Dysphagia Café: Dr. Crary, thank you so much for taking the time to “sit down” with me. I hear the temperature is quite intense this time of year in Florida, how have you been trying to stay cool?

Dr. Crary: Actually, it is not that bad.  We just tell people that it is excessively hot to cut down on road traffic.  Plus a swimming pool at home really helps!

This being Dysphagia Café, it’s very important we establish some important beverage information for our audience.

Do you ever go for the Grande Americano with a shot of espresso, upside down, with extra room and three sugar-in-the-raw or do you prefer a mean old black cup of Folgers ?

We recently got a Keurig coffee maker at home.  I like the variety with minimal low fat milk and just a tad of sugar.  At work, we have a Starbucks and the nonfat latte is my weakness.

Have you reached that stage in your career where you can say “I’ll have my usual”?

I hope not!

How has your summer been so far?

Fun, but busy.  We finished an NIH proposal in early June and then were in Germany at a scientific meeting at the end of June.  Just returned on July 1.

Do you usually go on vacation at the end of the Spring Semester? If so, any particular favorite spots?

No.  We are 12 month employees and we usually try to take a vacation near the end of summer so we can recharge for the fall term. 

Do you find it challenging not to think about work, when on vacation?

Who does not think about work?  Seems to never turn off….except when trying to land that prize fish!

A lot of my readers are big into social media. Have you spent much time on Pinterest or Twitter lately?

None!  My wife is savvy on such matters…but I am a bit of a dinosaur.  I just got on FB last year and have been accused of being a ‘lurker’. I don’t like to ‘post’, ‘poke’, ‘jab’ or whatever.

I am sure your work has taken you to many interesting places all over the world. What was the most interesting place you visited for work?

All of them.  I was raised in a very small factory town and have enjoyed traveling the world and learning of new cultures and ideals.  And, of course….food!

Do you find dysphagia practice to be quite different or the same, globally? Can you explain some of those differences?

I think at its base the practices are the same.  Thanks in large part to the pioneering efforts of people like Dr Logemann and Dr Groher the USA has been a global leader in dysphagia science and management.  That does not mean to undermine the excellent and novel contributions from around the globe…only to say we got organized a bit earlier. The day to day practice in this area does vary from place to place however. For example, in Japan, I was pleasantly surprised to learn the dentists and oral surgeons are highly involved in dysphagia management.  This is a distinct difference from the US.

When I have gone to the Dysphagia Research Society (DRS) Conferences, I am always impressed by the number of contributors from Asian countries such as Japan and Taiwan. Can you comment on the contributions coming from our colleagues in Asia?

I think they are significant and improving both in quality and number.  In fact, several prominent dysphagia specialists in Asia spent time in US labs and clinics.  I would like to think that we have been good friends, mentors, and colleagues to them.  Also, a recent paper in Dysphagia reported that between 2001 – 2011, 21% of DRS papers originated in Asia.  That is second only to US research at that meeting and a staggering number when you consider the travel involved.  Says ‘dedication’ very loudly to me.

Now, I would never been so bold to ask your age. But could you at least tell us, who was the quarterback for the Florida Gators when you first started at University of Florida?

I think it was Steve Spurrier!  (Only kidding here). Actually I had to double check on Google…it was Kerwin Bell and that year (1984) UF won its first SEC championship.  Believe it or not…I had no role in that accomplishment!

Looking back, can you tell us at what point in time did you decide you wanted to become a Speech-Language Pathologist?

In a sophomore undergraduate English Literature major.  Took an anatomy course by mistake and it was in the speech pathology program.  Never looked back.

What career path do you think you would’ve chosen if it wasn’t Speech-Language Pathology?

Well, apparently I was considering being a writer at one point.  Later, I considered medical school but did not feel it was the right move for me.  Later in life I am being drawn back to thoughts of creative writing.  In fact, I now teach scientific writing and dabble a bit from time to time on the creative side.

When you went into Speech-Language Pathology were you aware that there was a whole medical side to the field?

Somewhat.  I was not overly interested in a career in education systems.  So I sought out the science and health care folks to be my mentors.

How much did you enjoy sitting on the floor in child language clinic? Did you ever sing the “clean-up clean-up, everybody everywhere, clean-up clean up, everybody do your share” song?

If you heard me sing you would not ask that question.  Actually, though I was not a “language person” I had two mentors in graduate school…Drs Joann Fokes and Norman Garber….who made it fun, meaningful, and important. They were wonderful.

At what point did you decide to go on for your PhD?

During my master’s degree.  In those days it was possible to ‘accelerate’.  I was very interested in the research side…especially applied clinical research…so I finished my MA in 9 months and stayed on to finish my PhD in two years.  It was hard work, but even with hard work that schedule just would not be possible in today’s world.

Was there any one in particular who inspired you to pursue a PhD?

Who were/are some of your mentors in the field?  

Many at different points.  As an undergraduate student I had two brand new PhDs…both interested in fluency…Drs Ken St Louis and Charlie Diggs.  They just made you want to be better and work harder.  And, they were just great people.  They were probably the primary reasons I stayed in speech pathology during those undergraduate years when I was trying to ‘figure it all out’.

Clinicians seem to have an “ah-ha” moment during their externship or CFY; What was yours?

Well…not sure I had just one…and they seem to be continuing.  I did work as an SLP following my BA.  Learned a lot and took that experience into my graduate degrees.  But, I cannot honestly identify a single ‘ah-ha’ moment….every time we find the key to ‘fixing’ a patient I get that feeling….each experiment that produces something new or unexpected …I get that feeling.

What is it about dysphagia that drew you to dedicate your career to teaching, researching and treating patients?

I did not start out in dysphagia.  In fact, it was not even mentioned in my graduate training!  I was a VA consultant while teaching at a university in the mid-west.  In those days I focused on aphasia and apraxia of speech.  One day I was asked to see a patient who could not swallow (stroke).  I had just heard Dr Logemann give a talk at a state meeting and thought I would try some of her suggestions.  Liked it!  Kept going!  Later in Florida I met Dr Groher.  I was only doing clinical dysphagia work at that time.  Mike looked at what we were doing and told me to start publishing my work and encouraged (and helped) me to establish a dysphagia research program.  Once I started I just kept going and growing – both in knowledge and skill.  Currently, our team has developed interesting and effective interventions and the positive outcomes we get with people with chronic dysphagia who have basically given up hope….well…that keeps me going….one case at a time!

It seems that Dysphagia can be misunderstood outside of SLP, ENT and of course several other exceptions. Do you agree? If so, why do you think that is?

I am probably not the best person to comment on that.  I have worked in a high powered medical environment for nearly 30 years….and know most of the physicians in different specialties.  They all understand ‘dysphagia’ but have training-specific ideas of what it is.  Yet, I find them all to be open and willing to listen and learn in some cases.  Also, I get the opportunity to work with young residents and assist in their education on this topic.  So, maybe we need to be a tad responsible for informing and educating our medical colleagues.  Also, we need to be sure we listen with an open mind.  Remember…people had dysphagia long before SLPs got involved!

What runs through your head when you hear “did he pass or fail his swallow study?”

I absolutely HATE that phrase.  This is not a scored test and that phrase puts enormous pressure on patients (and clinicians I imagine). Currently, imaging studies are mostly descriptive studies.  We are beginning to ‘quantify’ the interpretation with efforts like Dr Martin-Harris’ MBSImp and Dr Carnaby’s C-VFE…but these are new and not widely known or used across the breadth of the profession.  No cut point exists for ‘pass/fail’ criteria for imaging studies.  So please…if you read this….don’t put that pressure on your patients. 

I am very excited about the research out there that is being pursued in the area of exercise science and dysphagia rehabilitation. Can you comment on this area of research?

We share that excitement!  In the early days many of us walked around hospitals with little laryngeal mirrors and cups of ice.  Not sure what the rationale was but we had something positive to do with our patient.  Then we used compensations and maneuvers.  Again…not always sure of who, how much, or even why…but we had something to offer our patients.  And yes…I did all of these!  Now we are shifting into active REHABILITATION and incorporating exercise principles into our research and clinical practice.  For my money this is a big step forward.  This shift does not eliminate or even minimize compensations/maneuvers for the RIGHT PATIENT.  But, it gives us a focus in rehabilitation for swallowing that has not been overt to this point in time.

I can only speak for myself, but I know many are very excited about the McNeil Dysphagia Therapy Program (MDTP). I have not yet been able to attend the course, but love the concept from what I have heard at some of your other courses. Could you explain for those that do not know, what this treatment approach entails?

I can give a brief overview…but it will likely raise more questions than it answers.  MDTP is a program not a technique.  By systematically evaluating the patient with a focus on rehabilitation steps/decisions the clinician has a stronger and more confident approach to pursue. MDTP is founded in exercise principles and we use swallowing as the basic exercise.  Based on patient progress we systematically introduce real foods/liquids and progress or ‘regress’ as clinically indicated. The program incorporates decision making criteria to help the clinician decide when to advance, to stay put, to go backward.  We also incorporate simple functional guidelines for patient involvement and diet modification.  We have spent nearly 8 years studying different aspects of MDTP outcomes up to and including completion of a recent clinical trial in stroke rehab conducted by Dr Carnaby.  We intentionally chose the most difficult cases we could find.  Most had been on feeding tubes for years and had received extensive prior therapy with little or no benefit.  We did this with the thought that if we could help these folks we could help more people with less severe dysphagia.  All of our work to date indicates that MDTP has strong potential to be an effective dysphagia intervention.  That said, part of MDTP training is to identify which patients are NOT rehabilitation candidates.  Sort of like medicine…..you need to take steps to match the treatment to the problem.  We are making progress in that area.

Any future plans to make the MDTP course available more nationally?

Time is our enemy.  We are constantly discussing ways to disseminate MDTP but have limited time to get out and teach.  So, we try to do at least 4 courses a year, but are also in discussion to develop online and text instruction and resources.  Again, time will tell if we can manage that approach or not.

You recently published an article in the journal Neurology “Spontaneous Swallow Frequency as a Screening Protocol for Dysphagia in Acute Stroke” What inspired you to address this area, and how do you see this manifesting in a clinical session?

Interesting question….my wife (Dr Giselle Carnaby) and I argue about who initially came up with the concept.  But fast forward…dysphagia screening was added to the Joint Commission performance measures for comprehensive stroke centers about 2009 (might have this date wrong). Over the next 2 years multiple articles appeared describing ‘clinical screening’ approaches to dysphagia in stroke.  Problems seemed to be many….no consensus on what should go into the clinical screener….who should do it….what was the best one…etc.  In 2009 I received a small grant to test and validate a ‘non-clinical’ screening technique for dysphagia in acute stroke.  We published our initial validation paper recently….just published a paper on auto recognition…and will be submitting our initial clinical application paper later this month.  Bottom line…it seems to work…the psychometrics on this automated technique are as good or better than most clinical screening tools. Plus, this automated approach does not rely on personnel being trained or available and does not require patient cooperation to complete.  We have more work to do but feel that if our future work goes in the same direction…we will have a robust and simple screening tool to screen for dysphagia risk in acute stroke that has direct global application.  Oh, almost forgot…we  just presented data at a meeting in Germany showing clinical application of this technique for patients with head/neck cancer.  Simple seems to be good in this case!

Is there a “must have” text out there that you think every dysphagia clinician should own?

No fair….loaded question! I have heard that the Groher and Crary text is ‘ok’. (am smiling broadly now)  And, a second edition will come out sometime in 2015 with expanded online support.

If I was a patient with chronic dysphagia seeking treatment from you at your clinic, what could I expect? What would intense exercise look like in your clinic?

First, we still run MDTP as a research effort.  That benefits us as we get outcome data…and it benefits patients as it is free to them.  Win-Win as the admin folks like to say.  But, since we follow research protocol all patients receive a standard comprehensive dysphagia evaluation including endoscopic and fluoroscopic swallowing studies.  If deemed appropriate for MDTP they begin daily (one hour – 5 days per week) therapy sessions with nightly homework based on in-therapy progress. During sessions they are swallowing frequently as this is the basis of the exercise component and each swallow includes some food/liquid. At the end of 3 treatment weeks (15 sessions) we re-evaluate them.  They return to us in 3 months for follow up evaluation.

Clinicians love talking about toolboxes in our field. Any wrenches in your treatment toolbox you can share?

Funny you should use that term.  Last year at ASHA we presented the concept of the Dysphagia Toolbox.  It was Dr Carnaby’s idea actually.  We have made space on our laboratory website (http://srl.phhp.ufl.edu) and called it the Dysphagia Toolbox.  There, clinicians can find links to published tools that have some degree of validity and reliability.  They will also find links to articles that support the psychometric properties of those tools. This is a free service to our dysphagia treating friends and one way we can give back to our professional community. Again, time is our enemy but our plan and hope is to continue to add to the toolbox and expand into treatment items.  Stay tuned.

Any advice or words of wisdom for clinicians who are embarking on a career in dysphagia?

Wow…tough one.  Start with knowing the basics.  You cannot work in this area if you are not well versed in anatomy and physiology and functional neuroanatomy.  By that latter term I mean the ability to look at patient signs and understand the neurologic deficits.  I was fortunate to have excellent training in that area as a graduate student, but encounter many clinicians who tell me they did not benefit from such training.  The second point (and the last I promise) is to understand that dysphagia is not “one size fits all”.  Disease parameters, patient characteristics, environment of care, and many more variables have the potential to impact clinical course and treatment outcomes.  Learn to be sensitive to multiple factors and above all listen to patients, families, and physicians – even when you may disagree.

There is so much out there to absorb in our field and every time I read one of your articles, go to one of your seminars or presentations, I always come away with practical applications that I can take back to my clinic. I can’t over-emphasize how important that is to me as a clinician. Thank you so much for your contributions to our field and I know many of us are looking forward to what’s next.

Thanks for those kinds words, Jonathan.  I am but one member of a stellar team that makes up the Swallowing Research Laboratory. One common denominator is that we try to focus on clinically relevant issues.  Another is that we all work long hours and very hard.  You will see the names on publications and presentations.  I know that each of them would be greatly appreciative of your kind remarks.  Thank you.

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