Privilege and unconscious bias in SP

My previous post perhaps didn’t clarify my thoughts well, so I’ll make another attempt here.

business-men-and-women_279-8741Unconscious bias

Back in February, I (and probably millions of others) listened to a This American Life episode about the intersection of policing and race in the US. I was introduced to the concept of ‘unconscious bias’ or prejudice as being something separate from racism. As I see it, racism is an overt, direct belief in the inferiority of a race or many races (or similarly the superiority of a particular race). Unconscious bias is best illustrated by a quote from the episode attributed to Josh Corell:

For most of us, we would say things like, oh, you know, I like black people. I like black men. I don’t have anything against them. I don’t have any negativity toward them. That’s an explicit report of an attitude.

But it goes through an editing process. When I flash a picture up on a screen and ask you to respond in 630 milliseconds, you don’t have time to edit. It’s like everybody has this gut response that is, oh, black means threat.

You can test yourself on many biases at Project Implicit.

This ‘gut response’ is almost hardwired. Here’s a more relevant example: in class when we were discussing a recorded consultation with a cleft client, I referred to the male in the room as the doctor. I don’t think women can’t be doctors (at least explicitly). Yet my expectation was that the woman in the video couldn’t be the doctor – this was my built-in assumption. As soon as I said “the doctor”, I immediately corrected myself and said to my tutorial full of women “well, he could have been the speech pathologist.”

Unsurprisingly, my colleagues had also assumed that he was the doctor. Just because you belong to the ‘marked’ group (in this case women) does not mean you are free from unconscious bias. Women and men alike share these unconscious bias about what men and women are like, and what they are able to do.

And really, there’s little to be done about addressing this at the source. Instead, I think we should alert people to these unconscious thoughts through experiments (although the surgeon story could probably use a sequel), and make them acknowledge that they exist. The worst option is to pretend that we treat everyone equally, implying that discussions of race, gender or sexuality are off-limits, because “I know I’m not sexist/racist/homophobic”. Several responses to Adrian Bradley’s survey said the following regarding men in SP:

  • “Not top priority for SLP, getting right candidate is more important”
  • “Attracting the ‘right’ people is more important than their gender.”

These responses reminded me of the ‘women of merit’ argument for Tony Abbot’s male-dominated cabinet upon forming government in 2013. As the argument went, only the right candidates were chosen for cabinet, and it is coincidental that few of the women were the right candidates. Unconscious bias was not acknowledged: instead, we were told that everyone was being treated equally.

What is the right candidate? Could it be for the survey respondents that the qualities that are considered ‘right’ for SP are interwoven with ‘feminine’ qualities? Can you pretend to ignore a person’s race or gender when interviewing them? It is noteworthy that when American orchestras began auditioning musicians behind a screen (i.e. heard but not seen), the number of women in the ranks shot up. Yet I’m certain that any panel member would claim that they were free from gender bias, their unconscious bias may have played a part when they could see the candidate.

In summary, we cannot ignore gender – we must acknowledge it, and the biases that we all carry that come along with it.

Privilege

The flip-side to unconscious bias is privilege, familiar to most Arts students from the essay ‘White Privilege: unpacking the invisible knapsack’ by Peggy McIntosh. Associate Professor Catriona Elder refers to privilege as “the unconscious, unearned and largely un-examined benefits of prejudice.”

I believe I have experienced privilege. For a case in point, once I left my wallet at a school in South Melbourne accidentally, before travelling to Bundoora by public transport (a long trip!). On the train to Reservoir, I was asked to see proof of my concession. Since I had been on placement, I was dressed in business attire and was reading on my iPad. I could not provide it, and said (rather lamely) that I had lost my wallet but still had my myki. The inspector looked at me for a moment, and walked away.

Of course, the plural of anecdote is not evidence, but I did wonder if I were a female international student from South-East Asia (a common target, as far as I can see) if I would have been simply let off without even a warning. Luckily, there is some evidence as this New York Times article summarises:

As they describe in two working papers, Redzo Mujcic and Paul Frijters, economists at the University of Queensland, trained and assigned 29 young adult testers (from both genders and different ethnic groups) to board public buses in Brisbane and insert an empty fare card into the bus scanner. After the scanner made a loud sound informing the driver that the card did not have enough value, the testers said, “I do not have any money, but I need to get to” a station about 1.2 miles away. (The station varied according to where the testers boarded.)

With more than 1,500 observations, the study uncovered substantial, statistically significant race discrimination. Bus drivers were twice as willing to let white testers ride free as black testers (72 percent versus 36 percent of the time). Bus drivers showed some relative favoritism toward testers who shared their own race, but even black drivers still favored white testers over black testers (allowing free rides 83 percent versus 68 percent of the time).

Male privilege is probably real in speech pathology, but probably only in areas where ‘male’ attributes are valued (e.g. perhaps in management issues concerning money, rather than ‘feminine’ rapport building skills with children). Anecdotally, more men work in adult populations, and are more likely to work in roles that could be construed as ‘technical’ roles rather than ‘care’ roles (I have never met a male speech pathologist who worked in disability, ASD being an important exception).

Once again, the way to combat privilege is to encourage those who benefit from it to acknowledge it, instead of pretending they got where they are solely and completely by their own personal merits.

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Men in Speech Pathology – the Speech persona

I volunteered for my university’s open day, talking with prospective students. It was interesting to see almost ten young men approach the Speech Pathology stand to inquire about the course. I remember one prospective student asking me about the role of SPs, and the course content. I related to him a memorable interaction with a client from my acute hospital placement. He was well-informed, correctly inferring that her aphasia was non-fluent – better than your average Year 12 student! However, his mother asked me point-blank: “how many men are in the course?”. I couldn’t lie, out of ~100, there are three, and I am the only local (non-international) student (not that that’s a problem – but it’s an interesting statistic). Also, I am a postgraduate – when my colleagues were in first-year there were two men, one of whom has changed to Audiology. His mother was not impressed. I couldn’t blame her – men like to talk with men on some occasions, and most people would not like the enhanced attention that comes from being the only boy in the room. I tried to sell the positives: the lecturers would always know your name, you would be in high-demand, especially in pediatrics, and since society views men as more competent than women, your career would probably progress faster (this was tongue-in-cheek, but is perhaps true).

I performed a quick ABS search a few months ago, comparing the gender-split in SP to other professions, finding that, in Australia at least, Speech Pathology has perhaps the fifth highest proportion of women. However, when looking at the other side, there are far more professions that have a more extreme gender split favoured towards men (mainly in trades and engineering). It’s nothing new to state that professions that have been historically viewed as feminine (nursing, education, etc.) have large proportions of women, but it is the size of the split in SP that is intriguing.

Here’s a table to compare health practitioners (taken from AHPRA’s Annual Report):

AHPRA gender

Speech Pathologists aren’t registered with AHPRA, but they would have a similar proportion as the “Nurse and midwife” category.

This week the @wespeechies twitter handle was curated by Adrian Bradley, an Acute clinician from Ireland. He discussed the position of men in the profession, as well as strategies for addressing the gender split.

Is it a problem?

Obviously, there needs to be a benefit to having diversity before we commit to pursuing it. My opinion is that professions with low diversity can lack external credibility. SPs working in all environments face skepticism of their expertise and clinical skills from doctors, teachers, parents, policy-makers (for example see here). Diversity in a profession creates an image separate from the stereotypical associations outsiders may have (the GP as an older man, the nurse as a maternal woman, etc.). SP certainly has an image problem: upon telling a medical intern friend that I was commencing study in SP, he was surprised – his impression was of a lot of petite ladies with high-pitched voices. I have met SPs like this. But the majority that I have met have simply been women – from the country, the city, private schools and public schools. SPs of different ethnicities, some who have completed previous study in medical science, linguistics, psychology, science, education. Some who worked in business and marketing. Certainly beyond the stereotype!

Perhaps one of the issues with the stereotype is socialisation. Through our training, we take on the SP persona, in which our individuality is diminished somewhat. I have been in several settings where I have been told: “we can’t do that here because of X”. X usually involves Other People, who are not SPs (physios, doctors and headmasters are often the culprits here). By enforcing this professional boundary, we lessen diversity.

My ideal professional persona is more consultative than directive. I see myself as someone who has expert knowledge in language, speech, communication and feeding; and who is able to provide expert advice or therapies in consultation with people, their networks (families, friends, colleagues, etc.) in order to help them achieve their goals. To do this, I am more “Team Allied Health” or even “Team Health Care” than “Team Speech”.

Perhaps this comes from belonging to various other groups before entering Speech Pathology (musician, linguist, cooperative director, etc.).

My experience

During clinical placements, my gender is seldom mentioned. It was never mentioned on my acute hospital placement, and only once by a nurse on my sub-acute placement (“we’ve never had a male speechie before…”). However, on paediatric placements, whenever I seem to build good rapport with a male client, their parent always says, “it’s because you’re a man.” Perhaps it is, but I’d like to think its because of my skill!

I’ve been told on numerous occasions that clients will seek out a male SP, and that my career will progress faster – “you’ll go straight to management”. While I don’t envisage working solely in clinic for the rest of my career, I’d like to think that any progress I make during in my career would be due to my skill rather than my gender. But how would you know?

This has turned into a rambly sort of post, but these issues are complex and interwoven. The position of women, the position of the profession, and individual factors coalesce – there’s not a simple explanation for the observed phenomena.

The Ecological Fallacy – When to Intervene?

I’ve been doing a bit of reading to prepare for my next placement in paediatric community health.
In an intriguing paper, Ukoumunne and colleagues pushed the ELVS data through a statistical machine to discern discrete trajectories of language impairment and precocity. The best fit had five average paths for the children’s language between 1 and 4 years:

  • Typical: 68.5% of children stayed pretty average
  • Precocious (late): These children started typical, but were more likely to outpace their peers from 24 months.
  • Impaired (early): These children were impaired up to 12 months, but were typical by 2-4 years.
  • Impaired (late): Typical development to 2 years, with impairment from then to 4 years.
  • Precocious (early): Likely precocity early on with a return to typicality at 4 years.

The authors are keen to stress that these paths are averages, and do not predict what individual children might achieve. To apply this analysis in a clinical context would be to commit the Ecological Fallacy, “where inferences about the nature of individuals are deduced from inference for the group to which those individuals belong“.

An example

Suppose there is a suburb called “Exampletown” with 400 residents who each earn $60,000/annum, except for one who earns $50 million/annum (an extreme example, but good for making the point!). The average income for Exampletown is $184,850/annum (the median is obviously $60,000). You might read a list of suburbs ranked by average income. Say you meet someone from Exampletown – you might assume they are quite wealthy, because you know their suburb has an extremely high average income. But they aren’t! You have committed the ecological fallacy, trying to apply an inference that applies to a group to an individual member from that group.

Application to Language Delay

While the model above is seductive, it is also true that 6% of the typical group will be impaired at 4 years, and that 52% of the Impaired (late) are typical at 4 years. Because there are a lot of more in the typical group, this 6% actually represents 55% of the total number of impaired children at age 4.

People might say that the data shows that children are too variable to allow clinicians to make the call to intervene before 4 years. After all, they might improve! Or we could be taking away resources from children who will need them when their impairment manifests. It’s a tricky problem.

I have a small issue with people using the ELVS data to make clinical decisions (if they do). The study was not conducted to look at the efficacy or efficiency or early language intervention. Instead, it was an observational study: it cannot answer these questions.

It’s a rather unsatisfying conclusion, but I’ll be interested to report on what my next clinic does. All community health services suffer from chronic under-resourcing, so decisions need to be made about priorities. Are these decisions being made with reference to efficiency/efficacy data, or observational/epidemiological data?

References:

Ukoumunne, O. C., Wake, M., Carlin, J., Bavin, E. L., Lum, J., Skeat, J., . . . Reilly, S. (2012). Profiles of language development in pre-school children: A longitudinal latent class analysis of data from the Early Language in Victoria Study. Child: Care, Health and Development, 38(3), 341-349. doi: 10.1111/j.1365-2214.2011.01234.x

Stroke 2015 – Collated tweets

Since I don’t self-host, I can’t embed the storify here.

So here’s a link to all my tweets from day one (plus those of colleagues)

https://storify.com/os_alexo/stroke-2015

https://storify.com/os_alexo/stroke-2015-days-two-and-three

Speech Pathology Management of Chronic Refractory Cough

One of my university assignments required me to research a new field of practice, and present the results as a proposal. I chose to write about Chronic Refractory Cough. Enjoy!

cough1.jpeg

Defining Chronic Refractory Cough (CRC)

Cough is the most common symptom for which people seek ambulatory care in the United States (Hsiao, Cherry, Beatty, & Rechtsteiner, 2010). Physicians usually separate cough that is less than three weeks in duration (‘acute cough’) from that which persists for longer (‘sub-acute cough’ being three to eight weeks, ‘chronic cough’ persisting for longer than eight weeks). Respiratory physicians have developed a series of care guidelines for the management of cough, from which we can broadly categorise chronic cough etiologies (Irwin et al., 2006; Morice et al., 2004; Morice, McGarvey, & Pavord, 2006):

Class Cause Recommendation
Environmental ACE Inhibitors

Smoking

Cease
Upper Respiratory Upper Airway Cough Syndrome

Post-nasal drip

Rhinitus

Sinusitis

Antihistamines

Decongestants

Anti-inflammatories

Lower Respiratory Asthma & COPD

Bronchiectasis

Eosinophillic Bronchitis

Bronchodilators

Corticosteroids

Leukotriene antagonists

Aerodigestive Reflux (GERD) Protein-Pump Inhibitors
Rare Psychogenic

Tourette’s Syndrome

Psychological counselling

Management involves a careful balance between empirical pharmaceutical treatment and objective measurements or studies. It is often difficult to identify the precipitating cause, as these conditions do not always cause cough. For example, the prevalence of GERD in Australia is 10%, and only a minority of these patients will develop chronic cough (Knox, Harrison, Britt, & Henderson, 2008). However, in some patients the etiology of chronic cough is not identified, and the condition fails to respond to empiric treatment. In this case it is considered ‘refractory’.

Why is CRC refractory?

New insights into the nature of cough are able to explain CRC. Cough is primarily a defensive mechanism of the airway to prevent irritants or foreign bodies from entering the lungs. The traditional understanding of cough describes a mechanical or chemical irritant triggering an afferent receptor in the respiratory tract, which activates a diffuse ‘cough-centre’ in the medulla, which then directs the glottis to close against a build-up of sub-glottal pressure. The glottis relaxes, causing the expulsion of air at speeds approaching the speed of sound, which expels the foreign bodies and shears the irritants off the mucosa (Irwin et al., 1998).

A more complex understanding, informed by recent research, hypothesises irritants triggering a cortical ‘urge-to-cough’ sensation which can vary in intensity according to the nature of the irritant. Through repeated irritation or inflammation, these afferent pathways may be damaged, or the cortex may neuroplastically respond to lower the ‘cough-threshold’ (the minimum amount of a given stimulus required to make a cough unable to be suppressed) (Morice, 2010; Morrison, Rammage, & Emami, 1999). Also, the larynx may develop ‘urge-to-cough’ with stimuli that would not usually cause cough (Vertigan, Theodoros, Gibson, & Winkworth, 2007). Thus even if the initial cause of the hypersensitivity (reflux, infection, etc.) is resolved, the cough may remain due to the induced sensory neuropathy.

Nature and implications of the condition

People with CRC may cough on stimuli that do not usually stimulate cough, such as talking, lying down, eating or performing exercise; as well as displaying hypersensitivity to stimuli that can cause cough such as perfumes, smoke or cold air (Chung, 2014; French, Irwin, Curley, & Krikorian, 1998; Morrison et al., 1999; Vertigan et al., 2007). It is important to note that triggers are often so varied that it is impossible for patients to avoid all of them in their everyday lives.

Investigations have revealed that people with chronic cough report reduced physical, mental and social health, reduced vitality, and sometimes have worries regarding personal safety (Morice, 2013). More than half of chronic cough patient surveyed in a New York study reported depressive symptoms, which correlated with the presence of cough over the three months of the study (Dicpinigaitis, Tso, & Banauch, 2006).

Epidemiology

A recent review suggested that the global prevalence of chronic cough, as measured by patient reports, was roughly 10% (Song et al., 2015). It is important to note that the condition is not localized to the Western Hemisphere. A limited number of small studies suggest that the proportion of those with chronic cough who fail to respond to specialist intervention is 12%-42% (McGarvey, 2008).[1] While it is difficult to work with these figures to arrive at a prevalence figure for Chronic Refractory Cough, it is clear that there are a significant number of people who will experience this condition.

According to a worldwide survey, two-thirds of chronic cough patients are female, and the majority are aged 50-69 years, although in China the majority are aged 30-50 years, given the higher amount of environmental pollution (Morice et al., 2014). Females in general display greater difficulty in managing noxious stimuli, and this has been confirmed by studies of capsaicin challenges (Kastelik et al., 2002; Morice et al., 2014).

Populations suitable for specialist management

Not all chronic cough patients receive adequate investigations through primary care. General Practitioners should at least trial therapy for GERD, asthma or upper-respiratory infections before referring for specialist management. These therapies are commonplace, and present minimal risk to the patient. The GP should also investigate common environmental causes, and discuss possible lifestyle changes with the patient. For example, the patient could implement diet changes to manage GERD or cease smoking (Gibson et al., 2010).

Better research is needed to separate refractory chronic cough patients from those whose cough will resolve. As already indicated, chronic cough patients can have poor response to empiric treatments, and cough-sensitivity testing is unfortunately not a specific measure of CRC (Birring, 2011). Better measurements will present patients with a clearer pathway to CRC resolution.

Speech Pathology Assessment and Intervention

Speech Pathology management for CRC has been used for many years (Blager, Gay, & Wood, 1988), but there has been a recent increase in published research since the mid-2000s. Speech Pathologists (SPs) do not require specific qualifications to practice in this area in Australia; however, it is an emerging area of practice not rigorously covered in tertiary courses, and is only tangentially referred to in Speech Pathology Australia’s Scope of Practice (2015). SPs could gain competency in this area through professional development workshops, contact with expert clinicians, and targeted reading of the literature.

SP assessment would involve a case history from the patient’s referring doctor and the patient themselves detailing the characteristics of the cough, its triggers, severity, impacts on the person’s activities and participation, and previous management. Associated symptoms would be investigated, including the presence of comorbid middle airway dysfunctions, such as paradoxical vocal fold movement (Vertigan, Bone, & Gibson, 2013). Additionally, the SP would ask questions typical to voice patients, including level of hydration, alcohol and caffeine consumption, lozenge use, exposure to fumes, breathing style, and vocal behaviours and demands. Finally the SP should assess the patient’s candidacy for behavioural therapy by investigating their concern and their ability to adopt an internal locus of control.

Over the course of 2-3 sessions, the SP would deliver a four-pronged intervention as per Vertigan & Gibson (2012). The patient would be taught about the nature of cough, and that cough is not always productive (in both senses of the word), along with basic respiratory anatomy and physiology. Then, the patient would learn the control techniques, in much the same manner as learning fluency-shaping techniques in stuttering. They would learn to apply the technique for short periods of time in unchallenging situations before moving up a hierarchy. The specific techniques include controlled breathing through pursed lips, effortful swallows, gum-chewing, and sipping water.

The SP would also give the patient a generic vocal hygiene education to reduce laryngeal irritation; and finally, provide psychosocial counselling to build an internal locus of control for the patient, in order for them to view their cough as a behavior rather than as an affliction. Resolution of the condition is best measured by patient report against a valid measure of cough-related quality of life (Boulet et al., 2014)

The treatment agent in SP intervention is believed to be the cessation of the ‘vicious cycle’, in which repeated irritation causes more coughing, which in turn creates more irritation (Vertigan & Gibson, 2012). By ‘controlling’ the cough and minimising irritation, patients should be able to neuroplastically restore their cough thresholds.

If the SP intervention fails, the SP should consult with the cough team (a respiratory specialist, otolaryngologist, or possibly a psychologist), who would order specialised investigations or prescribe pharmaceutical management. Gabapentin, an analgesic, and amitriptyline, an antidepressant, are used for resolving neuropathic pain with recent investigations solidifying the evidence base for their use in chronic cough (Bastian, Vaidya, & Delsupehe, 2006; Jeyakumar, Brickman, & Haben, 2006; Lee & Woo, 2005; Ryan, Birring, & Gibson, 2012). It is important to note, however, that they will only relieve central neuropathies, not peripheral, and thus may not resolve all cases of CRC. Also, recent evidence suggests that patients’ CRC may return after the cessation of Gabapentin (Gibson & Vertigan, 2015). Results soon to be published show the increased efficacy of speech pathology and Gabapentin protocol compared with either intervention (Vertigan, forthcoming).

Evidence for SP intervention

A single-blinded, randomised controlled study of the speech pathology management program outlined above was undertaken, where the control group were given a placebo ‘healthy-lifestyle’ education program (Vertigan, Theodoros, Gibson, & Winkworth, 2006). Treatment dose was four one-on-one thirty minute sessions over two months. Participants rated cough, respiratory, voice and upper airway symptoms, as well as overall limitation on two five point scales of severity and frequency. Participants in the intervention group improved on all measures at a significantly higher rate than those in the placebo group. Dropouts were similar across groups, effect sizes were not reported, and no follow up was undertaken. Other teams have made similar findings with less robust study designs (Murry et al., 2010; Murry, Tabaee, & Aviv, 2004). There is a clear need for further research to investigate the treatment agent in SP intervention; that is, which of the four prongs is specifically efficacious in treatment.

[1] It should be noted that these figures vary greatly between studies, with a recent paper suggesting CRC occurs in up to between 0%-50% of specialist presentations – a range that is not clinically useful (Gibson & Vertigan, 2015).

References

Bastian, R. W., Vaidya, A. M., & Delsupehe, K. G. (2006). Sensory neuropathic cough: a common and treatable cause of chronic cough. Otolaryngology and Head and Neck Surgery, 135(1), 17-21. doi: 10.1016/j.otohns.2006.02.003

Birring, S. S. (2011). Controversies in the evaluation and management of chronic cough. American Journal of Respiratory and Critical Care Medicine, 183(6), 708-715. doi: 10.1164/rccm.201007-1017CI

Blager, F. B., Gay, M. L., & Wood, R. P. (1988). Voice therapy techniques adapted to treatment of habit cough: a pilot study. Journal of Communication Disorders, 21(5), 393-400.

Boulet, L., Coeytaux, R. R., McCrory, D. C., French, C. T., Chang, A. B., Birring, S. S., . . . Irwin, R. S. (2014). Tools for Assessing Outcomes in Studies of Chronic Cough: CHEST Guideline and Expert Panel Report. Chest. doi: 10.1378/chest.14-2506

Chung, K. F. (2014). Approach to chronic cough: the neuropathic basis for cough hypersensitivity syndrome. Journal of Thoracic Disease, 6(Suppl 7), S699-707. doi: 10.3978/j.issn.2072-1439.2014.08.41

Dicpinigaitis, P. V., Tso, R., & Banauch, G. (2006). Prevalence of depressive symptoms among patients with chronic cough. Chest, 130(6), 1839-1843. doi: 10.1378/chest.130.6.1839

French, C. L., Irwin, R. S., Curley, F. J., & Krikorian, C. J. (1998). Impact of chronic cough on quality of life. Archives of Internal Medicine, 158(15), 1657-1661.

Gibson, P. G., Chang, A. B., Glasgow, N. J., Holmes, P. W., Katelaris, P., Kemp, A. S., . . . Vertigan, A. E. (2010). CICADA: Cough in Children and Adults: Diagnosis and Assessment. Australian cough guidelines summary statement. Medical Journal of Australia, 192(5), 265-271.

Gibson, P. G., & Vertigan, A. E. (2015). Gabapentin in chronic cough. Pulmonary Pharmacology and Therapeutics. doi: 10.1016/j.pupt.2015.06.007

Hsiao, C. J., Cherry, D. K., Beatty, P. C., & Rechtsteiner, E. A. (2010). National Ambulatory Medical Care Survey: 2007 summary. Natl Health Stat Report(27), 1-32.

Irwin, R. S., Baumann, M. H., Bolser, D. C., Boulet, L. P., Braman, S. S., Brightling, C. E., . . . Tarlo, S. M. (2006). Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest, 129(1 Suppl), 1S-23S. doi: 10.1378/chest.129.1_suppl.1S

Irwin, R. S., Boulet, L. P., Cloutier, M. M., Fuller, R., Gold, P. M., Hoffstein, V., . . . Rubin, B. K. (1998). Managing cough as a defense mechanism and as a symptom. A consensus panel report of the American College of Chest Physicians. Chest, 114(2 Suppl Managing), 133S-181S.

Jeyakumar, A., Brickman, T. M., & Haben, M. (2006). Effectiveness of amitriptyline versus cough suppressants in the treatment of chronic cough resulting from postviral vagal neuropathy. Laryngoscope, 116(12), 2108-2112. doi: 10.1097/01.mlg.0000244377.60334.e3

Kastelik, J. A., Thompson, R. H., Aziz, I., Ojoo, J. C., Redington, A. E., & Morice, A. H. (2002). Sex-related differences in cough reflex sensitivity in patients with chronic cough. American Journal of Respiratory and Critical Care Medicine, 166(7), 961-964. doi: 10.1164/rccm.2109061

Knox, S. A., Harrison, C. M., Britt, H. C., & Henderson, J. V. (2008). Estimating prevalence of common chronic morbidities in Australia. Medical Journal of Australia, 189(2), 66-70.

Lee, B., & Woo, P. (2005). Chronic cough as a sign of laryngeal sensory neuropathy: diagnosis and treatment. Annals of Otology, Rhinology and Laryngology, 114(4), 253-257.

McGarvey, L. P. (2008). Does idiopathic cough exist? Lung, 186 Suppl 1, S78-81. doi: 10.1007/s00408-007-9048-4

Morice, A. H. (2010). The cough hypersensitivity syndrome: a novel paradigm for understanding cough. Lung, 188 Suppl 1, S87-90. doi: 10.1007/s00408-009-9185-z

Morice, A. H. (2013). Chronic cough hypersensitivity syndrome. Cough, 9(1), 14. doi: 10.1186/1745-9974-9-14

Morice, A. H., Fontana, G. A., Sovijarvi, A. R., Pistolesi, M., Chung, K. F., Widdicombe, J., . . . Kastelik, J. (2004). The diagnosis and management of chronic cough. European Respiratory Journal, 24(3), 481-492. doi: 10.1183/09031936.04.00027804

Morice, A. H., Jakes, A. D., Faruqi, S., Birring, S. S., McGarvey, L., Canning, B., . . . Dicpinigaitis, P. (2014). A worldwide survey of chronic cough: a manifestation of enhanced somatosensory response. European Respiratory Journal, 44(5), 1149-1155. doi: 10.1183/09031936.00217813

Morice, A. H., McGarvey, L., & Pavord, I. (2006). Recommendations for the management of cough in adults. Thorax, 61 Suppl 1, i1-24. doi: 10.1136/thx.2006.065144

Morrison, M., Rammage, L., & Emami, A. J. (1999). The irritable larynx syndrome. Journal of Voice, 13(3), 447-455.

Murry, T., Branski, R. C., Yu, K., Cukier-Blaj, S., Duflo, S., & Aviv, J. E. (2010). Laryngeal sensory deficits in patients with chronic cough and paradoxical vocal fold movement disorder. Laryngoscope, 120(8), 1576-1581. doi: 10.1002/lary.20985

Murry, T., Tabaee, A., & Aviv, J. E. (2004). Respiratory retraining of refractory cough and laryngopharyngeal reflux in patients with paradoxical vocal fold movement disorder. Laryngoscope, 114(8), 1341-1345. doi: 10.1097/00005537-200408000-00005

Ryan, N. M., Birring, S. S., & Gibson, P. G. (2012). Gabapentin for refractory chronic cough: a randomised, double-blind, placebo-controlled trial. Lancet, 380(9853), 1583-1589. doi: 10.1016/S0140-6736(12)60776-4

Song, W. J., Chang, Y. S., Faruqi, S., Kim, J. Y., Kang, M. G., Kim, S., . . . Morice, A. H. (2015). The global epidemiology of chronic cough in adults: a systematic review and meta-analysis. European Respiratory Journal. doi: 10.1183/09031936.00218714

Speech Pathology Australia. (2015). Scope of Practice in Speech Pathology. Melbourne: Speech Pathology Australia.

Vertigan, A. E., Bone, S. L., & Gibson, P. G. (2013). Laryngeal sensory dysfunction in laryngeal hypersensitivity syndrome. Respirology, 18(6), 948-956. doi: 10.1111/resp.12103

Vertigan, A. E., & Gibson, P. G. (2012). The role of speech pathology in the management of patients with chronic refractory cough. Lung, 190(1), 35-40. doi: 10.1007/s00408-011-9333-0

Vertigan, A. E., Theodoros, D. G., Gibson, P. G., & Winkworth, A. L. (2006). Efficacy of speech pathology management for chronic cough: a randomised placebo controlled trial of treatment efficacy. Thorax, 61(12), 1065-1069. doi: 10.1136/thx.2006.064337

Vertigan, A. E., Theodoros, D. G., Gibson, P. G., & Winkworth, A. L. (2007). Voice and upper airway symptoms in people with chronic cough and paradoxical vocal fold movement. Journal of Voice, 21(3), 361-383. doi: 10.1016/j.jvoice.2005.12.008

Roger Smalley, 1943-2015

In 2013, I had the great pleasure of reviewing Christopher Mark’s Roger Smalley: A Case Study of Late Twentieth-Century Composition (1); a work that was fifteen years in the making. I was impressed by Mark’s innovative use of a 1997 as a ‘cantus firmus’ from which the analysis in the book grew. I was largely unfamiliar with Smalley’s work, which is likely due to a east-west divide in Australian music (Smalley spent much of his creative life in Western Australia).
I heard about Smalley’s death through a Facebook post, and thought I’d quote a few points from my review which show why his music deserves to be better known. Smalley largely avoided the trap of being an ‘Australian’ composer, and instead was content to write to circumstance. His music was not ideologically pure, instead he created schemes to serve his interests, and let his ear be the guide.
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Smalley’s move to Australia in the mid-1970s to become composer-in-residence at the University of Western Australia seems to have precipitated a stylistic shift, away from Moment Form, text pieces and conceptual purity toward a more comfortable relationship with consonance. While Mark attributes this change to Smalley’s relocation, he acknowledges that ‘it could be argued that the changes in his language could only have come about through the radical change in perspective that going to live on the other side of the world afforded.’ Mark footnotes that ‘it is a moot point whether migration to a different non-European country—for example, the USA—would have allowed this to the same extent’ (p. 150). However, both Mark and Smalley note, perhaps tongue-in-cheek, that this stylistic change came about because of the inexperience of Australian performers and audiences, who were not taken by Smalley’s earlier style. From the mid-1980s, Smalley began to rework the music of nineteenth-century masters, most notably Chopin. Raiding the music of the past was not new for Smalley (the Missa Brevis and Missa Parodias from the mid-1960s were based on the keyboard music of John Blitheman), but now he had sufficient skill for the development of borrowed material over longer spans.

While the analyses often seek to explain compositional processes, Mark is careful not to ignore the implications of a work for the listener, taking Smalley’s advice from the first chapter: ‘don’t get bogged down in musical technique for its own sake, and allow the music to go where it wants’ (p. 6). Mark is also not bothered by Smalley’s deviations from his pre-compositional schemes:

Musical works are valued not for the closeness of their correspondence to compositional theories … they are valued for the quality of their invention and their internal cogency. It would make better sense to view such theories as enabling devices … setting up ‘rules’ that it will be often more productive to break than to observe. (p. 96)

This statement could apply to much twentieth-century composition, and it neatly encapsulates Smalley’s method, which requires strict schemes at the conceptual level in order to free his imagination in working out the details.
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For more about Smalley’s music, go to his website or the Australian Music Centre.

References

  1. O’Sullivan, Alexander. Roger Smalley: A case study of late twentieth-century composition [Book Review] [online]. Context: Journal of Music Research, No. 38, 2013: 84-86

Evidence Evidence Evidence

Last week I had the immense privilege of attending a two-day workshop given by Dr Katherine Verdolini, covering her rather wordily named Lessac-Madsen Resonant Voice Therapy and Casper-Stone Confidential Flow Therapy (or LMRVT and CSCFT!). The programs are (I believe) proprietary, so I won’t talk about them too much.

However, Dr Verdolini did not limit the talk to the mechanics of voice therapy. She also talked at length about motor learning theory, patient compliance, and evidence-based practice. Her view was that while EBP is generally a good thing, the movement at present suffers from a number of flaws, which I’ll briefly summarise.

  • Systematic reviews of quality RCTs are considered the highest level of evidence, with clinical experience, available resources and patient preferences being consigned to the bottom of the ‘evidence pyramid’.
  • But RCTs will only tell you what will generally work for the ‘average’ patient, and these studies often exclude patients with complications – which are often the patients we see.
  • We develop a false sense of security with EBP that the research was external to the clinical reality it was measuring, when of course it took place within it.

I recall being in a clinic where I was working one-on-one with a ten-year-old boy with severe ASD. He was largely non-verbal, and we tried to convey the structure of his day to him through the use of a visual schedule. My clinic partner and I suggested supplementing the visual schedule with a ‘now/next’ board:

first+then+autism+5To keep our client oriented to the task, we would point to the board and say “Now we are doing X, then we will do Y” etc. I remember being surprised when my clinical educator asked if there was evidence regarding the use of such boards, in particular if there was evidence that colouring each space differently would be more effective.

I was a bit surprised. After all, it seemed obvious that it would, unless the client was colour-blind. What was absent from my CE’s comment was an exercise of clinical judgement – not every facet of our practice needs to be interrogated for its efficacy.

I believe what tends to happen is that EBP is used as a mallet to hit people on the head with. Evidence! Evidence! Evidence! Practicing clinicians are constantly told to integrate evidence into their practice, and for them, evidence is not clinical experience or consideration of patient preferences. Instead, they can have a narrow conception of EBP as being “that . . . double blinded, controlled thing.” (1). This conception probably comes from university courses which stress the evidence hierarchy, and actively ask students to challenge themselves if their thinking is ‘evidence-based’, which seems to be code for ‘I have read the systematic review’.

To put it simply, journal articles and other formal evidence is one piece of the puzzle for clinicians. If it were as simple as implementing a checklist from a guideline, SPs wouldn’t be counted as ‘professionals’ – we would be more like factory-workers. We add value from our ability to consider all issues: our resources, the patient’s/family’s preferences, the published evidence, and our experience in order to implement care.

In other news

One area which could probably do with more EBP is hydration in dysphagia management. I have talked about this before:

In the latest issue of IJSLP, I note a paper by a team from Curtin Uni (2), reporting that of all the factors considered by clinicians in bedside dysphagia assessment (such as oro-motor ability, oral hygiene, alertness, etc.), hydration status was considered the least, with less than 40% SPs surveyed reporting they usually or always consider hydration in their assessment.

This is worrying, considering the implications of dehydration, and the possible lack of coordination between dietetics and speech pathology regarding this issue.

However, more positively, I note that a student at JCU is investigating the impact of diet modifications on quality-of-life in dysphagic patients. I eagerly anticipate the results.

References

  1. Foster, A., Worrall, L., Rose, M., & O’Halloran, R. (2015). ‘That doesn’t translate’: the role of evidence-based practice in disempowering speech pathologists in acute aphasia management. Int J Lang Commun Disord. doi: 10.1111/1460-6984.12155
  2. Vogels, B., Cartwright, J., & Cocks, N. (2015). The bedside assessment practices of speech-language pathologists in adult dysphagia. Int J Speech Lang Pathol, 17(4), 390-400. doi: 10.3109/17549507.2014.979877