Improving Graduate Education Through the Clinical Fellowship Process

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Recently, ASHA posted an article in the ASHA Leader focusing on how to better prepare graduate students to enter the healthcare arena upon graduation. The article, penned by Dr. James Coyle of the University of Pittsburgh’s Communication Sciences and Disorders department, really got me thinking about my own education as a speech pathology grad student.

I often hear the words “I wish they taught this in grad school”, escape my mouth. I realize graduate school is meant to cover a large breadth of information in a brief amount of time, and nothing can compare to hands on experience. This is what your clinical fellowship is intended for.

I feel that changing the curriculum for graduate education is a necessary for future speech pathologists to remain relevant in the medical setting. However, I would like to take the point of the article one step further and focus on the clinical fellowship year. I feel it would be just as advantageous to focus on improving the clinical fellowship process, as it is to revamp graduate education.

Prepared to treat dysphagia?

Because I work in the medical setting, I find up to 70% of my caseload at times can have patients with some degree of dysphagia. I have to admit, I did have an awesome dysphagia professor during my graduate studies. However, without the hands-on component during the course, I was not able to apply the knowledge as I was learning.

Like most graduate students across the nation I did not have a clinical rotation with a focus in swallowing disorders. Our in-house clinic did not provide services for treatment or diagnostics for dysphagia because it was considered a liability without having other auxiliary professionals, including nurses or physicians.

I did not have the opportunity to work with dysphagia until I completed an externship at a VA hospital for 9 months. It was a fast-paced environment and I often had many patients to see; very different from the 1-2 patients I had at my university clinic. This often made it difficult to ask questions or think critically. I did not worry; however, as I assumed I would be able to continue learning once in my clinical fellowship year.

Once I started my fellowship period, things went from bad to worse. Like many recent speech pathology grads, I found myself very alone. I had to learn to make some very tough clinical decisions, at the same time that I was trying to navigate Medicare, billing, and the dreaded “P” word (productivity). My CFY supervisor was off-site, and could not always come to my aid. She was very helpful by phone, but after a three-day orientation, I did not get very much one on one time with her as a mentor.

This is why I think the biggest impact on clinical education could occur at the clinical fellowship level.

Identifying and Resolving Problems within the Clinical Fellowship

The first problem is often even finding a medical placement. I had an extremely difficult time finding a medical fellowship site. I had to move 1,500 miles away just to get a fellowship position. I was lucky, as quite a few of my classmates didn’t find a placement for several months.

I think what may be best is to streamline the search process for graduates by providing a network of fellowship supervisors willing and able to have students. It’s impossible to contact every facility in your state, let alone talk to the right person at that facility to see if they will accept a clinical fellow. Perhaps eligible supervisors can register through ASHA, that way new graduates will have the opportunity to search by geographic area to find fellowship opportunities. ASHA already provides mentorship for students called S.T.E.P., or Students to Empowered Professionals, so I think creating a supervisor network could be a doable task.

I also think that it would help to increase the minimum amount of time a student has to be supervised. Currently, according to the ASHA website, clinical fellows are only required to receive 6 hours of direct supervision during each 3 month segment of the fellowship. That means if a fellow completes their fellowship in the standard 9 months, they received a minimum of 18 hours of direct supervision.

In my personal opinion, that is not enough time for an individual to learn and adequately apply effective treatment for difficult disorders often encountered in the medical setting. Swallowing disorders can lead to life threatening complications, which is why diagnostic and treatment skills need to be practiced in a safer environment with more supervision and guidance provided.

I think improving clinical and classroom education has many facets that can’t be solved, or even completely summarized in one small article. I do however, think that more work needs to be done to better prepare students to become effective professionals. Your clinical fellowship year should not be a time “to just get through”. It should be a time for applying knowledge and critical thinking skills in real situations. My hope as a speech pathologist is to be not only a CFY supervisor for a 9-month stent, but a mentor, teacher, and colleague.

Brittany Wingo
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Brittany Wingo

Speech-Language Pathologist at Medical Setting
Brittany is a medical speech-language pathologist. Her interests lie in everything neuro-based. She has worked with adults in home-health, acute care, outpatient, and long-term care rehabilitation. Whether she is in the clinic or making house calls, her goal is to improve patients’ quality of life one session at a time.
Brittany Wingo
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  • Amber Bettencourt

    Thank you for this article Brittany. I just started my externship at a SNF, and hope to find a clinical fellowship this summer or fall in a medical setting because I want more hands on experience with neuro and dysphagia. The thought of working alone in a hospital without a supervisor or mentor on-site makes me nervous because of how critical dysphagia is; your article has confirmed my intuition and questions regarding my limited exposure to neuro/dysphagia/voice at my University’s clinic.

    I am looking at CF/CFY positions at teaching hospitals across the country, with the hope of obtaining an opportunity where I can learn from excellent clinicians who have dedicated supervisory time. I hope I am not being too idealistic; but right now in the SNF, I feel as though time is of more importance than providing the quality of care our patients deserve. I know there will be limitations regardless due to Medicare, yet I feel like it is imperative during my CFY to gain experience with complex cases, and be in an environment with leaders where I can ask questions, be a sponge, and receive constructive criticism to better myself as a clinician. Do you have any specific recommendations as far as medical facilities for new grads?

  • Mireidys Martinez

    Brittany, Thank you for sharing your experiences. I’m currently a CFY at a hospital after several months of applying and waiting for the appropriate medical setting that was willing to train me. Luckily I am receiving extensive training in working with dysphagia patients and a great team of support. However, as a new CF the transition has not been easy, especially when realizing that graduate school and externships don’t necessarily provide the training necessary to work as a medical SLP. Also, it’s difficult to meet other colleagues’ expectations of what should be known and not post graduation. Nonetheless, I have to spend more than the typical work hour educating myself and reviewing what I have learned. I agree with you that we need mentors and a great deal of support, especially during the transition.

  • Hannah Grassie

    Brittany, I’m giving a huge “AMEN” and “Yes, Please!” to your post. I have had 3 students work under me in a SNF setting who were well-educated by often expressed a fear in jumping into swallowing treatment alone. I often asked myself during my time of mentoring, “are you being a helicopter-supervisor?”. On some level, in dysphagia treatment, close supervision is necessary until the student is well trained, confident and able to make those quick decisions you wrote about with independence. I would gladly sign up to be in a supervisor network and think taking this suggestion to ASHA is an excellent step in the right direction! Thanks for your input.