But the Physical Therapist and/or Nursing says I’m OK to eat or drink whatever I want! I’m confused!

Having a health incident and working with many different professionals, there is bound to be some confusion when you get different opinions from differing sources. It is not unusual for patients to ask a Physical Therapist or Nurse about their dysphagia or cognitive abilities and get an answer different from that of the Speech Pathologist that they have been working with. Let me explain why this happens and what your responsibility is in the information gathering process.

There is no ‘chain of command’ among healthcare professionals. Although the orders come from your primary physician, He or she is making the recommendation for you to see a rehabilitation specialist because they do not do this type of evaluation and therapy. They are not educated in the specifics, which is why they are referring you to someone that is.  Look at it this way. It is impossible for any one professional to know the ins and outs of the sub-specialties associated with their myriad of different fields of medical practice.  If you are using a wheelchair at this time, you would not have let a nurses aid or dietary manager measure you for the specific fit you needed to accommodate your mobility issues. You can be assured that the wheelchair would not fit you like it would have if the Physical Therapist had spent time assessing your needs.  You would not have asked the Occupational Therapist to counsel you on the diabetic diet needs that have been recommended for you based on your insulin needs. Only a registered and licensed Dietician can do that effectively. Finally, you definitely would not ask your Speech Pathologist to guide you on alternative medications with lesser side effects than the one you are questioning. This would be a job for the Nurse Practitioner, Physician’s Assistant or the Physician to weigh the benefits versus the risks.  In all of these cases it is out of the scope of their ethical practice, as associated with their medical licenses, to guide a patient in an area for which they are not educated.

Unfortunately, not all practitioners honor those boundaries and defer to the professional in the area of expertise at question. So it is with dysphagia. We hear stories all the time of the nurse that will take a glass of water and give it to the patient and say, “ take a sip”. They then watch the patient swallow and say “I think your swallow is fine”. Oh, but if it was only that easy. I’ve seen patients being told by Occupational Therapy or Physical Therapy that they don’t see any issue with a patient eating X, Y, or Z when asked, yet they have absolutely no expertise in the area of swallowing akin to how the Speech Pathologist is educated. The Occupational Therapist works with you to get the food to the mouth, but once it is in the mouth, it is the purview of the Speech Pathologist to keep it out of your airway and to have it make it safely to the stomach. We have patients who take advice from a CNA (certified nursing assistant) because they are wearing scrubs, so they must be official!

Lets just look at the professionals you are working with and outline what areas of expertise they specialize in.

• Nurse Practitioner or Physician’s Assistant: They work with the overseeing physician, and in some states they can work alone. Know who they report to and who is coming up with your medical plan of care. It is ok to ask questions. This is the practice of medicine and you are unique. Insist that you be treated as such!
• Physical Therapist or Physical Therapy Assistant: These are two different education levels. A Physical Therapy Assistant may have received 2 years of a PTA program, depending on the state and when they went through school. They must work under a licensed Physical Therapist. They do not develop your care plan, rather they carry out the care plan developed by the Physical Therapist. The Physical Therapist has a master’s degree at a minimum, and in recent years has received a Doctorate of Physical Therapy as the new requirements. This added an additional year of college beyond their Master’s Degree. This additional education is in their field of expertise which is the function of your body.
• Occupational Therapists or OT Assistant: These are two different education levels just as in Physical Therapy. The OT Assistant works under the care plan developed by the licensed Occupational Therapist and does not work independently. The Occupational Therapist has a Master’s Degree at a minimum in order to become licensed in the state in which they work. The Occupational Therapy Assistant must complete a two year Associate’s degree to work, although state requirements may differ. Occupational Therapy focuses on your activities of daily living, ie toileting, dressing, grooming etc.
• Speech Pathologist or Speech Pathology Assistants: Speech Pathology Assistants, or SLP-A have a different educational level than the licensed Speech Pathologist. An SLP-A must have a 4-year bachelor’s degree or equivalent in Speech and Hearing Sciences or courses that would qualify one for that degree. The SLP-A is not able to perform evaluations and carries out the care plan of the Speech Pathologist. They are not able to independently develop a care plan or work with a dysphagia patient because of the complexity of the care and ongoing diagnostics involved. A Speech Pathologist has a Master’s Degree at a minimum and has completed their Clinical Fellowship Year following graduation and prior to licensure. The Speech Pathologist who specializes in the medical aspects of diagnostics and care has taken a different path than that of the school Speech Pathologist that specializes in infants or school aged children. It is important to note that a Medical Speech Pathologist would never give advice to a parent of a school aged child about an area in which they do not specialize, as that would be unethical and the advice may be completely inaccurate.
• Certified Nursing Assistant or Aide: A Certified Nursing Assistant normally takes a 4 to 12 week course prior to becoming ‘certified’. The education level that one must attain prior to training is a high school diploma or GED equivalent. No experience is necessary to go through this course. They are trained to help the nurses in any healthcare setting and have one of the most grueling jobs in healthcare. It is important to note, however, that just because they are wearing a name-tag and scrubs does not mean that should be your go-to for medical questions outside their expertise of your basic care. They are invaluable to the function of a healthcare setting. A nursing aide who is not certified, or a privately hired aide may or may not have that few to several-week course of training. This person may be invaluable to your care at home or in any setting, but also should not be the go-to for your medical questions and definitely should not overrule your licensed professional’s recommendations.
• Dietician, Dietary Manager, or Dietary Staff:  The Dietician has a bachelor’s degree in nutrition or a similar field at a minimum. The Dietician develops the patient’s plan of care in regard to the nutrition and hydration needs of that particular patient. The Dietician does not address dysphagia needs or consistencies compliant with those needs, but rather figures out the caloric intake necessary for adequate nutrition while on an altered diet. The Dietary Manager is not always a Dietician, but sometimes could be according to the state, company, and staffing practices of the facility. The manager runs the kitchen of the facility and assures that the physician’s orders are followed for each particular patient. They do not, however, make the decision on diet if they are not a dietician, and never make decisions on consistencies for dysphagia safety. Finally, the dietary staff prepares the food and keeps the kitchen clean and in working order. They are not allowed to answer questions about your diet orders, but make sure that the right diet and consistency gets on your plate. They are indispensable as well.

Working with patients who have suffered a medical incident is a puzzle with the many pieces that I have outlined. The best possible care happens when everyone works within their boundaries of expertise for the betterment of the patient’s condition. Know who to ask for what advice. The scrubs outfit does not make them an expert! What do they say about free advice being worth the cost you paid — ie nothing? That has never been more true than in this scenario.  Your Speech Pathology Dysphagia Expert is carefully designing your plan to get you to the highest level of outcome possible. Now that you understand the education levels of all involved, perhaps this will make it easier for you during these confusing times.