Stephen Covey got it right

Blogger' s note: Thanks to Jenniffer Weigel of the Chicago Tribune, for the inspiration for this post - "Outgrowing a Mentor: Navigating the Delicate Business of Moving On"

I complete another mentoring assignment soon with a new CSD professional. I noticed at work the other day, that this mentee feels good about being more independent. How do I know this? It was her asking less questions of me, or more to the point - she has moved to ask, when needed, questions of her peers and other staff. Earlier in my career, this would have been an almost painful moment - when the mentee left this training opportunity for greener employment pastures. All the energy put into this person, learning the fundamentals of doing a clinical job; this person is gone. I had been making the experience about me, and not keeping the focus solely on what the student needed.

The nadir of this whole mentoring evolution, came for me when one young person was facing a happy event in her personal life . I had been hoping for an invitation to the event, but - it did not come. Even though I had been this person's mentor in an employment setting prior to this one, I had also misread the level of our communication. I never told her that I had been disappointed. I had realized very clearly, how a mentoring experience needs its consistent borders and its skill set.

A character in my most favorite TV (cop) show once said: You've been around this dump for seven years and you still ain't learned the key to good murder police, which is this: Whatever you see, whoever's around you; you keep them at a distance. 

What I learned about good mentoring to close the deal; to make it easy for me to continue to take on mentees; it was- "Begin with the end in mind", popularized by the late Stephen Covey in _The 7 Habits of Highly Effective People_. How I adapt this concept to persons I mentor, is to modify a discussion with most of the persons I serve: "One day, you're going to be rid of me. That is the natural consequence of your success in what we do". 

From that point on, early in the relationship, I help the mentee learn the skill set of a speech-language pathologist  - beginning with the end in mind.

The People We Serve Deserve Quality Services

Speech - language pathologists have more opportunities than ever for exciting, rewarding work with persons of all ages. The US Bureau of Labor Statistics has projected growth of new jobs in our field of between 10-19%; this growth would be spread ideally across all the work settings where SLP's are found. In healthcare and in the educational arenas, there is so much good work to be done; so many inroads to be made with both children and adults in all settings; - so many opportunities for persons served from all socio-economic groups to improve their quality of life. If it were the case that new graduates, or vetted professionals looking to change their work setting, moved to fill all the positions that needed filling - it would be a wonderful world for our field.

But new grads often go for their perfect job at clinical fellowship time. They're often the "sexy" speech jobs, one that have the glamour afforded them by high technology being used, or the most "romantic" diagnoses being explored, or in the work settings that are exciting places to be - often, an urban center. Some clinical positions require, or their job requirements demand, more autonomy and initiative then a clinical fellow or new professional may be equipped. Some worksites are less than desirable for persons seeking a job, due to the physical surroundings, the demographics of the patient mix, or the budget available for an SLP to do her/his clinical work. With limited space to address all the issues related to - not having enough quality SLP's in all the work settings that need high quality professionals - ; all that need be said is: everyone deserves quality SLP services, be they in the educational or the healthcare sphere; low or high socio-economic status; child or adult. But how to achieve - the parity that is needed among work settings!

There are time-tested strategies for attracting both new professionals and vetted ones, to less than the most sexy work settings. Grants augment salaries. Student loans can be reduced or forgiven. Benefit packages swell and shrink, as a function of the largesse of the institution's governing body. Travel? Free housing? Continuing education budget? These budget gems disappear from budget lines as quickly as they appear - from this blogger's experience. So if you are the successful candidate for this job - you have had some incentive waved like a carrot before your face. Beyond that, you have to love those jobs you start, so the difficulty in filling the jobs remains high.

I can only speak for myself. Being in a clinical job that I want to continue, means that I have found a sense of mission about the work. Mission often compensates for the lack of benefits, or of glamor or of sexiness in the work setting. Working with a sense of mission helps you see the operation of a clinical setting, above and beyond the day to day contact with patients/clients. You see what keeps the lights on, and you see the interplay among professional, skilled and semi-skilled labor that heightens your awareness of how cultures work - cultures like THIS work culture. How it works, when it works best, for the persons served - is that you as a professional do, what needs to be done.

closing the sale

  "OK - you see that we have to keep many things in mind, during each day spent as a speech-language pathologist. We are expected to produce revenue, so that every success we see with the patient's function should accumulate alongside the successes with business volumes. That business perspective we can't ever lose, but neither can the business side be the predominant reason we do this work. We are here to help people; it's the reason many of us agreed to carry hefty student loans to begin our careers. So - if you need some guiding principles that help you meet the twin objectives, fiscal and clinical, here are some suggestions: -"

"The people we serve deserve quality healthcare".

"To get the best outcome for people with whom we work, the relationship you forge with them must be primary".

"Making progress towards the desired outcomes requires excellent time management”

 “Establish a context for the activities you bring to each session: WHAT I WANT TO DO TODAY IS…”

 “You are required to negotiate with the resident on the plan along the way”

“Complete necessary documentation of the plan's progression in a timely manner”

“Do not forget to train the patient, family and all who will be involved in assuring the plan's successful completion."

“Are you aware of the rules and regulations set by payer sources that influence how you do your job? Get a working knowledge of them”.

“Acronyms, jargon and shorthand, oh my! Learn the language of the persons with whom you are communicating, and speak or write in the language of your audience”.

“If you serve a person, by breaking down a single act they do not perform well into its components – then train the person to perform those components very well, without training the person to incorporate the components back into daily life – how has your work benefited the person?”.

“When you give someone a direction on performing an act – why not show them how YOU would do it? Provide a model.”

Persons who have difficulty initiating an action you want to see: Cue them first by saying “I want you to __________________”, instead of saying “Would you _______?”.

“Let’s address each of these principles for meeting both the fiscal and the clinical objectives”.

It's Too Dry, So - Make It Wet!!

Blogger's note: in the recent post "It's Too Dry", I had indicated a following post would supply some solutions to the dilemna - often seen in a clinical situation - of a person served who does not consume some foods due to their being dry or without flavor.To recap - why does this matter?

* Good nutrition and hydration is critical to recovering and maintaining wellness;
* Persons served may have problems with eating/drinking, therefore impairing wellness;
* Persons not eating a healthy diet may face serious compromises to their general health;
* Persons with impaired eating/drinking may have salivary production diminished;
* Impaired salivary production limits persons' thoroughly eating dry, coarse foods on a "general diet";
* Persons served may not drink enough, to aid in swallowing dry foods chewed;
* Persons served may be fed by institutional kitchens that limit moisture to limit fat/calories;
* Your intervention with the persons served may include reclaiming moisture for food;
* Reclaimed moisture for food will help improve food viscosity, and an easier swallow;

OK, let's figure out how to do this now. Increasing moisture in food may be a matter of increasing salivary flow. The person may also benefit from coaching to use a favorite beverage frequently. Still another approach would require amending flavors in the food this person receives, while remaining as true as possible to the dietary "restrictions" imposed by either conscience or doctor's orders.

Improved salivary flow? What about: regular and thorough oral care (brushing, rinsing, flossing)? What about stimulating saliva flow between meals, with water breaks and with flavors (eg fruit, mint) in candy or gum? How about flavor amendments (herbs, non-sodium spices) for our food?

A beverage at mealtimes, used not to fill up the stomach with frequent gulps but to form and wash out oral food material, will allow the person with practice to consume more of a dry solid diet. Alternating sips of a beverage with bites of food, is a natural strategy that helps function in all the valves of the swallowing system under our direct control.

Flavor amendments can be internal (again, through herbs, spices or other secrets) or external. Betsy Towner in the AARP Bulletin, created a comprehensive list of "Flavors to Shake the Salt Habit" for the holiday season. 1 Avoiding sodium is still a core aim of medically-modified diets, and this list assists in adding flavors internally. By contrast, adding externally a sodium-free or low-sodium flavoring, sauce or condiment to a dish will help accentuate the flavors, and stimulate more chewing/salivating/easy swallowing.

I would love to hear feedback from readers, on any similar enhancements to food that has helped persons challenged by eating/drinking. Please post comments!

1 Towner, Betsy, "Flavors to Shake the Salt Habit", AARP Bulletin, 12/1/2010. Online version  http://www.aarp.org/food/diet-nutrition/info-12-2010/healthy_herbs_and_spices.html accessed 1/3/15.

The Orlando shuffle

Here at the 2014 ASHA convention. What is your goal? Why are you here? What will you get out of 3-4 days of sitting in large and cold lecture halls, then dashing down corridors and fighting large waves of fellow travelers - ? I really did ask myself those questions, the day before the Convention had begun. A Convention Center hugely dependent upon Florida car culture - not that accessible by foot or by mass transit. Unless you were housed at one of the nearby Convention hotels, connected by either footbridge or shuttle bus, - it was a car commute through rather messy rush hour traffic. Ahhhhhh - but I was not driving: the Convention Center emerging from the swampy foreground; my hands rifling quickly through the canvas bag holding my convention tools: badge on lanyard, legal pad, convention program, and some high energy snacks for those mid-afternoon blood sugar crashes. The ride screeches to the drop off point, and like a Navy Seal you VAULT out and briskly stride into the convention center hallways. This formula has worked well for at least the past fifteen years at ASHA Conventions. This daily inter-session spring is a major undertaking: suddenly swerving swarms of professionals who are clustering, zooming and buzzing between meetings - coming straight at me! YIKES! Luckily my years of speed walking through the Chicago Loop District, dodging and passing commuters and others to and from work; - that skill has held me in good stead. WHOOPS SORRY....! But, the questions. I have been practicing speech-language pathology for over 30 years. What could the Convention do for me, at this stage of my career?? My first ASHA convention was in 1974, in Las Vegas. ASHA has not held a convention in that city after 1974. What effects have the years brought on the profession - and on me?

There are advances in pure and applied research that need be reviewed. For example, life participation approaches to neurogenic disorders like aphasia: how - in spite of being chronically and perhaps, severely disabled from brain damage that limits your speech and language, you are out living life to get the highest quality you can. Such as, participating in book clubs or computer clinics. Surface EMG for dysphagia, means that swallow functions are often trainable with the biofeedback capacity of this unit. And, because of proposed changes for reimbursement by Medicare for "speech generating devices" (SGD's), persons without the use of speech for everyday communication are deprived of technology that limit the quality of their lives. These examples are only a few of the hundreds of topics that were covered in Convention sessions. Why aren't the data obtained from the sessions in this blog post? 

This is a blog, with the content more the observations and opinions of the writer than a strict reportage of the events. I feel that life participation approaches are one of the best collections of tools and resources for SLP. If you accept that persons with aphasia can ultimately have vital roles in the life of their communities, even with chronic problems communicating - then you have ultimately some exciting career options, in giving assist to these people in real world environments. Treating swallowing issues with surface EMG allows the clinician and the person served to obtain rapid data series, to immediately judge the effectiveness of treatment trials. Did you know that persons with SGD's who had previously had full control of the computers unlocked by the dealer - that the persons will LOSE that capability, with the new Medicare regulations fully implemented?

There are numerous social and professional events, in addition to the educational sessions at Convention. It is the annual 'gathering of the clan', after all. Some of the changes over the years are more accommodating than others: the opening session pre-empts lectures for the initial 90 minutes of the first day; the box lunches that can be ordered for pickup each day in the exhibit hall; the shrinkage of the University open house parties, and the total elimination of the Convention dance! Through it all, Convention remains a don't miss event each year. It is my annual vacation time. It is my professional recharging time. It is also my professional growth time, as I have presented papers on horticulture, swallow screening and aphasia pharmacotherapy at ASHA. When November comes around, my canvas bag is packed and I'm ready to go.

You Are the Most Important Person

I started mentoring young professionals in the profession of communication sciences and disorders (CSD), in the late 1980's. I had been in a hospital job for a few years, with acute rehab, acute med, SNF, outpatient, home health and hospice among our services. Needless to say for many readers of this blog, we had a steady demand from master's students in the nearby CSD training program. It's been my good fortune since then to mentor more than a score of women and men, entering the field of CSD: whether a shadow during undergraduate years, a participant in ASHA's STEP program, or an intern prior to receiving the master's degree - they have all taught me a lot.

* the mentor does not have to be infallible - In these days, all the digital interconnections in our world allow persons with Internet savvy the ability to answer content questions. So, if the mentee needs to know  the efficacy of melodic intonation therapy, there may be little need for the mentor to actually provide the answer. Where the mentor will lend expertise is in framing the search terms for the answer: "efficacy of MIT w/ global aphasia"; "MIT short form"; "MIT and return to work for persons w/ nonfluent aphasia ";  - only one example of how the mentor may help hone the mentee's thinking on her/ his feet.

* a thinking mentee is a fearless mentee - the workplaces for CSD professionals  are constantly changing,  as the economic forces supporting their operation convulse and change.One day procedures in the worksite will require response "A" from the clinician, and the next day they are clamoring for your response to be "D". The mentor can be of assistance through contacts with the American Speech-Language-Hearing Association (ASHA), the credentialing and advocacy organization for professionals in CSD. When ASHA staff are able to give the working clinician advance word of  changes in reimbursement policy, or in development of regulations affecting practice, the mentee may adapt to the changes with more confidence. In numerous instances the mentor can help the mentee learn proactive,  evidence-based abd easily-expressed  action in the daily grind. which reminds us that -

* the relationship comes first - when a mentorship begins, how the dyad communicates sets the tone for how the mentee achieves her/his goals. The trust,
The clarity, feedback, and the focus and planning for the duration -they all begin with the formation of the mentor - mentee relationship. What the mentor seeks to give the mentee is not so different from what happens, at the first meeting of clinician and client in the CSD treatment setting -

* you are the most important person to me now -  at this moment, I am solely focused on you, and what you need is my top priority. I will be ethical and open throughout. I am committed to your great future.

My Swallowing Is My Business

Here's an illustration of one component of what I have called "organic SLP": teach, teach, teach. An actual teaching handout given to an actual patient - with the aim of the consumer of clinical service, taking action to prevent disability when possible. One way to do that, is to understand normal function. Feedback as always is VERY welcome!

I don’t have to think about swallowing most of the time. I started swallowing before I was born.

Scientists have found that the human fetus swallows at age 15-16 weeks. I developed my first taste preferences in the womb. After I was born, I was fed and then learned to feed myself, by learning all the skills to get food in my mouth.

Sitting up in a chair, or standing, seemed to be the positions where swallowing was done most often. When I was a kid, I also ate in every other position because – I could!  I ate upside down; lying flat while watching TV; - I even ate while spinning in a carnival ride!

But, as I got older, my swallowing seemed to work more easily when I was upright.

My swallowing happens because I use some muscles voluntarily, and because of other muscles that work without my thoughts. The voluntary muscles are controlled in this

  part of my brain.

 The muscles that work automatically   are controlled by this part of my brain.  So, even though I can control some parts of my swallowing and change part of the swallowing act, all the swallows I have done over my lifetime have made the way I swallow a strong pattern of habits.

Here is how I do it. Here are my habits:

I pick up the food with my fingers or a utensil. When I take a drink, I use a teaspoon, a cup or a straw to put it past my lips.

I hold the food or liquid on my tongue, and form it into a shape that can be squeezed back or chewed, until it forms a more slippery and sticky shape (left illustration).  The squeezing gets the material to the back of the tongue, where my control over swallowing changes. The swallow “triggers” there (right illustration) and pushes food or liquid into my throat. When the material goes DOWN, the voice box lifts UP. What I swallowed moves down past the voice box and pushes open a valve into the esophagus.  My swallowing is totally automatic at this point. Before the material goes into the esophagus, I can use my tongue to affect what happens to the food or liquid. In the esophagus material travels in waves of squeezing, down to the stomach.

There. That is my swallowing. It is my business to swallow well, because I eat to live. I eat to feel satisfied. I eat to be with others. My body, my business.