While shopping in the tea section of my local Whole Foods grocery store, I was approached by a woman who appeared to be in her 70s with a sweet grin and sharp eyes. “You seem to be a bright young lady”, she said to me keenly. “Do you think I should spend extra money on organic tea or should I just buy the same old cheap tea I’ve been drinking for years?” Amused, and a little surprised, I took stock of the large wall of tea that we were facing. As any of my close friends can attest, I am a self-professed tea connoisseur. I secretly “tsk-tsk” those who contaminate good tea with cream or sugar. I

However, being critical is not always inherently destructive. A reasoned critique should be based, first, on fact(s) or at least anchored to some widely accepted theory about an issue, followed by an intelligent hypothesis that allows one to extrapolate an outcome.

even travel with my own personal stash of tea just in case someone has the audacity to offer me Lipton “tea”. Yet her question stumped me, as I honestly had no clue what differentiates organic teas from non-organic teas. As a tea lover, I felt embarrassed that I couldn’t offer a thoughtful recommendation to this well-meaning, inquisitive woman.

I was unable to offer a sound recommendation was because I did not know the relevant facts. In this case, relevant facts would include a basic definition of “organic”, how it is incorporated into tea farming, and how nutrition differs between organic and non-organic teas. Then, I would need to ensure that my recommendation is relevant to the individual in question: This person is older and female, and she might be taking medications or have other underlying health issues to consider. Does she drink tea for her tasting pleasure or for medicinal reasons (digestion, staying awake)? Each of these steps in the process of deriving a well-formed recommendation or opinion requires critical thinking skills. Critical thinking means that judgments are based on reasoned thinking that involves detailed analyses and assessments (critiques). Often the word critique induces a negative connotation. Popular and influential fashion police, food critics, and political pundits are known for decimating someone or something, often while inserting personal, subjective reasons for a negative evaluation. However, being critical is not always inherently destructive. A reasoned critique should be based, first, on fact(s) or at least anchored to some widely accepted theory about an issue, followed by an intelligent hypothesis that allows one to extrapolate an outcome.

Dual process theory in clinical practice

The Dual Process Theory posits that humans process information using two distinct systems (Croskerry, 2009a, 2009b).

  • System 1 is intuitive, fast, and automatic, and derived over time by developing rules of thumb, shortcuts, and patterns for a specific cognitive process. System 1 processing, in clinicians, is developed through experience, repetition, formal academic training, and observing the behaviors of other clinicians (Bate, Hutchinson, Underhill, & Maskrey, 2012).
  • System 2 is analytical and strategic, involving careful, rational evaluation of available evidence. According to Croskerry et al (2009), humans prefer to use System 1 whenever possible, including in clinical situations. However, it has been argued that better clinical decision-making occurs when there is a balance between System 1 and System 2 processing to avoid costly errors in care (Bate et al., 2012). Bate et al (2012) also argues that critical thinking, based in System 2 processes, is missing from formal clinical training.

System 1 processing is likely common among SLPs who have little time to make clinical decisions, especially during videofluoroscopic examinations. They often prioritize safety concerns, such as aspiration, and then consider how aspiration can be reduced (i.e. bolus modification). System 1 processing might also take place after videofluoroscopy, when deciding which treatment(s) to use and might be formed after extensive experience and observing other clinicians. Bate et al. (2012) argues that clinicians quickly recognize patterns of pathophysiologies and move intuitively into treatment decisions that they have experience in, based on anecdotal evidence of success. However, given reports of inconsistencies in practice patterns of assessment and treatment among SLPs who treat dysphagia, System 2 processing might be limited in guiding clinical-decision making (Crary, Carnaby-Mann, & Faunce, 2007; Garcia, Chambers, & Molander, 2005; Mathers-Schmidt & Kurlinski, 2003; Okada et al., 2007; Smith, 2006).

Critiques of speech language pathologists in dysphagia management

Now, lets consider the question, “Should I use e-stim on my patients with dysphagia?” After giving seminars and courses on the basic principles of surface electrical stimulation, anatomy of the muscles in the head and neck related to swallowing, and outcomes from studies of immediate and long-term effects of electrical stimulation; this question (“Should I use e-stim on my patients with dysphagia?”) is almost always asked. At one time, that question baffled me. After lecturing for hours on these principles and the e-stim research literature, I couldn’t grasp why swallowing specialists did not automatically extrapolate the potential effects of e-stim treatment on their patients, whose impairments they know best. After years of conversation, reading, and listening, I’ve come to the conclusion that critical thinking in dysphagia management is not intuitive but rather needs to be explicitly taught.

Speech-language pathologists (SLPs) represent the primary health care providers for dysphagia and SLPs working in the healthcare setting report that they spend the majority of their time addressing swallowing disorders (ASHA, 2007, 2011). Thus, as primary providers of dysphagia care, SLPs should be among the most knowledgeable practitioners on the topic of normal and abnormal swallowing physiology. Nonetheless, the role of SLPs as the primary service provider was harshly attacked, with some assertions that SLPs are inadequately trained in swallowing physiology (Campbell-Taylor, 2008). Established experts in the field of dysphagia have also published concerns about evidence-based dysphagia management (Langmore, 1995; Logemann, 2012; Rosenbek, 1995). If SLP dysphagia care is not considered to be skilled, physiology-based behavioral intervention, then under recent health policy requirements, financial reimbursement could be reduced or denied. This would have profound negative effects on the scope of practice of SLPs and significantly limit availability of dysphagia care for patients. Another negative consequence is that SLPs could be downgraded to swallowing technicians, leading to another medical discipline filling the gap as primary dysphagia skilled specialists.

Dysphagia management is being targeted as a lucrative opportunity for our partners in industry. Recent controversies surrounding the marketing of devices to “cure” swallowing, as well as anecdotal reports by clinicians, have unearthed a disturbing concern that some SLPs who practice dysphagia management are doing so with little working knowledge of swallowing physiology. With the recent influx of industry-based treatments that are being marketed to SLPs for dysphagia treatment, it has become apparent that physiology-based clinical decision-making is lacking. For example, e-stim for dysphagia has been particularly indicative of deficiencies in SLP knowledge of swallowing physiology (Logemann, 2007). In other words, e-stim effects on swallowing should not require rote learning (based on training), but should instead be intuitive with a solid knowledge of swallowing physiology (Humbert, Michou, MacRae, & Crujido, 2012). This insufficiency makes SLPs vulnerable to industry-based therapies that can market treatment outcomes without critical appraisal by practicing clinicians. The possibility that clinical decision making among swallowing specialists is not being routinely based in critical thinking with physiologically-based rationales has not been directly examined, possibly due to a fear of ‘sounding the alarm’ on the current state of dysphagia management (Rosenbek, 1995).

Why critical thinking? A summary

Some clinical swallowing specialists still require a formula to determine which treatments should be applied to a specific swallowing pathophysiology. That is akin to a baker who can only bake bread when following a recipe. Truly, a skilled swallowing specialist should be able to provide a physiologically-based rationale for any treatment that they are currently using with their patients. This is akin to a baker who can look in any pantry and whip up a warm, delicious loaf of bread based on experience, skill and knowledge of the principles of baking.

Returning to the “tea” anecdote above, I did not know the basic facts about organic versus non-organic teas, so I could not critically think about the question that was posed to me. In the case of swallowing specialists, critical thinking requires one to know the basic facts about the system, then extrapolate those facts to make predictions about how a treatment might impact the impairments of an individual with dysphagia. The ability to do this is not straightforward and must be directly trained. As such, the ASHFoundation has funded a grant that addressed this need, entitled “Creating Swallowing Physiologists by Applying Physiology to Clinical Decision-Making”. As part of this grant, a course entitled “Critical Thinking in Dysphagia Management: Blazing a New Clinical Trail” has recently been launched. Critical thinking is vital to dysphagia management because the tools, devices, and certifications that we, as swallowing specialists, acquire are only as good as our ability to know how and when to skillfully apply them to address our patients’ swallowing impairments.

Links of interest


  1. ASHA, A. S.-L.-H. A. (2007). SLP health care survey 2007: Frequency report. Rockville, MD.
  2. ASHA, A. S.-L.-H. A. (2011). SLP health care survey: Caseload characteristics. Rockville, MD.
  3. Bate, L., Hutchinson, A., Underhill, J., & Maskrey, N. (2012). How clinical decisions are made. Br J Clin Pharmacol, 74(4), 614-620. doi: 10.1111/j.1365-2125.2012.04366.x
  4. Campbell-Taylor, I. (2008). Oropharyngeal dysphagia in long-term care: misperceptions of treatment efficacy. J Am Med Dir Assoc, 9(7), 523-531. doi: 10.1016/j.jamda.2008.06.001
  5. Crary, M. A., Carnaby-Mann, G. D., & Faunce, A. (2007). Electrical stimulation therapy for dysphagia: descriptive results of two surveys. Dysphagia, 22(3), 165-173. doi: 10.1007/s00455-006-9068-x
  6. Croskerry, P. (2009a). Context is everything or how could I have been that stupid? Healthc Q, 12 Spec No Patient, e171-176.
  7. Croskerry, P. (2009b). A universal model of diagnostic reasoning. Acad Med, 84(8), 1022-1028. doi: 10.1097/ACM.0b013e3181ace703
  8. Garcia, J. M., Chambers, E. t., & Molander, M. (2005). Thickened liquids: practice patterns of speech-language pathologists. Am J Speech Lang Pathol, 14(1), 4-13.
  9. Humbert, I. A., Michou, E., MacRae, P. R., & Crujido, L. (2012). Electrical stimulation and swallowing: how much do we know? Semin Speech Lang, 33(3), 203-216. doi: 10.1055/s-0032-1320040
  10. Langmore, S. E. (1995). Efficacy of behavioral treatment for oropharyngeal dysphagia. Dysphagia, 10(4), 259-262.
  11. Logemann, J. A. (2007). The effects of VitalStim on clinical and research thinking in dysphagia. Dysphagia, 22(1), 11-12. doi: 10.1007/s00455-006-9039-2
  12. Logemann, J. A. (2012). Clinical efficacy and randomized clinical trials in dysphagia. Int J Speech Lang Pathol, 14(5), 443-446. doi: 10.3109/17549507.2012.717966
  13. Mathers-Schmidt, B. A., & Kurlinski, M. (2003). Dysphagia evaluation practices: inconsistencies in clinical assessment and instrumental examination decision-making. Dysphagia, 18(2), 114-125. doi: 10.1007/s00455-002-0094-z
  14. Okada, S., Saitoh, E., Palmer, J. B., Matsuo, K., Yokoyama, M., Shigeta, R., & Baba, M. (2007). What is the chin-down posture? A questionnaire survey of speech language pathologists in Japan and the United States. Dysphagia, 22(3), 204-209. doi: 10.1007/s00455-006-9073-0
  15. Rosenbek, J. C. (1995). Efficacy in dysphagia. Dysphagia, 10(4), 263-267.
  16. Smith, P. A. (2006). Nutrition, hydration, and dysphagia in long-term care: Differing opinions on the effects of aspiration. J Am Med Dir Assoc, 7(9), 545-549. doi: 10.1016/j.jamda.2006.03.008



  1. The critical clinical question is did the dysphagia treatment such as e stim make a difference in the patient’s long term ability to safely swallow patient preferred food textures.

  2. I have enjoyed listening to Brainscience Podcast (Dr. Ginger Campbell) through the years and highly recommend it to anyone reading this. There are multiple lenses through which one can view ideas. Brainpodcast has heavily contributed to the lens through which I view this discussion. It gives a slightly different slant, but overall supports the author.

    The seasoned, published neuroscientists interviewed on this podcast have no problem referring to “System 1” (intuitive, fast, and automatic, and derived over time by developing rules of thumb, shortcuts, and patterns for a specific cognitive process) as “wisdom”. It takes many years in a field to be able to process large amounts of information quickly, effectively, and wisely.

    “System 2” is the route to “System 1” (extensive experience being analytical and strategic, involving careful, rational evaluation of available evidence). If S2 is not developed appropriately, then S1 is defective. S2 continues to feed and improve S1. As clinicians rely solely on S1, they tend to become irrelevant.

    “The greatest enemy of knowledge is not ignorance, it is the illusion of knowledge (Daniel J. Boorstin).” By this vein, the greatest enemy of science is Cognitive Dissonance.

    CD is an unconscious reaction that can be brought into our conscious processing and dissipated. CD results when the beliefs that define us are shown to be inaccurate. We defuse this uncomfortable state by justifying our beliefs or attacking the source that depreciated our beliefs.

    If we define ourselves by an approach, few of us can bare to process information that challenges this approach. This “CD –> justification” reaction permeates not just research and clinical practice, but also politics, issues of social justice, and is used to market products.

    I would describe good critical thinking as embracing our hard-earned S1 while never straying from the S2 path. This will support our awareness of CD in researchers, other clinicians, and in ourselves as we become cognizant of egoizing cognition.