I have not been writing blog posts for some time. I miss it. I enjoyed spending cold weekends at my cabin, by the fire, researching a new topic, hunting down references, and putting my thoughts to paper. Even with typos and half-formed thoughts, those blogs felt like an accomplishment and so many people read them! To this day. But I gave it up because my position as school director took so much time (you will not believe what I do on Sundays now) and also I froze my right shoulder and it became painfully impossible to type for long periods, seven days a week. After three months of physiotherapy, started way too late, I can finally move my arm, and I have decided to write some blogs again. The physio is relevant because I have been thinking about private practice, both the excellent service the physio provides, my own practice given up 20 years ago, and all the young practitioners that I am talking to because they contact me for help. In the past only very experience SLPs started their own practices but now it is common for people right out of school to end up in private practice of one form or another. Since I don’t have time to research weighty topics, I will set down what will be essentially rants about the right and wrong way to do this because I am seeing some stuff that curls my hair frankly. When the mood hits me, a different aspect of setting up a practice, starting with the most important resource that you need to put into your practice: expertise. What is expertise? Why is it so important in private practice? How do you gain expertise in private practice?

What is expertise?

In Canada clinical training now reflects a competency-based approach. The Canadian framework adopts a “daisy model” in which numerous professional roles are arranged around the core “expert” role. The daisy organizes the different competencies that are required for entry-to-practice with the expectation that competencies will improve and deepen with further practice. The expert role is defined over many pages of specific competences but boils down to this: apply knowledge of development and disorders of communication together with assessment and intervention skills to clinical practice. Another definition of expertise that I really like is: “apply skills and knowledge of the discipline to make decisions with limited information in relevant contexts.”

Why is expertise so important in private practice?

Expertise is always essential but especially so in private practice: in sole-practice settings, the SLP is completely responsible for her own decisions. In larger public organizations there is an infrastructure to support decision making. In schools for example, who gets service and what kind and how much might be completely determined by regulation. The type of service provided might be a matter of tradition or culture, rightly or wrongly. Certainly, you will have colleagues that you can consult when you need help. Your employer will send you to conferences and provide professional development. You don’t have that support structure in private practice. Your client will expect you to justify your decisions directly and you will need to do that on the basis of expertise and that means knowledge. On average, your clients will be richer, more educated, and will consider themselves to be more discerning about their needs. For sure, they will have a choice about whether to accept or abandon your service. I have walked out on physiotherapists in the past because they told me to do what they always do; lacking a rationale, I had no faith in their practice. I am willing to pay a lot of money to the current practitioner because I can tell that he has a coherent theory of practice and that he is using deep knowledge to guide his treatment plan and solve problems. I am motivated to engage in an hour of painful exercises a day by visible evidence of progress and confidence in the therapist’s competence. Even children will find tangible evidence of learning and positive assurance from their SLP more motivating than stickers. You have a professional duty to demonstrate competence. This means a coherent theory of therapeutic change, deep knowledge of development and disorder(s), and a clear link between that knowledge and your practice.

How do you gain expertise in private practice?

Naïve models of expertise assume that it accumulates over time as you acquire “more” of something. Recall that the definition is essentially apply knowledge and skills to clinical practice. It has been assumed that teachers with more years of education will be more competent than those with less as a consequence of greater knowledge but this has not generally been supported by research. It has been assumed that psychologists with more years of practice will achieve better results than those with fewer as a consequence of better skills but research dispels that notion as well. Private SLPs like to acquire more skills through the accumulation of certificates attesting to their ability to apply new techniques or programs. However, the acquisition of more knowledge or skills or even practice does not add up to expertise unless the result is greater ability to solve problems. For this reason, practice with feedback is key. Feedback, that is your client’s response to therapy, provides invaluable information about the efficacy of your practice (feedback from mentors helps but feedback from your clients is more important and pertinent). SLPs do not always use client information as a clue to the efficacy of their practice. Often the client’s progress or lack of it is attributed to factors outside of the SLP’s control which is unfortunate. There is no opportunity for learning and no chance of deepening expertise if the client’s progress is not taken as important evidence of your own competence.

What if you observe that your client is not progressing? I often present data in my conference talks from a child who made literally no progress over a three year period. He was receiving lots of intervention from public therapists and the same private therapist over that time. But there seemed to be no recognition of his flat trajectory. It was astounding to see it in our research data. How is it possible? In fact, I have seen this happen quite a bit in my research. It seems that we have a tendency to practice on the basis of past experience while by-passing both knowledge and feedback, like this:

Client A: Symptom A: Apply TxA: Achieve success

Client B: Symptom A: Apply TxA: Achieve no success: Repeat

In this case, the treatment plan for Client B is built on the basis of experience (practice) with a previous client without integrating past knowledge or current feedback. The necessary knowledge relates symptoms to diagnoses, like this:

Client A: Symptom A+B: Diagnosis A: Apply TxA: Achieve success

Client B: Symptom A+C: Diagnosis B: Apply TxB: Achieve success

I am pretty sure that SLPs are failing to apply knowledge to problem solving quite often because when they ask for help, they do  not have all the information they need to form a diagnosis and when I refer to my book, the one I taught them with, they don’t have it! How can you apply knowledge to solve a problem if you don’t have your knowledge with you? And how can you solve a problem if you have not analyzed all the parameters of the problem? This brings me to the last point I want to make about expertise. Knowledge and applying it appropriately is an essential part of the picture. It is hard to know about everything (I have forgotten more about syntax than I ever new, its shameful really). So, private SLPs should specialize. Start with one thing you know a lot about and then make sure you know more about that every day. You can add another specialty area after awhile if you get really knowledgeable and well practiced with the first one. Do not pretend to be an expert in everything. If you advertise your services in everything your colleagues in the milieu will know that you are not a serious member of the private practice community and you will not be serving your clientele properly. If a person calls and asks you to provide a service you are not competent to provide, refer them to a person who is competent to provide it. If no-one is and you are their best shot, tell them you are not too sure about what to do and you will need to consult experts along the way. Never pretend to be an expert when you are not. It is unprofessional and embarrassing. Fortunately, it is not that hard to become an expert in most parts of SLP once having obtained your degree. Basically, read stuff, lots of stuff including basic science and practice guidelines. Be careful what you read because some stuff is not credible. Read real stuff by real experts. Apply what you read and pay attention to the results.

A new paper has been published (Brennan-Jones et al, JSLHR, 2020) that examines the relationship between the outcome of a single tympanostomy assessment at age 6 with PPVT test scores at age 6 and 10 and CELF scores at age 10. My doctoral thesis was on the topic of otitis media with effusion (OME) and I noticed that the authors curiously omitted the most important large sample prospective study from consideration in their introduction and their discussion. The omission seems to have been strategic. The authors were motivated to compare their own study to others that had been flawed by ascertainment bias. However, there are other excellent studies that used a prospective design with good quality sampling procedures. Furthermore, these other studies have the advantage of multiple assessments of middle ear function at an age that is of particular relevance to language development. It is instructive to consider the findings of the literature as a whole when attempting to draw conclusions about the clinical implications of Brennan-Jones et al findings. The study cannot stand alone. For this reason, I offer my own commentary.

1. OME is Normal

The first and most important fact to understand about otitis media with effusion is that it is normal. Because it is a “silent” condition the fluid in the child’s middle ear can remain unnoticed for 30 or more days. Even worse, common treatments such as antibiotics or decongestants are quite useless when it comes to clearing up the fluid. Although infection is dangerous to the child’s health it is the fluid that impairs hearing and it is the fluid that is hardest to cure. So children can spend a lot of their life with suboptimal hearing. That study that Brennan-Jones et al ignored? It involved frequent prospective monitoring of middle-ear status in 2253 infants, from 61 days until 2 years of age (the Pittsburgh study by Paradise et al). The proportion of infants who were observed to have middle ear effusion more than once was 48%, 79% and 91% at ages 6, 12, and 24 months. On average these infants spent about 20% of their life with fluid in one or both ears. A similar study conducted in Boston (Teele, Klein & Rosner) followed children from birth to age 3 and recorded a range of 0 to 500 days with middle ear effusion and an average of 116 days. Half the sample experienced more than 90 days with middle ear effusion and almost half the sample had a bout of OME during their first year. To summarize, nearly every child gets at least one ear infection but the range of days with middle ear effusion varies greatly from child to child.

2. OME Causes Significant Hearing Loss

Almost every paper that discusses the conductive hearing loss that is associated with OME describes it as “mild” because most children achieve pure tone average thresholds of 20 to 25 decibels during an episode of OME and only 10% suffer losses of greater than 40dB (see Roberts et al for review). However the amount of hearing loss changes greatly during each episode and greatly across the population of children who have OME. Furthermore, children require a much greater signal-to-noise ratio to achieve the same perceptual performance as an adult when identifying and discriminating speech signals. The same level of hearing loss that is mild for an adult with normal language abilities is significant for an infant or young child that is engaged with the task of learning his or her first language.

3. OME is Associated with Variations in Language Development

Both the Pittsburgh study (2253 infants monitored prospectively from birth) and the Boston study (205 infants followed prospectively from birth) found that amount of time with middle ear effusion was correlated with language development. I am reproducing some of the date below, grouped according to days with MEE ascending down the rows and SES categories ascending across the columns. In both studies, MEE and SES are significant predictors of vocabulary knowledge. In the Pittsburgh study the vocabulary measure was parent report of productive vocabulary on the McArthur Communicative Development Inventory when the child was 24 months old. In the Boston sample, the measure of receptive vocabulary was the Peabody Picture Vocabulary Test.

How do we interpret these data? The first thing to notice is that variation in vocabulary size is normal (Fenson et al., 2000). At 24 months a child might produce no words or over 400. What accounts for this broad variation? It is common to call on genetic explanations but environmental inputs play a large role in vocabulary development specifically and SES and OME are both environmental variables. The point here is that OME does not cause language delay but it is one variable that helps to explain the large variation in early vocabulary development within the normal range.

4. What are the clinical implications of the research on OME?

It is a rather common tactic to conclude that the research data indicating a correlation between OME and slightly slower growth in some aspect of language development (as reported in Brennan-Jones et al between age 6 and 10 years for example) is of no particular clinical interest. The reason for this conclusion is that the impact of OME is taken to be “small” because the mean test scores are all within the normal range. In other words, OME does not cause language impairment and therefore “no clinical implications.”

Let’s think about this from the perspective of an SLP treating one particular patient. I have in mind the most common type of patient treated by the pediatric SLP in the world (I can predict this from survey data and large scale caseload studies): a child aged somewhere between 4 and 7 with a mixed speech sound disorder and expressive language delay. We can expect an underlying impairment with phonological processing that has a heritable genetic cause (Bishop et al, 2008). The most important protective factor (Rvachew & Grawburg, 2006) will be the child’s vocabulary size—something that is highly malleable. If the child receives sufficient high-quality inputs, it will be a lot easier to bring phonological processing skills into the expected range and ensure acquisition of literacy skills. If the child has chronic OME, you don’t really care whether the OME has caused the child’s speech and language skills or not. Even though I would still argue that there is reason to be concerned about permanent effects of OME during the first year on the development of the auditory system, you can let the scientists worry about that. The issue is that this child cannot afford to lose a single word of language input. Because right now, intense high-quality language input is all we have in our treatment tool box. Let’s make sure that each child on our caseload can hear the precious minutes of therapy input that we are providing. And when we send them back to their noisy homes and classrooms with their homework books, let’s make sure they can participate in those activities to their maximum benefit. Hearing impairment affects everybody. And this child in particular doesn’t have any days to lose.