Episode 234: The Role of Occupational Therapists in TOTs Care with Anna Dearman MBA, MOT, LOTR, CLC

Hi and welcome to episode 234 of the Untutored Podcast. Today we have Anna J. Noble Dearman joining us. Anna attended Louisiana State University Health Sciences center in New Orleans and graduated in 2012 with a Master of Occupational Therapy. She has extensive knowledge and experience in pediatric orthopedic conditions, including splinting, prosthetics and equipment management. From her time spent working at Shriners Hospitals for Children, she became a Certified lactation counselor in 2021 and is currently working towards International Board Certification by completing the requirements to sit for the IBCLC exam. She entered the space due to the lack of resources in community. She's currently starting her own private practice, Prosper Therapy and Feeding Solutions, where she hopes to provide the utmost quality feeding care in her area. She's very passionate about the field of occupational therapy and hopes to inspire many of her colleagues to advocate for what they do. Quick Disclaimer all information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host, Holly Balkan. I'm a certified myofunctional therapist, feeding specialist, podcaster, business owner and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, airway, tethered Oral tissue and pediatric feeding therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide. If you've been around since June 2019, thanks for being a loyal listener. As we jump into today's episode, remember to listen with correct oral rest. Posture, tongue up, up, lips closed, teeth apart, Breathe through your nose. Let's get started. Hannah, welcome to the podcast. I am excited today because I know we are going to deep dive into a topic that is so relevant right now. But before we go there, I do want to just have you share a little bit. You know everyone just heard your bio but I want you to share like who you are, what you do, how you got into your specialty.

Well, my name's Anna Ginoble, I'm an occupational therapist. I've got lactation credentials now and I'm working towards all of my requirements to sit for the IBCLC exam, which hopefully I'll get to do in the next year or two. I know, exciting. So I entered this space, started out my career at Shriners. Y' all may have heard that already. I ended up working at an inpatient rehab in Bossier City as a therapy director for a little while there. So that was good for me to learn a bunch of the medical side of things. I feel like that's really impacted my now career in pediatrics mostly. Just being knowledgeable about certain medications and whatnot has been really, really helpful. But the reason I entered the space is because my second child came out and was having a very hard time with breastfeeding. It really hurt. I can remember being in tears at three weeks old. Her second, I think they saw her two weeks out for her follow up. Her pediatrician, which is a whole nother story. But we were seeing med peed in town and she hadn't really reached back her birth weight yet. At this time, I had no, like real knowledge of anything. You know, I was like, oh, this is fine. You know, she was sleeping through the night when she came home. You know, all the red flags that, you know, I tell parents of now, but, you know, he encouraged me to wake her up to feed her. We did that. We got her weight back good. I knew about lip and tongue ties. I asked him if he thought she had one. He said no. I kept looking in her mouth. I was like. I called the lactation consultant, the only IBCLC that we have in town, to come see me at this point. You know, she helped me with positioning. And while she was there with me, we had one really good latch. Never had that again. She knew I was an ot. I'm not sure if maybe that intimidated her some. I was asking questions about the ties. She wasn't sure either. We had a dentist in town at the time that was known for doing releases. And so I went to see the dentist. That dentist recommended that we do her upper and lower lip. Interestingly enough, the dentist told me that she had a posterior top. But the dentist didn't recommend releasing it because she felt like. Sorry. The dentist felt like it wasn't impacting anything and that it looked good. So we didn't. Went back home, continued to have issues latching, continue to have issues with my milk supply. I look in her mouth again. I mean, her mouth was just so small and tight and started playing around, found all four buccal ties. It's like, is this, you know, anything here? So I went back to her, the dentist, back to her dentist. And basically the dentist was like, yes, they're there. I can release them. Okay, well, here's where, you know, I was working a job that we didn't have leave. So, you know, I wasn't being paid a paycheck at the time. It was like 750 per arch.

Oh, wow.

So I think I got like a two for one deal for the. The two lips. My insurance did come back and pay me back later. It was just one of those things where I really couldn't justify offsetting the cost of the buckle ties. So I didn't. Our breastfeeding journey ended at four months. I got pregnant again at five. Five months postpartum. So here we are. This time around I'm like. And I'm one of those people that, you know, I'm really. I would love for everybody to have breast milk. Okay. I wouldn't call me crunchy or anything, but, you know, I know the benefits of it and I just think that it's the best and it's all possible. I wanted my third child that was well on the way to have the best third. Time's a charm, right? Okay. So I go to my current employers and I propose that I take the healthy children's certified lactation counselor course. Talk about it for a little while. They agreed and thank God they allowed me to do that while I was on maternity leave. The majority of it. Well, knowing what I knew of Isla, my middle child, who had a grade four got low class four with bone notching on her upper clip. I look at my buddy boy, buddy boy. His name's Gray. I look at his. I mean his is definitely, you know, it was a full like the cutler 4 too. But his flange dwell. At that time I had not had like tops training and I suspected that he had a posterior tongue tie because we struggled a little bit. But eventually, you know, we. It got better. The thing with him though is that he wanted to feed every hour.

And.

I mean every hour. My output was fine at that point. I knew, you know, I needed to pump every two hours when I went back to work, that sort of thing. And once I got my credentials, I started seeing patients. Well, I brought him to see the dentist. Everything's good. All right? Everything's good. Awesome. His frenum is like at least four or five lawyers that now it's a thick one. I have to make sure to brush around it really good. But anyway, everything's good. So we didn't do anything, but we did successfully breastfeed until 14 months old. His latch was terrible. We had to supplement with maybe 1, maybe 3/4 of a can of formula the entire time he was Bottle feeding or nursing. So I consider that a success. But yeah, so those are, you know, two examples for me. My reasoning, entering the space. Well, once I got my lactation credentials, the people that were referred to me had some sort of tongue dysfunction. Nine times out of 10, you know, these were the ones that were low weight gain, pain, clicking on the bottle.

Even.

You know, so I'm looking and I'm like, okay, maybe I should do some exercises with their tongue, you know, just to see if I can build up strength. So start doing lateralization and lateralization and extension and you know, just seeing what outcomes I'm getting and realizing I have no idea what I'm doing other than sending them to the dentist that would release them and then they would come back and still have issues and I was not able to help them get a deep relax. Sure, here we go again. I'm like, oh gosh, what do I do now? Well, I do Autumn Henning stats course. For me it was very validating. Hey, I knew I was supposed to be doing something. But also, gosh, I've learned so much now. And knowing that the pre therapy, the body work, all of the components that need to happen, implementing that into my practice, wow, that's made a huge difference. Well, here we are now I'm working with people's babies mouths. Well now people start calling me about their bottle feeding baby. So okay, here we go, here we go again. You know, I'm like, okay, now what do I do? I think I did John, John Pishoff's course for the top savvy therapist. Then I'm like, okay, well this whole body work thing, we, I live in Monroe, Louisiana. We have a great little town. We're separated by a river with West Monroe, Louisiana, part of Duck Dynasty. That's where they from. So it's a great place to live. It's a great place to raise your children. Monroe is very different from West Monroe, even though we're separated by a river. And in saying that our access to medical care, we had a few companies that used to be headquartered here, State Farm being one of them, CenturyLink being one of them. And since they have moved out, I feel like our medical community is suffering because we don't have specialists that want to come here. You know, there's nothing really here for them that's appealing. So I say specialists, even down to body workers. You know, we have two female chiropractors that do body work that as far as I know and I could be wrong and I now that I'm opening My own practice. I hope to have time to reach out to them to learn more about what they can do for me, but they don't have touch training. I referred out to one of them for a body work session before. This child that I had seen for four weeks, and I'm sorry, not four weeks, four months. And was still having problems with feeding, that had a posterior tongue tie, but he had some body tension. And she goes for the session before she. The day before she's coming to get a release. Oh, that's not a tongue tie. That's body tension. Oh, interesting. Have you seen him eat for the last four months? At any rate, thanks for collaborating with me before you go off and tell my patient that. But that's just, you know, kind of where I am with that. But so in saying all that, I guess I'm kind of digressing here. I found a body workforce for better breast. Better breastfeeding. And I've started implementing that as my practice now. And I'm seeing, like, really good results with that. So I'm kind of. I think, at the end of my journey here, I've been able to connect with a small. Another small rural community in Richland Parish. There is a dentist there that has been trained to do releases as well. And she's very collaborative in the sense that she sends them to me before she does anything, which is great because the other providers in our community do not do that. And so that's been very beneficial for the patients that I'm seeing. And I've been able to open up my own practice as of today. Thanks. I'm still currently at my former practice as well. They've been super supportive for me, you know, in all the training that I've received. And I have nothing but good things to say about them. And I'm sad to leave, but I just found that the environment at a pediatric clinic is not always appropriate for an infant that's trying to feed. So I just felt it best for the patients that I see and their outcomes if I was kind of on my own in a. In a place where there's not another kid having, you know, a difficult time transitioning from, you know, his speech therapy session to his OT session right at the door in the hallway, so. So that's kind of where I am now. And. Yeah, that's awesome.

No, I'm. I mean, I'm excited for you because it does sound like a lot of. It's coming full circle for you. Right. And so many of us start in these spaces. I think Every single person I've interviewed in the past couple weeks came into the space they're currently treating in, whether they're craniofascial sacral therapists or craniosacral fascial therapists. Oh, my gosh, let me tongue twister today. Whether they're ot, whether they're slp, whether, you know, they're in the MYO or the feeding space, every single person I've been chatting with, like, recently all got into this space because of, like, their own children and then the patients on their caseload. And then, you know, it's. It really becomes like, your work. And it's like we were talking in the last couple episodes about how it's been a catalyst for a lot of us coming into our specialty. Like, our own children have been that catalyst for us. And, you know, a lot of us go, like, I don't want another parent to struggle like I did. I want the resources to be available in the community. I want to be at that sounding board, the person who, like, lets the parent speak what their gut is telling them and not gaslight them, not tell them or make them think that they're crazy or that this can't possibly be going on or that, oh, you know, this is normal. Because we all now know, like, just because it's common, it's not normal. So I love you sharing your story because it totally came full circle for you. And I also love how you, like, detailed, like, when you're like, okay, and now we've got this group of patients, and that meant I had to, like, deep dive into another component and then this component and then that component. And, you know, it's. It's a lot. And it's, I think for anybody listening who's not familiar, it sounds like, oh, it's just a course here, just a course there. No, like, this is like a very big time and financial investment in every single individual aspect that you mentioned. And you're like, you've dove in. You know, you're. You're an occupational therapist first by trade.

Right.

And then now with, like, you're going for your ibclc. You already have your clc. You're going.

You. You took tots, too. Feed the peas.

You know, Todd's training with Autumn. I love Autumn. Yeah. I mean, and then, you know, even to go in and take more, like, body work focused courses so that, you know, like, what to look for, what to maybe even do in your sessions and. Or who to refer to. Right. Because I think that's a big part of it, too. If you even have the people around you, like, you know, who you kind of alluded to, you don't really. Or you at least don't think you do at this time. Yeah. It's just there are so many moving pieces. And one thing I do want to dive into, because this has been coming up a lot lately, just with some turmoil happening in the myofunctional therapy world amongst one of the larger organizations and members of. Not that you're part of that, but I think, you know, we were talking before we. We hit record today, and everybody has. Plays a different role. Right. In a sense. And when it comes to whether it's MYO or pediatric feeding or whatever. But I think that there is, at least for SLPs and OTS, like me being SLP, you being OT, we can definitely have a conversation around that, because you have a role. You have a seat at this table. And a very important one when it comes to advocating for assessing and treating these pediatric feeding cases, whether they're breastfeeding, bottle feeding on solids, they are eating with a tube, you know, whatever may be going on. You know, I think a lot of people hear OT and they automatically go, oh, child on the spectrum with a sensory processing disorder, who needs to advance.

The number of foods they eat?

And.

Right.

I mean.

Right.

It's. So it's not just that. And one of the big things that I always, like, highlight is, you know, we can't separate sensory and motor. So, like, let's stop separating SLP and ot because, like, we need to work together. But also there's a lot of overlap in what we treat. And then if we have different specialties or different things we've dove into, you know, beyond like the. The table, you know, or not the table surface. The surface level stuff.

Right.

Then that's where you go, okay, it may not be that it's just SLP versus ot. It may just be the individual who may have those credentials too, because it's in their scope, but who's done further training in this area. So all that said, you know, will you share with us so we can kind of just like, lay this to rest for people? Like, what is the OT's role in tethered oral tissues? Like, you know, I know ots are qualified to assess and treat tots or children who present with tether oral tissues, but can you speak to that a little bit?

Oh, yeah. Okay. So I just said that, you know, I finished your. Your feed heats course. Well, that all kind of arose because I was seeing kids that had reattached, that were starting their solids. I was getting referred kids that were picky eating. And I would look in their mouth and they would have a Coralis type one time. What do I do with this? This kid's three, this kid's two. You know, at what point? Like, where. Where do I go with this? There's sensory stuff going on. There's. This kid was a nic. You grow up. This kid was, you know, eating stuff just fine, and now he's not. You know, I went. So I was like, okay, I'm going to take a deeper dive into that. Well, then I was getting referred kids that were 12 that had a Coralis type 1 and needed a release. And so I'm like, okay, I think I'm going to try the myofunctional route. So the first thing I do is go look at how to become a C O M. A comm. Is that what you'll call them? OT is not mentioned on the site at all. Like, well, this is odd. So what do I do? My happy little self writes in, hey, I'm noticing here that you are allowing SLPs, RDHs, dentists. Is there a reason that OT is not included? And can I apply? And I get an email back from the director, and I don't remember who this person is. I'd have to search the email. But basically it was like, hello. You would have to prove that it's in your scope of practice. Huh?

Oh, man.

You need two letters of recommendation. You have to show that in your curriculum that you covered the. I guess I can't remember exactly. Nathan. Something like Anatomy and physiology of the head and neck or something like that. Show that your coursework, like, you know, covers that aspect of it. And I'm looking at this, like, what the Is this? Like, what? So, you know, I go straight to my practice framework. I'm like, I knew it. We had updated it since I graduated OT school. But, you know, I'm looking, I'm looking, and sure enough, I find it where it's listed. And I'm looking it up here, too. Under occupation, Swallowing. Eating description? Keeping and manipulating food or fluid in the mouth and swallowing it. Swallowing is moving food from the mouth to the stomach. Hmm, that's interesting. So it's right there for everybody to see. And these supposedly well esteemed, educated people do not know this from our profession. Okay, well, that's interesting. And so I kind of got mad a little bit. And this is kind of where my whole. My whole thing is. Like, of course we're involved, we're, we're ots. And I feel like OTS have always been kind of the profession out of all the therapies that are least recognized. But we do the most. If you think about it, we overlap with not only speech, but physical therapy as well. We're looking at your daily occupation. That could be anything. You could be a surfer, you could be a baby that, you know, all you can do is crawl. You know, you could be a 65 year old woman that had a stroke and all you want to do is bake some cookies. You know, I mean, it's, it's just there's so much that, so many areas we can tap into. We look at leisure activities, rest and sleep. Gosh, I mean, I could go down the framework here.

I mean, you've already said like, what you've already said covers Maya, because you mentioned sleep, rest, right. Your rest, posture. You mentioned swallowing, prepping the food to swallow. That is what we do in Mayo. You just live like literally listed everything.

And two, like posture, partial, like even in your core area. I mean that all supports everything up here, which you can, by the way.

Which you can work on. But traditional, like myofunctional therapists, if they are not PT or ot. It's not in my scope to address like core postural instability or like the hips or the pelvic tilts or any of that. I might talk about it and screen for it, but like, I'm not assessing it to the point of diagnosis and I'm not treating it. I'm referring to my colleagues. And the same goes for RDHs and dentists.

Right?

Like, you know. Yeah.

Sensory, sensory concerns. Who's, who's the one that people are looking to for that. So in, in some sense, and no offense, we're more qualified.

Yeah.

Do it than an SLP or an RDH or a pt. So it's just kind of disheartening to see. Here we go again. You know, I don't know if you've noticed, like anytime there's a movie and the person has to have therapy, occupational therapy is hardly ever mentioned. I think there's like maybe one movie out there where they mentioned the OT newspaper articles. I've even been called a pt. Like, you know, it's just, it's just how it is.

Yeah, it's okay. We get called speech teachers, even if all we do is feeding.

So I get it.

I totally get it. But no, I, I think that you have a really valid point though, because there's a couple big issues going on right now. And you know, some people know about it, especially if they're involved in the iaom. If they are a member of. They've taken a course, they're hearing it, they're seeing it. They. It's been going on for multiple years now. One of the things that happened with the board of directors removed SLPs and OTs from the list of who and they added by the, by the way, which was not on the website before then they didn't have a separate section on infants. And then like toddlers and they added that. I think that maybe it got added at a certain point. But like SLPs and OTs were listed as individuals. Who you would refer these, these age groups to write this age group to along with maybe there's an IBCLC involved. If they're breastfeeding or some type of lactation, you know, counselor or whatever and other professionals listed. Well, they've removed SLP and OT and they replaced that with calm, which is completely illegal. It is completely illegal. It is misrepresenting individuals ability to work with these children. RDHS and dentists are not licensed to do feeding therapy. And if we are working in a child's mouth or on their face when they are under the h. No, let me back up. A dentist, right, has a license to be in the mouth. I'm not saying that they, you know, I'm not arguing that RDHs work in the mouth too. Fine. What I am saying is when we are working with like birth to four, right? Cognitive thinking, cognitive age. Because myo, as I often say, is really for a child who is at least, has at least a cognitive ability. Not chronological age, not like oh, they're four years old. No, they can think, act and, and you know, exist at at least a four year old level cognitively. But oftentimes kids aren't even ready until closer to five and sometimes it's not even six. So there's that whole disclaimer right under that age it is pediatric feeding therapy. What we do when it comes to teletural tissues and myo, upper airway, you know, oral prep phase bolus, all that stuff. This is pediatric feeding. And it looks so different at this age than it does with a five year old. It looks different than it does with an older child, a teen or an adult. It is completely different. We can't just adapt what we're doing to these younger ages. No, it requires a license, the license of an SLP or an OT and arguably even a PT because they have feeding in their Scope too, especially with. When it comes to like oral phase. So I mean, this is something I'm so super passionate about because this has been an issue and it says calm, which, which basically opens it up to anybody with a com, which could be currently slp. There is one pt, I believe there's only one so far that's gotten a calm. And because for the same reason as OTS, they just don't allow PTs to take their courses or get certified and RDHs and dentists, which. I'm sorry, I love my RDH colleagues and my dental colleagues and I have a lot of friends and work with a lot of really great individuals in these, in these who are RDHs and dentists who do, you know, work in their scope, just like I work in mine. Unfortunately, the board of directors and some of the big names making these decisions are working out of scope and there's a lot of big issues going on behind the scenes which we won't dive all into. But this is one of the reasons why I started a MYO course back into. I launched a MYO course in 2021 because the IOM has been like self imploding for years and it just keeps getting worse and worse. And I don't. Everyone says, oh, it's the gold stand. The gold standard of what? The gold standard of, of keeping licensed professionals from treating the patients that they're qualified and licensed to treat, but then allowing non licensed individuals to then touch those patients that they're not licensed to treat. Like that's the gold standard. Sorry, but no. Right. And so yeah, so like when you say that OTs, you know, are qualified and maybe even, you know, more qualified in certain situations. Yeah. Like you guys have a lot of knowledge and 100% should be in this space in my professional opinion. And I've. I'm an AOTA provider. My company provides CEUs to OTs and to SLP through Asha. Yay. And you know, and part of it is because I was like, holy moly, why don't we have OTs doing this? You guys need to know this information. These patients are sitting right in front of you. You could be working on this right now along with the other stuff you're already doing. And when we're talking like peed feeding our littlest ones, it's. You're already doing it. It's just a matter of like adding a different lens and maybe adapting a little. Few other little things in your sessions of what you're already doing in pediatric feeding to encourage nasal breathing. To encourage proper oral rest posture, to encourage proper chewing and swallowing. But again, so many of us are already doing that because we are licensed to. And those of us who are trained to do it are already doing it, which I know I've said 15 times already in the past two minutes, but it doesn't seem to be sinking in. So anyways, that's my little rant today, but. And I don't know where we'll be weeks from now. I know, like, while we're recording this, like, this is the day before the board, everyone's voting for who's basically gonna be on the board. And they have eliminated seats on the board of directors and the entire board, and not the board of directors, but the entire board is now in. Made smaller. And they've only elected. They've only moved one SLP onto the board. Everybody else is already aged. So now there's all this, like, turmoil between individuals on online because everyone is feeling like this feels very calculated and it feels, you know, like, because of. And I want to put out this disclaimer too. Again, I love my RDH colleagues. I love my dental colleagues. I don't. This is not the profession as a whole. Unfortunately, there is a group of bad apples, if you will, that are doing this. And at the end of the day, I want to stay out of all the politics. I don't want any part in this. But I can't stand by idly and not voice my opinion when it is causing misrepresentation of credentials and leading to potentially harmful behavior with patients.

Right, Right.

I mean, this is where, you know, this. It becomes a legal issue because misrepresentation of credentials and what someone can do from a nonprofit organization per their website, you know, that's where we start to get into. There's, there's. Maybe they say it's not mal intent, but it looks pretty malicious to me. You want to do this work, go back to school and get the license.

Right? Exactly. Yeah.

So anyways, so I know that you and I Both agree, like, OTs are qualified, highly qualified, especially when you go and take the courses. And again, that's why I opened it up to OTs and PTs, because I was like, we need a certification that allows you all to take your license, that allows you to do this and learn this information. And if you want to get certified, great. If not, hey, here's the course, right? Like, let's go help our patients. At the end of the day, that's the goal. But so often I agree with you. I see OT left out of the equation. And you know, one of the things that you and I were talking about for a few moments before recording too, was how there's this discussion online in a group right now about, you know, oh, like, we really got to advocate for our profession and we need to go do X, Y and Z. And I was like, I think SLPs and OTS need to be advocating together for our profession and for what we do. Because again, there's just a lot. When it comes to feeding, there's a lot of overlap. Right. So anywho, that's my hostfield.

Well, validating to know that there's turmoil and, you know, I don't know, maybe it'll resolve one day to where OTS can easily apply. But yeah, it's just. I was just kind of shocked and taken aback. Like, what?

Yeah, well, and I think that's also why there's other individuals who have created other courses and certifications. You know, that said, there are a lot of courses that just let anybody take a MYO course and let anybody practice mayo without any of these credentials, which is also scary. This is a medical, like, we can bill insurance for this as SLPs and OTs. We can build this under feeding. We can build this under feeding and then some of the other work you're doing, you know, I know you guys can build under your, your OT codes as well, because I have ots in my practice, so I know what that looks like, especially if you're working on core strength and stability and, you know, some of that stuff. You know, my ots may be working on various things and they have even more flexibility than I do as an SLP to build different codes to insurance. Not that it gets the best of reimbursement, depending on where that may be going. But we're private pay, so, you know, we just try to help our patients with a super bill the best we can. But I do think that that also opens up a whole nother conversation because there's actually courses where they're teaching, you know, non SLPs and OTS and PTS and basically how to bill for this. But you can't. It's completely bogus. You can't if you're not a medical professional who has this license. So you can't use our codes, which. Which I think actually makes it more challenging for those of us who are able to use these codes, because that's confusing to insurance, which is already a total shit show.

Yeah, exactly. Exactly. For sure. And like, some of those are listed for, for OTs and speech only, anyway. So that doesn't make a whole lot of sense at all.

Well, that's what I'm saying. Exactly. Like 92526. Right.

Right.

We only. We can build that. I don't know if PT can or not. Maybe they can, but I know SLP and OT can, but that's it. It's only, like, our code.

Yeah, yeah.

And then as far as, like, diagnosing goes, too, you know, I think there's some of the other things that I think are coming to light that, you know, need to be discussed as well as the medically complex population, whether it's a child or an adult, because a lot of these patients are not appropriate for traditional myo, and maybe we can, again, adapt MYO to their interventions. But if they're coming to us, like you said, if they've had a stroke or let's say they have a syndrome or they have something.

Right.

You know, going on, there's always more than an orofacial myofunctional disorder that may be present, and that may absolutely be something we should treat them for. And maybe, you know, maybe a professional who's not an SLP or ot, like, maybe a dentist or an rdh, can absolutely work with that patient. But beyond the omd, beyond what's going on in the orofacial complex that needs to be treated by another provider. And we're seeing.

I think. Yeah, go ahead. I can't tell you how many times I've gotten an infant that from the release provider prior to the release that had a lot of other medical issues going on, and that some of them I still haven't sent for the release because it wasn't appropriate for that child. And just think about all of them that fly under the radar, you know? Yeah. It's very disheartening. I'm just thinking all the kids that go on with, you know, like, Giuseppeli or, you know, Torticollis, and those are just. That's just skimming the surface. I mean, I'm talking Laryna, Malaysia, like, all those things that are missed. Yeah.

I mean, I kind of have this, like, rule in my practice where just because a parent comes and says, oh, we're going for a release and I want to have my child's, you know, tetheral tissues released. Well, what does function look like? Like, to your point? Like, let's assess function and see. Like, obviously, I can't decide that, and you can't decide that. And when they. When it's presented to you by A release provider. Then as a parent, you get to decide yes or no. Right. But you don't get to walk in and say, release my child. I mean, you can. It doesn't probably not going to go anywhere. I can't tell you whether or not a release is needed, but I can tell you if the tissue's tight. I do diagnose. I just can't say that you need a release for sure. And my goal at the end of the day is to avoid one if we can. I would love nothing more than to avoid a. No matter how minor that surgical procedure may be, it's still a surgical procedure. It's still. You know, some people call it trauma to the body. It's trauma to tissue, even if it's a tiny little area. I mean, a cut or a scrape on your body is trauma. Right. So when we start to look at it through that lens, I think that we have to remember that, like, people first. These are people, and you're gonna rock their freaking world if you just go and release this child and this family's not prepped, the baby's not prepped, the adult's not whoever, whatever the age. There has to be preoperative work.

My favorite is here. We're going to show you a video while your child is getting a procedure done on how to do your stretches. I'm like, come on, we've got to give them a little more preparation there. How distracting would that be? Trying to watch this video while, you know, your child's having a procedure done? Yeah, yeah. And then, you know.

I don't know.

I'm gonna. I'm gonna stop talking.

I know. It's like before we put our foots in our mouth. No, I'm okay. I'm good. Putting my foot in my mouth. I'm good. No, I really. I think this is a huge issue, and I think that we've dedicated a lot of time on this podcast over the years talking about this issue, because it keeps coming up. It hasn't been fixed yet. Right. This is still a problem that we have unfortunately not been able to solve. And so at the end of the day, like, if a provider, a parent patient, hears at least one episode here or there from this podcast and feels that much more empowered to be like, you know what? I heard that, like, we need to prep for this release before we go for the release. Like, we're going to hit pause and we'll come back to you. Like, we're not saying, no, we're not doing it. It's just no, not today.

Right.

Like, it is okay to say, no, not today. We're not ready. Because that should be a team approach. And the issue that I take with it is even when we have pre op, when we have prepped a child, sometimes feeding gets worse before it gets better. We don't know what that's going to look like until it happens. And that's something that we. We have to tell parents. There's inflammation, the child's gonna be a little uncomfortable. They're gonna have disorganized feeding because now they've got this, you know, their tongue is free, if you will, and they don't know how to use it because it was tethered. And so while we've prepped them, we prepped them with the anatomy at the time, and now they're going to have to adapt to their new anatomy, which is why we're going to try and teach them as much as we can before, and then we're going to go right back in there and continue that work so that we can hopefully shorten that window of disorganized feeding, swallowing, you know, transferring milk solids, whatever. So I think it's so critical that people understand, like, we're not just trying to tell you to spend more time and money. We're telling you you're wasting your time and money by going for a release without doing this other work. Because most of the time it doesn't do anything because you now just have a tongue that's sitting on the floor of the mouth. And, and I will say it's more so with the tongue. I've seen this more with the tongue than, like, the lips or the. The cheeks. But, you know, the child, it gets worse sometimes. And it gets so much worse. And, like, why rock that boat if you're not gonna even know what to do? And then you call frantically because now your child's not eating well at all. And they're, you know, sometimes these kids are feeding great, sometimes they weren't feeding great. It doesn't matter. We see it in both populations. And, you know, I'll. I'll let you speak and I'll turn this back over to you. But, like, I think I'm glad you.

Questioned this, because this is when I stopped talking and said, okay, I'm just gonna start talking now. This is exactly what I was gonna say. So you just took all the words out of my mouth. I was just trying not to, like, you know, go on my rant about it, but absolutely worsening after. And the parents aren't prepared for it. So they're thinking, oh my God, what have I done? I've done this procedure and it's not worked. And then they go into this frantic panic. And then the next thing you know they show up in my office and I'm like, here we go. Because the child had no pre work done, that tongue's going right back down where it was. It's already partially reattached. And then I'm having to tell this parent that and it's just not fun for me, number one. And then obviously not fun for the parent or the baby because it is trauma. It's not trauma only to their mouth, it's trauma to them. They remember this stuff. They remember it for a long time.

And the interaction right between the feeding dyad, there's like, there's some trauma there. There is definitely an impact in the relationship and the connection. And like if, I mean you're notice, maybe you can speak to some of this more too. But fight or flight versus rest and digest, you know, if we're not going to make progress if we're stuck here.

No 100%. Was it a little bit of like polyvagal theory? Like, you know, the baby's going to feed off how mom is feeling and when mama's feeling frantic, the baby's going to feel frantic. Nobody's going to relax. Tension is going to increase. Feeding is going to be worse. You know, mom needs to be prepared mentally for this. And. And a video in the waiting room is not doing it.

No, definitely not. If anything, arguably it's probably increasing that like fight or flight because it's like, oh my gosh, I'm already anticipating. My baby's not. My baby's gonna have a react, you know, response to this. You know, I don't know what's going to happen. I don't know what's going on back there. Like they're already worried and now they're. You're going to give them work while they're worried. Like the whole idea of pre op2 is because some kids only need a couple weeks and other kids need months. We don't know that right until that child is sitting in front of us. And part of doing that pre op work also empowers and educates the caregivers so that they're able to take what they're being taught and feel really good about it. Like we're in each other's mouths. I'm like, do it on me. You don't have to do it on your kid. Do it on me if you want to. Right. I'll do it on you. Like, let's see how it feels for you. So that when they do it on their baby, they're confident and they feel really good about it and they don't think they're going to hurt their baby. Because guess what happens when your baby's crying after a release? You're going to be like, I don't want to make it worse.

Right.

And the parents kind of going to like back off because they're afraid of hurting the child or oh, you know what? They finally, they, they were crying, they stopped crying. Not to say every child cries, but you go in their mouth and they just had a procedure. They probably don't want you anywhere near it, you know.

Yeah, absolutely not.

Yeah. And you know, and this is not to like make the whole experience sound horrible and, and you know, I don't anybody be afraid to go into this if that is something that you need. The point is, like, if you want it to be a calmer experience and one that you feel really good about and one that you feel like your child benefits from, that pre op is necessary. It's non negotiable. And honestly, when families are like, we're not doing that, then we're like, we're not working together because you're setting all of us up for failure. But it's going to be hardest on you and I don't want to see you do that to yourself and your child. So maybe like, we're not the practice for you, which I don't want to turn people away. But if you're not willing to do the work, then don't do the release.

Right, Exactly. And one of the things that I like to do is go through it with the parent, make sure they know how to properly do the stretches, make sure they're comfortable with doing it, give them tips and tricks on how to do it if the baby's fussy or crying, you know, just reassure them. I give them my cell phone number. I let them contact me at all hours. You know, sometimes you just need that support person and I didn't have it, you know. Yeah. So that's kind of, you know, my way of giving it back.

Yeah. Well, and I think that the other thing that you touched on earlier too, which is a big theme here on the podcast, is collaboration. Because I do think at the end of the day that these dentists or release providers, whether it's an oral surgeon or whoever, I don't think they're releasing to cause harm. I truly do not.

No.

But also, yeah, but if, like, your ego is so big that you won't have a conversation with me about collaborating on patient care and creating a protocol for us to work together because you're too busy or you feel more important or you've, you've been doing this much longer than me or whatever you it is because I've heard it all. You know, unfortunately, we can't just say, well, I don't want to work with you because sometimes that may be the only release provider in the area. Or it's one of two or three. Right. So it kind of becomes tricky to be like, oh, well, well, we just won't refer there. Well, okay, what if a patient ends up going there anyways? Like, we have no control over that. So it's, you know, while you're not going to change a provider, at the end of the day, I'm like, look like I want to refer to you, but in order for us to do that and have this collaborative relationship, like, can you give me 20 minutes of your time so that we can sit down and like, cash out? What I, you know, basically a plan and a system, if you will, doesn't have to take long because I, you know, I've had some of these providers on here who have these, these systems and they're beautiful. And it, you don't have to reinvent the wheel. They already exist out there. Like, go listen to an episode of, you know, with some of my release providers and they go, they detail like, like, what's required, step one, step two, step three, before they'll ever go for a release. So anyhow.

Well, yeah, I definitely admire those who collaborate because ultimately you're doing what's best for the patient, not for your practice. I feel like some of the release providers feel like they're doing their patients a favor by not having them come in for a second visit to have it done after their consultation. They'll just do it then. Or maybe that they are busy and they don't want to have to block out time again to see the patient later to do it. And I understand that, I guess to an extent. But like you're saying if, if you don't have the time to carve out for me because you're too busy like that, that really is kind of not the way I want to be. Anyway, I'm actually, I just discovered through your Feed the Pizza long group that wanna. There's another OT yay in Westona across the river that that is has the TOTS training And is doing some of this too. And I'm actually meeting with her next Friday. So like, I'm not above, you know, you know, collaborating with even a colleague to help get this done. I mean, it's all about the patient at the end of the day, not about me or my practice or anything like that. You know, I just want to be able to approach the providers in our area that aren't aware maybe, or aren't willing to listen. And maybe if we do that in a united front, they might. Yeah, yeah.

I mean, I think that whole collaboration over competition thing that you're, you know, speaking to here is so powerful because, like, why did we even get into these professions in the first place? To work with patients, to help patients. Maybe we can't. We got into this with a different specialty or subspecialty under our licensure in mind, and we've changed course, you know, fine, whatever. At the end of the day, we all got into this because we wanted to work with humans and help humans, whether they're pediatrics or adults.

Right.

And so I think so many of us, like, and I do truly believe that's true of individuals who go into medicine, period. Right. They want to work with people and they want to help people. And I think unfortunately, you know, at least in America, the way that our healthcare system operates, it's just moved so many of us. Not, not me and you necessarily, but like, you know, I've worked in the schools, I haven't worked in a, in a hospital or an insurance based private practice. I've only been in, yeah, I've only been in private pay, private practices like one prior to mine. But I see from all the private practice owners that I coach that have moved out of other facilities or that, you know, own a facility and they do take insurance, I see what happens and I see, not that this is happening in their practices, but I see how hard they fight, you know, reimbursement and they fight to get, they advocate for what they're doing because reimbursement, solo, it impacts who you can pay what to, how much they can, you know, invest in themselves to even learn a specialty area and how much you can invest in your employees, you know, and the hospital truly are the ones that have the upper hand and can bill whatever they want for whatever they want, which is like, okay, fine, but then allow everybody else to do the same. You know, it shouldn't matter what, where you're located and where you're providing these services because again, at the end of the day, I Think it's just. It drives the way therapy. It changes how therapy's done.

And I know that view their profession as well, because. Okay, for example, how much is school nowadays?

Like university, college.

Yeah, like going to occupational therapy school. Okay, we're moving to the doctorate. All right. Why? So somebody else can make more money. What is that going to do us any good for? We can't write scripts, we can't diagnose. We'll never be able to. Why do we need a doctorate? It's to fill somebody else's pocketbook. But in turn, what you're doing is you're going to start an escalation of people not going to. Or a de. Escalation, I guess. You said people going to OT school because you come out with all this debt, but yet we cap out at a certain salary because our reimbursement rates aren't good. Right. And then we have job dissatisfaction. You have this low salary. How are you going to better yourself? How is our. How are our ots going to better themselves when they don't have enough money to spend on a specialized ceu? Where does that money come from? You know, so I see a lot of therapists getting stuck in a rut. They'll go on occupationaltherapyce.com for a hundred dollars a year and get their 15 CEUs they need and then stop. I mean, I'm not trying to brag on myself I've done this so that I could help my patients this year, but I probably won't fix continue doing this many CEUs this year, but I've done like over 60 this year alone. Yeah, And I'm just, like, just now. I mean, there's been a lot of discussion in some of these occupational therapy groups online, too. I'm just discouraged about joining the profession. I've got all this debt. You know, I make $60,000 a year. I'm like, like, how do you survive? How does our profession survive? I feel like we're very under. Under, underappreciated, and then you're going to change to a DOT and make it even harder, you know, and so now I feel like in the coming years, there potentially could be a shortage of us, and then we're going to be again, overworked, underpaid. You know, I'm just. I'm trying to think of ways to advocate for our profession, whether it's reimbursement rates. You know, Medicare in Louisiana is probably one of the lowest in the country. You know, I'm just speaking out loud here. But what do we do? Where do we go? Right, right, right.

No, I mean, at the end of the day, it all comes down to money, right? So it's whoever is running the show up there and making the determination of how much gets reimbursed based on the location. Not the code, not the amount of minutes, but the location. Location in which you're providing the same type of therapy. And like, look, I understand that it might take more money to run a hospital than it might to run a smaller private practice, but that's irrelevant because they all have individual groups within. So when people come at you with like all this, like. But you got to consider this and you got to consider that, fine, well then have some kind of a skill where it makes sense, because it doesn't make any sense right now. And you're basically pricing people out of being able to take insurance. We can't accept insurance if we can't keep our doors open and put food on the table for our families. Which is one of the reasons why my practice, practice has always been private pay. But we work, we try to help our patients, we give them super bills and we will try to advocate for them to get like a gap exception, which means that they'll get paid at the in network level, but they have to front the money to us and then submit on their own to get reimbursed by their insurance at that in network level. Then there's some times where actually they're out of network benefits, reimburse them higher than if they went in network, which is completely opposite because it used to never be like that. But it's. I've seen that, I can't tell you how many times in the past eight, nine years of having a practice. So, you know, I think also people just don't know how to play the insurance game. Patients. When I say people talking patients and we give them guides, we're like, call your insurance and ask them all these questions. They're going to tell you that like none of this is guaranteed. And that's true. But do your research, like know what you do have available. And then especially in your area, if there is not another person who has the specialty that you have, your patients, you know, whether you're in network around a network should be getting reimbursed at the highest in network level allowed. Because, you know, so I share that in case someone else is listening where they're like this, because I know the insurance thing is like such a big conversation. And I'm. This is as far as I go in that Conversation. I don't have a lot of, I've never been in network, but I do think that we, at the end of the day, like I advocate for my patients in the way that I'm able to and in the way that I know. And if I can get them reimbursement or at least help them, I should say help them, you know, get themselves reimbursement because they're paying for that insurance plan or they have some kind of an employer sponsored insurance plan or what ever then you know, we will do that. But it's still, you know, it's still, it's not a lot compared to other, other professions like you were sharing. I think OT and speech are very similar and having some of the lowest reimbursement rates unfortunately.

So yeah, that's, yeah. Given the importance of our role. It's just like, I mean you need.

To be able to speak and breathe and eat. Yeah. I mean what's, what's the number one thing you need in life? Airway. You need your airway, you need to be able to breathe or you know, and then the second thing after that is eating. So the fact that like the, the professionals who like obviously there's respiratory therapists and others who deal with the airway but the fact that like these are two big things that like people come to us for and that it makes, it makes no sense. Like make it no sense. Yeah.

I don't know, I might have to get like a little rally going.

There you go. I love it.

Yeah. My area is rural. I can never say that word right. You know what I'm trying to say?

Rural. I know. And.

A high percentage is Medicaid too. So, you know, I'm here to serve everybody, not just the select few, you know. But yeah, reimbursement. And then they'll, then they can come back and take it back at any time too. That's what's so crazy.

I, which makes absolutely no sense to me. Absolutely no sense for like absolutely no reason.

Oh wait, give me all that money back. Because you didn't put the right time in.

And you're like, but I did. And they're like, but you didn't.

We're like, it looks like you treated that patient at 3:00am really, really. Like, I'm serious.

No, I, I haven't heard about like that. Which it doesn't surprise me. Unfortunately. I've heard of, of them coming back and asking for money back for like overpayments which, okay, fine, I get that. But also it's so hard To I think for people to track, like you're usually not getting your reimbursement, usually fighting for it to even get paid as a practitioner who's providing insurance based services. So the fact that like you get a check and then you have to like go cross check your books to make sure that they sent you the right amount of money or that whatever it's, I've heard so many interesting stories where you know, and then other times where they've just said, nope, give us the money back the patient xyz. And you're like, that has no bearing on my practice. Like go talk to the patient or go talk to those other providers. Like they used my services first and you know, it was order of how it was billed by which practice. And it's just so convoluted and I don't think people realize how deep rooted the issues are again unfortunately. But so do you take, do you take insurance in your private practice or are you private pay? What does that look like for you?

A little both. So I'm thinking I had four patients scheduled today through your private pay and then I'll do the super bill thing. But after talking to you, I'm thinking about going ahead and reneging on some of these contracts and just do a cash pay all together.

You know, I, it's, it's hard, right, because like you said, you want to be able to serve your community and I, you know, I don't know, I think again, like maybe it's worth a try and you see how it goes and you can always back out. Some of them, I have heard of some insurances reimbursing at higher levels and being easier than others. And then I've heard of others just being complete nightmares. So, you know, I, but I, it's, it's all hearsay because I've never been in network. I've only been on the, out of now, you know, out of network side of things. So don't, don't, don't do anything based on what I shared because it's all hearsay.

But that sounds, oh yes.

So where can everybody find you if they're like, oh my gosh, I live close to you. Like, where's your practice? How do they get in touch with you?

Well, I just started Prosper Therapy and Feeding Solutions and I'm off North 19th street in Munro, Louisiana. I have a website, Prosper Therapy LA.com. but I have not let it go live yet. Still kind of working on things. Things have been, like I said, a little wild for me. I'm still at my previous job too, and I'll be back and forth for a little while. So, yeah, I'm excited. I'm ready to. I'm really ready to start collaborating with other people because as I tell my patients, you know, as all physicians are not equal, all OTS are not equal, all SLPs are not equal. You know, we all have individualized training. Some may have more than others. You know, I do this, you know, I can. Can I do all the other things in pediatrics? Absolutely. I've done it for the last six, seven years. So, I mean, I'm not above just, you know, treating general pediatrics either. It's just that I feel like there's so many out there that need the lactation and heating services at this point.

Yeah, I love this. I'm excited for you. It's obviously so needed in your community and so I love that you, you took the leap and you're doing this and so you know, these episodes live on. So even though at the time of recording the website is not live, it will be in the show notes so that everybody can find you in the future once it does go live, you know, in the near future for you. And yeah, congratulations. It's so exciting.

Yeah.

Thank you so much for joining me today.

I've enjoyed talking to you. Thank you for having me on.

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