Update on Thickened Fluids

On Twitter I saw the following article linked: ”

A randomised trial of the effect of different fluid consistencies used in the management of dysphagia on quality of life: a time trade-off study

Briefly, the authors found that “on average those allocated to Grade 2 fluid would be willing to sacrifice 5 years of a 10-year lifespan not to be restricted to fluid of that consistency.” I’m not familiar with how the thicknesses (in this case Irish) compare to those in Australia. ‘Those’ in this case refers to non-dysphagic patients and healthcare professionals.

While I suggest that the study was at least partly lighthearted, there is an issue I have with the paper:

  • All participants only trialed water thickened by powder:
    • “Subjects were randomly allocated to sample from one of two opaque containers prepared within the previous 30 min with Nutilis powder (a modified starch thickener (Nutricia)): one of Grade 1 (very mildly thick [15], equivalent to ‘naturally thick fluid’ in the UK [16]) and the other of Grade 2 consistency (mildly thick, equivalent to Stage 1 thickened fluid in the UK and nectar-like consistency in the USA).”
    • I’ve written before about patients’ dislike of thickened fluids here.
    • Patients generally prefer pre-thickened fluids, and in my experience prefer flavoured fluids to thickened water.
    • It would have been nice to compare this, but perhaps the study was reflecting the fact that many people in the community with chronic dysphagia cannot afford to buy pre-thickened fluids long-term (which is more expensive than thickening at home).

Just a quick thing to think about before presenting this research to patients who are considering long-term management options for chronic dysphagia.


Aggravating aggregates

I was interested in the recent debate surrounding the federal government’s plans to cease the bulk-billing incentive for pathology (here’s a good example, and Minister Ley’s response here). There was quite a kerfuffle on facebook when Royal College of Pathologists of Australasia president Michael Harrison was quoted as saying the cuts (the incentive is ~$3.50) would lead to co-payments of $30. Never mind the obvious conflict-of-interest in the peak body for pathologists defending a government payment directly to pathologists, let’s look at some data.

Using the Medicare statistics for 2014-2015 we can plot the rate of bulk-billing for out-of-hospital pathology, and the average government benefit per pathology item (I have excluded the pathology initiation fees for clarity). As you can see there is a kink in 2009 when rates were dropping, causing the Labor government to introduce the incentive payment. I have adjusted the average benefit per pathology item to CPI (presented in Jul 2015 dollars according to ABS 6401.1). You can see that this benefit has been dropping in real terms (15% since 2003/04), due to the fact that the government does not automatically index items on the Medicare Benefits Schedule.


Using the Health CPI (ABS 6401.2) instead, the real value of the benefit drops 32%. It is well known that health costs increase at a more rapid pace than inflation (e.g. Private Health Insurance premiums increased three times the rate of inflation last year):

It may seem that the government is sticking it to pathologists and pathology consumers by implementing a harsh efficiency dividend. But maybe not.


There are several stories the data tells. I’ll put forward two hypotheses. Imagine the government funded 10 pathology items in 2003. Of those, 8 were standard blood tests (@$10 each in 2015 money, bulk-billed) and 2 were complex fertility tests (@$60 each, with $30 co-payment). The bulk-billing rate was 80%, in this case because all the standard tests were bulk-billed. The average subsidy was $14.

In 2015, let’s say bulk-billing rate was 95% and the average subsidy was $11. Looking at these figures, you might say that the government had failed to increase its subsidy with inflation, and the industry had increased productivity to make up for the short-fall, ensuring they were still able to bulk-bill.

The other hypothesis is that pathology experienced greater growth in standard blood tests than in fertility tests. Indeed if there were 95 blood tests and 5 fertility tests in 2015, that would explain the lower subsidy.

I don’t know if statistics on individual Medicare line items are available, but we need to see a sophisticated analysis beyond aggregate figures in order to make a reasoned judgement about the impact of the incentive on bulk-billing rates. Merely reporting the percentage rise/fall of an aggregate figure representing many heterogeneous items will not suffice.

In Death’s Waiting Room – Book review

Browsing the shelves of the library looking for books on communication in dementia, I came across Anne-Mei The’s In Death’s Waiting Room: Living and Dying with Dementia in a Multicultural Society (Rotterdam University Press, 2008).


The book is written as an anthropological, first-person narrative in two sections. The first tells of the author’s experiences observing life in a Dutch nursing home over two years, talking with managers, doctors, care staff, patients and family-members. The second recounts ‘the Blauwbörgje Case’; a case of alleged attempted murder involving a resident of a different home with advanced Alzheimer’s Disease.

Each section is broken up into chronologically ordered episodes. The’s focus is fine-grained, revealing truths about the position of aging in society through small anecdotes. The second section centers around primary documents (such as police reports) and interviews The conducted four years after the incident.

The most intriguing and complex issue discussed is how elderly people die. The problematises the binary between treatment/no-treatment, revealing the choice is always blurry and murky, and that these choices are not one-offs, but continue throughout a patient’s admission. Conversations with doctors reveal stark reasoning about particular treatments: doctors tend to plan treatments not necessarily on the advice of family, but in response to how ready they believe the families are to accept their loved-one’s death.

Her description of the Blauwbörgje case offers few solutions for those seeking to tidy the complex issues surrounding end of life care. Mr Bruggeling was admitted to overnight nursing home care in the context of acute infection on background of early-onset Alzheimer’s Disease (he was in his late-fifties). Over the course of his care, the home enforced its end-of-life care policy, which was not to artificially hydrate or feed patients with late-stage dementia. Mr Bruggeling’s daughter became aware of the situation, and demanded the staff insert a drip. When they refused, she discharged her father, and took him to a hospital, where he was rehydrated. Mr Bruggeling was eventually placed in a different nursing home where he lived for five further years. His daughter pursued criminal charges against the nursing home and its doctor, but these were eventually dismissed. The doctor died of leukemia a few years after the incident.

Many interviewees reflect on the incident and diagnose a failure of communication to be responsible for the drama. The is more circumspect, and states that while communication could have helped, it was difficult to anticipate the complex family dynamic between Mr Bruggeling’s ex-wife and his daughter, who often perceived facts differently. His daughter held that he was cogniscent of her presence, and participated in activities in the home. The nursing home staff disagreed, stating that he was unable to participate in any social activity (even acknowledging another person’s presence), and was for all intents and purposes, gone.

The suggests the strong media-driven backlash against the ‘policy’ of versterven (‘refraining from artificially and hydrating nursing home residents with advanced Alzheimer’s disease’) was driven firstly by a misunderstanding of what modern medicine has become, and secondly by a dangerous lack of knowledge about the nature of aged care. People continue to associate medicine with an illness-cure cycle, rather than interventions that promote function and participation. Medicine, unfortunately, continues to structure itself to respond to episodic, curable illness, rather than the chronic, progressive illness that pervades modern aging. Thus the idea of a doctor refusing treatment to one who may live another four years may seem difficult for a layperson to understand. The also reveals the segregation in aged-care: low-cost migrants from old Dutch colonies predominantly staff nursing homes in the Netherlands, and what happens in these places is hidden from the view of society. Or perhaps more accurately society chooses to cover its eyes.

One final note: it was interesting to see how prominent issues of eating and drinking are in end-of-life care. At least in the homes studied by The, there was no mention of the role of Speech Pathologists in assessing eating/drinking safety and function. While I’m sure the situation is somewhat better in Australia, I do wonder how many older people are written off simply because they are not being provided with appropriate meal modifications.

The Con(s) of Private Health Insurance

I was offered a 12-month New Graduate Speech Pathologist role in a large city hospital in early December, which I will commence at the beginning of February. Over the break, I’m considering things that full-time work necessitates thinking over: investments, salary-packaging, tax and insurance.

When I turned 25 a few years ago, I ceased being covered by my parents private health insurance (PHI). I took out ambulance cover, but really didn’t investigate the implications of not having insurance. After careful study over the past few weeks, I have decided not to take out PHI for the foreseeable future.

Advantages of PHI

Many websites (e.g. here) list the benefits of PHI. The most prominent are financial reasons:

  • Avoiding the Medicare Levy Surcharge (MLS) if your income is above ~$90000.
  • Lifetime Health Cover: for every year you delay taking out PHI from the age of 30, your eventual provider can charge an additional 2% on your premiums for the first 10 years of your policy.

Next on the list is ancillary services or ‘extras’ such as allied health, massage, complementary and alternative medicine (CAM), optometry and dental.

Next (and it’s interesting these reasons are on the bottom of most lists), medical reasons:

  • Shorter waiting lists for elective surgery (remember ‘elective’ surgery is that which you can wait >24 hours for)
  • Ability to choose your physician/surgeon.
  • Ability to be treated in a private facility.
  • Decreased exposure to healthcare costs if you become seriously ill.

In an interesting conversation on facebook, I saw people list a few more reasons:

  • Better quality of care in private system.
  • Ethical necessity to use private system if you have capacity to do so, in order to take pressure off the public system.

I’ll explain why each of these reasons was insufficient for me:


  • I don’t (yet) exceed the threshold. I can’t find the figures but I remember hearing that lots of people pay the surcharge anyway, even if it would be cheaper for them to take out PHI.
  • Obviously if you never take out PHI, Lifetime Health Cover won’t affect you. If you instead invest the money that you would spend on premiums at a rate exceeding inflation, you will always end up ahead, even if you take out PHI in the future. I’ll spare you the equations, but remember if you take out PHI at age 40, you’ve saved $10,000 (in today’s money) that you would have otherwise spent on premiums, which exceeds the 20% penalty on your premiums for 10 years.


  • One would never take out PHI to cover extras only. Extras are ‘icing’ on your PHI cake, but you’ll never come out ahead.
  • The average copayment for ‘ancillary’ services was ~$46 in 2014 (source) – this affects the benefit-cost consideration further.
  • One can always access Allied Health through the community health sector. During my community health placement, it was interesting to see how many high-income families chose community health over the private sector. They reported they were driven by lower costs, and a perception of greater quality in community health.
  • I’m more than happy to pay for dental and optometry services out of pocket entirely, as I know I will never pay more for these over my lifetime than PHI premiums.


  • Waiting lists for elective surgery are bandied about in the media as a sign of the impending collapse of life on earth. I really don’t know a lot about this process, but I do know that:
    • Elective surgery under PHI still involves a copayment (average $285/episode), which can be significant.
    • Elective surgery statistics can not be naively converted into an expected wait time.
    • I live in a big city with lots of services. In Tasmania things would be different.
  • Ability to choose your physician/surgeon:
    • This was a tricky one for me. For most Australians, I’m surprised this is a big deal. There is a substantial information asymmetry in healthcare. How do people know who’s a good doctor and who’s not? Through my job however, I’m more likely to develop a better idea of who to see and who to avoid.
    • That being said, all doctors and surgeons operate under extremely strict regulations. I see no reason to trust one more than another.
    • Also, if I really wanted to see a particular doctor (say, for a knee replacement), I could fund that surgery myself using my fund (which will probably be in the order of $300,000 by the time I’m 70, enough to cover a $30,000 knee replacement).
  • Ability to be treated in a private facility.
    • Lots of people like the ‘luxuries’ of a private hospital (private rooms, TVs, better food, etc.) – Point blank, I don’t think these luxuries are worth the premium investment. It’s like air travel – I’m sure business class seats are more comfortable, but at the end of the day I still get to London, it’s a miniscule proportion of my life, and I pocket the difference.
    • Lots of private patients are treated in shared rooms (it was one of the biggest complaints nurses reported when I had my private hospital placement).
    • No study has shown a significant difference in public vs. private quality/safety outcomes that could not be explained by patient mix (public hospitals tend to treat sicker, poorer, more vulnerable patients).
  • Decreased exposure to healthcare costs
    • A lot of people reported ‘not wanting to be out of pocket’. I found this odd. When I took my housemate to emergency at my (now new) workplace, he was admitted within six hours and had his appendectomy within ten hours. Total cost: $0.
    • He did not report being a private patient and thus avoided the gap.
    • If I had taken him the few kms further to the Epworth, he would have been liable for a gap (Private hospital funding comes from Medicare, the insurer and out-of-pocket costs; as opposed to public hospitals, whose funding comes predominantly from healthcare agreements between the federal government and the states).

Other reasons

  • Better quality of care in the private system
    • Someone reported that private hospitals have no incentive to kick you out before you are ready after surgery given the strains on the public system.
    • As far as I understand, most private hospitals are funded by insurers on a per diem basis (rather than a per admission basis like public hospitals). Thus they also have an incentive to over-service you, and keep you longer than necessary.
    • I personally don’t believe a public hospital would discharge someone if such a discharge presented a safety risk – or that they would be more likely to do so than a private hospital.
  • Ethical necessity to use private system if you have capacity to do so, in order to take pressure off the public system.
    • I was a bit surprised at this point. I already pay the Medicare Levy, GST, and income tax. The companies I purchase goods from pay company tax. All these taxes contribute to our public health system.
    • I don’t pay tax as charity. I pay tax to contribute to the public institutions that are set up to benefit all Australians, regardless of income.
    • If wealthier Australians left the public system to the poorest and most vulnerable, one could see how the system would be viewed as the province of ‘leaners’ instead of ‘lifters’ – subject to increasingly harsh efficiencies.
    • I don’t want to create a two-tiered system for rich and poor, as is happening in the education sector.
    • And neither did the politicians who set up Medicare and the Health system. Essentially, a universal system is designed to achieve equality of access (if not necessarily equality of outcomes).

Things may change in the future, but I see no reason to enrol now.

What makes a professional?

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.

2015-12-04 17.10.16

Portfolio accepted!

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?

  1. O’Hare, M., & Doell, E. (2015). What supports speech-language pathologists to implement treatments with fidelity? JCPSLP, 19(3), 140-143.

Who are you calling cute?

As part of my paediatric community health placement, I assisted the dietitian with a health promotion visit to a local primary school. The message was fairly simple: we eat different foods for different reasons, there are some foods we should eat less of than others, and eating healthily and being healthy are not quite the same thing.

During the activities, one boy (aged 6 or 7) told me that he used to like sushi, but does not anymore. I asked him why not. His answer: “because of the tsunami”. As if it were that obvious. I paused for a moment (It’s a fault of mine that I think too carefully about how I speak with children), and then asked: “what does sushi have to do with the tsunami?”. What followed was a rather disorganised narrative (I think, my norms were not at hand, and I wasn’t counting t-units), describing how the tsunami had damaged the seaweed, which had rendered it poisonous, which meant sushi was now poisonous. Like many stories told by six-year-olds, it was presented in a very matter-of-fact manner, with no shades of possibility. I said “well that makes sense”, but I was honestly bamboozled.

I related the story to friends, who exclaimed “how cute!”. I was inclined to agree, but remembered something that had come up on twitter about that word and applying it to vulnerable people like children and old people. More on that below.

Interlude: what does ‘cute’ mean?

I went to the bible of English lexicography, the Oxford English Dictionary, which I remembered fondly from a classes in the History and Structure of English. We can see that ‘cute’ originally (at least at the beginning of the 18th century) was a shortening of ‘acute’, meaning ‘clever or sharp witted’. The contemporary usage arose through American schoolboy slang, appearing in the early 19th century with the meaning ‘quaintly interesting’, being later extended to encompass its contemporary meaning of ‘attractive, pretty or charming’. The last example is from an issue of American Speech in 1966.



The entry in the OED is very old, and has not been updated since the 2nd edition came out in 1989. I would say that the word now has attracted a set of new connotations (although I would need to do more to collect sufficient evidence to prove this):

Cute now means attractive with the following:

  • simple
  • non-threatening
  • childish
  • invoking a care response in the viewer (something like: “awwww how cute!”)
    • Presumably because the ‘cute’ thing cannot care for itself.

Here’s a website dedicated to cute things – note that the pictures are all pets. Here’s a Vanity Fair article analysing the role of the internet in introducing ‘cute’ to the mainstream.

Back to the story

During my acute hospital placement, my fellow students sometimes described older patients (‘he’s very cute’). It’s not a rare way to describe older people – see this tumblr blog entitled ‘I love cute old people’. I explained that I found that language a bit cringe-inducing. As we saw above, we apply ‘cute’ to things that cannot care from themselves, things that lack inherent dignity (does a cat or a baby have the same level of dignity as an 80-year-old?). The simplest way to know how to behave in a health care setting is to imagine, is this the care I would be happy having relatives of mine receive?

I would not be happy for a grandparent to enter a hospital, and have people referring to them as ‘the cute old guy in bed 26’.

You Need a Reason to Learn


During my current paediatric placement, I have worked out the following rules when working with young children (0-4):

  • ‘Classroom’-style approaches do not work. Very few of the children I have worked with work well sitting at a table drilling targets.
  • Tasks must be a simple as possible, and then simpler! Many of the children I see have not quite developed the skills to take on board more than two instructions at once.
  • Most importantly: they need a reason to learn

Many therapy tasks in paediatrics involve picture labeling or description. We target a sound, lexical item, morpheme or grammatical structure; and hope by repetition it will sink in. This is the approach many of the parents I come into contact with take. For example, this would not be an uncommon exchange:

Parent: What’s happening?
Child: Girl walking.Parent: Is walking. The girl is walking.
Child: …
Parent: Say “the girl is walking”
Child: The girl walking
Parent: Do it again. Say “the girl is walking”
Child: The girl is walking
Parent: That’s it.

I find this excruciating to listen to. The child has no idea why the parent is pestering them, and is merely parroting a phrase. Also, the child is not learning the contexts in which the target is expected, which leads to overgeneralisation:

Clinician: What’s this? [holds picture of a snake]
Child: /nειk/
Clinician: remember your /s:/ sound.
Child: /s: nειk/Clinician: whose snake?
Child: /s:/ my /nειk/

Here the child has confused sentence-initial with word-initial contexts.

Some therapies target both the error pattern and the target. In phonological interventions this is the basis of minimal pairs approaches. But I have never come across it in grammar interventions.

Case study

We had a child (whom I’ll call J) who was not marking plurals (and should have been at her age). J had no phonological errors beyond those expected for her age. A ‘minimal pairs’ approach would have her produce “horse” and “horses” alternately, in such a way that I could distinguish which she meant. I could get J to tell me to point to one, and when I pointed to the wrong one she could correct me, and hopefully make the contrast more salient.

However, I’ve never found this very natural! Somewhere in the book “Interventions for Speech Sound Disorders in Children”, I saw the game “go fish” suggested.

I thought this would be perfect for my plurals goal. I would print pairs of cards with one or many of certain objects. The goal for J to request those that J needed to make pairs, and therefore win! If J requested ‘incorrectly’ (i.e. saying “do you have a horse” instead of “do you have the horses”) J would not get the cards needed to win. This would be her reason to learn.


There are a number of therapies that rely on creating a reason to communicate in a certain way. PECS comes to mind immediately. And while the Hanen program may seem very different to the game up above, it’s core purpose (as far as I see) is creating opportunities for the child to feel like communicating, rather than telling them to communicate.