As an A-level student I recall visiting a number of universities for interviews. This was all part of the application process to getting onto a speech and language therapy course. I must admit I was a young 17 year old with not a lot of life experience. The interviews varied- most included an element of talking about why I wanted to be a speech therapist but some included a kinds of comprehension or listening test. Others included group tasks. All were rather scary and at the same time quite awesome. To my amazement I was offered a place at UCL, city, reading and Leicester – argh how to decide. I was going to have to pay for my degree and was planning to choose the university closest to where I lived. I was the first cohort of students who would have to pay- across the board (all subjects). But just as we were undergoing these interviews we found out that the NHS were planning to pay our fees. This was great news!
Many years later I have started helping out with the entrance interviews at UCL. It is equally awesome to sit on the other side. The interviews I helped out on last year include the old “what will make you a good speech and language therapist?” question but also included service users as interviewees. People with communication difficulties- adults who have had brain injuries or strokes attended part of the interview. Potential students were asked questions by these people with communication difficulties. These service users were directly involved in deciding who would make a good future speech and language therapist. What a change. It’s a brilliant example of how service users can be involved in building the workforce who support them. It’s an inspiring example of how people with communication difficulties can be involved.
This initiative was driven by an NHS that would like to ensure they are training the right people to become the right speech and language therapists. It was formulated and implemented by a wonderfully creative group of speech therapists and teaching fellows whom I admire greatly for their innovative and creative thinking. Often it is assumed that people with communication difficulties are unable to engage in service user involvement activities. This just shows that people with communication difficulties are brilliantly able to do this- with the right supports and strategies in place.
Sadly this is one of the last years that speech and language therapy training courses (and many other health professions training courses) will be financially supported by the NHS. End of an era. I do hope however that doesn’t change the way we try to hone and develop the profession to continue finding and training skilled and empathic therapists.
As an undergraduate student I wrote my essays by hand and then trekked into uni to write them up in the computer room. I would then print my assignment and place it in the relevant pigeon hole. I did much of my masters by distance when I was living in Australia, and consequently submitting assignments electronically, listening to lecture casts and chatting on online forums seemed rather natural. Now I am doing my PhD – 18 years after starting my undergraduate degree things have changed even more. In order to do my systematic review of the literature I have a relative plethora of new-fangled software and databases I can use. Now I hear some of you muttering under your breath “but a literature review surely basically involves reading a bunch of stuff, what does she need all that for?” Ah well let me tell you, it seemed intimidating but as I have got the hang of it I have been experiencing the occasional serotonin high each time I do get it right. But that doesn’t answer your question. Let me see….
So, I have a list of databases to search. Each database allows you to download the masses of articles you have found. But each database has a different method of doing this. Fear ye not, just google how each one works and lo and behold you can create the rarest of file types (RIS files are currently my favourite). You can also download all the articles you have found directly onto a reference manager system such as Endnote. This seems like another massive hurdle but once you get the setting right, I swear the joy of seeing the article titles flooding in to populate the screen is rather addictive. That is when the serotonin high hits. I got it right.
I have around 10 databases to search. Once all the articles are saved in the reference manager you can check for duplications. Once the duplications have been eliminated that is when the reading begins. Oh what a thrill….I think this is where my next hit of serotonin highs will come in. I do love a list of inclusion and exclusion criteria. It is just so orderly and attractive. I have a beautiful table prepared where I will insert the number of articles I find in each database, and the number of articles which are eliminated after duplication and the number of articles eliminated after screening for the inclusion and exclusion criteria. I will then create a prisma flow diagram (basically a really nice flowchart) using revman.
I have just recently been to a fascinating talk by a visiting professor of linguistics from Cardiff (Professor Alison Wray) who spoke about her research around formulaic language in Alzheimer’s disease. One of the points she made is that there is a possibility that we could diagnose the risk of getting dementia in later life from a simple language sample when people are in their early 20s. Wow! Yet she also emphasised that many individuals would not wish to know this information. How many people would want to know that they were going to get Alzheimer’s disease in 30 years time when as yet we simply do not have any sign of a cure. Would you have children? Would you get a mortgage, health or holiday insurance? Possibly not.
Putting yourselves in others shoes is an important skill for an empathic clinician. Similarly this is an important aspect of research. Researchers should consider the value of their work to the participants themselves. Is the desired outcome of this research useful for people living with the condition? I have met many people with dementia who long for a cure. Equally many understand that this research is perhaps more relevant to their grandchildren and yet to be born great grandchildren. What they also speak about is research to support what helps them live with the condition. In speech and language therapy this seems to be about therapy that can help them live well with their families and continue to function in their current lives.
Clinical research can have a direct impact on the lives of people living with the condition. Asking people what research should focus on can assist in guiding and justifying your choices. And this really is not as complicated as it seems. As a clinician you have an enormous resource at your finger tips; your patients and their families. There is no reason you can’t ask your patients what they think!
This type of consultation is an entirely appropriate way of seeking input for small (quality assurance work, pre-development work) or large-scale research proposals (fully funded trials). It makes your work stronger and more relevant (and more likely to get funding). And it is not as complicated as you think. You could:
Use your clinical knowledge and experience of what people ask for or talk about in therapy.
Collect feedback (verbal or written) from groups or individual therapy sessions.
You can write a brief survey or questionnaire.
You can even contact previous patients by phone to ask them.
You can go to support groups or charities to consult with people more broadly.
Be creative but ask. Don’t assume that as a clinician or researcher we know what is best for the people we work with. Population health research is important but so is person centered health research. Providing evidence based day-to-day care is as and perhaps at the moment more important. The NHS has limited funds and we need to spend it wisely.
As a newly graduated speech and language therapist working with real life people I always endeavoured to apply what the research literature or expert guidelines advised. At this point I understood that the most effective interventions were those that had been tried and tested and shown to work. This seemed a foolproof plan for clinical practice.
However I quickly (perhaps within a month or so) found that the people of Barking, Dagenham and Havering didn’t fit this plan. My first job as an SLT was in Barking and Dagenham and it was a great initiation to people. People are frequently much much more complicated than I had expected as a student. Yet I was well prepared; best practice also means being person centred. Thus there were frequently many people for whom I could not simply apply what I had read. I would take one element from one paper and a recommendation from somewhere else and I would cook up the most appropriate intervention plan using this dynamic clinical judgement.
Yet by the time I began working in complex brain injury and memory disorders at South London and the Maudsley I confess I would sometimes wonder if what I was doing bore any relationship at all to evidence based research. The people I worked with here were incredibly complex, with layers of difficult medical and social dynamics to be considered.
I realised that as our population ages and society evolves individuals also become more intricate. We are collecting more diseases; meaning people frequently present with many co-morbidities making it even harder to find the research to match that individual for evidence based care. We are also more socially complex; we own more houses, we have more money (to spend on drugs and alcohol), we are more educated and we have more opinions (often from dubious internet based resources). How do we choose the best interventions for the person, their multiple medical issues, their families, carers and financial/housing situation…..
In this respect I would say that clinical practice is often well ahead of research and clinical guidelines. Clinical practice can be and has to be flexible and creative. Often the research to back up what clinicians consider intuitive takes some time to catch up. Yet research can make incredible leaps and we also find it is difficult to change to clinical practice. They say that it takes 8 years for recommendations from research to be integrated in clinical practice.
So I say that as clinicians we must open our arms to research. We must also leap into the unknown and attempt to create the research and guidelines to support what we do. Experienced speech and language therapists (and many other allied health disciplines) often underestimate their own expertise. Join a committee, write a guideline, a policy or do a piece of research. No matter how big or small our voices count. And on paper they count even more. Be open to change both as a clinicians reading research and a clinician doing research or setting research agendas.
Many of us will recall this line with pleasure and hilarity. The Monty Python films are a piece of British comedy genius. Yet even famous, intelligent actors and actresses can be afflicted by disease. And as we and they live longer they may also be afflicted with progressive neurological disease. Terry Jones, who delivered the famous line quoted above, has recently been diagnosed with PPA.
Terry reports he has been living with a progressive decline in his language skills for some time. The Times article this weekend reported that he has been reading his lines from prompt cards for his most recent live performances of the Monty Python show. What a wonderful strategy he has been using to maintain his functional communication and continue in his job role. I wonder if he has non-fluent agrammatic variant of PPA. Reading aloud is often easier for this group. Although reading aloud can also support those with logopenic variant in retrieving the words they are searching for.
Unfortunately Terry Jones’ communication will continue to deteriorate. Speech and language therapy can provide genuine support. Provision of bespoke therapy tasks such as personalised word relearning, scripting, conversation training and communication aids may be useful. Speech and language interventions can maintain language, conversation, relationships, functional skills and a sense of self.
For the speech and language therapy community people such as Terry Jones can also help. We can tell our patients about him, many people find it reassuring to know there are others even someone like Terry Jones who had what they have. It provides a sense of community for many who will feel isolated by the condition. This is a man who can spread the word increase understanding and reduce stigma for others.
One of my favourite things is when I read something that says exactly what I would like to say or perhaps something I do say; but they have said it even better than I ever thought it could be said. I was recently reading an article that really excited me. I loved it from the moment I read the title: Will You Still Need Me When I’m 64, or 84, or 104? The Importance of Speech- Language Pathologists in Promoting the Quality of Life of Aging Adults in the United States into the Future (Bourgeois et al, 2016).
The authors of this article describe the breadth of the role of speech and language therapists (SLTs) working with people with dementia. They highlight the valuable contributions SLTs can make when people are pre- or just post diagnosis and describe the plethora of approaches that SLTs may take when working with people with dementia, their families and carers as the disease progresses. They emphasise the need for these interventions to be person centered and often focused on participation in day today communication activities.
The authors go on to explain some of the barriers to providing these services including the lack of knowledge within the speech and language therapy community themselves. The authors stress the need for a change in the training of SLTs. My favourite part of the article is where they suggest that clinicians should be trained in disorders according to the incidence of these conditions within the population as a whole. Dementia is effecting more and more individuals in our community. There are no cures, no preventative measures that have demonstrated success. We have little research examining the effectiveness of interventions to support people living with this condition. The authors of this article flag that more time needs to spent training SLTs in how to support people with dementia. We will be seeing more and more people with dementia on our caseloads and we need to know how to support them.
This article is a call to arms for SLTs. The authors encourage SLTs to develop research in this area, to become leaders in the field and to represent the SLT profession to a wider audience.
Reading this article is encouraging and motivating. I want to develop this research, I hope to become a leader in this field, and I would be honoured to represent the SLT profession. I am in!
Bourgeois, M., Brush, J., Douglas, N., Khayum, R. & Rogalski, E. (2016) Will You Still Need Me When I’m 64, or 84, or 104? The Importance of Speech- Language Pathologists in Promoting the Quality of Life of Aging Adults in the United States into the Future. Seminars in speech and language; 37(3):185–200.
One of the wonderful things about doing a PhD is the rich interdisciplinary setting in which you can do them. Just like any good multi-disciplinary office or ward my office is a melting pot of minds from all different disciplines. Instead of physiotherapists, occupational therapists, nurses and medics I am sharing with psychologists, linguists and speech and language therapists from all over the world. These wonderful colleagues of mine are interested in a vast array of topics and have embarked on a vast array of research. And the even more wonderful thing is that I am able to hear and learn so much more than I bargained for because of them.
I toyed with the idea of giving this blog post the title of “sharing is caring” as that is kind of how it works as well. My colleagues are also my friends and we care about each others work and interests so we also help each other out- doing a recording, engaging in a pilot for an experiment, listening to ideas, theories and concerns and general woes. Yet sharing research and helping each other also means we learn and gain from one another.
I have found to my surprise that my skills in networking and social media (yes apparently I write a mean tweet !?) are something of a useful currency in trading helpful hints and skills. I have also been able to provide lots advice on communicating with people with communication difficulties. In exchange I have learnt ever so much, particular as regards statistics- how to actually use SPPS for example. How to make SPSS draw me a graph, what parametric and non-parametric mean, and how to conduct the odd statistical analysis….I have done a basic course on some of this BUT…..statistics are not my forte and having these colleagues around me to ask and brainstorm with is such a relief!
I have learnt about formulaic sentences, functional imaging and neural processing of syntax, dutch vowel acquisition in English children, Gerstmann’s syndrome and word monitoring tasks. I have also had opportunities to work together with colleagues to run focus groups, thematically analyse data, organise seminars and practice presentations and lectures.
Doing a PhD is a rich and wonderful experience – it is also an experience undertaken with a group of colleagues. And one can learn so much from this pool of brilliant minds. I know this will always change the way I think about research, plan projects and work with people as a speech and language therapist.