Way to Grow What do you do when you have an explosion of undergrads … a huge market demand … and limited training slots with maxed-out trainers? You don’t panic. You get to work. Features
Features  |   January 01, 2015
Way to Grow
Author Notes
  • Carol Polovoy is managing editor of The ASHA Leader. cpolovoy@asha.org
    Carol Polovoy is managing editor of The ASHA Leader. cpolovoy@asha.org×
Article Information
Professional Issues & Training / Features
Features   |   January 01, 2015
Way to Grow
The ASHA Leader, January 2015, Vol. 20, 40-46. doi:10.1044/leader.FTR2.20012015.40
The ASHA Leader, January 2015, Vol. 20, 40-46. doi:10.1044/leader.FTR2.20012015.40
There’s a seat in the stadium for every ticket-holder, but on every game day hundreds of fans line up at the gate. As gate employees scan tickets and search bags, the lines eventually clear, and every fan navigates through the bottleneck.
Not all bottlenecks clear, however—even when there is ample room on the other side. That’s the case in communication sciences and disorders training: There are plenty of applicants for graduate school, and plenty of jobs for speech-language pathologists and audiologists (see below). But graduate programs routinely reject more than three-quarters of speech-language pathology applications and more than two-thirds of audiology applicants.
Why, then, don’t graduate programs accept more students?
Simply put, accepting more students means finding more clinical placement opportunities for student clinicians and more licensed, certified SLPs to supervise them, so that all students meet clinical and competency requirements for certification. And graduate programs don’t have the staff to make that happen.
The clinical bottleneck frustrates the work settings that can’t find qualified SLPs to fill job vacancies. It frustrates college graduates, especially those with undergraduate CSD degrees, who can’t get into CSD graduate programs. It frustrates training program faculty who scramble to expand opportunities for students to gain clinical hours.
There is no simple way to increase capacity. But some programs have pioneered new ways to provide students with clinical experiences: new client streams, simulated patients and community-based externships. With some creativity, other programs can look to adapt these alternatives to help ease the bottleneck.
Move into the community
Sometimes the constraints on offering clinical experiences are purely a matter of space: There’s just no physical room for an on-campus speech and hearing clinic, the place where first-year graduate students most often get their clinical feet wet. With no on-site clinic, training programs turn to facilities in the surrounding community to provide first-year opportunities.
The result takes careful and intricate administrative planning, but the benefits make the effort worthwhile: The program can adapt with the size of its student population, and it produces speech-language pathology graduates with a richer experience base than they may have received in a campus clinic.
That’s the experience at the University of Pittsburgh, where the on-campus clinic closed in 1997 after the Communication Sciences and Disorders department, previously housed in the College of Arts and Sciences, moved to the School of Health and Rehabilitation Sciences.
The system works, according to Cheryl Messick, director of clinical education, because of the university’s urban setting. She places first-year students in local school systems, private practices, post-acute facilities and hospitals—including five major hospitals within walking distance, where students are exposed to patients they would not ordinarily see in a typical university clinic.
Some of the clinical instructors hold dual appointments in the hospitals and the CSD department; supervisors in other settings are under contract to have one or two students each term.
“If I have more students, then I add more supervisors from the community,” Messick explains. She cites two consecutive years in which enrollment was higher than anticipated. It took a bit of scrambling, but she located additional community spots.
The program requires Messick to develop and maintain solid relationships with the facilities and community supervisors. “We train everyone that’s going to be a clinical instructor,” she said, and checks in with them often. The CSD department also offers free continuing education programs, either at the off-campus placements or at the university.
“We have to make it so that it’s value-added, not just a burden, for supervisors to have students,” she says.
And when dramatic changes occur—for example, hospital administrators change or hospitals are taken over by larger institutions—she reaches out to new department heads to ensure the system’s continuity.
The placements are smaller and more intensive, with more teaching time and less patient contact time, than second-year placements.
Messick also emphasizes to students the big-picture difference between an on-campus clinic compared to the community-based settings. “In a university clinic, clients know that they are going to receive services from supervised students,” she explains. “But our students know that some of the time they’re going to be learning by watching, not learning by doing.”
Messick believes that her students end up with a deep experience base that comes from early exposure to so many settings and patients, which university clinics can’t provide. “Our students are well-received nationally, because when they interview for a job, they’ve been in five or six different types of settings during the program,” she says. “They have been in early intervention, special education, acute care, skilled nursing facilities. Yes, some of those experiences were only one day a week—but at least they understand what that setting is like. And people looking to hire are amazed because our graduates have such a rich range of experiences.”
Add new client streams
If you’re a student in a training program specifically designed to prepare SLPs for medical settings, you don’t necessarily want to spend a lot of your clinical hours working with young children on articulation errors. But working with adults who want to reduce their accents uses many of the same principles of assessment and training, and opens up a whole new patient stream for first-year students.
The University of Washington’s Pronunciation Improvement Program met a dual need, according to Amber Franklin, who coordinated PIP for two years: a number of university staff wanted to improve their English skills, and the speech-pathology students had the opportunity to work with adult clients.
“What was nice about the program—and I think this is something we as a profession can really tap into more—is that even though there’s a clear distinction between clients who have disorders and clients who have differences, a lot of the principles of assessment and training still apply,” explains Franklin, now an assistant professor at Miami University in Oxford, Ohio.
“People who seek accent modification have a speech difference, not a disorder. But the students working with them still had to learn how to do an interview, they still had to get background information on the client, it was still important for them to understand how to find valid and reliable ways to measure performance at baseline.”
In short, Franklin says, the students learned how to administer probe data, how to identify ecologically valid outcome measures for this client population, and how to address speech-sound errors at varying levels of linguistic complexity. “These are all things that you think about when you’re working with children,” she explains. “But you’re also expanding your clinical repertoire a little bit more than you night with some pediatric articulation clients, because you also address suprasegmentals, working on intonation and stress patterns and contour.”
The university paid for its staff members who wanted to receive services. It was a win/win for the university and for the speech-language pathology program, Franklin says, which had recently expanded in size to accommodate a new medical SLP program and needed additional clinical opportunities for first-year students.
Even after university funding dried up, clients continued to pay for services out of pocket. “They were getting quality services from students supervised by ASHA-certified SLPs, and the clients saw the value in that,” she explains.
This type of clinic—which could definitely help training programs expand capacity—could work at any university with a large international student and faculty population, Franklin says. “The clinic doesn’t stigmatize accents,” she emphasizes. “In fact, it’s about enhancing intelligibility while still celebrating the linguistic diversity that exists around us. If someone has a hard time being understood, it doesn’t matter that it’s because of their accent—they just want to be understood.”
CSD departments would also need to have a faculty member who has the expertise to handle accent modification, she says. “But I do think that anyone who has some expertise working with articulation and phonological disorders can apply those skills to a group that has differences.”
At Miami University, two clinics outside of the Department of Speech Pathology and Audiology offer opportunities for first-year speech-language pathology graduate students to gain clinical hours.
The first is the Miami University Concussion Management Program, established in 1999 to monitor university athletes. The program’s director is Kelly Knollman-Porter, a clinical professor of speech-language pathology. Knollman-Porter, who coordinates speech-language pathology externships, supervises the first-year students as they conduct baseline neurocognitive testing on student athletes—about 200 per year.
“Often when our students begin their first externship experiences, they find the implementation of diagnostic protocols to be challenging,” Knollman-Porter explains. “In the concussion management program, students are given the opportunity to complete baseline neurocognitive testing on healthy, uninjured adults before they must use these similar techniques with an individual with neurogenic communication impairments. It’s a great method to help the students learn foundational principles while still obtaining their much-needed diagnostic hours. Then they can progress gradually to more complicated diagnoses.”
Knollman-Porter also trains three students more intensely to conduct testing on athletes suspected of sustaining a concussion.
Although designed for the safety and protection of student athletes, the clinic also benefits the speech-pathology program, which often has difficulty finding clinical placements for first-year graduate students. The students are more prepared for their medical placements, are more comfortable with the diagnostic process and have developed critical skills.
“They realize very quickly that if they rush through the diagnostic process, the goals they establish may be inappropriate and lead to treatments plans that are less effective,” Knollman-Porter says.
Miami has not used the concussion clinic to expand its capacity, but Knollman-Porter sees potential there. “It’s a challenge to find externship supervisors who have the time to give students the experiences we want them to have,” she concedes. “Better placements yield better clinicians. But it’s challenging. Clinicians in the schools and health care are continually facing greater productivity demands. Supervising a student becomes challenging because it adds one more duty to their already full schedule. However, in the long run, clinical supervision is always a win-win opportunity for both the student and the supervisor.”
A second Miami program—a voice assessment clinic for theater and voice majors—also uses first-year speech-language graduate students. “We have developed a close working relationship with the university’s music and theater departments, supporting care for their students’ voices,” says voice clinic director Renee Gottliebson, visiting assistant professor.
The program was initiated by the Speech and Hearing Department and the College of Creative Arts.
“Our first-year graduate students benefit by gaining clinical experience with this population of professional voice users,” Gottliebson explains. First-year graduate students help the supervising clinician collect voice history information, collect data, and write reports for approximately 25 new voice and theater majors each fall. The screenings include a voice history questionnaire, videostroboscopic examination and perceptual evaluation (all performed by a licensed, certified SLP).
“This is one of many ways to expand clinical opportunities,” Gottliebson says. “Additionally, our voice clinic offers services to transgender students on campus.” The voice clinic sought and received Safe Zone training through the university’s Office of Diversity Affairs to make sure clinic staffers were providing voice care to this population in a supportive atmosphere.
I’m not a patient, but I play one on TV ...
A first-year speech-language pathology graduate student faces a series of seven patients, all of whom have different types of aphasia. His assignment is to spend 15 minutes diagnosing each patient.
Down the hall, another student is meeting with a 79-year-old man with Alzheimer’s disease and his wife to discuss the man’s speech-language assessment and proposed treatment plan.
These clinician-patient encounters can be critical to the patient’s eventual ability to communicate and to face their own—or their loved one’s—impairment. Diagnosing a disorder, developing and carrying out treatment plans, and counseling patients are key components of a clinician’s skill set.
Students in the above scenarios, although they want to do the best for these patients, need not worry about harming them with incorrect information or less-than-refined interactions as they develop their skills. The students are working with “standardized” patients—people trained to portray patients with various communication disorders and their family members.
Richard Zraick, chair of the Department of Communication Sciences and Disorders at the University of Central Florida, believes strongly in using standardized patients—not just to build clinical capacity, but also to build students’ skills.
Zraick used standardized patients for about 15 years at the University of Arkansas for Medical Sciences—where he was on the faculty for 17 years before joining UCF in July 2014—to develop students’ professional communication skills, diagnostic ability and interprofessional collaboration competencies. His initial work, funded by a 1999 American Speech-Language-Hearing Foundation New Investigator Award, laid the groundwork for additional projects that spurred interest in the use of standardized patients in recent years.
“For example, if I wanted to have students see an interview with a mother of a teenager who had a head injury, I would create that scenario with that standardized family member,” Zraick explains. “The students would watch that interaction and provide feedback and commentary, and we would discuss the emotions and the words expressed by that mother. Similarly, we had students share the results of an evaluation with people portraying a patient with Alzheimer’s disease and a family member, so students would get the perspective of and counsel both the patient and family member.”
Zraick developed a complete video library of most acquired language disorders: right hemisphere damage, TBI, aphasia and Alzheimer’s disease. They are especially helpful, he says, when no real patients with particular disorders are available, and to demonstrate different severity levels of a disorder.
“So if we’re learning about anomia,” he explains, “I can train that standardized patient to have a mild form, a moderate form and a severe form, so the students can see across a spectrum of severities.”
However, the time spent working with standardized patients cannot be counted in a student’s clinical hours required for certification—a situation Zraick would like to see changed.
“My dream has been that someday, standardized patients can be used legitimately to get clock hours,” he says. “This practice is legitimate; the medical schools are using it, many other licensing boards are using it, from pharmacy to nursing to physical therapy. It would be great if speech-language pathology got on board.”
Counting standardized patients in clock hours could “absolutely” increase capacity in graduate training programs, Zraick believes, because many more students could participate in these clinical experiences. It would also be helpful to small programs that don’t have robust clinics and, therefore, don’t have a broad patient population, especially for low-incidence disorders.
The Vanderbilt University School of Medicine has made a major commitment to simulation training through its Center for Experiential Learning and Assessment. CELA is an integral part of audiology training at Vanderbilt, according to Anne Marie Tharpe, hearing and speech sciences chair in the Vanderbilt medical school and associate director of the Vanderbilt Bill Wilkerson Center. She is a strong proponent of the method, but does not advocate for simulated training to be included as clinical hours.
“We use it a lot throughout our training program, especially in pediatric audiology training,” Tharpe says, “where students can practice and refine their interpersonal relationships with client and parents. The student takes the case history from the simulated parent, obtains computerized test results, makes a decision about the hearing status of the child, and then consults with the parent about the findings and a treatment plan.”
Because the scenario is simulated, there is no supervisor to step in and correct student errors or techniques. “It forces students to take charge in a way we can’t allow them to in the clinic with actual clients,” Tharpe explains.
Students in audiology, deaf education and speech-language pathology also participate together in Individualized Family Service Plan and Individualized Education Program meetings with simulated parents, school principals and teachers. Other scenarios allow students to perform actual tests on simulated patients—vestibular examinations with adults, for example.
Tharpe believes, however, that even the best simulations cannot take the place of interactions with patients. “If a program can’t offer the clinical experiences required, then that’s a problem,” she says. “Simulation is not a solution, and I find it a little scary to move toward that model. I would not be comfortable going to doctoring professionals—an optometrist or physician, for example—knowing they received all their training on actors.”
But simulation can be used to enhance student preparation for “real” clinic, Tharpe says. “And there may be an opportunity for simulated scenarios to replace some observation hours on a limited basis.”
Graduate programs have a responsibility to run real clinics, she says, and expanded capacity will result when university clinics run on a business model: a year-round clinic that brings in a steady stream of patients that, in turn, brings in revenue that can be directed toward more faculty supervisors.
Sizing Up the Supply—and the Demand

The number of undergraduate communication sciences and disorders degrees granted over the last three academic years (2010–2011 to 2012–2013) has averaged just shy of 10,600. Compare that to the numbers of newly enrolled audiology clinical doctoral and speech-language pathology master’s students, which have averaged 742 and 7,811 respectively over this same three years. Audiology clinical doctorate entry-level programs indicate that they are operating at 95 percent capacity, and master’s speech-language pathology programs are at 99 percent capacity. Do the math and it’s easy to deduce that there are plenty of undergraduate CSD degree recipients who can’t pursue graduate CSD degrees.

At the other end of the spectrum, the U.S. Bureau of Labor Statistics projects “much faster than average growth” for the audiology profession between 2012 and 2022. Specifically, the bureau expects a 34 percent increase in job openings with 4,300 additional audiologists needed to fill them.

High growth also is projected for speech-language pathology. Projections anticipate “faster than average growth” through 2022, with a 19 percent increase in job openings to be filled by an additional 26,000 SLPs. Several factors contribute to these growth projections, including an aging population, more emphasis on prevention, and medical and technological advances—factors that likely will continue to keep audiology and speech-language pathology in the high-growth category.

Outpatient care centers and health practitioners’ offices are among the settings that show the greatest percent change for audiologists between 2012 and 2022 (59.7 percent and 54.6 percent, respectively). Speech-language pathologists will see the greatest growth in home health care services (58.4 percent increase), outpatient care centers (57.1 percent) and health practitioners’ offices (53.4 percent).

—Sarah Slater, ASHA director of surveys and analysis

Council of Academic Programs in Communication Sciences and Disorders and the American Speech-Language-Hearing Association (2014). CSD Education Survey National Aggregate Data Report: 2012-2013 academic year. Retrieved from www.asha.org and www.capcsd.org.
Council of Academic Programs in Communication Sciences and Disorders and the American Speech-Language-Hearing Association (2014). CSD Education Survey National Aggregate Data Report: 2012-2013 academic year. Retrieved from www.asha.org and www.capcsd.org.×
Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2014-15 Edition, Audiologists. Retrieved from http://www.bls.gov/ooh/healthcare/audiologists.htm.
Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2014-15 Edition, Audiologists. Retrieved from http://www.bls.gov/ooh/healthcare/audiologists.htm.×
Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2014-15 Edition, Speech-Language Pathologists. Retrieved from http://www.bls.gov/ooh/healthcare/speech-language-pathologists.htm.
Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2014-15 Edition, Speech-Language Pathologists. Retrieved from http://www.bls.gov/ooh/healthcare/speech-language-pathologists.htm.×
Bureau of Labor Statistics, U.S. Department of Labor, Employment by industry, occupation, and percent distribution, 2012 and projected 2022 for 29-1181 Audiologists. Retrieved from www.bls.gov/emp/ind-occ-matrix/occ_xls/occ_29-1181.xls.
Bureau of Labor Statistics, U.S. Department of Labor, Employment by industry, occupation, and percent distribution, 2012 and projected 2022 for 29-1181 Audiologists. Retrieved from www.bls.gov/emp/ind-occ-matrix/occ_xls/occ_29-1181.xls.×
Bureau of Labor Statistics, U.S. Department of Labor, Employment by industry, occupation, and percent distribution, 2012 and projected 2022 for 29-1127 Speech-language pathologists. Retrieved from www.bls.gov/emp/ind-occ-matrix/occ_xls/occ_29-1127.xls.
Bureau of Labor Statistics, U.S. Department of Labor, Employment by industry, occupation, and percent distribution, 2012 and projected 2022 for 29-1127 Speech-language pathologists. Retrieved from www.bls.gov/emp/ind-occ-matrix/occ_xls/occ_29-1127.xls.×
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January 2015
Volume 20, Issue 1