I’m all finished. I submitted and passed my final hurdle last Friday – a portfolio matching my experiences to the Competency-Based Occupational Standards of Speech Pathology Australia. Now it’s time to relax. I’ll be completing some work at the La Trobe University Aphasia Lab, as well as interning at the Centre for Speech Neuroscience at the University of Melbourne, before commencing work next year in February as a New Graduate Speech Pathologist in a rehabilitation unit with a large Melbourne Health Service.
It feels like someone has flicked a switch. I am no longer a Speech Pathology student – I am now a Speech Pathologist. Upon reading an article in the latest issue of JCPSLP, I felt the need to reflect on what this professional identity actually means.
The article was ‘What supports speech-language pathologists to implement treatments with fidelity?’ by O’Hare and Doell (1). Briely, O’Hare and Doell explore the challenges SPs face in implementing interventions with fidelity, and offer recommendations for supporting SPs to do so.
My problem with fidelity
O’Hare and Doell refer to three popular paediatric interventions: Hanen’s More than Words program, the Lidcombe Program and the Picture Exchange Communication System (PECS). They present the ‘phase 4’ (higher-level) evidence supporting each, and then describe the ways in which fidelity was measured in research.
Fidelity means the extent to which the aspects of an intervention matches a reference intervention, or the research on that intervention. If PECS requires you to follow a manualised series of stages and you instead devise your own order, perhaps your treatment has low fidelity (but only if you call it PECS).
O’Hare and Doell take as a given that fidelity is the goal of intervention. There reasoning is as follows:
- Allocated results should result in optimal outcomes.
- Therefore clinicians should be able to demonstrate that their implementation of EBP is effective and efficient.
- SPs should consider their fidelity as this ‘has a significant impact on effectiveness … and outcomes’.
They report that clinicians commonly report poor fidelity with Hanen, Lidcombe, PECS, and other ‘packaged’ interventions. Reasons include:
- Clinicians have fewer resources than researchers (e.g. cannot offer dose used in clinical trial).
- Consideration of family preferences for treatment.
O’Hare and Doell recommend program supports (i.e. ongoing specialty assistance provided by Lidcombe, PECS and Hanen trainers) and organisational supports (increased resources to match research, supervision and mentoring, and coaching).
My issue with this argument is the connection between fidelity and outcomes. I believe the association between fidelity and effectiveness is an example of the ecological fallacy, in that RCTs and ‘higher-level’ evidence merely report an average change on an average patient; and while these studies may help inform practice at large, they are not templates for individualised therapy.
More importantly, it is interesting that the authors refer to PECS, Lidcombe and Hanen. While PECS is highly scripted and manualised, Lidcombe and Hanen emphasise an individual problem-solving attitude in the clinician. The intervention is not a cookbook – instead the SP must use their clinical skill, experience and judgement to determine which aspects of the intervention to highlight. This poses an enormous problem for efficacy research – what part of the intervention is ‘the active ingredient’? Pretending that Lidcombe can be analysed using research tools designed for pharmaceutical trials is naive – I think we should embrace the poor fidelity (or is it flexibility) of our interventions to match all aspects of E3BP (resources, preferences, experiences, etc.).
Worryingly, the emphasis on standardised treatments could affect the status of our profession. I often hear clinicians at PD events and conferences ask for the easy answer: ‘when I have a client with X, what should I do?’ What is the recipe that I follow to fix them? In my mind, SPs are professionals, and professionals are not recipe-followers but recipe-creators.
What is a professional?
In my mind a professional is one who has completed a course of study in a particular field, and has demonstrated skills and knowledge in this area. Most importantly, they are able to respond to change and make decisions. In Allied Health, this is what distinguishes the professionals from the Allied Health Assistants, who cannot make decisions, and must seek approval to deviate from a plan devised by a professional.
If the goal of EBP is to codify treatment, so that SPs will simply implement interventions with fidelity, will we still be professionals? Or will we be AHAs?
SPs are vulnerable to moves to push routine tasks down the ladder (e.g. Nurse Practitioners and AHAs). If we are not performing as ‘professionals’, how can we defend our positions?
- O’Hare, M., & Doell, E. (2015). What supports speech-language pathologists to implement treatments with fidelity? JCPSLP, 19(3), 140-143.