Dr. Suiter, thank you so much for “sitting down” with me.

Dysphagia Cafe: What is the most complex order you have ever heard while in line at Starbucks?

Dr. Suiter: The most bizarre one I’ve heard is a “Grande Chai Latte, extra hot, no water, no foam, double pump of cinnamon dolce, no whip, and a sprinkle of cinnamon on the top.” I wasn’t aware one could make tea without water.

What is your morning beverage of choice?

Right now it’s Wild Mountain Blueberry from Green Mountain Coffee Roasters with lots of vanilla Coffeemate added to it (I like my coffee sweet). If I’m at Starbuck’s, I’ll get a vanilla latte with soy milk.

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

I hope I never reach that stage. One of the things I love about speech pathology is that the field is ever-evolving. We are constantly learning about new ways of evaluating and treating our patients, and we are constantly learning from our patients.

Have you ever added up your monthly coffee/tea expenditure?

Um…no. I know we go through a box of K-cups and a bag of Community coffee each week at our house, but a large part of that is due to my husband’s coffee consumption.

How has your summer been? Any interesting travels/vacations?

Summer has been good. No vacations, but we have one planned (to the beach) in the Fall. I’m also getting ready to run a relay race from Chattanooga to Nashville with 11 friends. That’s in October.

Okay, it’s the day after graduation in May. Papers are graded and no loose ends to tie. What is your traditional way to unwind from a busy semester?

Since moving to the VA (I missed seeing patients) almost 5 years ago, I only teach one class at U of M, and it’s in the Fall. So, no need to unwind.

“Pre-Hashtag” #

Do you keep up with the fast-paced world of social media?

I’m on Facebook and LinkedIn. I don’t understand Twitter.

Did you know there’s a whole SLP community on Twitter and more specifically a small but growing population of those with an interest in dysphagia?

Still trying to figure out the Twitter thing. I think technology has finally left me behind.

It took me a while to get use to hashtags (#). Remember when it was purely a number symbol? Those were the days : )

I’m still trying to figure out what a hashtag is!

Well, I know there were no hashtags when I started my career. Looking back, PH (Pre-Hashtag), can you tell us at what point in time did you decide you wanted to become a Speech-Language Pathologist?  

Well, I started out in undergraduate school as a pre-physical therapy major. That didn’t work out, but I did spend a lot of time observing physical therapy one summer in college. One of the patients there had just had a stroke and was aphasic. I got to observe some of his speech therapy sessions and found it fascinating. I decided to look into speech pathology as a possible career.

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

No, I had no idea. I especially had no idea that we worked with people with swallowing disorders. I got into this field because I wanted to work with adults who were status-post stroke and had aphasia.

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

I started thinking about it while I was still working on my Master’s degree. The chair of the department at UT-Knoxville at the time really encouraged me to consider it. I felt strongly, though, that I needed to get at least some clinical experience under my belt before going back to school. So, I worked for 4 ½ years between my Master’s program and doctoral program.

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

Dr. Jerry Carney at The University of Tennessee was the primary person who inspired me to go back to school.  I also had a patient with ALS who refused to wear a speaking valve when he ate because he was afraid he would aspirate if his trach cuff was not inflated. He inspired the study I did for my dissertation.

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

Dr. Carney, of course. People specifically in the area of dysphagia include Jeri Logemann, JoAnne Robbins, Susan Langmore, Bonnie Martin-Harris, Barbara Sonies, Jay Rosenbek, and, of course, Steve Leder, with whom I have been collaborating on research for the past several years. 

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

I’m not sure about an “ah-ha” moment. I do remember my last externship at a hospital in Knoxville where I was first able to observe modified barium swallow studies and learn about dysphagia (I went to school in the dark ages when we didn’t have a course in swallowing disorders). I had no idea up until that point that speech pathologists were involved in anything that medically-based, and I knew then that I wanted to work with individuals with swallowing disorders.

I think during my CFY I made a comment in my charting that “it was unlikely the patient had aspiration, since aspiration is not found in left lower lobe pneumonia.” Let’s just say I had a humbling experience when there seemed to be tactful, yet firm, humiliation of my statement in subsequent progress notes by a host of Physicians. Oops! Did you ever have any humbling experiences like that early on you wouldn’t mind sharing?

I’m sure there have been many. No specific incident comes to mind at the moment. But, there are things I did as a CF that make me cringe.

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

I think it’s the fact that eating and drinking play such major roles in how we perceive our quality of life. Before I got involved in speech pathology, I had no idea that there were people who had difficulty swallowing and had to rely on tube feeding or other alternative means of nutrition. It’s hard to imagine how isolated our patients must feel when they can’t participate in one of our most basic social activities. Wanting to improve the lives of patients is what drew me to the field. Wanting to make sure that the assessments and treatments are effective for our patients is what led me to get involved in doing research. Our patients trust us to deliver appropriate and beneficial treatments. We owe it to them to make sure we’re giving them treatments that work. I enjoy teaching graduate students about dysphagia and stress to them the importance of using evidence-based tools when they treat their patients. Students and new clinicians are faced with a lot of conflicting information regarding various available treatments for dysphagia. I like to think I teach them to examine any new treatment carefully and critically so that they can provide the best care possible to their patients.

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

I’d love to be a personal trainer or a yoga instructor.

What was the process like for you to obtain your BRS-S?

It was lengthy, but well worth it. I think it’s important for clinicians who identify themselves as having expertise in dysphagia to pursue specialty recognition.

Grabbing Aspiration by the Horns

You have authored and co-authored many articles. I have a particular interest in you and your colleagues work because I work in acute care and find most of it has direct clinical implications to that particular setting. In particular, I really appreciate the 3 ounce water swallow test. Can you discuss some of the origins for the development of the 3 ounce water swallow test?

Well, the 3 ounce water swallow test was actually developed by DePippo and colleagues who first published on its use in 1992 (click here for abstract). It has been studied pretty extensively by others (e.g., McCullough and colleagues), but most of the research had focused on patients with stroke. Steve Leder and I got interested in screening several years ago. He’s actually the one who suggested we research the use of the 3 ounce water swallow test in a broader, more heterogeneous patient population. We’ve now studied the use of the 3 ounce test in a sample of 4,102 patients from 14 different diagnostic categories, not just stroke.

Has there been any additional questions or hypotheses that have developed from these studies that were not originally thought of?

In the original (2008) article we published (click here for abstract), we looked solely at the results of the 3 ounce test and whether or not they were predictive of aspiration on instrumental examination. We then wanted to determine whether someone who passed the screen could begin an oral diet without the need for further testing. We’ve published several papers in which we followed-up with patients for up to 5 days (which is about the most we can do in an acute-care setting) and found that vast majority of those who pass the 3 ounce test can, in fact, tolerate p.o. diets. We also started looking at our data and wondered if there were other factors involved in the assessment that might also be predictive of aspiration risk. That led us to look specifically at whether a patient’s ability to follow commands and orientation status ( to person, place and time) is predictive of aspiration risk (and found that not being oriented or not being able to follow commands actually resulted in increased odds of aspiration on instrument exam). Additionally, we looked at whether results of an oral mechanism examination (something we’ve all be taught to do as part of our exam) could be used to predict aspiration risk. This programmatic line of research has resulted in us developing what we’re now calling the 3-ounce water protocol, which includes a brief cognitive screen (orientation and command following), an oral mech exam, and the 3 ounce water test.

Not only do I really appreciate the 3 ounce water swallow test, but it has raised many questions for me. For instance, in the right situation, I have become more of a proponent of increasing bolus volume, during my clinical swallow trials, as I believe it has the potential power to identify would-be silent aspirators.

I think that’s exactly the point. People don’t typically swallow liquids in teaspoon size boluses. Using larger boluses in the right situations with the right patient is absolutely appropriate because it’s more representative of how a person is going to drink when you’re not there watching him or her. It’s very important to note that we don’t advocate handing 3 ounces of water (or any other liquid, for that matter) to every single patient we see. There has to be some sound clinical judgment on the part of the speech pathologist. We need to consider the patient’s medical status, his or her alertness level, other cognitive factors such as impulsivity or poor self-awareness.

What do you think of silent aspiration?

I think it’s a bad thing. I also think our research suggests that it may be volume-dependent. In other words, patients may silently aspirate with smaller bolus volumes (e.g., 5 mL) like those typically given during an instrumental examination. But, if a larger bolus is given, that same individual is much less likely to aspirate silently.

Do you think clinicians put too much weight on its presence?

Well, I think clinicians are scared, and they’re worried that they’re missing something when they rely only on clinical signs/symptoms to determine aspiration risk. I understand that we don’t want to overlook someone who is aspirating. But, at some point, we have to say that either all patients at risk for dysphagia/ aspiration (two different things) need an instrumental examination, or we need to be comfortable that the screening tool we’re using is evidence-based and is accurate to the point that we can feel comfortable saying a patient does not need further assessment. I would argue that every patient does not need a full assessment.  

Sometimes I find myself stifled when suspected silent aspiration is commented on during a clinical swallow evaluation, because I find it hard to justify doing further PO trials on subsequent follow-up visits until they have an objective study.

I feel the same way. If the medical history or current medical status seems to indicate that silent aspiration is occurring (e.g., chest x-ray results suggest a pneumonia or the patient has h/o recurrent pneumonia), I would recommend doing an instrumental examination. You can, of course, use the 3 ounce water protocol (cognitive assessment, oral mech exam, and 3 ounce water test) to screen your patients.

How would you address the following statement: “Recommend a VFSS or FEES to rule out silent aspiration?

I receive a lot of those consults. I try to explain to the physician ordering the exam that the purpose of the instrumental assessment is NOT to determine if a patient is aspirating, it’s to determine swallow pathophysiology and appropriate treatment options.  Depending on the patient’s medical history and current medical status and results of my own screening, I will then determine whether or not an instrumental assessment is indicated.

What would you say to the new clinician regarding aspiration and even more specifically silent aspiration?

Regarding aspiration, I require my students to read Susan Langmore’s article, “Predictors of Aspiration Pneumonia: How important is dysphagia?” (Click here for abstract) The results of that study really drive home the point that aspiration and dysphagia, in the absence of other risk factors, do not necessarily result in the development of aspiration pneumonia. We have to consider the whole patient when we make recommendations for oral vs. non-oral means of nutrition. All too often I see clinicians who make recommendations for non-oral means of nutrition based on the mere fact that someone is penetrating or aspirating with thin liquids without taking anything else into consideration (e.g., Is the patient ambulatory? Has he or she had a history of pneumonia?). We really need to consider what we’re doing to our patients when we tell them they can’t eat and are going to have to rely on alternative means of nutrition for an extended period of time. As for silent aspiration, again, I think you have to look at the whole patient. 

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

Logemann’s book, “Evaluation and Treatment of Swallowing Disorders”, is still one of my favorites for teaching students and new clinicians basic information regarding dysphagia. For more advanced practitioners, I like: “Principles of Deglutition” by Shaker and colleagues.

What are some seminal works either text or article that you would recommend for all new dysphagia clinicians?

Susan Langmore’s article that I mentioned earlier is a must read.

Any words of wisdom for new dysphagia clinicians?

I would tell them what Dr. Carney told me way back when I was in my master’s program…Question everything. Critically assess new assessment and treatment techniques and look for research to back it up. Don’t be afraid to keep learning and to re-examine/adjust what you’re doing clinically when new information comes along.