The Scope of Medical Speech-Language Pathology

The field of speech-language pathology has a rich and long history of service to individuals who suffer from a variety of physical and psychological symptoms and diseases. The study of speech-language sciences and disorders includes attention to

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  The underlying anatomy and physiologic processes that are used in thinking about, understanding, formulating, and producing communication;

  
  
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  The psychological and social mechanisms that nurture communication or destroy it;

  
  
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  The physical processes that allow sound to be generated, transmitted, and perceived;

  
  
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  The conditions, both developmental and acquired, that impede the use of communication;

  
  
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  The environmental inputs and factors that encourage or discourage communication in all its forms;

  
  
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  The effects of communication and swallowing problems on individuals, on their environments and families, and on society.

When such topics are studied from perspectives that emphasize the physical processes, causes, associated signs and symptoms, pathophysiology, and underlying disease processes, then we are using models and tools developed most typically in the medical sciences. Over hundreds of years, those who have studied human medicine and disease have used a common model to expand the understanding of disease and approaches to its treatment. It should be no secret to those in our discipline that our processes and models have evolved from a similar framework, as have those in many other health disciplines (dentistry, optometry, veterinary medicine, psychology, etc.). Although those who study and practice clinical medicine have developed and emphasized the use of surgery and pharmaceutical treatments as primary, speech-language pathologists (SLPs) have provided distinctive behavioral and physiologic approaches to patient management. Additionally, an understanding of the underlying causal factors and the various cognitive and physiologic contributions is the unique contribution of speech-language pathology to clinical science and practice.

The scope of medical speech-language pathology is included in the American Speech-Language-Hearing Association (ASHA) Scope of Practice, most recently published in 2007. ¹ As noted in this document, this version of the Scope of Practice in Speech-Language Pathology is framed by two guiding factors: evidence-based practice and cultural and linguistic diversity. These two considerations serve as guideposts across practice settings and contexts, including those that are primarily found in health settings. All practitioners in these settings should be using knowledge of evidence and cultural appropriateness to guide all of their decisions.

A broader framework for consideration of disability, and specifically cited in the ASHA document ¹ is the World Health Organization’s (WHO) International Classification of Functioning, Disability, and Health. ² This document serves as an overarching guide to provide a standard language across various disablement classification considerations worldwide, and also highlights the role of the client/patient across a continuum of functioning and their participation in a variety of contexts. This WHO framework provides particularly relevant guidance to those who practice in post-acute rehabilitation settings where treatment is essentially focused on reducing limitations and barriers to participation in social, environmental, and employment settings.

According to the ASHA Scope of Practice, SLPs provide services when individuals exhibit disorders of voice, speech, resonance, fluency, language, cognition, or swallowing. Individuals with these problems frequently have health concerns as either causal or coexistent with their speech, language, or swallowing concern.

At the time of this writing, ASHA is replacing many of its key resources for practitioners (guidelines, practice documents) with a set of new online resources housed in their new “Practice Portal” (www.asha.org/Practice-Portal/Clinical-Topics/). This resource serves as a comprehensive and current repository for practice-focused guidance information on evidence-based practice, available practice guidelines, related advice and discussion forums, and related information from other sources. Any SLP in a medical or other health setting now has up-to-date information available to provide guidance for clinical decision making. This integration of immediate online access with current best practice information represents an exemplary effort in implementation of best practices for SLPs.

1.2 Why Differentiate Medical from Nonmedical Speech-Language Pathology?

In considering the field of speech-language pathology from a very broad perspective, there are few good reasons for differentiating medical and nonmedical speech-language pathology practice. Every clinician practicing in the field needs to know about the care of individuals with a variety of disorders. Regardless of the setting in which he or she practices, the SLP must understand the causes and effects of communication disorders. This understanding can only come from in-depth knowledge of the physical, anatomical, psychological, and physiologic processes involved in communication, and from knowledge of the conditions producing the disorders that interrupt it. Thus, a medical (cause-effect, scientifically based) perspective is useful to every SLP.

Although this broad perspective on medical speech-language pathology holds true for most practitioners, it is important to highlight two general views regarding the categorization of speech-language pathology into components that are medical and those that are nonmedical. One school proposes that a distinct category of professional practice within the field encompasses a body of information and a range of clinical activities that affect a patient’s health status or are affected by a patient’s medical condition. Proponents of this school of thought suggest that this aspect of speech-language pathology practice should be delimited and defined by the term medical. This approach serves to signal the key feature of the speech-language practice being discussed and also to differentiate it from other aspects of the field (i.e., educational, developmental, etc.). This first view was highlighted in the 2000 revision of ASHA’s Scope of Practice. In this document, the concept of communication enhancement in the “absence of known diseases or impairments” was explicated. This perspective has been maintained in the subsequent version of the Scope of Practice. ¹

A second perspective suggests that all speech-language pathology is medical. That is, the bases of our understanding of human communication and its disorders are found in the interplay among the physical, biologic, and behavioral sciences. This viewpoint emphasizes that, regardless of the setting in which we practice, the types of patients (or clients or students) whom we treat, or the nature of our clinical activities, the practice of the profession is based in clinical science and is therefore medical. This group would argue that there is no area of practice that could be considered nonmedical. Although this appears true when one focuses on understanding the underlying bases of human communication, it is a less precise description of the services that are delivered in non-health care environments. The professional activities of many SLPs concentrate on the use of language and communication for particular purposes in highly specific settings, such as the school or the workplace. Additionally, in the field there is an important continuing trend toward recognizing the needs of persons who experience communication challenges as a result of dialect, stylistic differences, or other nonclinical situations. It is perhaps easier and more fruitful to consider these concerns in a social or educational context. An argument can be made for differentiating this particular set of practices from those directed to more immediate health concerns of the patient.

Our own position represents a compromise between these two perspectives. At the superordinate level, it is easy to recognize the interplay among the behavioral, physical, and life sciences in understanding the nature and treatment of speech, language, and swallowing disorders. At the more direct practice level, the benefit of discussing a “category” of practice within the field helps to align discussion of the important details of clinical diagnosis and treatment for the practitioner. Thus, we recognize the essential contribution of the scientific bases of the discipline, acknowledging that this foundation is shared with other health science professions. At the same time, we argue that there are SLPs who apply this information in nonmedical settings with persons who may or may not be ill, with expected outcomes that are vocational or educational. Thus, for pragmatic reasons, we feel comfortable in utilizing the term medical speech-language pathology to categorize an aspect of speech-language professional practice that is not necessarily specific to a setting. Instead it represents a specific approach to patient care and a specific set of clinical processes and outcomes that are related to the medical, social, and psychological well-being of the patient.

The practice of medical speech-language pathology may be examined from three different viewpoints. These reflect the ways that we can characterize this area of specialization within the larger field of speech-language pathology. These viewpoints also guide how we regard our professional identity and how we plan for the future. Medical speech-language pathology may defined by (1) where it is practiced (the continuum of care); (2) who delivers speech-language services (the specialists and subspecialists); and (3) how and what types of services are performed (procedures and competencies). The contributors in this text reflect these various approaches to medical speech-language pathology in their chapters. As the reader progresses through this text, discussion of setting-specific (acute care, rehabilitation, outpatient) issues, skills and knowledge of practitioners, and specific competencies will be found.

1.3 The Continuum of Care in Medical Speech-Language Pathology

Medical speech-language pathology can be practiced in a variety of settings, including academic facilities (university medical centers), community hospitals, outpatient clinics, subacute care facilities, rehabilitation settings, home care, nursing homes, and hospices. Medical speech-language pathologists can view themselves within the context of these physical environments. The emphasis on various skills and knowledge shifts, depending on where services are delivered. For example, clinicians must be attuned to rapid changes in communication and swallowing as well as medical status when they practice in acute care settings. Their focus of management is primarily consultative. In chronic care environments, SLPs work to strengthen functional communication for patients whose disease processes are relatively stable. Interventions are rehabilitative or monitoring in nature. However, practice in both environments requires a strong base of knowledge in the pathophysiology of communication disorders (e.g., neurologic disease) as well as the effects of other diseases and conditions on patients.

1.3.1 Palliative and Hospice Care

The areas of care that are focused primarily on communication and swallowing when illness is not treatable have not been a focus of speech-language pathology discussion in the literature. This is surprising given the number of patients with communication and swallowing problems at the end of their lives. Clearly, many SLPs are involved in providing services to many individuals with terminal conditions. Frequently, in these situations, the goal, while not rehabilitation, is to facilitate communication, nutrition, or comfort for people at this most vulnerable time. While this topic has not been explored in the research literature, a number of practitioners have begun to write about their experiences with patients in end-of-life care and a few recent examples are listed in ▶ Table 1.1. This particular area of practice provides an important opportunity for study of best practice and measurement of outcomes that affect quality of communication and quality of life.

1.3.2 The Role of the SLP in Primary Care

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