A Week of General Practice

This week I had three very different clinical experiences, which I’ll reflect on below:

Stuttering Support Groups

I attended a Speak Easy meeting on Tuesday in Box Hill. The purpose of the organisation is to offer support for people who stutter in furthering the gains they make during treatment (see my previous post on relapse).

I found the group delightful: the facilitator had a friendly manner, but was firm in implementing activities to give all attendees the best practice in a fluency-inducing environment. Personally, I had some difficulty with the meeting, as I was attending as an ‘outsider’ – one who doesn’t stutter. I also found it awkward asking members if they wanted feedback on their speech (most did), and then I felt I had to ask what kind of feedback they wanted – especially as not all of them had learned the Smooth Speech method.

Some members had experience with the McGuire Program, which takes a different approach to stuttering. In this program, the emphasis is not on speech, but the ‘whole person’, with an emphasis on developing confidence in speaking. For an advocate of evidence-based practice, there are a few red flags:

  • Only people from this organisation can implement the program (although this is also true for some SLP-endorsed approaches as well)
  • The perception I have of an anti-scientific attitude in their course materials: pride is taken in the convenors being people who stutter, not people with an academic grounding in fluency.
  • A large fixed cost of participation: ‘lifetime membership’ of $2530 is compulsory, even if you only attend one workshop; and there is a daily fee of $33. By comparison a (government-subsidised) Smooth Speech program at La Trobe is $600 for 60 hours of treatment, with 8-hour review days being $60 (concessions are half-price).

However, it seems to work for some people – this makes it hard to argue with them! I explained to the people at Speak Easy that I was not precious about which intervention people chose. If asked, I would make an informed recommendation, presenting them with the established facts about success and the long-term risk of relapse in a Smooth Speech programme. However, I couldn’t give the same information for McGuire, because such statistics do not exist. In summary, while an RCT may tell you which intervention will produce the most successes in a large group of people, it gives no guarantees about the success of an intervention in a single person, despite their prognostic indicators or risk factors.
Bigot_Boy_Singeing_Bat

Transgender Voice Clinic

I had the tremendous fortune to be able to observe La Trobe’s Voice Clinic, which has been operating for thirty years. For male-to-female transsexuals, vocal issues (pitch in particular) often present severe restrictions in participation [1]. In this program, clients are taught a variety of voice therapy tasks (Accent method, altered-focus of resonance, Stemple, etc.) in order to enable them to speak at a higher pitch without affecting their naturalness or causing hyperfunctional disorders.

Importantly, they must be able to speak about a new reference pitch (say 160Hz): i.e. the reference pitch is the average pitch within a new normal range. Some MTF clients try to speak too high, and end up attracting unwanted attention, because their range of pitches is perceived as unnatural, leading to the counter-intuitive task of intervening to lower their pitch!

Attending the clinic, I was reminded of a short quote from Debbie Phyland during a workshop given last year, where she advised the role of transgender voice therapy was to create a “female voice, not a feminine voice”. There are a wide variety of female voices, and it is not the goal of therapy to create a stereotypically feminine voice (after all, men can have feminine voices, but that’s a topic for another post!). I was impressed with my peers, who were implementing the therapy confidently, producing convincing results. I helped some out with Praat, and was convinced that some of the recordings were of (female) clinicians, not the clients. Voice therapy is the fastest therapy, and seemed particularly rewarding in this case.

Acute Hospital

My three days at the hospital brought a variety of challenges. I was confronted with a patient with advanced Alzheimer’s, who appeared to have lost the will to eat. Nursing staff and family had reported that the patient had stopped eating a week before, and was refusing all meals and drink. I assessed the patient, and convinced them to eat three teaspoons of custard, but the patient expectorated (spat out) all other offers. I was unsuccessful in communicating with the patient (they had the ‘non-verbal’ descriptor attached to them), and couldn’t really make a judgement about their choices.

It seemed possible that they were communicating their desire to cease eating entirely, and if this were true, I thought perhaps we should respect that decision. However, there were a number of other possibilities that entered my mind:

  • The patient found feeding painful (oral pain, pharyngeal pain, oesophageal pain, gastro pain, etc.)
  • The patient did not like any of the food options
  • The patient wanted to eat but was fighting motor abnormalities (I noticed some tongue-thrust)
  • The patient did not like to be fed (the patient required full assistance with feeding)

I tried to eliminate all these options by palpating for oral pain, observing for signs of discomfort, seeing if the patient ate for family members, or attempted to self-feed if given the option. Then I had to reassess why I was there. My goal was not making the patient well again, instead it was to assess if the patient could benefit from Speech Pathology input: to which the answer was no. I noted that the family had attempted creating a positive mealtime environment, and this had not increased the amount they fed. In the end, all I had to communicate was that I had made no finding, beyond that nothing I had attempted had increased or would increase oral intake. I saw this patient on Monday, and one of my colleagues made the same finding on Wednesday.

I’ve been thinking about this patient a bit since, and really can’t decide if I had tried everything, or if it’s ever okay to walk away from a patient. No conclusions yet…

References

  1. Dacakis, G., et al. (2013). “Development and preliminary evaluation of the transsexual voice questionnaire for male-to-female transsexuals.” Journal of Voice 27(3): 312-320.
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