Is Speech-Language Pathology Stressful?

The caseload math. I have 74 kids on my caseload right now. District policy caps it at 55. But there's a shortage and nobody's hiring, so I got the overflow from two schools that don't have their own SLP. Seventy-four kids, pull-out model, 30-minute sessions. I'm supposed to see each kid at least twice a week. That's 148 sessions per week. I have about 40 slots. So some kids get seen once a week, and some of those sessions are 15 minutes instead of 30 because it's the only way I can physically get to everyone. I set my personal timer to beep every 15 minutes. When it goes off during a session, part of my brain starts calculating who I'm about to short-change next.

Then there's the paperwork. I write IEP present levels for every one of those 74 kids. I attend IEP meetings, eligibility evaluations, parent conferences. None of that counts as "seeing students," but it takes hours. I skip lunch three days a week to write present levels in Frontline, our IEP software. I eat a granola bar while I'm typing. I have a first grader named Jaylen with a severe phonological disorder. His mom, Mrs. Okafor, emails me asking how he's doing. I want to write her back something meaningful. I want to tell her that Jaylen is making progress on his cluster reduction and that the Boardmaker visuals are helping him self-correct. But I'm rushing between sessions, so I send her three sentences and feel guilty about it. My supervisor, Dr. Miriam Telford, keeps saying "we're working on it" when I bring up the caseload. She's been saying that for eight months. I believe she means it. I also believe nothing is going to change before the end of this school year, or probably the next one.

I went into this field because I wanted to help kids communicate. And I do. Jaylen is making progress. But 74 kids cannot all make the progress they deserve when one person is sprinting through a hallway with a rolling cart of articulation cards and a timer that beeps every 15 minutes. The stress isn't that the work is hard. The stress is that the work is good and I can't do enough of it.

The NPO recommendations. NPO means nothing by mouth. When I do a modified barium swallow study and I see penetration on the fluoroscopy screen, I'm the one who writes "NPO, recommend PEG tube evaluation" on the chart. The attending, Dr. Kwame Harris, signs off. The nurses carry it out. But I'm the one who walks into the family meeting and explains that their 89-year-old grandmother can no longer eat solid food because she's aspirating, which means food and liquid are entering her airway, which means she could develop aspiration pneumonia, which could kill her. And the family looks at me. Not at the doctor. At me. Because I'm the one with the images. I'm the one who did the study. I'm the one who saw what I saw.

There's a nurse on 3 West named Bonita who always asks me how the patients are doing after a swallow eval. She means well. But sometimes I finish a study and I know what I'm about to take away from someone, and I don't want to talk about it in the hallway. I want to sit with it for a minute. Last month I recommended NPO for a woman whose family had driven in from Akron with a homemade peach cobbler. They'd baked it that morning. I could smell it when I walked into the room. I did the MBSS, saw the aspiration, wrote the recommendation. The cobbler sat on the bedside table, untouched, when I left. I think about that cobbler.

I go home at night and eat dinner with my wife, Patricia. Some nights I can't finish. She doesn't ask why anymore. She used to, the first few years. Now she just puts the plate in the fridge and says she'll save it for later. I've been doing this for 22 years. The clinical skills get sharper. The VitalStim protocols become second nature. The Epic charting gets faster. But the weight of telling a family that their person can't eat anymore, that never gets lighter. You just learn to carry it differently.

Late referrals. I see it at least twice a month. A parent walks in with a 4-year-old who has maybe 30 words. They're scared and confused and sometimes crying before the evaluation even starts. And when I take the history, the story is almost always the same. They brought up concerns at the 18-month well-child visit. The pediatrician said "boys talk later" or "let's wait until he's 2" or "Einstein didn't talk until he was 4." So they waited. Then at 2, the pediatrician said "give it six more months." Then at 3, someone finally said the word "referral." Then there was a three-month wait for an evaluation. So now this child is 4, and I'm looking at a kid with a severe expressive language delay who could have started therapy at 18 months, when the brain is most plastic, when early intervention could have closed the gap before it became a canyon.

I have a patient right now named Camila. She's 3. Her father, Rodrigo, told me during intake that their pediatrician said to wait. Rodrigo trusted the doctor. Why wouldn't he? And now Camila is using about 25 single words and no combinations. She's frustrated. She bites. She screams. Not because something is wrong with her temperament, but because she literally cannot tell anyone what she wants. I'm fitting her for a PRC Accent AAC device and starting LAMP therapy, Language Acquisition through Motor Planning, because she needs a way to communicate right now, today, not six months from now when her verbal language might catch up.

There's a pediatrician in town, Dr. Amir Petrovic, who refers early. He sends kids at 15 months if the parents have concerns. I wish every pediatrician operated the way he does. I can't say to Rodrigo, "Your doctor cost Camila two years." That's not my role and it wouldn't help. So I start therapy and I try to close a gap that didn't need to exist. That's the stress. Not that the work is too hard, but that so much of it is catching up from delays that were preventable.

Productivity requirements. My facility demands 85% productivity. That means 85% of my 8-hour day, 408 minutes, must be billable direct patient contact. Let me walk you through the math. I have patients on three floors. Just walking between rooms takes 47 minutes per day. I timed it once with my phone. Documentation, family meetings, team conferences, consulting with nurses, restocking my therapy materials, going to the bathroom: all non-billable. My lunch break is unpaid but I document through most of it because there's no other time. My supervisor, Ronaldo, hands down the productivity mandate from corporate. He's not a bad guy. He's just passing along a number that someone in an office in another state decided was reasonable without ever walking the hallways of a three-floor facility with 28 patients on the caseload.

So what happens when the math is impossible? You start charting while treating. You're sitting across from Alma, a 74-year-old stroke patient with expressive aphasia who lights up when I walk in the room, and instead of looking at her face while she works through a word-finding task, I'm looking at PointClickCare on my laptop because I need to document the previous patient's session before I forget the details. Alma deserves my full attention. She's working so hard to get her words back. I can see it in her eyes when she almost finds the word and then loses it. And I'm typing. I went into this field because I wanted to help people communicate, and instead I'm staring at an EMR while a woman tries to tell me something she can't quite say.

My daughter Zoe is 9. She asked me last week why I "talk about work being hard all the time." I didn't realize I did that. I told her my job is actually really good, which is true. The patients are the good part. Every single one of them. It's everything around the patients that's crushing. The ASHA NOMS data I submit, the compliance checklists, the productivity tracking spreadsheets Ronaldo sends out every Friday with our percentages highlighted in green or red. Mine was red twice last month. Both times it was because I spent extra time with families who needed to understand their parent's prognosis. I don't regret those conversations. But the spreadsheet doesn't have a column for "did the right thing."

The driving. My territory covers 4,200 square miles. That's larger than some states' worth of counties, but there are maybe 12 kids on my caseload because the population is so sparse. Those 12 kids live in towns with 200 or 400 people, scattered across the high plains and mountain valleys. Some of my home visits require 90 minutes of driving each way. In winter, some roads are just gone. Not closed officially, just covered in ice and drifted snow, and you make a judgment call at 7 AM about whether you're going to risk it. Last February I drove 2.5 hours to see a 2-year-old named Eli in a town with 400 people. Did a 45-minute session. Drove 2.5 hours back. Five hours of driving for 45 minutes of therapy. My mileage reimbursement covers about 60% of the actual cost of operating my car, and I put 38,000 miles a year on it.

Eli's mother, Karen, can't drive to me. The nearest clinic is in Billings, and that's over two hours from her. So I go to Eli. And when the roads are bad and I have to cancel, Karen understands, but Eli doesn't understand. He's 2. He just knows the lady with the iPad who plays sounds with him didn't come this week. Or the week before. Last winter I canceled on Eli's family three times in five weeks because of weather. That's three sessions a toddler's brain needed and didn't get, during the most critical window for language development. My program director, Dr. June Whitfield, in Billings keeps our funding going and fights for reimbursement rates. She's good at what she does. But no amount of administrative skill changes the fact that Montana is enormous and the kids who need services live hours apart from each other and from me.

I keep a portable AAC app on my iPad for sessions. It's good software. I carry everything I need in a bag in my passenger seat: toys, picture cards, the iPad, a portable speaker. My whole clinic is a 2013 Subaru Outback with 187,000 miles on it. I think about Eli on the long drives home, especially the ones where the sun is already setting by 4:30 and the road is empty and straight and I'm alone with the question of whether this is sustainable. Fifteen years of this. I love the kids. I love the work. I'm not sure how many more winters my car or my back can take.

Trying to do articulation therapy through a screen with a 5-year-old who won't sit still. I live in Austin and serve school districts in rural Texas and Oklahoma that can't hire SLPs locally. The access problem is real. These kids would get nothing without telepractice. But the clinical compromise is also real, every single session. I can't position a child's tongue. I can't feel the airflow during a fricative. I can't redirect a kid physically when he slides under the desk, which happens roughly once per session with my kindergarteners. Last Tuesday a kid named Micah, who I've been working with for months, finally produced a clean /s/ sound. I did a silent fist pump in my home office. My wife Deepa, who works in the next room, heard me whisper "yes" and knew exactly what had happened. She hears me say "can you show me your tongue?" about 60 times a day through the wall.

The whole system depends on the paraprofessional in the room. I need someone at the other end who can hold the device steady, redirect the child, position a mirror, hand them a tongue depressor. My favorite aide is Mrs. Thornton at a school in Guymon, Oklahoma. She's incredible. She anticipates what I need before I ask. When I say "can you angle the camera down?" she's already doing it. She makes telepractice feel almost like being there. At a different school, an aide held the iPad upside down for four minutes before anyone noticed. Four minutes. I was looking at a ceiling and the top of a child's head, trying to figure out why the room looked wrong. That's the range of what I'm working with.

And then there's the internet. The connection drops every third session, roughly. The audio cuts out mid-word during a Boom Cards activity. The video freezes while I'm modeling a tongue placement. I'm using Zoom on a district-issued Chromebook with a second monitor for documentation, and when the feed pixelates, I can't tell if the child is rounding their lips or not. That matters. Lip rounding is the difference between a correct /sh/ and an incorrect one. I can't assess what I can't see. I chart "unable to assess due to connectivity" more often than I'm comfortable with. The kids in these districts deserve the same quality of therapy as kids in Austin. They're not getting it. They're getting the best version I can deliver through a screen on a bad Wi-Fi connection, and some days that's pretty good, and some days it's not enough.