What is ‘critical thinking’ in dysphagia management?

The word ‘critical’ derives etymologically from two Greek roots: ‘kriticos’ (meaning discerning judgment) and ‘kriterion’ (meaning standards). Etymologically, then, the word ‘critical’ implies ‘the development of discerning judgment based on standards.’ Applied to thinking, we might define ‘critical thinking’ as ‘thinking that explicitly aims at well-founded judgment and utilizes appropriate evaluative standards in the attempt to determine the true merit or value of something.’ (Paul and Elder, 2014)

 When applied to dysphagia management, ‘critical thinking’ encompasses the ability of the swallowing specialist to:

  • Understand the basic facts about the normal swallowing mechanism
  • Use known facts to evaluate and identify abnormalities in swallowing
  • Extrapolate known facts to make predictions about the most effective treatment strategies for impairments in individuals with dysphagia.

Critical Thinking in Dysphagia Management: Blazing a new clinical trail

According to ASHA’s 2013 SLP Health Care Survey, dysphagia is the largest practice area for Speech-Language Pathologists (SLPs) in medical settings. 87%-90% of respondents indicated that SLPs were the primary providers for swallowing services in their facility.  With the healthcare industry moving towards a pay-for-performance based service delivery model, SLPs as ‘dysphagia specialists’ need to increasingly demonstrate the use of skilled, physiology-based interventions. It is not acceptable for an SLP to walk into a patient’s room, deduce whether a patient is aspirating or not based on a bedside evaluation, modify a patient’s diet without any objective assessment and/or physiologic rationale and blindly complete the same set of swallowing exercises with all the patients on his/her caseload. This kind of dysphagia management is neither skilled, nor evidence-based. It has one vital component missing; one that distinguishes a swallowing ‘technician’ from a skilled swallowing ‘specialist’ i.e. ‘critical thinking’.

To address the aforementioned issue, the ASHFoundation funded a grant titled ‘Creating Swallowing Physiologists by Applying Physiology to Clinical Decision-Making.’ As part of this grant, a course entitledCritical Thinking in Dysphagia Management: Blazing a New Clinical Trail’ was launched by world-renowned clinical researchers Dr. Ianessa Humbert and Dr. Emily Plowman. I (an adult medical SLP with 5 years of clinical experience and a specialized interest in dysphagia) was among the first group of privileged SLPs to attend this trailblazing 2 day course at the Johns Hopkins Hospital in Baltimore, MD on September 19th and 20th, 2015. For the benefit of those who couldn’t attend this first time around, I’ve shared some highlights from Days 1 and 2 of the course, along with some important ‘critical thinking’ clinical lessons I learned below.

Day 1 Highlights

“I was really impressed with the caliber of attendees at the inaugural Critical Thinking course, their ability to seamlessly translate our critical thinking framework for evaluation and treatment and the interactions throughout the weekend.  I am really excited to see what 2016 holds!”
~ Dr. Emily Plowman

Close to 50 attendees (national and international SLPs) arrived at 7.30 AM at the conference venue on a Saturday morning; excited to see what the weekend ahead had in store. We were greeted with breakfast, coffee and the happy-shiny faces of the wonderful volunteers (students and staff from Dr. Humbert and Dr. Plowman’s labs) to kick-start CTDM. In Dr. Humbert’s introduction, she reminded us, “The best tool that you have to improve your clinical practice is between your ears. No device or certification will get you there. Our goal in this course is to unlock your potential to critically evaluate clinical decision-making in your dysphagia practice.”

Here are some of the session highlights from Day 1.

  • Elucidating inconsistencies in clinical decision-making

Why are instrumental assessments not used by everyone? Why are current assessment and treatment measures not standardized? Why is our documentation still so subjective? Why do we focus so much on the bolus? Why are we using a one-size-fits-all approach to treat our patients with dysphagia? These are few of the many thought-provoking questions raised by Dr. Humbert, as she elucidated inconsistencies in current clinical decision-making practices. With fascinating analogies to supplement and simplify our learning, she encouraged the attendees to ‘think critically’ and stressed the significance of asking ‘WHY’ (understanding the physiological rationale) before treating a swallowing impairment.

  • Live-streaming videofluoroscopic swallowing examination

Never have I seen an audience-participation activity like this one in a conference before! Live VFSS (Videofluoroscopic Swallowing Studies) videos were broadcasted, via a popular new app called Periscope, for the attendees in the conference hall and anyone else following the live feed on their phones/computers. Using a remote device (called the iClicker) we could select options from a list of choices to recommend the next texture/strategy to try with the patient. Essentially, it was 50 heads thinking critically together, to differentially diagnose live MBS studies in the fluoro-suite. If I could, I would attend the next course just to experience the thrill of participating in this activity all over again.

  • Applying motor learning and neuroplasticity principles to rehabilitation

As a dysphagia expert, particularly in individuals with neurodegenerative diseases, Dr. Plowman discussed her research findings with the attendees during this session. Her clinical experiences, primarily working with the ALS population, were very enlightening. Dr. Plowman summarized the important principles of Neuroplasticity; describing how we, as clinicians, can best harness these in our everyday practice, while providing innovative examples of dysphagia treatments that incorporate these principles. What really stood out to me as a clinician was her discussion regarding compensation vs. rehabilitation; the difference between the two, her appraisal of the ‘current state of play’ and how dysphagia therapy can incorporate different interventions along the same treatment continuum, at different times. In Dr. Humbert’s talk on the principles of Motor Learning, she described how biofeedback can improve skill learning (Mendelsohn maneuver) and how the electrical stimulation protocol we use can determine what aspect of airway protection improves over several swallows.

  • Supporting clinical decisions with physiologically-guided metrics

This part of the course seems to have been the most novel session for most attendees and it also felt rather ‘game-changing’ to me. Dr. Humbert shared findings from her years of research regarding normal and abnormal temporal swallowing measures. She elucidated different bolus flow measures and structural kinematic events in swallowing. We were divided into groups to analyze MBS studies together and infuse physiologically-guided metrics into our clinical decision-making. Lesson learned for life: Timing and physiology matter in dysphagia management and HOW!

Day 2 Highlights

After a spontaneous happy-hour gathering, a good night’s rest to consolidate all the information we’d learned and a kick of caffeine, we arrived excitedly the next morning at Johns Hopkins’ Chevy Chase auditorium for Day 2 of CTDM. Here are the highlights:

  • Clinical decision tree templates

Day 2 started with Dr. Plowman teaching us to create a physiologically-guided clinical decision tree. It was interesting applying this template to common and challenging swallowing pathophysiologies and learning to customize our clinical database to improve standardization in SLP practice. We were shown how to infuse objective validated assessments, using this template, into our everyday practice. This will be invaluable for documenting outcomes, increasing efficiency and standardizing clinical practice.

  • Hands-on workshops

This was one of the most exciting sessions, where we really got to apply what we had learned practically. The attendees, divided into 4 groups, were rotated through a series of four 30 minute hands-on workshops, involving demonstration and use of Respiratory Muscle Strength Training, Electrical Stimulation, Lingual Strength Training and Surface Electromyography (sEMG) for biofeedback. This part of the course was extremely informative and truly eye-opening for many clinicians, young and experienced alike.

  • Outcome-based dysphagia management

Clinical expertise is one of the trilateral principles forming the bases for Evidence-Based Practice (ASHA). In order to contribute to EBP, we need to start using objective measures for reporting and tracking patient outcomes. Dr. Plowman provided a framework to think about swallowing impairments as either primarily ‘bolus-efficiency’ or ‘airway-protection’ issues and went on to describe various validated outcome measures for each of these. It was exciting to learn supplemental facts about some already known outcome measures in dysphagia such as EAT-10, SWAL-QOL, NOMS, PAS, FOIS etc. in addition to learning information about new scales such as the Eisenhuber scale, CAM-ICU, RASS to name a few.

As I’m writing about these session highlights and pondering about the impact this course had on my thinking, a quote by Alan Alda comes to mind: “Begin challenging your own assumptions. Your assumptions are your windows on the world. Scrub them off every once in a while, or the light won’t come in.”

As a passionate dysphagia clinician, I genuinely believe that we need to be willing to challenge our assumptions and be flexible in adapting to the ever-changing healthcare climate and evidence-based practices in our field. We must advocate; advocate for better patient care, better dysphagia graduate education and better training opportunities for clinicians to become skilled and competent swallowing specialists. We owe that to our patients. I sincerely thank all the brilliant leaders who are doing so much for clinicians in the field of dysphagia. Thank you Dr. Humbert and Dr. Plowman for enlightening us and for helping bridge the supposed research-practice gap in our field.

Closing remarks

Here are some closing remarks from the dynamic ‘deglutition duo’ themselves, when I emailed them to tell them about this post I was writing for Dysphagia Cafe:

“We are so overwhelmed by the positive feedback that we received from our first Critical Thinking in Dysphagia Management (CTDM) course. We are excited to announce that the next CTDM course will be located in Gainesville, Florida on March 19th and 20th of 2016.”
~ Dr. Ianessa Humbert

“I was really impressed with the caliber of attendees at the inaugural Critical Thinking course, their ability to seamlessly translate our critical thinking framework for evaluation and treatment and the interactions throughout the weekend.  I am really excited to see what 2016 holds!”
~ Dr. Emily Plowman

Such exciting news! I’m certain many of you are marking your calendars already. Here’s hoping for a lot more skilled, objective and competent patient care and dysphagia management in 2016 and the years to come.

Links of Interest