Why This Matters for How You Advocate

If you’ve ever tried to make the case for instrumental assessments to an administrator or a DOR, these are the numbers you want in your back pocket. Because when the conversation shifts from clinical reasoning to budget and outcomes (and it always does), being able to say that dysphagia adds nearly four days to a hospital stay and increases costs by a third is a different kind of argument. It’s the kind that gets attention in a boardroom.

I once had a conversation with a radiologist at a tiny rural hospital. Friendly guy, totally willing to do video fluoroscopies, but genuinely surprised that I thought they were so important. He said they just never really did many swallow studies there. So I walked him through the clinical reasoning, and then I pulled out the cost data. I told him about the impact on length of stay, the downstream complications like aspiration pneumonia, and what all of that costs the system. He looked at me like I had 27 heads, but he wanted to hear more. I sent him the papers, and after that, he was completely on board to do VFSEs whenever I needed them.

That conversation sticks with me because it was a reminder that sometimes the people around us aren’t resistant to what we do. They just don’t know what we know yet. And having hard data makes that conversation so much easier to start.

The Skilled Nursing Facility Picture

Once a patient leaves the hospital, the financial reality doesn’t stop. It shifts.

When a skilled nursing facility accepts a Medicare patient, they agree to cover any additional testing that patient needs. That includes instrumental swallow assessments, transportation, all of it, and it comes out of the bundled payment the facility receives. So while the SNF does get reimbursed, every diagnostic test eats into that allotment.

If a patient arrives at a SNF without an instrumental assessment from the hospital (which happens more often than any of us would like), the SLP may be working without the information they need to provide the most effective and efficient treatment. That can mean unnecessary diet modifications, treatments that aren’t well-targeted, and longer timelines to functional improvement.

And here’s where the financial consequences really pile up. According to the research, the presence of dysphagia is associated with malnutrition and dehydration. These aren’t just clinical concerns. Dehydration, malnutrition, electrolyte imbalance, sepsis, and UTIs account for 78% of all 30-day rehospitalizations from skilled nursing facilities. Each one of those rehospitalizations can cost a facility around $30,000.

Aspiration pneumonia is one of the leading causes of death in nursing homes. If a patient is rehospitalized from a SNF because of aspiration pneumonia, that’s another potential $30,000 hit to the facility.

So what can you actually do with this information?

Push for access to instrumental assessments as early and as often as possible. Those assessments help us target treatment, avoid unnecessary diet modifications, and make our interventions more efficient. Offer to give in-services on oral care. Talk to PT and the restorative aides about getting patients with dysphagia up and moving. Reducing aspiration pneumonia rates takes a village, but the SLP is uniquely positioned to lead that charge because we understand how these body systems work together in a way that most other professions don’t.

Even small conversations matter. A five-minute chat with a CNA about oral care protocols. A quick in-service for administration showing the connection between dysphagia management and rehospitalization costs. Showcase what you know and offer solutions that benefit both the patients and the bottom line.

The Hidden Costs Patients Carry

There’s another layer to this that often gets overlooked: what dysphagia costs the patient and their family directly.

Keeping one patient on thickened liquids can cost a facility up to $7,000 per year. That’s just one patient. And thickener isn’t inherently the villain here. It can be genuinely helpful in the right clinical situation. But we need to make sure it IS the right situation, that the patient truly needs it, and that it isn’t causing further harm.

Research shows that palatability issues with thickened liquids, including dissatisfaction with taste and texture, increased feelings of fullness, and greater thirst with thicker consistencies, all contribute to poor adherence. And when patients don’t adhere to thickened liquid recommendations, they may be at increased risk for dehydration and the cascade of complications that follows.

Beyond thickener, patients may need specialty straws, slow flow cups, or prepared food products designed for modified diets. The innovation in this space is growing, but so are the costs. And for families, the burden isn’t only financial. It’s logistical. It’s remembering to bring special products everywhere. It’s worrying about supply chain issues. It’s the mental load of managing something that touches every single meal, every single day.

We shouldn’t make assumptions about whether a patient can or can’t afford these products. But we should acknowledge that every recommendation we make ripples outward into someone’s daily life, and we should make sure those recommendations are grounded in solid clinical evidence rather than guesswork.

The Bottom Line

Dysphagia is costly at every level of the healthcare system. In acute care, it adds days and thousands of dollars to a hospital stay. In skilled nursing, it drives rehospitalizations that cost facilities tens of thousands. And for patients and families, it creates an ongoing financial and logistical burden that extends far beyond the clinical setting.

As SLPs, we are the professionals trained to understand, diagnose, and treat this. The data exists to support what we’ve known clinically for years. Now it’s about making sure the right people see it.

In 2015, Kelly Kalseth was working 50 to 70 hours a week in corporate America when her water broke at 30 weeks. Her son Caleb arrived at three pounds, and for the first five months of his life, Kelly had no idea anything was wrong with his swallowing.

It was actually his daycare teacher who caught it. She handed Kelly someone else’s baby and said, “Do you hear this baby breathing?” Kelly said no. Then the teacher said, “Now hold Caleb.” And Kelly could hear it. The loud, labored breathing she’d assumed was normal because she was a first-time mom and had nothing to compare it to.

That was the beginning of a diagnostic journey that led to ENT visits, swallow studies, and a diagnosis of Tracheal Malacia. Caleb was aspirating every time he drank from his bottle. The treatment plan: thicken his liquids to nectar thick (with rice, because this was 2016 and that’s what they had), get him off the bottle entirely, teach him to drink from a straw, and transition to pureed foods.

So Kelly started cooking.

Every night after putting Caleb to bed, she’d make his purees from scratch. She wanted to physically see every ingredient going into his body. He’d already had multiple surgeries. She’d already survived a swallow study where the doctor shoved a camera down her infant’s throat with what she describes as zero tact while the speech pathologist stroked her arm and told her she was a great mom.

She was not going to hand that kid a jar of something she couldn’t identify.

The Meals on Wheels Kitchen That Changed Everything

By 2019, Kelly had been selling baby food under the name Momma Gourmet at baby shows around Chicago. Her original concept was “Blue Apron for baby food,” a 12-week program that transitioned kids from purees to solid foods. It was going well. She was hand-delivering meals to moms she met at fitness classes.

Then she met the guy who runs the Meals on Wheels contract for Cook County.

He invited her to tour his kitchen, and that’s where the whole thing shifted. She saw what they were serving to their puree clients: brown, shelf-stable food that could sit on a shelf for over a decade without changing. Kelly looked at it and her reaction was immediate. “What is happening here?”

She offered to help. And when 2020 hit and she became an essential kitchen worker making Meals on Wheels deliveries while pregnant with her third baby, she realized something. The baby food company wasn’t her real calling. The people who needed her most were the adults, the seniors, the stroke survivors, the head and neck cancer patients, the people living with Parkinson’s, the entire population of humans who struggle to swallow and had been handed food that looked and tasted like it had given up on them.

What Momma Gourmet Actually Makes

Kelly runs a small operation out of a commercial kitchen in Chicago (the same space that handles Meals on Wheels for Cook County, which works out nicely since they help each other). She recently hired her first employee, but for the most part, she’s doing this herself. She batch cooks everything fresh, flash freezes it, and rotates through about ten meal varieties, cooking three types each week in bulk.

The ingredients are real. Red beets. Cauliflower. Lentils. Quinoa. Beans. Greek yogurt. Fresh herbs. Real chicken and beef stock (not broth, the actual stock). No added salt beyond what’s naturally in the stock. She uses vegetarian proteins because, as she puts it, she doesn’t love the way actual meat purees after you freeze it and reheat it. Fair enough.

Every single meal has at least 28 grams of protein.

The meals land between IDDSI levels 3 and 4. She notes that flash freezing can introduce some moisture on reheating, which is why she’s careful about labeling level 4 specifically, but her clients can thicken at home if needed.

And the colors? Not brown. Not gray. Not “what is that?” She described oranges, pinks, rich greens, creams. The kind of food that looks like someone cared about it, because someone did.

She just launched a halal option after a client’s family asked if she’d be willing to make meals with vegetarian ingredients or halal chicken broth. She said absolutely, worked with the client’s father on taste testing, and now it’s available on her website.

The Part That Matters Most

There’s a quote Kelly shared from one of her clients in Florida that I think every SLP and every caregiver needs to hear.

The client said the biggest complaint from caregivers is that pureed food tastes awful and starts thickening once you warm it up. She said Kelly’s meals don’t do that. She said they’re delicious. And then she said this: at 99 years old, her mother has no skin breakdowns, no constipation (two of the biggest issues with elderly patients who have limited mobility), and she eats every single bite.

Every. Single. Bite.

If you’ve worked with patients on modified diets, you know how significant that is. You know that malnutrition and dehydration are constant concerns in this population. You know that skin breakdowns and wounds become exponentially harder to heal without proper nutrition. And you know that when patients refuse to eat because the food is unrecognizable or tastes like nothing, every other intervention you’re doing is fighting an uphill battle.

Kelly gets that. She talked about the emotional experience of eating and how she doesn’t want anyone to lose that just because they have a swallowing disorder. Her food smells good when you warm it up. It has real color. It tastes like something a person would choose to eat.

Where She’s Going

Right now, Momma Gourmet ships nationwide on dry ice, mostly in bulk orders of 14 or 20 meals that fit in a standard freezer. Most of her direct-to-consumer customers are adult children caring for aging parents with swallowing disorders. She also serves the Meals on Wheels program in Cook County, where the speech pathologists who do home visits have started approving more clients for pureed diets specifically because they know the food those clients will receive is actually worth eating.

Kelly wants to expand into more Meals on Wheels programs, but she’s hit a wall with some of the smaller community-run operations in Illinois that make their food in-house and aren’t set up to bring in outside vendors. She’s also looking at senior living centers and hospice programs, places where the in-house kitchen staff are making one-off specialized meals that could be supplemented or replaced with her products.

And if you reach out to her, you’re getting her. She made that very clear. She’s not a faceless online retailer. If a meal gets damaged in shipping (which she says happens maybe once in every 30 orders), she covers it and resends it. She wants to be a partner in this, and if you have a specific dietary need she isn’t currently meeting, she wants to have that conversation.

Listen to the Full Episode

Episode 395 of the Swallow Your Pride podcast is out now wherever you listen.

If you’re an SLP working with patients on modified diets, a caregiver doing the meal prep at home, or someone in food service at a healthcare facility, this one is worth 20 minutes of your time.

Learn more at mommagourmet.com Find Momma Gourmet on Instagram and Facebook