Diagnose and adios? Stay a while longer, my friend.

Diagnose, stabilize, and move on to the next chart. That's a common model in acute care, but it's the one this team walked away from. One patient sat trached, decannulated, retrached, and off food, stuck until his care team decided the plan wasn't working and changed it. Three days later he was doing seventy-five to a hundred swallows a session. Four weeks after that, he was eating regular food, off the trach, and walking home. That case was one piece of a bigger shift. The SLP team at Johns Hopkin’s borrowed ideas from physical therapy, occupational therapy, and even an old animal study on stroke recovery, then built a case out of patient outcomes, hospital priorities, and a story that was hard to argue with.

Join us for a chat with Nicole Frost of Johns Hopkins Hospital.

Guest: Nicole Frost, M.A. CCC-SLP, BCS-S 

Contact: nlangto1@jhmi.edu

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https://swallowthegap.com

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Transcript

Welcome to Swallow the Gap. Swallow the Gap podcast is a production of Gap Education, and we are predicated on a mission to improve dysphagia care. Nothing we say is legal advice. Nothing should be taken without scrutiny. While we strive for accuracy, we do not imply perfection. Through critical reasoning with open minds, we serve as catalysts for advancement in medically focused speech language pathology

Welcome to Swallow the Gap. Today, I have with me Nicole Frost from Johns Hopkins University. Nicole has been a speech pathologist for 16 years as of recording this on the 31st of July, 2026. She spent 12 years at Johns Hopkins in an acute care setting, and right now she works as the rehab therapy manager, wait for this, over PT, OT, and speech.

So those do exist. For any of you who are SLPs looking for a rehab therapy manager position, call Nicole and she will tell you how to do it, 'cause apparently she, she does a pretty good job. But anyway, it is a pleasure to have you here. Thank you for putting up with all of my pre-prep before this. I know all sorts of unfiltered thoughts and stuff to get us here, but so glad that we could finally connect.

Thank you so much for having me. I'm very excited. Yeah. Good deal. So you were telling me a little bit about some publications that y'all have with enhanced rehab therapy models in the acute care setting. What is that? Tell me, tell us a little more. Yeah. So when we think about enhanced therapy models in the acute care setting, we're thinking about a higher intensity of rehabilitation than what is frequently provided in the acute care setting.

Um, so I think for most of us, we, when we are treating in the acute care setting and in the ICUs, we often recommend that patients be seen more often. Um, we might recommend five days a week, but the reality of being able to do that, at least wherever that I've worked, is, uh, is a challenge. So how do we look at the literature and identify maybe populations that the literature does support a higher intensity or higher frequency therapy in the acute care setting, and then how do we test that and see if we actually do make a, a positive improvement for those patients compared to seeing them less frequently?

So those are some of the things that we've worked on, um, for PT, OT, and SLP with our, um, stroke population, as well as some of our post-surgical populations. And we've been very fortunate to be able to demonstrate some positive outcomes for patients when they've received this higher intensity therapy.

Okay. Very interesting. I know a lot of us get in the mindset, myself included, um, when you're in acute care, you kind of diagnose and adios, or diagnose, stabilize, you know, check in, reevaluate, monitor progress, see if things are getting better, make sure nothing's getting worse, and a lot less hands-on treatment, which can be unfortunate, but can, it can be a byproduct of many things.

I mean, just how long people are there, fluctuating senses, sometimes having more people and trying to staff therapists proportionally to the patient demands, which I can imagine as a manager would be extremely difficult. What do you think are some of the, the main positive takeaways that you have learned within that research?

Yeah, that's a great question. You're absolutely right. It's, um, it- this is not something that we always did. We definitely were, uh, when I started here 12 years ago, we were definitely doing, like you said, you know, evaluate, and then that was it, or evaluate and then just follow up to see if they could be advanced.

And that has just evolved over time, and as that has evolved, our staffing has evolved as well. So we've been able to demonstrate the value of speech in the acute care setting with these patient populations, and then we're able to go to the hospital and say, "Hey, this is the value that we bring. So, but in order to do this with more patients or with a different patient population, we would need additional support."

And that's the way that we've been able to advocate to grow our team over time. Um, so when I started, I believe I was the eighth SLP on our team, and we now have 16. Um, so in 12 years we've essentially doubled our, our SLP team. So you've had to demonstrate your value, that you're, you know, that you're doing something that's worth hiring more people.

Exactly. And really l- trying to link it to the hospital's strategic priorities. So what is the hospital really focused on at that time? Is it length of stay? Is it readmissions? Is it hospital infection rates? And how can you link what you're doing to that? Because then that really demonstrates your value to the hospital and what their overarching goals are.

That- that's interesting, 'cause if you think about it, a lot of, at least in the United States, um, I mean, it's about making money, right? Um, we, we go into it from the perspective of wanting to help patients become better, and then we get into this kind of corporate hospital world. I'm not speaking for where you work or for anyone works in particular.

Just kind of as a general rule, that's the language that a lot of administrators speak. But there are certain times, there are certain foci that they're looking into. And so I love what you have said about being mindful of that, to be able to demonstrate our value. So not just more broadly, like, "Hey, how can we help them to save money?"

But, like, knowing the particular initiative at the time the administration's looking into to be able to, at that moment in time, reinforce our value or, or help them to, to see that better. That's great. Very smart, very strategic. Yes. I have learned that over the years. Um, you know, being in a management role, those are some of the things that I have to think about, is how can I think about this from a more standardized or strategic approach, and how can I communicate our...

how can our goals align with the dep- our overall department goals and the hospital goals? Because at the end of the day, everyone does care about patient outcomes and patient safety, and how can we demonstrate that, but specifically linking it to the things that, that the hospital's focusing on. Um, what are the other things, you know, can you focus it on things that are maybe state-specific?

So I can speak to Maryland, the discharging to post-acute care is a bit of a challenge and is becoming more and more challenging. Um, so are there opportunities for us to rehab in the hospital and maybe bypass a post-acute care stay? Maybe they don't need to go to sub-acute. Maybe they can go directly home.

Can we provide that level of rehab earlier and overall maybe reduce the overall cost of care for that patient across the continuum, because now they can go directly home? So those are some of the things we think about, and how can we demonstrate our impact to help support those goals. Yeah. That's great.

I mean, I think one of the- A, a huge thing within our field is not always feeling particularly valued for the services that we do, and I, I think we are more aware than others of the value we bring to the table, just understanding more of the science and understanding more of the research. But to be able to convince others, hate to have to be able to convince others, you know, that we're working with of our, of our value, but that's a challenge.

So appreciate that you're doing that, and I think that provides some good strategy for anyone who's in a similar position. Question for you about, so this model that you are focusing on of spending more time on rehabilitative measures when someone is in the acute care setting, tell me a little bit more about, like, what that looks like specifically Yeah.

So f- depending on the, the patient diagnosis, there's some, there's more research to support earlier rehabilitation versus others. So our approach, it isn't a blanket, like every patient gets X number of therapy sessions. We have a few populations like that. So for example, our stroke population is seen five days a week.

And our, some, a small subset of our post-surgical patients are seen five days a week. But all other populations are, um, a little bit more fluid based on the patient's needs. But we are... Our goal is to prioritize treatment, so we might, when we're doing our triage in the morning, because we never have enough staff to see every patient we want to every day, just like I think every acute care hospital in the US, we might prioritize a treatment session over a new evaluation.

If that patient is on a regular diet and thin liquids, and that patient doesn't have high risk factors for the development of pneumonia, maybe that evaluation doesn't have to be the priority right away. Maybe that NPO swallow treatment is the priority so we can potentially progress them to an oral diet, or maybe somebody who's on an unmodified diet, but if we provide a little bit of rehabilitation, they might be able to transition back to regular thin before they discharge from the hospital.

That's interesting. A lot of times w- we make rules for a purpose, but then we forget of the purpose that we made the rule for. Like, or this- Mm-hmm... this general rule of thumb, you gotta see evaluations first. I mean, you can think of the rationale behind that, like because a lot- Mm... more of them are NPO or, or whatever, whatever.

We don't know anything about them. So this is neat because you, you've stepped back and you're not just, like, following the rule as a blanket, but you're like, "What's the purpose of this? Oh, yeah, the purpose is to create these positive outcomes for the patients," and in terms of, like, urgency and those si- types of considerations and, and really reassessing and, and directing your care based upon that.

Super cool. Yeah, exactly. Yeah. And then the treatment that we provide is, is really what you would see in an inpatient rehab facility. We try to do that level of treatment in the acute care setting. Oh, wow. Um, we're not doing hour-long sessions. They, you know, they're typically 30 minutes or so, I'd say. But we are, after instrumental assessment and we identify the physiologic impairments, we are doing the typical pharyngeal strengthening exercises or we do have sEMG available, so we do some skill-based training using sEMG.

We do have respiratory muscle strength training and lingual resistance tools that we can bring. So we're, we're very fortunate that over the years our department has been very supportive of purchasing these treatment tools to help support implementing more intensive rehabilitation or more frequent rehabilitation in the acute care setting.

Is there anything that's been particularly helpful, uh, like any metrics or, or anything else that's been particularly helpful in being able to advocate to get those devices or, or, um, resources that you need to work with patients? Yeah, I think there's a couple things. I think, and I think patients' cases or stories are really helpful.

So I can think, there's, feel like I talk about this case a lot, but this was one of the ones that really helped us start to shift our focus. This was a really complicated medical patient, post-surgical patient, who, um, had been here six months, um, when we made our shift in our treatment plan. And the patient had, had been trached twice.

They'd been trached, decannulated, and retrached. Um, they'd been NPO for really the entire time they were here. We had been seeing them for treatment intermittently, but, you know, once or twice a week for maybe, you know, 10 to 15 minutes. They were maybe doing 20 swallows a session. They really weren't making gains.

And the provider came to us and said, you know, he came to PT, OT, speech, nursing. It was a col- multidisciplinary discussion. And he said, "You know, this patient- is I worry this patient's not gonna make it out of the hospital and we need to make a change to the plan. What can we do to m- to take a step back, think, reflect on what we've been doing, and where are we missing?

Where's our gap? What can we do differently? So we decided to pivot to a more rehabilitative approach. We brought in sEMG, and the patient went from doing 15 to 20 swallows in a session to 75 to 100 in, like, three days. He was super engaged. He was... wanted to participate in therapy. We started seeing him five days a week.

And in, I believe it was four weeks' time, he went from NPO to regular thin after being NPO for six months. Um, he was decannulated. He went... He walked home, so he, from a PT and OT perspective too, he made huge gains. But it wasn't until we kind of reflected on what are we... what could we be doing differently, maybe this isn't just the patient's medical status, maybe there's something that we can do differently to change this patient's trajectory and outcomes, that it wasn't until we took a step back and did that, that we actually changed the outcome.

So I think that's a case that we used in- initially to show the value of rehab in the acute space, because this patient would've just been in the hospital or would've had to transition to a sh- skilled nursing facility or long-term care facility, and we bypassed all of that. Um, so that's one thing. I think some of those stories are really helpful.

Yeah. Another piece, I think, is finding a physician champion. Um, so having a provider who really sees the value and being able to also advocate is really helpful, to have it come from not just therapy, but from other members of the multidisciplinary team. And then, again, like I mentioned, linking it to those outcomes.

So with some of our research, we've been able to show that we can reduce readmissions. So our rehab to home paper that looks at post-surgical patients, we were able to bypass subacute rehab stays for a high number of them when we compared them to s- like patients before we started this. Um, and then we were also able to reduce avoid- m- the avoidable u- utilization, avoidable utilization, I forget the exact term, but readmissions.

So we, uh, we were able to demonstrate that, and we brought that to the hospital, and they are now supportive of increased staffing to be able to potentially expand that model. So those are the things that I think I focus on most often. Wow. Very systematic, strategic. Makes a lot of sense. There was something I wanted to ask you about on the first point.

Like, you mentioned sEMG in particular. I'm just curious, I don't know if you've got, like, a definite answer for this, but what do you think about that? Or what do you think it was about that particularly for that patient that was helpful to get them from 10 or however many swallows you said to, like, 75 to 100?

I think it was that he could see his progress, and he could see instead of me looking at him and saying, "Okay, swallow again. Swallow again," there was more interaction. He could see what was happening. He could see the goal. He could see when he met the goal or when he didn't meet the goal. Um, and I think just being able to have that real-time feedback made a difference for that patient specifically.

That's really cool. I have lately been thinking a lot about how gamification, just from a psychological perspective, helps tremendously. You know, when things are palpable, when you can see the results of what you're doing, of course that helps. But even just, like, if you can make something fun, get some sort of like a dopamine hit, some sort of a reward from it, and sometimes that's just seeing, like, oh yeah, I swallowed.

Look, I did that, and it's not just a normal proprioception of, like, feeling your throat muscle squeeze, but it's seeing it visually, uh, somewhere else, you know, on a screen or wherever. Yeah, I completely agree, and I think that there is some upper limb literature that supports some of that as well. Um, there's some research that looked at, um...

It's for the upper limb, and they play when they move their arm, a dolphin swims, and it goes and it catches fish. And they found that they have a lot more time on task, meaning they're moving their arm a lot more when they're playing the game compared to traditional therapy. So there is a... And they found that the patients then have improved outcomes with the movement of their arm because they're so engaged, and there's something motivating them to, to move their arm more often I think I am a lot more interested in looking at, like, the psychological components of treatment too, because we can see in a sterile environment, like, what works.

What works? If you do 100 of these versus 100 of those for X, Y, Z, you know, pathophysiology or whatever, what works better? But from a practical perspective, what is gonna help the patient to do those things and, and make it happen, and I believe gamification is a really strong way to do that. I would be interested in hearing or reading more about that overall too.

And I know earlier you had mentioned, um, research outside of speech pathology that's helped to guide your perspective for what we do, and I, I think that's a great example what you mentioned there. Is there anything else that just really comes to mind that you have learned from outside literature that you think very much applies to our world?

Yeah. I think specifically in the stroke r- research, there is... When we think about early rehabilitation in the acute care setting, there's definitely some things out there for speech that demonstrate that there is likely some value in us providing treatment in this acute phase. But I think the PT literature is maybe a lit- has a little bit more, um, like larger tr- larger studies, and one of them is the AVERT trial that was published, uh, a number of years ago looking at mobility post-stroke.

And they found, um, what they're, they're findings were actually surprising in that they found that really high doses really early on was not beneficial for the patients. But when you looked at their control group where they found it was beneficial, those patients were being seen three times a day for anywhere from 10 to 18 minutes.

So it, it suggests that maybe short, frequent therapy sessions are more beneficial than these longer hour-long sessions like you would get in an acute rehab. But I think looking at either group, it does demonstrate that early rehabilitation is valuable from a mobility perspective. So it's different muscles, but it's still muscles, so could that be translated to swallowing?

Maybe. And then there's another study that... And this is an animal model, so this is definitely theoretical, um, but I found it super fascinating. It is a, it was an animal model study done by one of our neurologists who works here at Hawkins, and they had, um, they were looking at the, um, upper ex- the, looking at the arm, and they, the, it was with mice, and the mice were, uh, had a stroke, and they could, they had been trained to do a task with their arm, and then they had a stroke.

And then they, for one group, they started their rehab on day one, and the other group, they didn't start the rehab until day seven, and they saw significant change, significant differences in the amount of function that the m- mouse, the mice got back So the people, the mice that got rehab starting on day one had better recovery than the mice that had rehab starting on day seven, which is kind of modeled what we typically do, right?

They don't get a ton of rehab in the acute care setting, and in- it's not until they go to rehab where they start getting that intensive treatment. So it looked like maybe we should have been starting it earlier. And then what they ended up doing, they did a second study, and they t- they did the first part again, so the mice practiced, learned this activity, res- they received, they had a stroke, they re- didn't receive therapy for seven days.

They rehabbed them. They didn't get a ton back. And then they gave them a second stroke, and then started the rehab right away. And what they found is it actually reopened that neuroplasticity window, and they were able to recover the movement almost to the level of before the first stroke. So they were able to, like, f- almost fully recover after that second one because they did the rehabilitation during that hyper-neuroplastic window.

So again, mouse model, so very theoretical, but what I think the neurology literature is suggesting is that there is this neuroplasticity window f- essentially, it, that is, peaks within the first seven days. And I feel like our traditional approach is missing that. So how do we start intervening in those first seven days to try to capitalize on some of the natural things that are happening in the brain from a neuro recovery perspective?

Well, I mean, I, it, it sounds to me like you've already started doing that, because in your acute areas, you're focusing- Mm-hmm... much more on treatment than just diagnosis and stabilization, which- Yeah... I, I mean, that makes a tremendous amount of sense. Why wouldn't it apply to the muscles of, of swallowing or, you know, to the muscles of speech, depending on, on what we're looking at?

It's skeletal muscle. Mm-hmm. And, and you're talking about, uh, you know, neural pathways. You know, the idea of use it or lose it or use it to improve it, those types of things. It makes sense. It makes sense. It's, it's funny why we don't think of these things. I mean, I, there are so many things that I hear about people doing and that work well, and I'm like, that seems so obvious.

Like, why didn't I think of that? But just preventing disuse atrophy and, and, and getting things going, that's great. And I love to see that you're, like, doing something about it, and that it's, that's working well. Yeah. I mean, I think it's hard. I think culture change is hard. I think everyone is really busy, and if that's how you've been doing it, it's hard to make that shift.

But y- I think l- think looking at the research that we have for our discipline, but then also looking outside our discipline from a neuro, neuro recovery perspective, from an exercise science persept- perspective, sometimes that can guide us in a, a little bit of a different way. And that, that's how we developed some of our models, was not necessarily only looking at our own discipline, but looking collectively w- what maybe makes the most sense for this patient population.

Yeah. That is, it sounds like something very cool that you get from your perspective since you're a manager working with PT, OT, and speech. You're getting doses of, of what work in these different worlds. Like, you've already, you brought over an example from physical therapy about, uh, you know, doing rehabilitation so early.

You brought over this idea from the biofeedback and the gamification with occupational therapy on, on upper limb. Is that right? Yep. Yeah. And so, and you're, you're seeing the translation, like things that are commonalities between that and speech and are able to make these application. The value just in collaboration, whether it's PT, OT, neurology, or whoever it is, that helps to pull us out of our, our being siloed and, and sometimes, like, the, this can be the stagnation of our ways.

I don't mean that in, like, a deprecating way. I just mean that it's easy. If you don't, if you don't talk to other people, you get stuck in your own head. But if you have other people who are willing to challenge your ideas in a productive way or you're willing to discuss them and see what they're doing, there is so much more that can be brought over, and I think that is one of the ways that we move forward, not just in our rehabilitation, but in our education.

So much of our education is siloed between coursework and what we do in, in the clinic, whereas really I believe we should be doing so much more of learning and then doing, learning and then applying immediately because you're, you're learning from the perspective of what's declarative knowledge, like learning facts, learning information.

But then the difficulty can be in translating that to procedure and to the things that you're actually doing, and there are things that just don't always translate easily. They don't make sense. So if I hear you talking about this early rehabilitation, you know, working with patients soon, providing biofeedback, all that sort of thing, like, it makes sense.

I wait six months, I might forget about it. Or also, like, if I get to go and try it now, I see, I identify, well, like, I know this principle makes sense, but in my clinical practice, this is a barrier. This is a question that I have that gets in my way from me being able to do that. But while the information's fresh in my mind, like I can problem solve through that more.

I can go back to the instructor who taught me about that thing and, and while the conversation is fresh, to be able to work out those gaps from it being just conceptual, abstract, declarative knowledge in my head to something that's procedural. Not sure how I got on that tangent, but I feel very strongly about it, obviously.

Like, there are just, there are so many things that we can learn from what others are doing. That doesn't mean that the things that we're doing are necessarily wrong or that we have to feel bad about it, but there's just a lot and I... That's why I absolutely love getting on here and like talking to people about these sort of things, 'cause I learn a lot from what they're doing, and I hope that the people who are listening are like, "Oh, yeah," learning, learning a thing or two or, as well from this perspective, so.

Yeah, I completely agree. I think I learn so much from, from my SLP colleagues every day, because everybody has different perspectives, everyone has different experiences, everyone reads different research. So I'm learning from my SLP colleagues on a daily basis, but I also learn so much from people outside of SLP who give me a different perspective or a different way of looking at something that will g- guide me in a different direction or maybe help me think about something more outside of the box or maybe not as traditional from how I was specifically taught.

But I wanna go back to one of the things you mentioned about the education, like you teach it and then they do it. Do you envision that, do you think like a simulation in the, like simulation center or something like that in clinical education addresses that? Or is it more like they learn it and they do it in their clinical rotations?

How do you envision that? I think there are a lot of different ways to go about it. I think simulation is incredibly valuable because with... Man, I, I will, if you're not careful or if I'm not careful, like I'm gonna steer this whole conversation over to education and like how I think it should be. So hold me in check so I don't-

get us off the rails too far, but since you asked, so like, okay, I'll go- I'll go into it a little bit. Um- Yeah... you think of the constraints that we have. Like, you can teach somebody about anything, anything you know something about. You can teach somebody how to, um, give d- you know, do dysphasia diagnostics without instrumentation in an impoverished third world country and this, that.

Like, just so many different ideas. But how do you get them to apply that? It is so much harder to be able to apply something than just to learn about it. It's like if you're working in an outpatient clinic, it's not like you can snap your hands and, oh, a patient with bulbar onset dysphasia or a, you know, bulbar onset ALS with dysphasia walks through the door, and now let's practice on this case.

Like, you- Right... see the patients that are coming through the door. The see... You see the patients who you have experience with. And so the simulation perspective, you can design things. You can be more premeditated. You can be more intentional. You can be more deliberate. I just said the same thing with three different words.

Sorry. I'm off the rails. But you can do that. And you can- Yeah... do it in a way that even though it's a little bit less real, 'cause it's not a real patient, it is still leagues ahead of just teaching and hypotheticals within the classroom. I mean, not just simulation. There's that, but there's case-based learning.

Not just saying, "Hey, this is what you do," but like, "Okay, we know what you do. Now imagine you have Johnny B. Whoever who's coming through the door. They have this medical diagnosis. They ha- they have these symptoms. They have these signs. How do you make sense of that?" Or like just work through it and it applies it in a very practical way because our critical thinking skills are just, they're primed for development.

We need to work so hard on that, not just memorizing facts and information. The way that people learn is by constructing knowledge based upon their prior experience. So I learn something in a class about dysphasia or about rehab science or whatever- Typically, I'm not just trying to memorize that. I'm trying to see how that fits with my experience, with the things that I already know, and I, uh, like attach it to that experience.

Or if it's incongruent with my experience, I might try to revise my understanding of my experience, or I might try to bend and break this new information to make it fit with what I already know. And so there's just so much to it. But yeah, I love the idea of simulation. But however we can get these opportunities to learn and to practice happening together is amazing, and really where I think the opportunity- one of the biggest places where the opportunity is, is where you are.

And I say this as I point to you, Nicole, but I also say this as I, like, in my mind, point to everybody who is listening who is working in a clinical setting, who has students. You are not just there for these externs to, like, to let them observe you and to observe them and to see how they're doing. You're there to teach them.

Mm-hmm. And that becomes fragmented way more than it should be. But you have just the most prime, seemingly one of the most prime opportunities to teach them in a way that it's going to stick with them because they're having the experience simultaneously with how you're teaching them. So you're a clinical service provider, but you are absolutely an educator.

Yeah. That is an honor, and that is something that you can do amazing things with, so take advantage of it. Absolutely. I completely agree. And I think I love everything that you said because I agree. I think, you know, there's a difference between what you learn in a textbook or from a PowerPoint and then actually doing it hands-on.

And I think for students being able to do that with the learning in a safe space where it's okay to not have all the answers and it's okay to ask a lot of questions is so important. And even for our staff, um, I know this is a swallow podcast, but, um, an, an example for when we teach our, when we teach people to do inline speaking valve, we can use our simulation center to- So talk, talk to me about that sort of thing.

Like, sorry to interrupt you. It, it- No, you're fine... it's largely focused on swallowing, but it really is broadly focused on the whole MedSLP world, so I would love to hear more about that. Yeah. So I think when, like, when I think about teaching inline speaking valve, there's a lot that goes into that, and doing that sometimes the first time in a patient room with a patient, with the, with the respiratory therapist, with the vent, with all of that might be a little bit overwhelming.

So how can we use our simulation center to practice that in a, in a safer s- a safer environment where they can ask questions, where we can talk through the different vent settings, or we can do, or we can talk about what if this happens, now what? Or like you mentioned, kind of putting it into a case-based context is a, is sometimes a good starting point, and then people feel more comfortable in the patient room when they're actually do- when they're actually starting to do that with their preceptor or their mentor or their, their clinical instructor if it's a student, those types of things.

Absolutely. Expert blind spot is a really big part of this. Think about yourself as a clinician who's been practicing for a long time. There are many things that just become natural procedure with what you're doing, and you forget having to work them out and wrestle with them in your head. Mm-hmm. And so when you get a, a student coming in, you've gotta reverse engineer what you're doing and think about all of those parts that were so difficult so that you can provide the support in, in doing that.

And so that just kind of, like, goes back with the transition from what's in the textbook to the patient that you're seeing in front of you. Like, in the textbook you might learn XYZ with inline speaking valves, but then you have a patient who's in front of you, and you're like, "Okay, how do I position them?"

Like, what about this part with the respiratory therapist? Just all these little pieces that weren't a part of the, what you were being instructed about, because what you were being instructed about was very general, and it wasn't specific to your setting, wherever that is, with the resources you have available to you.

And- Absolutely... yeah, just in, in everything we do, it's so important to be mindful of the expert blind spot, even in our, like, our education to, to families. You know, breaking it down in a way, like if I were in their position, what would I understand? Breaking it down into lay terms. Super important, but I mean, I- that's, I think, is enough of my educational rant that I probably go on at least once a podcast episode.

But I completely agree, and I think, I think what you, what you talk about is one of, like, one of my favorite things about mentoring, is it forces you to think about why you're doing what you're doing. And if you don't have a good answer, then taking a step back and being like, "Why do I do this? Is this what I should be doing?

Let's look at the research together. Let's see if I should, if, like, this makes sense or if there is something new where I should be doing it differently." And I think that's one of the, one of the benefits of mentoring, is I- you learn along with whoever you're mentoring, because you have to be able to explain the why, and if you can't, you have to figure out why that is.

I, yeah, I am, I'm with you there. That is one of the biggest benefits of having a student. It's not just you prep- uh, you know, passing along good education and teaching and so on, but you're put in a position where you are forced to, like you said, understand the reasons why you do the things that you do.

And that ultimately makes you better unless, unless, you know, we kind of dodge that and become intellectually dis- dishonest, which of course is the wrong thing to do. But it forces us to better understand the reason for the things that we do. So I'm gonna take that just, like, a step further to be like, if you don't have a student, just, like, give yourself reminders, like, to pause and step back and like, "Why am I doing it this way?"

To periodically think about that. Reflective practice, I mean, is just tremendous. One of the things that I tell my students, and I mean this in a general sense, I don't mean this in an absolute sense, but usually no one's chasing us around to be like, "Are you competent? Are you competent? Are you seeing that patient?

Are you competent with that patient?" Uh-huh. You, you pay your dues, you do your CEUs, you do a CFY, and you're, most of us, relatively independent. So if we're not doing the type of self-assessment, and then it, it is easier to stagnate. And so that's one of the tremendous benefits of students, but if you don't have a student, like, definitely get in that mindset.

It is so helpful. Yeah. Absolutely. All right. Let's circle back around and kind of wrap things up with what we were talking about before. I mean, there's a lot to learn from other professions. There's a lot to learn outside of our silos and outside of the things that we're doing. And so perhaps being willing and able to hold conversations, not just with other speech pathologists, but with other types of therapists, physicians, looking into their literature and, and hypothesizing based upon what we learn, what are some ways that that could apply to the things that we're doing so that we can keep growing where we are and, and not to stagnate?

Um, I love what you're saying about not putting off therapy, and I think there's some really solid empirical evidence with what you're saying about, like, the delay in waiting. I, I know a lot of it is in, in animal models, but- Mm-hmm... but, but still, I mean, it's a starting point, and I think that it's very reasonable that s- some of those things would generalize over to, uh, to what we're doing.

Is there anything else that you want to, like, elaborate on with that or, or to speak to? Just even if it's just kind of, you know, kind of re-summarizing. I don't know. I mean, I think the big thing, I guess the big takeaway is, you know, I think hearing that, oh, we should be doing therapy more often in the acute care setting might feel overwhelming- Right

especially if that's not how you're practicing right now, and knowing that, you know, this change takes time. And there are some implementation models that you could follow if you are interested in making a shift in your practice, and this could relate to any type of shift or you read a new research article, there's new evidence that comes out.

How do you implement that into clinical practice? There's a lots of different models out there, um, if you look at implementation science. Um, but one of them that I, that we use most often is it's Translating Evidence into Practice by Dr. Dale Needham. He's one of our attendings here. But it goes through the different steps, and it talks about, you know, the first step is summarizing the literature, and then it's looking at what are...

looking at the barriers and trying to problem solve with some kind of core stakeholders. What are some solutions to those barriers? You're never gonna fix all of them, but what are some of the low-hanging fruit barriers that you could address? So if there's, if maybe if your team is, maybe if you feel like your team is a little hesitant to make the change from eval- primary evaluation to treatment, having journal clubs, having clinical reasonings, talking through some of the research together, talking through different cases to see if there's, to try to harmonize your practice a little bit more.

And then how can you measure performance? How can you demonstrate the change, um, and the benefit to what you're doing so that you can share that with others? And then always reevaluating your practice. So even if you make a change, it might not be perfect the first time. I will share from our experience, any time we roll something out, there's always bumps.

It's never p- beautiful the first time, but we're constantly making changes based on feedback from our team, from other colleagues, and eventually over time it becomes the culture. But there's multiple iterations of that. So knowing that what- the first time you try it, if it's not perfect, that's okay and that's normal.

Um, and try not to get discouraged, and you'll eventually make slow gains over time. A lot to be said, for sure. Well, I appreciate everything. I, I've learned a lot. I... These conversations are very intellectually stimulating. It helps to keep me excited about what I'm doing. I mean, even just, even just to hear not even about what it is that works, but that there's something that works.

Because I know a lot of clinicians, well, I don't know if you can say I know a lot, but you see clinicians in forums, and I've been there too, I'm just wondering, like, is what I'm doing really helping in the way that I would like it to? And so just to hear more about that is encouraging. It helps to motivate me to keep going, to motivate me to try to become better and to continue to try to further our clinical practice and, and bridge the gaps that exist.

So again, Nicole, I appreciate everything that we've discussed. One thing that I would like to just revisit briefly before we go is the idea of trying to prioritize evaluations and treatments, um, in a way that allows you to work with patients in, in a more continual, um, way, but without necessarily, well, not necessarily, but without neglecting patients who are, have not been evaluated and who really need care.

So that's a, a great question, and the way that we've approached it is we have created a kind of systematic triage system so that we make sure that any SLP who's triaging is doing it the same way, just so we have consistency across our team. But it's definitely a balance where we're not saying that we always do treatment over evaluations or vice versa.

We're really looking at where is the highest priority for that specific patient, and how quickly do we need to intervene? So if we look at just evaluations, we, if this patient is admitted to a, a medicine floor, they are on a regular diet, there's n- they're, they don't have a lot of risks for pneumonia, um, and briefly looking at the chart, it might be more GI related, that's an evaluation that maybe could wait a day or two.

Versus if we get a consult for a patient who's in the ICU, he's, who's NPO without access to meds, and they've been intubated for seven days, that's definitely gonna be a really high priority for us that day. So it's definitely, um, it's not, we don't have really, like, hard lines like evals or treats are one versus the other.

It's really kind of based on what the patient's needs are. So are they on a modified diet, and we think that within a few sessions they can progress? That might be a higher priority, so we can get them on a regular diet before they leave. Versus a patient who maybe we think is gonna take a longer time to recover, we're still gonna see those pat- that patient, but maybe it's not a priority every day.

Maybe it's a priority two or three days a week. Um, so it's, it's a constant kind of balance between all the other priorities that we have. Yeah, but you're taking, like, a very mindful approach to it, which is good. You know, not just having a rule for the sake of the rule, but really analyzing, like, what the point of that is to make sure that you're seeing the patients who are likely to need it the most or most urgently.

Yeah, we're trying to really optimize, and a- as best we can with... You know, 'cause this is an art, not a science. We're trying to balance, um, or optimize the care that we can provide to all of the patients on our caseload, knowing that we're never gonna have enough resources to meet the demand. How do we optimize with what we have?

And that's, that's been our goal. But it's an art. It definitely evolves over time. It's evolved, I think we've had four or five iterations in my 12 years here, so it will continue to evolve as more evidence comes out. Excellent. Sounds great. Well, again, I appreciate the opportunity to chat. Is there anything else that you want to leave listeners with?

No, that's it. Thank you so much. I really enjoyed the conversation. Yeah, me too, and if any of you would like to reach out to Nicole, I will put her email address in the description for the episode. Feel free to do that. I've gotten permission beforehand. I think one of the things with this is it's nice to...

I mean, y- you hear about people who are doing great things, and I think the podcast format makes it a little more human, especially, you know, when you get people who've been writing textbooks or publishing articles left and right, that sort of thing. It, it can seem, um, like there's a lot of distance between us and that individual versus if you just hear them on here talking just like the rest of us, thinking things through like the rest of us.

It can make it more comfortable to reach out and to ask questions and really open those doors of opportunity. So I hope you all take advantage of that. I think Nicole's a great resource, comes very highly recommended from someone I have a lot of trust in. And so appreciate it again, and thanks for joining us.

And, uh, anyway, looking forward to the course you're putting out, and hope to chat more soon. Thank you so much.

Great to be back for another episode. A quick notice on three upcoming events. First, a no-cost office hours session with Dr. Michael Creary on Thursday, August 13th at 7:00 PM. Second, a no-cost live webinar with Dr. Janina Dumscota on an SLP guide to using information from brain imaging for the management of stroke dysphasia.

This will be on Thursday, August 27th at 8:00 PM Eastern. And lastly, for those of you who are interested in teaching and supervision, maybe you'll have a student for the first time coming up, I'll be teaching a course called Teaching and Supervision Using Learning Science to Develop Calibrated Confidence.

This is a two-hour course eligible for ASHA CEUs on Sunday, August 16th at 6:00 PM Eastern. More details for any of these events can be found on swallowthegap.com. Thanks so much for sticking around, and hope to see you soon.