Scope of Practice vs. Clinical Competence: Are You Prepared to Treat?

Just because a patient falls within your scope of practice doesn't mean you're prepared to treat them. So what happens when your caseload outgrows your clinical training? Let's talk about it. Welcome to the Untethered Podcast. I am your host, Hallie Bulkin. 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, lips closed, teeth apart, breathe through your nose. Let's get started. I want to talk about something today that I think happens far more often in our professions than any of us are willing to admit. And that's being expected to treat patients we don't necessarily feel prepared to treat. I want you to think about your own caseload for a second. Like, have you ever received a referral, looked through the patient's history, and thought, okay, I know this technically falls within my scope of practice, but I'm not entirely sure what I'm supposed to do with this child? Maybe you've been an SLP for 15 years, you've worked with hundreds of children, and then a feeding referral comes across your desk. You know, that feeding and swallowing fall within our scope, but you haven't had extensive training in that area. Or maybe you've started noticing things with your speech patients that you were never taught to look for: mouth breathing, difficulty chewing, poor oral rest posture, sleep concerns. You're recognizing that there might be more going on, but you're not really sure how all those pieces fit together. And now you're trying to figure out like what to assess, what to treat, whether you should even be treating this patient at all, and who else might need to be involved in this case. Sound familiar? I think this is one of the biggest challenges we're facing in our professions right now. We have incredibly broad scopes of practice and we're working with patients whose needs can be incredibly complex, right? Yet the training and the clinical support available to us, they just don't always match the level of care that we are actually being expected to provide. And so I wanna be really clear here because I know some of you are gonna have strong feelings about this. I am not saying that we need to narrow our scopes of practice. I mean, you could niche down. I have. I'm not saying generalists are bad clinicians, and I'm certainly not saying that everyone needs to specialize in feeding or myo. What I'm saying is that having something within your scope of practice and having the competency to provide that service are 2 very different things. And I think that we need to get much more comfortable talking about that distinction. Just because it's in your scope doesn't mean you're ready to treat it. Okay, let's use speech pathology as an example. Our scope of practice is Enormous. We work with speech, language, cognition, voice fluency, feeding, swallowing, and so much more. We can work with newborns, older children, older adults, like literally every age in between. I love that about our profession. I think it's incredible how many different areas we have the opportunity to work in, but I think that also means something from an educational perspective. We're expecting graduate programs to introduce us to all these areas, prepare us for clinical practice, and help us build the foundational knowledge that we need to enter the profession. There's only so much you can learn in that period of time. Most of the grad school programs are about 2 and a half years, like you go 2 full years plus like a summer through in between. There's only so much you can learn, right? And I don't think graduate school was ever meant to be the end of our clinical education. It's the beginning. The challenge is what happens after we graduate because suddenly you're working in either a school or an outpatient clinic or a private practice or wherever you are and you're being assigned Patients based on your professional license and the services your employer provides. And sometimes those patients fall squarely within the area that you are ready to treat, right? You've been trained in that, you are ready to go. Other times you're encountering something you have very little experience with. And I remember when I was first getting into feeding and myo, how much I didn't know, despite thinking I knew much more than I did. And the more I learned, the more I realized there were things I didn't even know to look for. Before all this education, right? And that's a really interesting place to be as a clinician because you can be doing everything you were taught to do and still be missing information that could significantly change how you approach a patient. And that doesn't mean that your previous treatment was automatically wrong. It means your clinical reasoning was limited by the knowledge and experience that you had at that point of your career. And that's true for every single one of us. I certainly don't look at patients the same way I did when I graduated, right? But here's what concerns me, okay? I think we've created environments where clinicians are expected to take on increasingly complex patients without necessarily being given the time, the training, the mentorship, right, that they need to develop the skills. And then we wonder why these clinicians feel overwhelmed. Like, it's no wonder, right? So here's the thing, like the caseload problem, it isn't always about the number of patients. Sometimes it is, but it isn't always. Like when we talk about caseloads, I just feel like the conversation typically goes straight to volume. How many patients are you seeing? How many evaluations do you have? How many treatment sessions are scheduled every week? Because, you know, productivity, that's a thing. And those numbers matter, but I don't think the number of patients tells us nearly enough about the demands that are being placed on a clinician. You could have 2 speech pathologists seeing the same number of patients every week and their workloads could look completely different, right? One might have like a relatively consistent caseload of children with similar clinical needs. The other might be seeing children with complex medical histories, feeding and swallowing concerns, neurological diagnoses, multiple developmental challenges, right? And that second clinician may be coordinating with more physicians, reviewing medical records, trying to interpret instrumental swallowing assessments, collaborating with OT and PT, making ongoing decisions about whether the patient needs additional referrals or supports in other places, right? And all of that work is part of providing appropriate care. But, and not all that happens during that scheduled treatment session. In fact, most of that that I just listed does not. So when we simply look at how many patients someone is seeing, we're missing a huge part of the picture. And I think employers really need to hear this. I know it's not a popular conversation because that's not like the time that they're putting in. That doesn't make you money, right? But it's how you do best care. It's best practice. It's most ethical practice. But that's why I really think employers need to hear that, like, you can't assume too 2 clinicians with the same caseload have the same workload. You also can't assume that every clinician with the same professional credentials have the same competencies. And, you know, an SLP who has spent 20 years specializing in voice disorders may be incredibly skilled in that area. That doesn't mean that they're prepared to evaluate a complex infant with dysphagia, right? And the reverse is true too. So being an experienced feeding therapist doesn't automatically make somebody competent to treat every type of communication disorder. Right? Again, this is not a criticism of any of these types of clinicians. It's recognizing that expertise develops through education, supported clinical experience, and ongoing learning. And that brings me to something that I really want you to think about. What happens when we expect clinicians to treat everything under the sun simply because they're licensed to do so? Because I think that's where we start seeing some of the problems that eventually show up as burnout and frustration and lack of confidence. Not because the clinician doesn't care or they're not capable of becoming skilled in that area, but because we haven't necessarily given them what they need to get there. Okay. And so there's this gap between knowing what to do and knowing why. And I want to talk about that. Okay. So we're going to take this one step further because this is the next layer to the conversation. And it's something I see all the time in clinicians who come into my feeding and myofunctional therapy programs. They're often not brand new clinicians. I mean, we do get new clinicians too. And I love that, CFs, even some grad students. Some of them though have been practicing for 10, 15, or even 30 years. They've treated a lot of patients. They've taken a lot of continuing ed courses. They may already be treating children with feeding difficulties or oral motor concerns or myofunctional, you know, myofunctional concerns, OMDs. But they tell me that they don't always feel confident in their clinical decision-making. And when we start to dig into that, I often find they've learned what to do in certain situations without necessarily understanding Why they're doing it. So let me give you an example. Say you're working with a toddler who isn't chewing efficiently. Maybe somebody taught you in a particular like oral motor course that there's this particular oral motor exercise that you can use, and you've been using that exercise to work on chewing. But when you look at the child's actual chewing pattern, like, can you identify what's actually happening? Can you differentiate between a child who has not yet developed an age-appropriate chewing skill and one who's demonstrating an atypical pattern? Or maybe there's both things going on here because we're a little delayed and now we've got these compensations at play and this is not so difficult, right? Can you identify what the jaw is doing, whether the tongue is moving independently of the jaw and how the child is managing the bolus, right? And once you recognize what's happening, can you determine whether the primary limitation is related to motor coordination, sensory factors, structural considerations, or something completely different, right? Because those findings may lead you toward very different treatment decisions. And sometimes the most important next step isn't the exercise. It's actually maybe a referral or additional assessment or collaboration with another provider, right? And this is why I talk so much about clinical reasoning and becoming critical thinkers. You can collect all the exercises and protocols in the world, but if you don't understand what you're observing or why an intervention is appropriate, it's going to be really difficult to individualize treatment. And the more complex your patients become, the more important that clinical reasoning is too. I think that's also where like clinicians clinicians start to feel exhausted in a way that isn't necessarily related to the number of patients they're seeing. Okay? Because when you're constantly questioning yourself and your decisions because you just don't have a strong foundation in the area you're treating, or you just, you haven't had the proper mentorship, you don't really understand why you're doing what you're doing. You're just doing what you were taught to do, right? Every case requires a tremendous amount of mental energy if you're kind of doing those mental gymnastics, if you will, right? Questioning every decision. You're researching between sessions. You're asking colleagues what they would do. You're trying to figure out whether your treatment is appropriate. And maybe even why your patient's stuck, they're not progressing right now. Don't get me wrong, asking questions and collaborating are amazing things. We should be doing that. I still think experienced clinicians should be doing both as well. But there is a difference between consulting with a colleague about a genuinely complex case and feeling like you're starting from scratch every time you get a new referral. And I think that difference really, really matters. Okay. So I want to challenge something that I hear in our professions. There's this idea that when you specialize, you become so focused on one area that you lose sight of everything else. And I understand where that concern comes from. We absolutely have clinicians who become very focused on particular diagnoses or treatment approaches, and they start seeing that same problem in every patient. We have to be careful about that. You know, we've talked about this on the podcast before, especially when it comes to like tongue ties and myofunctional disorders. You know, if every feeding difficulty becomes a tongue tie or every speech sound disorder becomes a myofunctional problem, We're not practicing good clinical reasoning. We're just applying the same explanation to different patients. Okay. But I don't think that's what true expertise looks like. In my experience, the deeper I went into pediatric feeding and myofunctional therapy, the more I realized I needed to understand what was happening beyond those specific areas. So let's think about feeding for a moment. Okay. You cannot fully understand a child's feeding difficulties by looking at the tongue alone. You have to consider the child's developmental stage. skills, nutritional and medical status, sensory experiences, oral motor abilities, and the environment in which feeding is taking place. Okay. And depending on the patient, you may also need to investigate concerns involving like sleep, breathing, posture, movement, et cetera, right? There could be other things going on. That doesn't mean every child has a problem in every one of those systems. It means you need to recognize when something outside your primary area of treatment, your specialization, maybe influencing what you're seeing. And sometimes that can completely change your next step, right? So let's say a child comes to you because they're having trouble chewing. Okay. You evaluate, and maybe that's not the actual chief complaint, but you just recognize that when they walk in the door and they have a snack with you. You know, you evaluate their oral motor skills. You notice they're, they're, yes, they are having trouble chewing. They're just kind of mashing foods, only wanting purees, but they're also demonstrating persistent mouth breathing. Parent mentions maybe the child snores regularly and they seem tired even after a full night's sleep. And now, does that mean that you've identified the cause of chewing, you know, like why they're having trouble chewing? No, but you've identified additional concerns that warrant, you know, attention. They need attention too. So you might need to collaborate with the child's pediatrician or recommend an appropriate airway evaluation, you know, while you're continuing to address the feeding skills within your scope and competency. And that to me is integrated clinical care. Okay? It's not deciding that every symptom is connected or assuming that one hidden diagnosis explains everything. It's recognizing relevant findings, understanding that different systems may influence one another, and knowing when another professional needs to get involved, right? When you need to refer to somebody or bring someone else onto the team. So I actually think there's a really interesting relationship between specialization and integration. Because the deeper you specialize, the more you may realize how important it is to understand what exists beyond your specialty. And I think that's a really important and incredibly valuable shift actually, because becoming a specialist shouldn't mean becoming someone who only sees and diagnoses one thing, right? It should mean becoming someone who understands their area of expertise deeply enough to recognize where it intersects with other areas of care. So we really need to stop confusing confidence with competence as well. If you've been following me for any period of time, you know that I have promoted Feed the Peeds since 2020 when we launched it. And we've always talked about how, you know, so many people lack confidence and truly, you know, if you want to be confident, you need to get competent. So basically we teach competence so that you can become confident, right? Competence leads to confidence. You've probably heard me market it 500,000 times because I believe it. It's true. But there's another part of the conversation, right? Or this is another part of the conversation, right? That really is important to talk about. And they're not the same thing, right? Confidence and competence. I've met clinicians who are very confident in their abilities, but they have significant gaps in their clinical knowledge. And I've met clinicians who are extremely knowledgeable and skilled, but continue to question themselves because they recognize how complex clinical care can be. And I don't think confidence on its own is very, a very useful measure per se of whether someone's prepared to treat a particular patient. We actually need to look at what the clinician actually knows, what they can demonstrate, and whether they're able to make appropriate decisions, right, in patient care. And this is where continuing ed needs to go beyond simply exposing clinicians to more information. Taking a course is a great starting point, sure, but understanding a concept during a lecture or a course or whatever, and then applying that concept appropriately with a real patient, those are different levels of learning. You have to be able to look at a patient, interpret what you're seeing, determine what information you're missing, and develop a reasonable plan. That's a lot of work. That's not easy, especially with pediatric feeding, right? And then you, you need to then also evaluate whether your plan is working as you go through therapy. And if it's not working, can you figure out why? Can you recognize when your original clinical hypothesis may have been incomplete? Can you identify when it's appropriate to change your intervention or involve another provider? Right? That's what we should be building towards as clinicians. And I think mentorship can also be so valuable here because it creates opportunities to work through those decisions with someone who has more experience in whatever the, you know, particular area is that you need some guidance on, right? Some mentorship in. And it's not because you need someone to hand you the answers forever, because that's coaching. That's not mentorship. That's different. Mentorship is discussing cases, receiving feedback, and then being able to reflect on your decision-making With somebody else there. And that is what can help you develop the skills to reason through future cases more independently. Okay, I see that progression in clinicians all the time. They start out asking, what exercise should I use for this patient? And eventually their questions change, right? They're asking whether a particular finding is clinically significant and what might be contributing to a pattern and how do I prioritize this treatment. And that's just a completely different level. And it's the kind of thinking that I want more clinicians to have access to. Okay. Now I want to bring employers into this conversation because I think they all, or you, if you're listening as an employer, have a significant role to play. If you're a practice owner or clinical director even, I want you to look at the patients coming into your practice and the competencies of the clinicians who are being asked to treat them, right? Or that maybe you're just assigning to them, not just their credentials and how many years they've been practicing, like what have they actually been trained to do? And what courses have you put them into? And are those courses actually helping them become critical thinkers and apply clinically what they just learned? Or was it just information overload and they're still stuck? They're still questioning every move, right? What have they actually been trained to do? What types of patients do they have experience evaluating and treating? And where are the gaps? Because I think there's an opportunity to approach professional development much more strategically. Like, let's say you own a multidisciplinary pediatric practice and you're consistently receiving feeding referrals. Okay. Maybe your therapists are already seeing children with speech and developmental concerns, but families are being referred elsewhere for feeding because your team doesn't currently have the training needed to provide that service. Well, now you've got a decision to make, right? You could continue to refer those patients out, which might be entirely appropriate, or you could evaluate whether developing a pediatric feeding service makes sense for your practice. And community. Okay. And if it does, you need to think about what training your clinicians would require, how they would receive ongoing support, what resources the practice would need, and how you'd ensure services were being provided competently. Okay. And that's where investing in your clinicians becomes more than simply approving a continuing ed request. You're building clinical capabilities within your organization, right? You're creating opportunities for clinicians to develop meaningful expertise. While potentially improving access to services for the families you serve. But that development has to be intentional. Okay? You cannot expect someone to complete a course and suddenly be prepared to independently manage every type of patient within that specialty either. Competence develops over time, right? And it needs to be matched to the complexity of the patients that are being treated. And for those of you who are employees, I want you to think about this from the other direction. If there's an area of practice that you're interested in developing, especially one where you're seeing a need within your current setting, I would encourage you to have that conversation with your employer. And rather than, you know, simply saying like, I want to take this course, I want you to explain what you're seeing in your patient population and how additional training could strengthen the services that your organization provides to these patients, right? You can advocate for the education and the mentorship you need while also demonstrating how that professional development supports the larger goals of the practice. I think that's the really important conversation to be having, okay? Because we do need employers who invest in clinical growth and we need clinicians who are intent about developing their skills. So what does this all mean for you if you're listening and you're recognizing that there are areas of your caseload where you don't feel as prepared as you'd like? I don't think the answer is to panic or assume that you need to completely change your career. That's not it. I think the first thing you need to do is get really clear on what your actual gaps are, and I want you to distinguish between a patient who's challenging because their presentation's complex and a patient who's challenging because you don't yet have the knowledge or skills needed to provide the appropriate care. Right? Those are not the same situation. Maybe they are. There could be a patient that fits both, but those are typically not the same situation, okay? A complex patient might require like collaboration, additional info, consults, right? Even when you're highly experienced in that area. But a patient who like, who has needs that fall outside of your current competency, they may require additional, you know, like training, supervision, or referral to someone more appropriately prepared. So being able to recognize that, that difference is an important part of practicing responsibly. And then I want you to pay attention to the types of clinical problems that consistently interest you, because if you find yourself drawn to pediatric feeding or myofunctional therapy, or maybe another area entirely, that could be worth exploring more intentionally, right? You don't have to become an expert in everything, but you can choose areas where you want to develop a deeper foundation and begin building those skills. And lastly, I just, I want you to look at what support you have available. Do you have a mentor? Do you have colleagues you can collaborate with? Does your workplace make time for case discussions and professional development? Because I don't, I don't think we should expect clinicians to develop all these advanced skills in isolation, right? And that's a big part of why I've built the educational and mentorship programs that I have. I want clinicians to have opportunities to learn not only what to do, but how to think through what you're seeing, right? I want you all to recognize clinical patterns and understand when something requires additional investigation and make more informed decisions for the patients and the families that you're serving. And when I look at the bigger picture, I think this is how we begin addressing some of the gaps that we have in access to specialized care. Okay, we need more clinicians who are appropriately prepared to provide these services. We need organizations willing to invest in developing those clinicians. And we need to recognize that expanding access to care And maintaining the quality of that care have to happen together because simply getting more children into therapy isn't enough if we're not making sure they receive the care they actually need. All right. So I want to leave you with something to think about. The next time you look at your caseload, I want you to look beyond the number of patients you're seeing. I want you to think about the complexity of those patients, the clinical decisions you're being asked to make, and whether you have the knowledge The experience and the support to make those decisions appropriately. And if you identify an area where you need more training, I don't want you to see that as a reflection of your worth as a clinician. I want you to recognize it as information that should guide your professional development and your next steps. Okay? Because our scope of practice might be broad, but that doesn't mean we have to know how to treat every patient on day one. We do, however, have a responsibility to recognize the limits of our current competency And continue to develop the skills needed to provide appropriate care, right? And so the more intentionally we can approach that process, the more capable we become of recognizing when some there's something beyond the presenting concern that deserves our attention. Okay, so if pediatric feeding is one of those areas where you're like, I'm recognizing a gap in my training, well, I have a course for that, right? Feed the Peds. It was created to help clinicians build that foundational. Pediatric feeding and swallowing knowledge and clinical reasoning needed to begin developing competency in ped feeding assessment and treatment. But regardless of the area that you choose to develop, I hope this conversation changes the way that you think about your caseload, because I don't think the question should just be, how many patients do I see? How many patients can I see? Right? I think we need to be asking, am I appropriately prepared to provide the care these patients need? And if that answer is no, Well, what needs to change so that I can be? That's how we become better clinicians and ultimately how we provide better care for the children and families who depend on us. All right guys, that's it for today. Thanks so much for listening. I will talk to you guys next time. Quick disclaimer, all information, content, and material of this podcast are the opinions of the speakers and serves as the informational purposes only and not intended to serve as a substitute for the consultation, Diagnosis, and/or medical treatment of a qualified healthcare provider. Thanks for listening to this podcast. If you found value in this episode and want to hear more of these myotots, airway, and feeding-related episodes, be sure to leave a review on Apple Podcasts and share this episode on your social media platforms. You can access free resources and all I offer at halliebulkin.com or pop over to @halliebulkin on Instagram to get all the latest updates.