A Non-Traditional Clinical Experience in Costa Rica Are you creative? Can you fashion a treatment tool when you don’t have access to the technology that we all take for granted? Are you interested in an intimate understanding of another culture? Do you want to become part of a highly trained professional team? Would you like to see ... World Beat
World Beat  |   May 01, 2002
A Non-Traditional Clinical Experience in Costa Rica
Author Notes
  • Carolyn Wiles Higdon, is an assistant professor at The University of Mississippi and the CEO of Dr. Carolyn W. Watkins, P.C. Higdon has directed rehabilitation delegations in Russia, China, Hong Kong, and eastern Europe in addition to her participation in delegations in Costa Rica, Mexico, and Canada.
    Carolyn Wiles Higdon, is an assistant professor at The University of Mississippi and the CEO of Dr. Carolyn W. Watkins, P.C. Higdon has directed rehabilitation delegations in Russia, China, Hong Kong, and eastern Europe in addition to her participation in delegations in Costa Rica, Mexico, and Canada.×
Article Information
Augmentative & Alternative Communication / Professional Issues & Training / International & Global / World Beat
World Beat   |   May 01, 2002
A Non-Traditional Clinical Experience in Costa Rica
The ASHA Leader, May 2002, Vol. 7, 4-16. doi:10.1044/leader.WB.07092002.4
The ASHA Leader, May 2002, Vol. 7, 4-16. doi:10.1044/leader.WB.07092002.4
Are you creative? Can you fashion a treatment tool when you don’t have access to the technology that we all take for granted? Are you interested in an intimate understanding of another culture? Do you want to become part of a highly trained professional team? Would you like to see the world?
Here’s a way to make all of this happen.
For the past five years, the Costa Rica Medical and Educational Rehabilitation delegation sponsored by the Partners in Mission (United Methodist Church) has formed transdisciplinary teams that include speech-language pathologists, audiologists, rehabilitation technologists, dentists, nurses, physician assistants, teachers, occupational therapists, and physical therapists. This particular group was organized through the Texas Conference of the United Methodist Church, but most denominations have some type of short-term medical missions. In 2000, this team included a speech-language pathology graduate student, Kimberly Shrader, from Our Lady of the Lake University in San Antonio, TX, in the international practicum experience.
Shrader was selected based on her clinical skills, maturity, and interest in international practicums. “The experience offered me an opportunity to understand communication issues of the Hispanic culture firsthand, to understand the transdisciplinary model in educational and medical rehabilitation, and,” she adds, “especially to increase my knowledge of the use of assistive technology in another culture.” This international practicum opportunity allowed Shrader to travel with a multidisciplinary group of professionals to another country and to gain clinical experience while under the supervision of an ASHA-certified SLP.
All in a Day’s Work
Upon arrival in Costa Rica, we journeyed by a small van to Alajuela, Costa Rica, where we lived during our time in the country. A typical day started with an early breakfast and a 45-minute bus ride to the town of Santa Ana. Our destination was a school (hogar) in Santa Ana that used to be owned by the Catholic Church and is now under the direction of the Minister of Education. Part of this school is a rehabilitation center—Escuela Hogar de Rehabilitación Santa Ana—that was the primary site where we worked for the next week, although we also visited smaller facilities and homes.
Upon arrival at the work site, we divided into teams and located adequate work area in the rehabilitation center to see children and young adults. The SLPs (Gil Hanke, our delegation leader, and Deborah Bankston from Nacogdoches, TX; Kathy McChesney, Macon, GA; Shrader; and myself) divided into evaluation and therapy teams with the other delegation members.
Shrader was assigned to different groups, depending on the experience to be gained with particular assessments or treatments. We worked approximately six days, from 8 a.m. until 5 p.m., evaluating and recommending treatment and educational plans for all individuals referred by teachers, physicians, or parents. Evaluations were completed by audiologists, SLPs, and other medical rehabilitation professionals in a team setting. We also conducted parent training, informal staffings, and periodically, formal staffings with medical and educational personnel from the surrounding communities. We offered five inservice trainings on specific topics such as autism, sensory motor issues, dysphagia, hearing screening, and dental care.
Every afternoon at about 4 p.m., when the heat became almost unbearable, the skies clouded and rain came, cooling the building and grounds (there is no air conditioning). By the time the delegation arrived back at the Methodist Center in Alajuela, dinner was served. We spent the evening debriefing on the day’s patients, and planning materials and schedules for the next day.
During the six-day period, over 90 individuals received comprehensive speech, language, and hearing evaluations. The types of clients who participated in the evaluations ranged from those with developmental disabilities to individuals with complex neurological, cognitive, sensory, and orthopedic disabilities. We had to address issues complicated by lack of services and poor medical care in some regions of the country—for example, determining the type of testing possible for a young child recently left at the church orphanage by his parents. The couple had walked two days through the mountains from another country ravaged by bandits and war to take their child to safety at the orphanage so that they could get him services and help.
We assessed and counseled parents of a child with a brain tumor who, through the interpreter, wanted to know when their daughter would talk and how they could receive adequate medical care to save her. We developed an augmentative and alternative communication (AAC) system for an individual with no arms or legs, who understood a few words in Spanish, had a limited caregiver support system, and remained in bed for the majority of every 24 hours. We knew there was minimal funding available to follow up on recommendations.
One of our home visits was to the home of Fabiana, 16, who had suffered a traumatic brain injury from a car accident several years earlier. Although Fabiana attended sixth grade, she was performing at a second-grade academic level. Her evaluation determined that she had cognitive communication difficulties, as well as oral and verbal apraxia. She could produce limited written sentences, demonstrating the same difficulties in both English and Spanish. She lived with a supportive family, although the home had limited modifications, preventing her from increasing her level of independence.
Our team had evaluated Fabiana the previous year, recommended and completed seating and positioning modifications, and had left a Delta Talker (AAC system) from Prentke Romich Company (USA) with her. Fabiana’s teacher and family had been trained in the programming and use of the device. Upon the team’s return, Fabiana demonstrated the use of the system by communicating in short sentences and phrases through the AAC device.
Our experience with Fabiana illustrates the benefit of returning to the same location, where both local and visiting team members are familiar to the clients. This allows consistency and carry-over through the year. During the intervening time, funding had been located through a private foundation resource, and the team was planning to purchase the AAC device for Fabiana.
Minor, a 43-year-old man, had lived at the facility for his whole life. He was born without arms and legs, and because of his weight, the care staff limited his time out of bed to being propped on a stretcher. Although nonverbal, Minor was able to eye gaze to select items or to answer yes/no questions. A series of medical issues—including kidney difficulties, bowel and bladder difficulties, and ear infections—complicated Minor’s opportunity for independence and for communication.
The local team wanted seating and positioning and augmentative communication for him. We were able to modify seating to allow Minor to be shifted into other tentative seating positions, began to educate the care staff about the need for him to be out of bed and seated, and initiated low-technology AAC options using eye gaze for functional communication with care staff.
Paola, 9, who had cerebral palsy and limited language, was seen both at the rehabilitation facility and in her home. In the year that had passed since the team was last in Santa Ana, Paola’s mother had a stroke, and her father was the chief caregiver for both Paola and her mother. Paola used a pediatric wheelchair, had good receptive language, severe dysarthria, learning difficulties, and was computer literate. She had been attending the local public school, was bilingual, and was receiving occupational therapy at the local hospital.
The team looked at ways to improve Paola’s access to the computer keyboard and completed a language/literacy evaluation. Paola had made good progress over the four years that the team had been working together. However, the most immediate concern was the support and care required for both Paola and her mother. The team worked with school and community officials to develop additional support systems, as well as with tutors and teachers, to keep Paola progressing in her program.
Cristian, 20, had cerebral palsy and blindness in one eye. He had lived with his mother in an abusive situation for many years until he was placed at the center for respite. Cristian came to live permanently at the center, in apartments built for supported living. Although Cristian was limited in his academic abilities and was nonverbal, his receptive language was excellent.
The team started with low-technology options of head pointers and mouth sticks to access a Dynavox and an AlphaTalker. Upon the team’s return in years two, three, and four, Cristian showed an increase in complexity of his communication abilities. The local team was in the process of locating funding to purchase Cristian an AAC system, as well as to modify his wheelchair to mount the device and to provide training for caregivers, and vocational and teaching staff. At the close of our last visit, Cristian was beginning vocational training and learning to live more independently in his apartment, as well as to direct his care via his AAC device.
Prerequisites for Success
During the delegation visit, swallow studies were conducted, nutritional programs begun, and parents were taught how to communicate with their children through an AAC system for the first time. Ears were cleaned, hearing was tested, therapy programs were written for use in the classrooms, materials were shipped or brought from the United States to be shared with the teachers, wheelchairs were modified or new chairs were provided, and walkers and other durable medical equipment were customized for individuals who needed improved mobility.
What does our student, Kimberly Shrader, gain that may not be available in her home university or clinical placement? The international practicum opportunity allows students to participate in the communities, to observe the cultural framework that guides and binds life practices, and to understand the cultural practices that enhance this relationship. Cultural sensitivity is a prerequisite to participating in this type of delegation, and cross-cultural competence is the goal for the student during the experience.
Shrader feels that, personally, she has gained much more. “This was the best way for me to face the reality of what our field is all about,” she says. “You have to go in with your whole heart and mind. I had always just read about the interdisciplinary approach to treatment, but this was real. We were teaching children to be as functional as possible.”
The student should be prepared for possible culture shock, the result of a series of disorienting encounters that occur when an individual’s basic values, beliefs, and patterns of behavior are challenged by a different set of values, beliefs, patterns, and behaviors. In an attempt to minimize the initial challenges, in pre-trip meetings we discuss language barriers, system barriers, differing perceptions of professional roles, family priorities and beliefs, and the use of interpreters. There are competencies and skills as well as maturity issues that each graduate student should exhibit.
Students who accept short-term international practicum placements must hit the ground running and adapt to the challenges immediately. Perhaps the most exciting aspect for the student in this practicum experience is the opportunity to observe and participate on a professional team at its best, creatively developing and manufacturing tools to meet the needs of the patients when our standard technology, instrumentation, and materials are not available.
This delegation found Shrader’s inquisitiveness and high energy to be very rewarding. On her side, the experience, she says, “changed my life—but in the best way. It convinced me that speech-language pathology is really what I want to do.” And—a brief footnote—she is indeed doing it: Shrader has received her master’s degree and her CCCs and is currently one of only two SLPs at Shannon Medical Center in San Angelo, TX.
Certainly, Costa Rica is not the only opportunity for such a practicum. Delegations have also gone to Russia, China, Hong Kong, and eastern Europe, with student practicum opportunities in many of the delegations. Over the past 15 years, I have seen effective use of both group and individual opportunities for students in the international practicum arena.

What to Consider When Selecting an International Practicum Placement

  1. Determine your key objective(s). Be able to define objective(s) with rationale and purposes.

  2. List the questions that you hope to answer with an international externship. Research the country that you are considering.

  3. Determine what it means to be culturally sensitive, understanding that, at the most basic level, cultural differences as well as similarities exist.

  4. Understand and demonstrate trust, knowledge, and interest in the cross-cultural skills that rehabilitation professionals need to consider when working in different delivery systems.

  5. Understand and respect familiar protocols and conceptions of what is acceptable and desirable.

  6. Understand both freedoms and constraints placed on people by their cultural norms and values.

  7. Understand family commitments and hierarchy, the status of clients and family groups, and the client’s need to consult with significant others.

  8. Understand inter/transdisciplinary teams (nursing, physical therapy, occupational therapy, speech-language treatment, volunteers, audiology, teachers, vendors) as they exist in the country or culture that you are visiting.

  9. Understand how to train/work with other disciplines in the particular country that you are considering for an international externship.

  10. What type of speech-language pathology and audiology services exist in the country you are considering?

  11. Are there materials, equipment, or resources that will be useful for you to take or to ship?

  12. Plan to ship or bring specialized technology such as AAC systems, hearing evaluation equipment, computers, and software, as well as treatment materials, professional journals, and literature.

  13. Search for funding resources to support the student’s expenses in the international practicum site. Resources are available through grants, foundations, loans, and private corporations, as well as the possibility of using student loans.

  14. It is professional courtesy for the student to send a letter of appreciation following completion of the practicum. These letters should be copied to all parties who have been involved in the planning, permission, and completion of the practicum.

  15. Plan to have fun and to enjoy the amazing opportunity to learn about yourself and to gain knowledge from the many wonderful professionals in the world.

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May 2002
Volume 7, Issue 9