Advice for New CF’s

You made it through grad school and now are looking for that first job. So exciting! Here is what I wish I could have told my CF self or advice I would give to you: 

  • You probably won’t get your dream job right after grad school. Sure, it can happen, but don’t count on it. Instead, i recommend making a list of what are your non-negotiables. For example, you want to work with adults only, so you may not take that job at the clinic where they treat all ages. Or, perhaps you prefer to work 5 days a week but will consider four 10 hour days. You may not find a job that meets all of your preferences, but you should be able to find one that meets your most important ones. 
  • Don’t get so excited you are getting a job offer that you make sacrifices you know won’t work. For example, maybe you need to pick up kids at 4:00 but you sacrifice and take a job that runs past 4:00 frequently. Chances are, you won’t like the job and won’t stay there for too long. 
  • Make sure you have a supervisor that is available. All supervisors still have their own work to do, but make sure that you have someone that is able to help you when you need it and is able to move their schedule around at times to observe and teach. Your CF is the last opportunity you may have to directly learn from another SLP before you are on your own in a building, so make sure that you get all of the mentorship you need. 
  • Professionalism is extremely important. You should have learned this during your externships, but you are now a professional and need to make sure you act like it. That means don’t be late. Don’t be on your phone when you shouldn’t be. Make sure you are prepared for each day. These things can make a big difference in someone’s opinion of you and your work. 
  • Take your lunch. Let me say that again, take your lunch!! Don’t fall into the trap of working on documentation or whatever else during your lunch break. Just don’t do it! You need that time to relax and refresh for the rest of the day. Don’t skip it!!! 

Good luck to all the new CF’s out there! You’ll be great! 


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Let’s Talk!

One of my weekly activities is finding and reading EBP literature. I know this is not everyone’s favorite activity. That’s why I collaborated with Ashley Laudick, another wonderful SLP to bring you the Dysphagiology Journal Club. Each week we will be discussing an article that directly impacts our dysphagia practice. We invite you to join in!

Look for the event announcements on facebook. We will post the week’s article ahead of time so that you have time to read and review if you’d like. Each Wednesday night, we will host a live discussion of the article. 

We would love to have you join us. Different perspectives are so important and we know that you can bring your experience and knowledge to help everyone to learn. Don’t feel comfortable joining in on the discussion just yet? No worries! You are more than welcome to just listen in. 

We are always looking for new topics and articles to discuss. If you have a suggestion, please send it to

Hope to see you Wednesday! 

Until then..#ScopeOn

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My Advice For Students and New Grads Part I

Let me start by saying I am in no way an expert in job finding, interviewing, or professional counseling. This is just what I have learned from my own experiences and those of SLP’s I know. 

Medical placements for externships or finding that good CFY position in a medical setting can be difficult. There is a lot of competition and many places do not or can not accept students or clinical fellows. Finding a job in the medical side of SLP can be close to impossible if you didn’t get experience in a medical setting in your externships. Plus, trust me, you do not want to be on your own in a medical setting if you haven’t had good mentorship before you start your job. 

So first thing: How to get that externship?

In general, most SLP graduate students are very invested in the program and will all probably get straight A’s. At least this was the experience in my grad school. So good grades aren’t really going to do it. You need to find other ways to make yourself stand out from the crowd and show your interest. If you were interviewing two people for the same job, wouldn’t you probably choose the person that has done more in the field? 

Some Ideas:

  • Job Shadows- For me as a student, it was intimidating to reach out to practicing SLP’s and schedule a shadow. I was definitely hesitant to reach out because I thought maybe I was bothering people. I was wrong. I would guess that no one gets into this profession because they don’t like helping people. Probably the opposite. Personally, I love having students around. I am always happy to share what I do. So my advice, quit worrying and just make the call. Make sure you can be as flexible as possible with scheduling. This will help out whoever you are shadowing because in general in the medical side of SLP, things can be a little (or a lot) unpredictable.   


  • Don’t discount that part time job you have while you’re in school or during summers. Just because it might not be directly related to the field of SLP, there will be some skills you need for that job that would make you more successful in the externship. For example, are you a server in a restaurant? Great! That means you have multitasking skills, customer service skills, and experience handling conflict. (We all know there will be that one person who regardless of what you do, they just aren’t going to be happy). 


  • Ask questions! When students ask me questions about what I do, that to me shows the greatest interest. You actually care and are interested in what I do beside just having something to add to your resume. One of the worst ways you can portray yourself is disinterested. 


  • When searching for an externship, don’t be afraid just to ask. Maybe they don’t list the positions online. I mean it can’t hurt and it again shows your interest. 

Next time I’ll dive in more about advice transitioning into that coveted CFY position. Until then..


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Clinical Focus, Education

20 Reasons to Choose FEES

  1. No need to transport the patient out of the facility or even our of their room. Transportation can be very taxing. Some people are worn out before the swallow study even begins. Add in inclement weather and things get even worse. The fragile patient can also stay with the nurses and care team who knows them best. 
  1. The patient can be tested in the position they are usually in when they are eating and drinking. Some people, despite all encouragement not to, will eat and drink in bed. Often times reclined. With FEES, we can complete the test or portions of the test with the patient in this position to determine if it changes the safety and/or efficiency of the swallow. 
  1. There is no time limit. With MBSS, time is limited because of course we can’t radiate people all day. Because FEES does not use radiation, studies can last as long as needed. 
  1. A FEES examination can be completed quickly. We provide the FEES within 24-48 hours of receiving the order. Patients don’t have to wait for care they need. 
  1. There are few to no directions to follow. The patient is given foods and liquids and allowed to swallow naturally instead of at a cued time. This is perfect for patients with cognitive or language deficits. We also get a better picture of how the patient eats and drinks on their own. 
  1. FEES uses real foods and liquids. Nothing other than food coloring is added to the foods and liquids keeping the taste intact. There is no need to change the taste with barium. The patient’s swallow will not be affected by having to eat something that tastes bad. 
  1. There are no size limitations. FEES can be completed on bariatric patients without difficulty. 
  1. The treating SLP can be present for the FEES. In fact, we prefer it! The treating SLP knows the patient best and will be proving the daily dysphagia therapy. We believe that when the SLP can be present, outcomes are improved. 
  1. A report of the findings is left at the facility before we leave. No more long searches for results. We hand deliver full color reports after detailed interpretation of the study. 
  1. Aspiration can be identified early to reduce the risk for serious pulmonary complications. If you have to wait weeks for a MBSS, your patient may be aspirating the whole time which can contribute to pulmonary complications. 
  1. Get a view before and after the swallow. With FEES, the camera never stops rolling. We are able to see what happens both before and after the swallow. This is not possible with MBSS because of the radiation exposure. 
  1. FEES provides a clear view of the laryngeal and pharyngeal structures. In a recent study, incidental findings of laryngeal pathology were found in 39% of FEES examinations (Pazak et al., 2021). Routine FEES examinations can be beneficial for this reason. 
  1. FEES can provide real-time biofeedback. Using biofeedback is an effective strategy in many cases. Patients have also reported a higher level of understanding of their swallowing problem when they can see what they are doing in real-time. 
  1. Compensatory strategies and interventions can be tested to make sure that the patient is able to perform them accurately. An exercise is only effective when completed in the correct way. Instruction can be provided with real-time feedback. 
  1. FEES offers visualization of secretions and secretion management. Poor secretion management and aspiration of secretions is an indicator for risk of pneumonia. 
  1. FEES allows for visualization of the vocal folds. Unilateral or bilateral vocal fold paralysis can be easily identified. 
  1. We use a protocol for our studies which allows for comparison of serial examinations. Some patients will need more than one swallow study while they are receiving dysphagia therapy. Our test allows for direct comparison to gauge progress and improvement. 
  1. FEES can be used to assess the patient over a meal. This can provide an answer to the question of if the patient fatigues or not, and if they do, what happens. 
  1. A nurse can administer the patient’s actual pills during the examination. Many patients report difficulty swallowing pills. We are able to use the actual pills that they have trouble with to determine what can be done to help the patient swallow them easier. 
  1. FEES is highly sensitive and accurate in determining the safety and efficiency of the patient’s swallow in order to quickly determine what intervention is needed. 

FEES is a great tool for use for the above reasons and more. Reply here and let us know how FEES has positively impacted you and your patients. 


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Clinical Focus, Education

Thick or Thin

Thickened liquids are a common intervention recommended by SLP’s. Garcia and Chambers (2008) found that 85% of SLP’s who responded to their survey reported that they believed thickened liquids to be an effective clinical intervention. Of those, 72% reported recommending nectar thick liquids most frequently and 19% reported they recommended honey thick liquids most frequently. This survey did not differentiate the use of thickened liquids as the first choice, second choice, or last choice. I would be very interested in learning more about the choices made by SLP’s in regards to thickened liquids. (Hint hint grad students) 

My first question would be, are we recommending thickened liquids just to eliminate aspiration or are we taking the whole picture into account?

Let’s talk about what the positives of thickened liquids are. Thickened liquids have been shown to reduce prandial aspiration. We know that there is not a simple link from aspiration to pneumonia. Aspiration is just one factor needed for the development of pneumonia. Elimination of aspiration can offer relief to patients who cough excessively with thin liquids. Elimination of aspiration in the short term may also be important for those with very compromised pulmonary status. They may also have utility in the short term for individuals in the acute phase of CVA. 

What about the possible negative consequences? What problems might they create?

Thickened liquids are not very palatable to patients in general. Cichero (2013) found that thickened liquids do not offer satiety of thirst. They do not offer that satisfying mouth feel when you are thirsty and get a drink of cold water. So even if someone drinks enough thickened liquids to achieve adequate hydration, they may not feel satisfied. Thickened liquids also create a feeling of fullness. So combined, people feel thirsty and full at the same time all of the time. 

Thickened liquids can change the way that some medications are absorbed (Cichero, 2013). Medications are designed to be delivered in a specific part of the body at a specific rate and at a specific time. The thickener can also impact the availability of the active ingredients in the drugs. This is all very complicated but just know that there may be an impact. 

Patients that are prescribed thickened liquids may have reduced access to the liquids (Cichero, 2013). Research has shown these patients to have limited access due to reliance on staff to get the liquids, difficulty opening containers of the liquids, or difficulty obtaining the containers of liquids. Patients already don’t like the thickened liquids in general, and limiting access reduces intake even further. 

Dehydration is more common with patients consuming thickened liquids as compared to those consuming thin. Dehydration can cause a wide variety of problems including urinary tract infections, electrolyte imbalance, increased falls, poor muscle strength, and kidney failure among others. When we think about the whole patient, we need to think about the risks associated with dehydration. 75% of patients on thickened liquids were found to be dehydrated in a 2001 study by Finestone et al. 

Aspiration of gastric contents is very dangerous and can quickly lead to respiratory infection and or failure. Thickened liquids increase reflux and subsequently increase risk of aspiration of that refluxed material. 

All together, it’s clear that recommending thickened liquids is not a black and white decision. We need to think beyond just aspiration. My recommendation would be to avoid recommending thickened liquids whenever possible and to use thickened liquids as a tool to bridge a patient over into safe consumption of thin liquids by providing aggressive, evidence based dysphagia treatment. 

One final thought: I would challenge all SLP’s to consume only thickened liquids for an entire day. Maybe even consume just honey-thick liquids. I think this would be an interesting experiment and may offer more insight into the experience of our patients. 




Cichero J. A. (2013). Thickening agents used for dysphagia management: effect on bioavailability of water, medication and feelings of satiety. Nutrition journal, 12, 54.

Finestone HM, Foley NC, Woodbury GM, Greene-Finestone L. Quantifying fluid intake in dysphagic stroke patients: a preliminary comparison of oral and nonoral strategies. Arch Phys Med Rehabil. 2001;82:1744–1746. doi: 10.1053/apmr.2001.27379.

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Advocacy, Clinical Focus, Education

What Does ASHA Say?

ASHA, our governing body provides us guidance for clinical decision making. Below is the information they provide for adult dysphagia assessment. Note that the bolded text is from ASHA and the unbolded text is my own thoughts. 

Instrumental Swallowing Assessment

SLPs use instrumental techniques to evaluate oral, pharyngeal, laryngeal, upper esophageal, and respiratory function as they apply to normal and abnormal swallowing. In addition, instrumental procedures are used to determine the appropriateness and the effectiveness of a variety of treatment strategies.

Instrumental techniques are usually conducted either independently by the SLP or by the SLP in conjunction with other members of the interprofessional team (e.g., radiologist, radiologic technologist, physiatrist). Competence in videofluoroscopic swallowing study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) requires appropriate training and education. SLPs help guide medical decision making regarding the appropriateness of these procedures given the severity and nature of the patient’s swallowing deficits. SLPs interpret and apply the results of objective testing to the formulation of dysphagia treatment plans, and they also determine patient capacity and safety for oral feeding.

Indications for an instrumental exam include the following:

  • Concerns regarding the safety and efficiency of swallow function
    • Contribution of dysphagia to nutritional compromise
    • Contribution of dysphagia to pulmonary compromise
    • Contribution of dysphagia to concerns for airway safety (e.g., choking)


At times we may fall into the trap of focusing in too closely on the patient’s dysphagia only. We have to remember to look at the entire picture, look at the patient as a whole. When we collaborate with the medical team, the outcomes can only improve for the patient. 


  • The need to identify disordered swallowing physiology to guide management and treatment

We can’t treat what we can’t see. Let me say that again. We can’t treat what we can’t see. 

  • Inconsistent signs and symptoms in the findings of a non-instrumental examination

Remember that there is not always a cough response to aspiration. And sometimes, there will be a cough with aspiration of thin liquids but no cough with thickened. We can’t depend on the bedside swallow evaluation to determine when aspiration happens. 

  • The need to assist in the determination of a differential medical diagnosis related to the presence of pathological swallowing

SLP’s can sometimes be the first medical professional to identify signs/symptoms of a neurological condition. 

  • Presence of a medical condition or diagnosis associated with a high risk of dysphagia

Think CVA, TBI, COPD, HANC, Parkinson’s Disease, Progressive neurological conditions, MS, dementia, etc. 

  • Previously identified dysphagia with a suspected change in swallow function that may change recommendations

If there is a change in status for a patient with known dysphagia, an instrumental swallow study is warranted and needed whether it is a change for the better or for the worse. 

  • Presence of a chronic degenerative condition with a known progression or the recovery from a condition that may require further information for the management of oropharyngeal function

We are an important part of the care team for these patients. 

Contraindications for an instrumental exam include the following:

  • The patient is not medically stable enough to tolerate the procedure.
  • The patient is not able to participate in an instrumental examination (e.g., cognitive difficulties, inability to maintain an appropriate level of alertness).
  • The SLP’s clinical judgment indicates that the instrumental assessment would not change the clinical management of the patient.

Similar to non-instrumental assessment, instrumental assessment also includes a thorough case history; an oral mechanism exam; and assessment of overall physical, social, behavioral, and cognitive/communicative status (see previous section on Non-Instrumental Swallowing Assessment for details on these components of an evaluation). 

The purpose of the instrumental examination is to enable the SLP to

  • visualize the structures of the upper aerodigestive tract;
  • assess the physiology of the structures involved in swallowing and to make observations, measures, and inferences of symmetry, sensation, strength, pressures, tone, range of motion, and coordination or timing of movement to determine the diagnosis of dysphagia;
  • determine presence, cause, and severity of dysphagia by visualizing bolus control, flow and timing of the bolus, and the individual’s response to bolus misdirection and residue;
  • visualize the presence, location, and amount of secretions in the hypopharynx and larynx, the patient’s sensitivity to the secretions; and the ability of spontaneous or facilitated efforts to clear the secretions;
  • determine the cause(s) for laryngeal penetration and/or aspiration; and
  • determine with specificity the relative safety and efficiency of various bolus consistencies and volumes.

You can see above that at no time does ASHA recommend that a clinician only rely on a bedside swallow examination when there is suspected dysphagia. We can’t treat what we can’t see. Mobile FEES with Midwest Dysphagia Diagnostics provides easily accessible, high quality instrumental examinations for your patients and residents. Reach out today!

American Speech-Language-Hearing Association. (n.d.). Adult Dysphagia. (Practice Portal). Retrieved month, day, year, from

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Advocacy, Clinical Focus, Education

With a Little Help From My Friends

In past blogs and social media posts, I have offered help in whatever way I can. I believe strongly that we should help each other instead of being competition. In that spirit, I want to share more specific ways I can offer help and assistance. Check out the list below and if you feel like you could benefit, please reach out! 


Have you been asked by your facility to provide an inservice? Feel like the staff at your building could benefit from a refresher on dysphagia? Not sure where to start? Midwest Dysphagia Diagnostics provides free inservice to facilities. We are prepared to speak on dysphagia in general, diet consistencies, how to fill out section K, or how FEES could benefit the facility and residents. We are ready to provide the entire inservice or collaborate with you. We’ll even bring the snacks! 


Have a difficult dysphagia case that you aren’t quite sure what to do with? Need some resources? Reach out! We have a large library of EBP articles ready for you to implement in your practice*. Ran into a diagnosis you have never seen before? Let us know! We can talk about dysphagia all day. 

FEES Advocacy Help

Are you ready to implement FEES in your facility but not everyone is on board yet? Are they still in the dark as to the benefits of FEES? The information they need is right here. We have compiled the latest research and cost/benefit analysis material to show the staff in your facility. Getting the needed instrumental assessments to all patients is our passion and mission. Let us help you show the value and necessity of FEES. And again, we will bring the snacks!


Just feel like you need to vent? Looking for that one article that you can’t find*? Questions about MDTP? Want to do a job shadow? Reach out! We would love to hear from you. 

Remember it is community over competition and we are all stronger together. 




*We only provide full text versions of open access articles. 

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Two Day FEES Class Part II or The Time I Learned to Say, “I Meant to do That”

In the last blog I wrote about the first 2 day class I attended. The second class I attended was the 2 day course by SA Swallowing Services from Tennessee. 

Oh SASS…really some of the most talented, intelligent, ambitious, kind, etc. group of clinicians. If Michelle called me right now and offered me a job, I’d drop everything, grab my dog and my scope, and start driving south. 

This class was a perfect combination of the fun side of speech language pathology with a large side of information. The time really flew by during the lecture parts of the class. There were definitely several moments where the class all gasped in unison by information we were learning. 

The first day of practice passing the scope was on the SASS employees and one (poor) Atmos rep. Talk about intimidating. Before we started, Michelle Skelly-Ashford gave us a demonstration on her business partner and husband, Dr. John Ashford. This is when I learned a very important tip- never say you’re sorry. Whatever happens, you say, “I meant to do that.” Bloody nose? I meant to do that. (This is actually super rare and happens maybe 1/1000) Made the person gag? I meant to do that too. Spilled green food coloring all over someone’s floor? I meant to do that…..?

The second day we practiced on each other. I was ready for this since I had been through this before. But….SASS didn’t use lidocaine spray. This made things a little more nerve wracking as we did not have that crutch to make us feel better. But honestly, having been scoped both with and without lidocaine, I definitely prefer without. Lidocaine burns and that burn sticks with you. There really isn’t any pain associated with being scoped so why add the burning?

I know I have not given this class the review it deserves, because I still think about things we talked about and learned from that class. Like I said before, I haven’t been to all of the classes offered, so I can’t speak on those. But for the SA Swallowing 2 day class, I couldn’t recommend it more. 


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Two Day FEES Class or the time that Dr. Susan Langmore complimented my scoping skills.

To start with FEES you first have to take a two day course. I actually took two just to get more practice in before competency training. There are many providers that offer the class. In this post, I am not trying to convey a certain class is better than another. I haven’t taken classes with all of the providers so I can’t say for sure. This post is just about the first two day course I went to, which was Dr. Susan Langmore’s. 

If you don’t know who Susan Langmore is, she is basically the creator of the FEES examination. She has published many papers on the topic of dysphagia, all of which I would recommend checking out. 

So back to class. The first day was all lecture. We learned about the procedure, the equipment, and a quick review of anatomy and physiology. Hearing how to complete a FEES from the source was pretty amazing. This day went really quickly for just sitting in one spot for the whole day. 

The second day was scope day. We knew it was coming, that we would be practicing (for the first time) on each other. I knew it would be fun but there was also a small feeing of impending doom. 

We were split up into smaller groups and went to separate rooms to learn from mentors who are skilled in the art of FEES. I was lucky, and someone volunteered right away to be the first “scopee” and the “scoper.” The SLP started to insert the scope and within 5 seconds or so, the volunteer had a raging bloody nose and started to cry. At this point I am pretty sure that I started looking for the exit. 

After that first eventful attempt, the rest were much tamer. No more blood was shed. When it came time for me to be the “scopee” for the first time, I just shut my eyes and took a deep breath and hoped for the best. Turns out, it wasn’t that bad. Really. 

We passed from room to room with each room adding a new skill on to the skills we had already learned. I was just about to pass the scope for maybe the final time when Dr. Susan Langmore walked in. Having to demonstrate a newly learned skill in front of arguably one of the most experienced at it is very nerve-wracking. But I pushed ahead and then I heard it…Dr. Susan Langmore complimented my manipulation of the scope. I felt like I just won the lottery. 

Of course passing the scope on willing participants in generally good health is a lot easier than in the wild, but it’s a great place to start. 

We finished up the class with some interpretation. This is the real meat of the class. Anyone can learn to pass a scope, but it takes our expertise to make sense of the results and to recommend a treatment plan. 

So what would I recommend before your first class?

  1. Make sure you know your anatomy. Know the muscles and the nerves. This will help to get more out of the class instead of just trying to learn the anatomy then. 
  2. Make sure you know your physiology. Know what should happen first, second, and last. 
  3. It helps to have an understanding of what “normal” is in terms of swallowing. 
  4. And lastly, get ready to have a lot of fun and meet some great colleagues. 


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