Episode 2: Is the Evidence Gap in Our Field Graduate Programs' Fault?

[Music] Hi colleagues, welcome to Evidence and Argument, a podcast for SLPs, audiologists and the scientists who support them. This is a podcast where you'll come with questions and leave with more of them, a podcast by two people who love thinking, hate beating around the bush. This is our second episode called, "Is the Evidence Gap in our Field Graduate Programs Fault?" [Music] All right, so our last episode, we talked about whether or not anybody knew shit. And so the next obvious question is, well, if they don't know shit, who's fault is it? Which is why I really love this next question. And when we thought of this question originally, I thought this made a lot of sense. But the next question, or maybe the preceding question, should be, we might not all agree that there even is an evidence gap in our field. And this position is certainly up for discussion. And that I thought maybe we have another question to ask before that, which is, what is evidence? Do we all agree on what evidence is? And Meredith, you are the founder of the informed SLP, where a main goal is to inform SLPs with evidence, to arm them with evidence. How would you define evidence? So, evidence is basically just like a shorthand way of saying research. And when we're talking about evidence, we generally mean the research that's published in journal articles. And that's the only place, you know, you're going to be able to make direct contact with the version of it that's been peer reviewed. Sometimes when we use the word evidence is kind of like a shorthand to refer specifically to research, people will bring up the issue of, oh, what about clinical evidence? What about like, you know, evidence that you might draw from like your clients' data files and stuff like that? And all of that stuff is obviously important evidence, but usually when people just say the word evidence, they tend to refer to research. And that's what I usually mean when I say the word evidence. And that's also, you know, when people are like advertising products on our field and stuff, they'll say things like, oh, this tool is evidence-based. And they're usually meaning to, you know, get people thinking that it's based on research and peer reviewed research specifically. So while that might be the case, evidence-based sits on three pillars, though. So I guess I'm a little bit curious about why you think the shift from the patient's perspective, which is a pillar, the clinician's experience, which is a pillar, and the scientific evidence, why is there this distinction that evidence falls primarily more than, you know, 70% on science? Why do you think that came from? Well, I think there's kind of like two different things. Like there's what do we mean by the word so that when we use the word, we're all on the same page. And then what do we want for clinical practice? To me, those are two totally different things, right? So like when I say, when I refer to evidence, I mean the research. I literally just mean that's the way I use the word. So when I use that word, that's what I'm referring to. And that's what most people in our field generally are referring to. But in a no way suggests that problem solving for individual clients should, you know, be like 70% based on the research at all times, or you know, like, you know, which should be weighted more heavily than others. And clinicians have asked me that before, you know, like, so which part of, you know, the evidence triangle, do you think, should be weighted more heavily? And it's like, well, it depends entirely on the situation. It depends on if there's good evidence available for you to, you know, be leaning on or if there's hardly anything available. It depends on what's going on with like the individual client situation. That makes a lot of sense that evidence varies. And obviously if you are treating a population for which there are no research studies, a lot of the weight is going to be on patient experience and your clinical experience. And so, you know, if you are treating people for what's going on with the evidence, you know, what's going on with the evidence, and you know, if you are treating them, you can use them to see what's going on with the evidence. And so, you know, if you are treating a population for what's going on with the evidence, you know, be like, well, if you are treating them, you can use them to see what's going on with the evidence. And so, it's almost kind of a funny question to ask. I'm glad you're asking it, but there's a lot of research to suggest that clinicians often don't know what our field science says very deeply. And obviously there's going to be variability. Some clinicians know it really well. Some clinicians know it hardly at all. And it varies per topic. You know what I mean? Like it varies per are we talking about speech sound disorders? Are we talking about autism? Are we talking about dysphagia? And there's actually I can bring the citations and we can put it in our show notes to suggest that there is a huge disconnect between practicing clinicians, knowledge base, and the research. And the thing that can maybe give some sort of peace of mind is this isn't an SLP thing like there's research showing that in PT and OT and education and nursing and medicine, you know, and so it's not that we're uniquely messing it up. And it's actually why certain areas of studies for scientists exist like implementation science. So people who are implementation scientists, what they study is the uptake of research evidence into daily life, right? So there's an entire field of study looking at the evidence gap. So for me, for somebody to say something like I don't think there's an evidence gap, it's like, well, have you looked? It might not be as bad in some areas and you might have situations that you're observing where there's no evidence gap. So the interesting thing about implementation science is that there are some studies that suggest that it takes about 17 years for evidence that people pretty well agree on in terms of there have been several studies generally telling us the same thing to actually be implemented at least in clinical practice. So it's something like hand washing everybody pretty much agrees it's a good idea to wash your hands to keep them clean, especially if you're dealing with sick people, but implementation of actually washing your hands just before you go into every patient's room and just after you leave is a different story. So you said what implementation science is it's getting humans to heard right we talk about hurting cats, but really it's hurting humans a lot of times. So we know what we should do and we don't always do it now that's something is seemingly simple and generally understood and accepted is washing your hands. So here's my suggestion for why I wonder whether or not the evidence gap in CSD is different from other fields like let's say nursing or something like that. We don't have research that's been going back quite as long as these other fields have that's one and the other thing is we don't have as many people studying it as medicine does right. So they have so many divisions of medicine is not just your doctor so you deliver babies and cut out eyeballs. I don't even know if people cut out eyeballs, but if they did I assume a physician would do it and I assume that that person would not also be delivering babies right unless you're like I'm going to do something. And so if that's the case they have all of these sub disciplines that have been so extensively studied right we're newer so my thought is that the evidence in our field based on research I've done at least in swallowing is do you understand how the mechanism works not what therapy would you use to me understanding the mechanism is far preceding how would you assess it which then far precedes which treatment should you use. So I'm sometimes dismayed that in CSD our question in terms of what our gap is is which therapies work when you really look at the question some people don't even under don't even agree on how the mechanism works so of course what therapy might work is so far down the line. On the other hand in general there's a whole lot more agreement on how a system works in just the most basic function like let's say say how does walking work PT's can probably along the line have a general description of how walking works. Whereas a lot of speech with all just based on our research don't necessarily agree on how a swallow works so while there is a gap the question is what is the gap on in my opinion our gap is on some very preliminary ideas and not perhaps on more advanced concepts. Yeah I see that for sure and like in other areas of our field like you know language development or so you know there's definitely a lot that's known theoretically that most clinicians don't know but I think that understanding physiology for something like swallowing is going to be much more crucial than like when you take it over to some of the like cognitive processes like you know language development and stuff like that like I can almost see. The jump to how do we treat it being a smidge more appropriate because we don't have a good enough understanding of even like the order in which you know various grammatical and morphological things come in line with you know kids between the ages of like six and nine and what you do when they're disorder and stuff. to use the theory even alone to help inform practice in that area. And what you've done is just told me that we are the physician who both takes out eyeballs and delivers babies because I don't know what you just said. And we have the same degree. So bring on your kids with their MLU problems because I'm going to put an epiglottic in them. That's all I have to say. Right. Right. Like you can show how hard it is by asking either of us. If you were to ask me how swallowing worked, you would probably die at how terrible my answer would be. And the same thing with you. If I was like name me three evidence-based techniques for treating speech sound disorders. Like some of our strongest ones, you'd be like, "Can you just remind me what a speech sound disorder is? Is that the artichewan or is that the language one?" No, I'm just making -- I'm not that bad, but let's just assume I am. Yeah, so that makes it hard for clinicians. That makes it hard for clinicians like my gosh. It's hard for clinicians. It's hard for scientists because we don't speak the same language a lot of times and we have the same degree, right? So we can't even vet each other within our expertise of understanding how research works. Yeah. So now, I guess the question that we can finally answer is the one that we said this podcast was based on, which is essentially is the evidence gap in our field, the fault of graduate programs. So we know we have a general sense of what evidence is. We have a general sense of what we think the gap is. Whose fault is it in the event that we both agree that there is in fact a gap? Whose fault is it in your pan-marital? Well, skipping straight to the answer. My opinion and prediction is that it's a combination of a lot of different factors that come from both within our field, that we have some control over and things that come from outside of our field. And again, this is actually based on implementation science, research and kind of like knowing where these barriers are coming from. But there's a lot of things that even if we were to fix it internally in our field and get clinicians and scientists communicating more sharing with each other in efficient ways so that we really are like brain dumping into each other all the time, you know, when get that set up real nicely, there's still going to be issues with insurers. There's still going to be interest issues with school districts and hospitals that we work at and all that stuff. So it's not any one group's fault per se, but I think anyone that could be identified within our field has some amount of both blame to hold in the situation where there's room for improvement and also they need to know that they don't need to feel like it's all on them. I do think that there's a little bit of history in our field of the blame for not knowing our field's research being put on clinician shoulders where it's basically like it's your fault, you don't know it, like figure it out, you know what I mean? But clinicians have so many barriers in place and everyone else who is kind of in our field. So talking about like leadership, so national organizations, state organizations, talking about university faculty, clinical supervisors, scientists on our field, business owners on our field who are selling CEU courses to people and products and stuff. Like everybody in our field has a role to play and kind of has a unique responsibility in the situation. And you can blame the clinicians, but it's the graduate programs that made them clinicians. So yeah, you know, that's the interesting part. So while you could blame a clinician who's been, I always like to say, do you have 20 years of experience or do you have year one repeated 19 times? And there are some clinicians who have year one repeated 19 times and they didn't grow upon graduation and they just didn't take the courses that would really push them and challenge them. But even to be a clinician at ground one, maybe they needed that scaffolding to say, this is how a clinician functions. We can't give you all the answers, but it is your job as a clinician to be an active learner. And maybe that's what graduate programs can do. They can teach you, they can't teach you what to see, but they can teach you where to look. Right? It's their job to say, this is how you grow, not to just say you are finished and you are done. And maybe that's their role. Yeah, for sure. So graduate programs, I think we know for sure. That they have some sort of role in that and we'll kind of go through and discuss what that could possibly be. But another reason I think this is a really interesting question is because I see clinicians blame their graduate programs all the time, where if they don't know something within the first five years of clinical practice, they're like, well, my graduate program didn't teach me that. You know, my professors have screwed up. And so I think there's both some like, you know, over exaggeration of the role graduate programs play as well as opportunities for growth and identifying what maybe they could do differently. And may I also suggest that you and I have been on both sides? Uh-huh. We've been on all three sides. We've been a student. We've been in the clinical realm and we've been a professor. And so we perhaps have a unique view of where fault lies and where responsibility also lies. We can talk more about that because I actually do have a note for the future about what incentivizes a professor, right? And this idea that it's teaching is not the case. I would also like to suggest the following, which is I feel like graduate students are in line with teenagers when you're raising kids, right? So they are not ready to go like you could they could live on the street at age 16. It's just not going to be as good as if they make it out there at age 20, but they're also not babies, right? So they've been they've had the college experience. So I think that you can't expect a teenager to be who that person is as if they showed up as a teenager. They've had X number of years before. So what should we be saying about undergrad programs? And obviously undergrad programs are supposed to be teaching the foundations in terms of what's normal. And my opinion is this, there are so many more studies generally in our field about what's normal that they should have learned evidence about understanding the basic mechanisms and how we came to know them based on the literature, not pure textbook regurgitation, which is, well, it says here that you should have your S sound by this age. Well, how did we come to know that? Well, these studies conducted this design. And together collectively, they have found XYZ. Now here are the limitations to that that you may experience in the wide range of what normal will be when you go out in the school system. To me, that's how normal should have been taught as opposed to we got to epiglottis and we got to this and we got to that. Just know it because someone's not going to have it one day and you got to understand that. So to me, the responsibility really starts with undergrad to incorporate and you have them for the same amount of time, typically about two years, last two years of undergrad, to be able to instill this idea of even though we're doing foundational principles, they too came about because of the literature. What do you think about that? And of course, incorporating critical thinking in that whole process. Yeah, I agree with that entirely. And a hundred percent, you know, issue of not just memorizing where in the brain does this happen, where in the brain does that happen? You know, what it, but understanding the science behind how we got there and the science behind a lot of the stuff in our field is really interesting, like really interesting from like a storytelling perspective too. I taught the neuroscience undergrad course at the university I was at last at Rockhurst University in Kansas City. I did it a lot from like a storytelling perspective in terms of not just like, this is what the cerebellum does. This is what it looks like. This is what a perkangie cell is. Like that put me to this voice. Are you doing whenever you do that? You're always like, who is this person in your life that you're entertaining? Who is that person? Who is the uninformed SLP who you're learning from? But you know, when it comes from the story of the science, I think that it makes it a lot more engaging and memorable. And that's just basic like storytelling and teaching stuff, right? But you got to know the story. So while you're saying that, it makes me think of a course that I put on called normal swallowing 101. And it's for clinicians who've been practicing. And you would think we wouldn't need a course called normal swallowing 101 clinical workshop. But actually we did. And I would talk about the things they think they know based on the story of how they've come to think it. So maybe something as simple as at what point should the swallow initiate? At what depth the food is basically should the swallow initiate? And everybody would be like, by the time the ball is his hair, it's like, why do you think that? We don't know. Well, let me tell you why you think that. It's because in 19, so and so, somebody said this. Then these studies came out and they had an argument. And then this study came out and this study came out. So now you are just picking this one because the textbook said it when really there were 10 studies saying there's all kinds of answers to this question. And then the story is so much more interesting to introduce the idea that the study that the literature is mixed and that's okay. I know you want to have one answer. That's why we love textbooks because somebody has baby birded it into our heads. Listen to episode one. If you don't know what I mean by that. If someone is baby birded it into your head, it's so cool to say the swallow should start when the ball has hits this particular structure. But really understanding the nuances to me, that's far more interesting. But as you said, encasing it in a story is important. But the people who are often teaching the courses because we have so many programs don't always know the history. They often get a textbook and a syllabus that's been passed down to them. They're hired to teach this course and the whole idea of the history of how we got here is not known to them. Not that they wouldn't be interested if they know them, but how would they learn that? Yeah, 100%. There's a lot of pressure put on faculty to know the broad. scope of SLPs just in the same way that it is for SLPs and it's hard for them too. Yeah, I was fortunate enough that I never got a class dumped on me that I really wasn't prepared for, but it could have very easily happened. All it would have taken is one little shift in another faculty member at the university and I could have landed with like teaching fluency on my lap and been like, "Okay, I better read a couple textbooks over the summer before I, you know, pick up this class for the students, you know?" Like, I actually almost got phonetics dumped on me. Like, that's not cool. That's like asking me to watch your pet gecko for a month. It's not coming back alive, dude. It's like, "I don't know what to do." But I just wanted to ask you one more question about what you think critical thinking is. It's something that you hear all the time. It's like, evident space. You know, everybody thinks they know what it is, but really, how do you think you teach critical thinking in undergrad? And then again, in grad school. Like, to me, the threat of what it means should be the same across the domains. I actually don't think that I have the expertise to really answer that question because I'm not so sure that in my time spent as a professor, I'm not so sure I mastered that. I'm obsessed with critical thinking because I don't like it when I get things right too quickly. I'm always like, "It can't be that easy. There's got to be something else." And I'll keep digging and digging until I find the edges of my knowledge and people have to be patient with me learning because I'm usually asking them a gazillion questions. And because that's the kind of learner I am, that's the kind of learning I unfortunately force on my students, which is why my teacher of ours are amazing because they'll answer a question, "Oh, go, why do you think you know that?" And you can't just accidentally get the right answer with me. You have to explain why you think you know that. And it has to be a sound rationale for why you think you know that or it's not, but sometimes I have to express to them, "Sometimes you learn the right answer because you got it wrong, not because you got it right." Part of learning is the trial and error. It's the getting things wrong. And so I try to incorporate that into my classroom, like set up these moments where sometimes the answer is, "I don't have enough information." And I'll even set up a scenario where I'll go, "Do you have enough information to answer that question?" That's a tough question to answer because they want to answer you because their job, as a student, has always been answering my questions. And it's hard to get them to say to a professor, "Man, or sir, you have not provided me sufficient evidence to answer that question." Right. I love that. And you know, there's so few places in life where the process of going through something like that and asking why and asking, "How do you know this?" And all that type of stuff just isn't supported or encouraged. People get to do that in their job other than scientists, right? And so it makes sense that our students wouldn't have experience with it because of how we know, you know, our education system is currently set up in a lot of ways. But also because their parents might not model it for them either if their parents aren't used to doing things like that in their daily life, simply because of the type of work they do. And whether or not it's something that is in some ways like a luxury they're afforded to take the time to deeply think on things rather than be a producer of tasks and stuff. You know? Well, what I do is I have a practical solution that I like to tell students, clinicians, scientists, scientists are not exempt from this. And I wish they were. But how many times have you been to a scientific meeting? Everybody knows that the person, somebody needs to go to that microphone and ask this question because everyone's moaning and groaning and texting each other about how on earth they come to that conclusion. And nobody has the courage to say, um, can you, I just, your methods could not have possibly answered that research question. That's the conversation we need to be holding each other accountable. But now it's become so nice and bland that you actually look down upon for that. But I always say everybody's marching orders is that we have to give everybody a license to be skeptical. You have a license. Your duty to ask why and how until something makes sense. It is your job to take ownership of your learning. To me, that's what critical thinking is. If you know the answer and you don't know why it is your duty to ask why until they can answer that. So you have every right to be skeptical if you're in a learning environment. And when I, when I sort of set the stage that way, critical thinking can sometimes happen, which in my opinion forces the students to say, well, what's the evidence, professors so and so. So the professors then know they can't just go, whether they're undergrad or grad, say, establish that so and so. Somebody should raise their hand and say, can you help me understand how it became established that this is a known entity? And the professor should know the answer. And in fact, apologize and say, you know what? I should have given you that you should have had to ask you. Ask me that question. But since you have, let's walk through that. Yeah. And I think a lot of our faculty would have, you know, in our field would have really rich answers to some of those questions. And they kind of have in some ways maybe forgotten to provide it. So let's talk about that. What do you think are the things that are saved for grad school? So what are the things that grad school in your opinion are definitely responsible that they can't put on anybody else's shoulders in terms of helping to keep the evidence gap as minimal as possible? Any ideas? I actually think one of the biggest things is how graduate students end up feeling about research when they graduate. So that's kind of like a core thing is like, you know, when, when they put on that cap and gown and leave, it's somewhat what more to ask them. And if they were to give an honest question, and if you said, do you think you're going to end up looking to the researcher reading journal articles? Like, do you think that the research is going to be influential in your clinical practice? You know, whether or not they say yes or no? And how important they rate our field science in their daily life as clinicians. And whether or not they find our field's data to be interesting, useful and enjoyable, or nitpicky, annoying, and boring, you know what I mean? And so I think that that actually is one of the like core things that has to happen is a little bit of an audit in terms of like, how are you developing these future clinicians relationship with our field science and research? Because how they just feel about it, whether or not they look at it, and they're like, I like that stuff. It's valuable or whether or not they look at it and they're like, hell no, I'm not touching that again, is going to make a huge difference. So I really like that you said that because a lot of institutions would not openly and honestly say, yeah, we don't teach them anything about evidence. We don't, your syllabi has ashtag terminology in them that you have to put in there to be accredited. And they don't say evidence is up to you, right? There's an assumption that it's based in research. But then what you said made me think that we think we teach clinical skills, right? We teach bedside matter and we teach, you know, how to counsel and interact with a caregiver. These are things that we think are skills that we expect students don't come in with and we have our question, will they be a good clinician, right? But what we don't think is that reading and understanding and appreciating literature is in fact a skill that needs to be taught. Where else would they learn it? I mean, I learned how to read papers by reading papers in my PhD because at that point, it was imperative that I figured out and it only came with practice, just like the first client that you approach unless you just have it is probably not going to be your first, your best ever clinical interaction. And you might look back and go, oh my God, I can think about the things that I said to clients are the way I felt with a client when I first saw them. And later on, I just feel so comfortable walking into a client space or a patient space. The same thing with a paper. And so this idea of how you feel translates to what we say about them in the clinical realm, which is how do you feel about your clinical skills? And we hope they say, I feel strongly over the last two years that I've been here. Well, that question, how do you feel about your research skills? We don't ask it and we don't really, and we definitely know we didn't actually directly teach them research skills. What we have is a research methods class. But actually, we don't just have one clinical practicum class and go, well, you had your clinical practicum class that one semester of it just applied to the rest of your life. In fact, what we should do is not have a research methods class. We should incorporate that into every class because there's literally no class where there's no research that could be used to back up what you're doing. And if there is, maybe we should question that. Exactly. Exactly. And the research needs to be integrated into clinical problem solving all along the way. I think one of the most dangerous things is when I see like a single research methods class assigned to the one faculty member who's never worked as a clinician because they're like, oh, this person's a rock star scientist. They're going to be able to teach research methods in their sleep and they can. But what they often can't teach is how clinicians use research, which are totally different things. Like there's a big difference between the way you would teach someone research methods if it was like semester one of a PhD program, right, versus the way you would teach it. If you know this person is about to go work in a hospital or a school. And that's why having one person be responsible for all things research methods when we say evidence-based is everything we care about is akin to having one person do the clinical practicum class because they were a clinician at some point in their life and say that's all you ever needed, right? So having that same and the each program probably needs to decide what are maybe the five to 10 core things that we want every student to be able to have so we can know we have to implement all of those things into our class in our own way. They need redundancy, but the variability in the way it's presented and that to me is the best way to translate those concepts. A hundred percent. Another thing that I see that bothers me too is disconnect between research faculty and clinical faculty because what that models is we don't work together nor do we need to. And I really think that like if you've got you know, faculty where some people are you know cranking out studies, you know via their big grants and everything and then you've got faculty who are responsible for you know like running the university clinic and stuff. One of the most meaningful things you could do is model working together, model working together and valuing each other's expertise and showing why that scientist has value in the clinic and showing why that clinician has value in the class the scientist is teaching or value in the lab when they're you know like planning and looking at their studies and things like that because you know another thing that's often discussed in our field that I think is a big issue is the disconnect between our fields clinicians and scientists and that we need to have better relationships with one another and a lot of times when I say stuff like that people will be like no no no there's not clinicians and scientists like we're all one big field we're all one big happy family and I'm like yes yes that's exactly the way we want it to be but we also need to discuss ways in which it's not that way so that we can identify some of the things that are causing clinicians to say things when they go to like conferences like oh I don't need to go to any of the scientist talks because they won't tell me anything about clinical practice you know what I mean like that's what allows all that type of stuff to continue to perpetuate. I would say that I hear a lot of range in terms of how the clinical faculty and the research faculty believe that they're valued in my experience often the clinical faculty believe that they're valued to a lesser degree than the research faculty and as a result of that even though the students are getting a clinical degree they still feel that they're beholden to the research faculty and I think that has to do far with bigger things beyond CSD like you know who's bringing the research money we don't get into that you make a really great point which is people want to believe that they're one big happy family but really if you ask them that same how did you feel questionnaire that the students are getting they'd say on the down low like I low key totally don't really believe that I'm valued here as a clinician faculty member and so when we talk about theory and practice which theory would be more on the research faculty and in practice is on the clinician end I understand what you're saying but I think that there isn't a total polyanna sort of approach to what we want because we are we want totally different things in the clinicians do ultimately for instance scientists we have fixed study protocols so we go to these clinicians to say let's do a study together and they're like okay I'm going to provide individualized patient care and was like oh clinician we're like no no no you got to follow this protocol so we have different goals there they expect variability we hate variability if every patient came with exactly the same demographic and problem they'd be like am I in the twilight zone why are all my patients you know white males 45 with a list what the hell right yeah but we want to get so easy exactly but meanwhile in our research we're like yeah we only want that particular demographic and we value group data they value individual data so if a patient is getting better and they don't know necessarily know why that's a point in their box whereas if we have this outlier of a person is getting better and everybody's not or everyone's saying the same we're like what the hell's going on here you're an outlier you're not it's a sort of a bank right right so we have to have these conversations where we say where are we on the same page and where are we different and the students need to hear this conversation so they can understand that it's okay that you incentivize differently in different settings and you have to understand how and when to put on different caps and sometimes you have on two caps the point is to know there isn't just one answer for this complicated problem that we're all trying to grapple through yeah 100% and making sure that everybody's in the conversations at the table being valued being heard all of it another thing that's you know kind of analog as to what we already said but I think needs to be said is that if we want our fields clinicians to see value in our research we need to make sure that we're looking toward the research for the purpose of solving clinical problems during graduate school rather than only looking to the research for the purpose of doing things like writing a thesis paper that's another thing that I've seen among clinicians is that like they're like okay I've read journal articles in um you know grad school but I read them for this point of like doing background research so I could insert citations and write this paper they have never like actually practiced the art of like information seeking in order to develop their clinical practice or to like do clinical problem solving and so I think just the whole concept of you know which actually gets to another totally different question too which maybe we do and maybe we don't want to go down this path but are we training our graduate students for a specific job like is it a professional degree or are we training them for like a liberal art sort of like holistic education where we want them to be able to you know we want them to make sure they're practicing writing papers a whole bunch and stuff too you know what I mean because I think there's a little bit of confusion and disconnect with that but it goes back to the point of the clinicians need to see how the evidence is used for clinical problem solving not just how the evidence is used to write papers and I hear what you're saying but I'm going to go down a more difficult path it's very rocky and thorny where I'm going there are both fires and floods down this path what do we do what do we do about clinical faculty who don't know the answers themselves yeah so yeah so here is where I'm going to jump out and be ENSA on 10 it is at least enjoyable part of being around me I will tell you this most people like me on 5.73 so ENSA on 10 would say as many places as I've been oftentimes you walk in and they see you as this person this ivory tower guru who they dare not expose their knowledge to for fear of being exposed as somebody who doesn't know what they're doing or at least doesn't know as much as they should know so you're either blocked from interacting or you are appeased maybe let along like yeah we'll have to do these things but it's just so busy here and sometimes it is just so busy here I do have some colleagues who have had those difficult conversations with where for instance at Hopkins some colleagues that I was treating with neck side by side just as a clinician not as a researcher and that was just the part of my day where I only saw patients and you know a statement would be made and I'd be like huh you think the larynx does what during a swallow now I can't help myself I can't just let them think that the larynx does something it just doesn't do and that conversation is very like dun dun dun in a sahum bird is asking me about the larynx on this patient who might die if I don't get it right you know what I mean and so I can't help myself and so sometimes those conversations turn into amazing I've published with clinicians who I've had those conversations with because they've said how can I learn more about these basic concepts that in your world are basic but frankly I just never learned it I've been on the job for 20 years and I've just never had a dysphagia class and we've learned together they've come to my lab we've trained together and now they actually know a ton collect data analyze it at the level of the people in my lab and then for everyone of those people there's somebody who basically shuns you because they just don't think that either what you have to say is important or they don't want to be shown up as somebody who doesn't know I would suspect that in most programs you have a decent range of those and a question is do we keep the peace because I have these are faculty members who I'll be doing social things with who we have to make with the vote on things together with how much does it matter that they don't understand how a system works or what the literature says if it's going to blow up the whole faculty do you know what I'm saying like there are there are those issues where your human beings together like I just don't feel like being the bad guy just fine they don't know what they're talking about yeah 100% and that's like one of the like realistic barriers of you know research faculty who are like okay I want to make this better like that's a perfect example of a barrier of it but like and so it's not just like you know faculty at the university like clinical faculty for example but also clinical supervisors which is even harder that is like basically cussing out your nanny and you had no other backup right exactly so if people who are listening don't know this because you haven't you know been at university or you know been a clinical supervisor it is really difficult for universities to get SLPs who are willing and available to take their graduate students it's really hard and there's usually one or two people at a university who it's their job to foster and maintain those relationships with basically the network of however many SLPs they have in the hopper who are willing to say yes pushing on them in any way to you know like level up certain clinical and research skills would be even trickier than doing it with colleagues who you're with and the reason it's difficult is because most CST programs have a very bad business model which is everyone's incentivized to participate at the top of their game, except for the clinical faculty, which is the exact bottle life for why we don't have that many students. So the students are incentivized because they get a degree. Professors are incentivized as our staff because they get a salary. Clinical supervisors who are externs, maybe they get a little bit of money here and there. Maybe they get their ass should do's paid. Maybe they get to go to a conference, but ultimately it's more volunteer work on their part. So we're not exactly going to hold them to this ridiculously high standard. We're just happy to have them. Just make sure my kid doesn't die while I'm out with my husband for dinner. Just please keep him alive. Right. We're like, don't make our graduate students cry too many times and don't tell them anything too crazy. Otherwise, it's fine. But I do think to a certain extent, focusing on a little bit on the newest people in our field, kind of can help shift some of that a little bit over time, right? Because like all the clinical supervisors are former graduate students. So, yeah, which is another factor, which is there's a bit of incestuous activity there, which is you have this, you know, this good will toward a program you were in. And that's not always the best reason to come in and say things. The professors who are your professors are still those professors. And you might question whether or not you can say, you know, I actually had kind of a shitty experience. And this would have made it better for me. And you know, it's kind of hard to speak up in all of these circumstances. Yeah. Oh my gosh, the relationship between SLPs and their former professors is funny. I mean, you know, you'll have SLPs who are, you know, 50 years old, excellent careers, highly competent, really skilled. But then you get them in front of that, you know, professor who they were maybe a little intimidated by when they were a graduate student or whatever. Yeah. And they're like, but I can't, you know, I can't engage in a debate with this person because they're, you know, they know everything like, yeah, I keep telling them. My name is Ian S. It's like, I just can't Dr. Humbert. I'm like, well, I'm not going to answer to you anymore if you don't call me Ian S. But yeah, I think we're touching on some really important parts. I suspect that there are a bunch of people either driving, screaming, yes, yes. And then and in my school and blah, blah, blah. And hopefully, tagging their colleagues and going, we were just talking about this. Our goal here is really to sort of scratch up some dust because it's important that we don't all just have these experiences and go home. We kind of need to get together and say, other people are talking about this. And it's okay to talk about this, even though there is a bit of conflict associated with it. Yeah, for sure. And there's going to, you know, the people who are most comfortable, I think, can be called upon first to set that model for everybody else. They're discussing these things as important and matters and it's going to be awkward. And it can get messy, but good things can come from it. So can I make a suggestion that is on the solution and perhaps a bit more radical? Do we need a curriculum overhaul? And so let me give you a good response alone. It's like, I dare not speak. I'm like thinking of everybody I know on like, okay, here's my thought. There are systems that no matter if you're in hearing or cognition or language or swallowing or voice or motor speech, there are consistent themes that we all need to understand. Right. So there is basic concepts like neuro anatomy, neurophysiology, neuroplasticity. There are concepts related to motor learning. There are so many concepts that people can habituate. And there are all kinds of things that most of these systems draw from development, some basic development concept, concepts aging, right. What it means to have an injury, how the system responds, those to me are the overarching concepts that are more important than having a class where if you're in voice, you talk about the learnings or voice. If you're in speech, you talk about the learns for speech. If you're in spallowing, you talk about the learnings for swallowing, it's the same God damn lyrics. And I just swallowed, I donated and I articulated in the last hour, so many times in my brain was it like, yep, that was for the voice class. And this was for the motor speech class, and that was for the swallowing class. So the problem is we think that these systems are so separate that we have so many faculty members making so many things complicated. We need a voice person. We need to this person. As opposed to saying we need people who specialize in the way a system works across these functions, because our bodies, our brain processes, you know, pronunciation of a sound differently than closing off for a swallow, but it's the same damn brain, the same damn lyrics. And what we do is we compartmentalize these systems as if they really are separate and we could become binding forces to help people understand, because one patient will have a tongue that works perfectly for articulation and horribly for a swallow. And you need to be able to parse it out on your own. You can't say, well, I never had a real good motor speech class. So I don't understand why it's doing this here and not there. You have to understand the whole system, but we don't teach it that way, even though the patient presents as one person with a lyrics or a tongue or whatever that's been functioning across these functions, right? And so to me, a curriculum overhaul is not that CAA needs to do anything. It's that our curriculum needs to allow for the to decide what concepts go across all these systems. So we are constantly preaching the gospel in that area, but we're just tweaking it for this task tweaking it for that task, tweaking it for this population. Oh, it's an infant. It's not an 80 year old. We're going from pediatric, er, geriatric, here are the considerations, but still the basic structure functions this way, right? To me, that's a way to consolidate our efforts to have faculty members who can cross train, right? There's no reason I shouldn't be able to teach the motor speech class and the voice class and the swollen class equally well. But I was really trained to understand just one thing and not so much the other, right? But that to me is the issue with the overhaul that could extend the then the clinical faculty would already think across the domains that way. It wouldn't be, well, I only do this. I only do that. Now I understand hearing and, you know, our tech aren't exactly the same thing. And certainly there are errors where AUD and SLP do in fact truly separate more, but not necessarily on speech perception, then they are way more together than I am with them with either of them. Swallowing suddenly has nothing to do with these things, right? So my point is there's a network of things that we need to figure out where we have common ground. And what are the general theories that we need to understand well and train well and just realize that this function is just a subset of the things that this system does. It's sort of like you have a car, you don't just teach backing up and parallel parking at, you know, totally different section. You might in one trip have to drive fast, have to screech to a halt. You might have the backup and parallel park in the one trip. You can't separate those things. It's driving. I agree with that entirely. And that would be something that an individual department would just have to prioritize making happen. The only, the biggest barrier I've ever heard to this when I've suggested is, but I already done made mislads, you see, right? Right. My PowerPoints are done. And sometimes I'm like, are those PowerPoints or those PowerPointluses? I mean, is that part of PowerPoint list? Because really, we keep having this conversation. And I've been in this field for a couple decades now. It's a same conversation. So obviously we need some kind of an overhaul or a new view. Yeah. 100% as comfortable as a lot of us have gotten with, you know, teaching online and having more like flexible classes and stuff. Like there's no reason that that problem solving needs to happen in isolation over and over and over again. Like you would think that some amount of collaboration, even across departments, could make it really doable and actually end up making it lower labor for the faculty because the more you work together with people, the more likely it is that you're going to be able to share teaching responsibilities. So I mean, I mean, do you think your math department's like, yeah, we kind of don't really have addition in any, I mean, are you kidding me? It's just like when does one of the basics go away? No, calculus doesn't just not have certain parts. So it just builds on it a foundation and the foundation is what we got in kindergarten. Yeah. Our division person retired. We need another division person. So yeah, I agree with that entirely. So what would you say should sum up this brain vomit that we just kind of, I like our brain vomit. So what would you say is a pretty decent summary of the point we're trying to make to answer this question? This evidence gap thing. What do you think? Yeah, I think that the core take home is that we need to be having conversations around why this continues decade after decade after decade. And it's the same problem over and over again. And there's going to have to be people who step into, you know, positions of leadership to start to really push these conversations forward toward action and not be, you know, as a tent to look critically within our own field and identify ways in which we can improve. I would also say there's something key that you suggested and you kind of echo through this, which is the students need to be evaluated and surveyed. And those students are going to become us in one way, shape or form. They're going to be a clinician. They're going to be a clinical superpots or they're going to become clinical staff. They're going to become a researcher. They're going to become administrators at Asha. They're going to be something and we once were students. We were, our opinions maybe were not quite as, it's not the one value. They just weren't taken into account in a formal way. So people could use that as a stimulus to determine whether or not things should change. And then those same students are now us saying, not considering what the students are saying. We somehow think that we've transitioned from parent, from child to parent and they're not the same. But in fact, you used to be somebody's child and you never forget that. So, I think that that's probably an important perspective. And I'm sure I've forgotten about all the things I used to think as a student because of where I am now and I'd love to hear more about what they think. Yeah, 100%. I remember a lot of it. I have some very vivid memories of being a student, but yeah, I'm sure I've forgotten a lot about it too. But, well, this was really good. I'm glad we got through this topic. Hopefully, there will be a lot of conversations coming out after this. The topic of episode three is "Soodle Science and Misinformation." Join us then. [Music]