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For struggling school kids, what’s the difference between seeing a speech pathologist and a tutor?

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Over the years, parents have asked me this a few times. I’ve also been asked why speech pathologists are allied health workers; whereas most tutors come from teaching or education backgrounds.

Clients and their families should be fully informed about this stuff. So here’s my attempt to answer these tricky questions, recognising others may have different views:

Basic distinction: biologically primary and secondary knowledge

As health professionals, most speech pathologists are concerned mainly with helping students with disordered or significantly delayed “biologically primary knowledge” – communication-related knowledge and skills humans are wired to acquire and that most kids get at developmentally appropriate times without being explicitly taught.

Tutors, as education professionals, help kids learn biologically secondary skills, including subject-specific skills that kids learn at school, e.g. about maths. Some kids struggle with one or more subjects at school, and school tutors work with teachers to help them out.

Clear as mud?

Let me explain the difference in more detail by reference to some of the science, specifically evolutionary theory and one of its offshoots, cognitive load theory.

Speech pathologists and biologically primary knowledge

Human brains have evolved to pay attention, process, and respond to information that is significant for survival and reproduction. In other words, we are wired to learn and use “biologically primary” or “core” skills we need to cope in our communities.

Although languages and cultures can look and sound very different from each other on the surface, there are many common features beneath the surface that make us all human. To survive in any human society, people need to manage relationships with other people, other living things (including plants and animals), and their physical surroundings. Although details differ community-by-community, several “core” abilities are needed to do this successfully:

  • In/out grouping skills to help break our social world into categories of people (e.g. family, friends, enemies, races, religions, tribes, States and Nations).
  • Attention to the biological and physical world around us, including skills needed for hunting, horticulture, navigation, and tool use. These skills include knowing movement patterns of potential predators and prey, the ability to form mental representations of our environment, knowledge about the “essence” of different species of plants and animals, and the ability to categorise them.

Human communication skills are much more advanced than those of other species, including the other “Great Apes”, like chimpanzees and bonobos. Some researchers think early-developing communication skills advantaged human babies with care and attention from adults, with later communication skills helping kids (and adults) succeed socially within groups of adults and peers. In other words, developing these skills from a young age helps us to survive within our families and communities and to reproduce.

For most people, biologically primary knowledge is acquired with very little cognitive effort. We’re wired to pay attention to this information and to respond to it efficiently. We apply several rules of thumb to respond to situations requiring primary knowledge quickly and simply. For example, we respond almost automatically to social signals like smiling, and gravitate to things like sport and dance, and hanging out socially with friends. Amazingly, most of us learn how to speak intelligibly in our native language without being taught how to do it.

But some of us don’t. For example, some people have:

Many of my clients have more than one of these issues affecting their communication skills.*

Teacher, tutors and “biologically secondary knowledge”

Biologically secondary knowledge consists of academic and vocational knowledge we need for cultural, vocational, political and knowledge transfer reasons. It includes most of the content in the school curriculum like maths, science, literature, and history.

Unlike the case with biologically primary knowledge, acquiring biologically secondary knowledge tends to be conscious, relatively difficult and effortful for everyone, although some kids struggle more than others. For example, no-one learns algebra, or about the causes of World War I, or the elements of the Periodic Table, or how to program a computer without taking the effort to learn how.

Most of these biologically secondary skills seem to be subject (or domain) specific. That means if you want to get better at algebra, you need to practice solving algebra problems not, say, playing chess or the violin.

The importance of transferring biologically secondary knowledge to our kids and young adults is the key reason schools, teachers and tutors exist. Great teachers and tutors are highly skilled at teaching subject-matter content to kids in such a way that they learn it.

Are there grey areas, or overlaps between biologically primary and secondary knowledge?

Yes. Probably the best example is reading.

Many kids first learn about books in one-to-one social interactions with a parent while discussing picture books. Shared reading practices often include parent and child pointing, object naming, and language learning mechanisms – all biologically primary systems.

As we discuss in detail here, reading itself is biologically secondary – or unnatural. In human evolutionary terms, it’s a recent development and everyone has learn how to do it. (Otherwise, we’d have near universal literacy, which is – unfortunately – far from the truth.)

Many reading skills are based on biologically primary oral language or other knowledge. Oral language comprehension skills, phonological awareness, vocabulary and naming skills, theory of mind, knowledge of human relationships, knowledge of biology (notably animals and plants) and physical environments contribute to helping kids decode and understand what they read.

Brain studies have shown that reading engages many of the same areas of the brain involved in expressing and processing language (including the Broca’s and Wernicke areas, as well as areas of the brain evolved for object naming. Literacy is thus essentially a language skill. And kids with oral language, social use of language and/or speech disorders are at a heightened risk of having reading problems, including dyslexia.

Learning to read is both a health and education priority. Both speech pathologists and tutors who are up to date on the scientific research and trained in how to apply it know that children learn to read most effectively with systematic, organised and adult-led direct instruction focused, initially, on letter-sound links, blending and segmenting of speech sounds, and word decoding skills using a synthetic phonics approach. Both speech pathologists and tutors with literacy training have an important role to play in helping kids with reading difficulties learn to read.

Other ways speech pathologists can help with reading and academic issues

Many (though not all) of the students I see for reading instruction have underlying language and/or speech deficits. That’s why our literacy assessments include tasks probing underlying primary communication skills, including phonological awareness skills like letter-sound links, vocabulary, receptive and expressive oral language skills, and speech clarity. This can help us figure out whether a child’s reading problems are related to decoding written words into speech, oral language comprehension, or both. (You can read more about this here.)

Language and speech disorders can have long-term academic and social effects on children and teenagers. As children move from learning to read to reading to learn, kids with language disorders can struggle with reading comprehension and writing tasks. They can also struggle with other language-dependent tasks, like understanding academic verbs, maths and other subject-specific vocabulary, complex syntax used in exam questions and school texts, organising their thoughts into written and spoken language at the discourse level (e.g. in stories, presentations, and essays), understanding higher level language (e.g. idioms, jokes, metaphors, and analogies), and planning and executing evidence-based study practices.

Speech pathologists frequently collaborate with teachers and tutors to implement strategies to help students with communication disorders cope with the school curriculum.

Clinical bottom line

I’m lucky to have good relationships with many excellent local teachers and experienced tutors. The key issue is making sure that the student is getting the right help from the right people at the right time. By working collaboratively with:

  • students;
  • parents;
  • teachers, principals, and learning support staff;
  • tutors;
  • allied health colleagues like occupational therapists, audiologists, and education psychologists; and
  • other medical professionals like general practitioners and paediatricians,

we can help clients and their families identify and prioritise communication and other issues affecting academic and social participation at school, treat health issues like communication disorders (and mitigate their effects), and educate students in areas of academic challenge so they can pursue their work and life goals.

Principal sources:

Geary, D. (2008). An Evolutionarily Informed Education. Educational Psychologist, 43(4), 179-195.

Tomasello, M. & Gonzalez-Cabera. (2017). The Role of Ontogeny in the Evolution of Human Cooperation. Human Nature, 28:274-278.

Kirschner, P.A., Sweller, J., Kirschner, F., Zambrano, J. (2018). From Cognitive Load Theory to Collaborative Load Theory. International Journal of Computer-Supported Collaborative Learning, 13:213-233.

This article first appeared on our clinic website, Banter Speech & Language. We’ve received great feedback from speech pathologists about it, and thought it would be helpful to post it on Speechies in Business too.

*For completeness, I should add that some people also have problems swallowing food, drink and/or medicine. Speech pathologists help these people, too.

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Australian SLPs: do you store progress notes in a cloud-based practice management system?

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Reputable cloud-based practice management systems, like Cliniko and HealthKit, are becoming more sophisticated. Many Australian SLPs in private practice are using them to store client progress notes.

I’m all for using systems to save time and money. And it’s hard to ignore the (as yet, unrealised) dream of a paperless clinic. But if you are using or planning to use a practice management system to store progress notes online, it’s best to be aware of some of the legal risks, if only so you can think about how best to manage them.

First, it’s worth recapping some key laws that regulate speech pathologists’ progress notes in Australia.

1. Do we need to keep progress notes?

Yes.

In most Australian States, there is a legal requirement to take progress notes. For example, under the NSW Code of Conduct for Unregistered Health Practitioners, we “must maintain accurate, legible and contemporaneous clinical records for each client consultation”. For States and Territories who have not yet implemented the National Code, there is still an ethical requirement (see clause 3.3.6 of the Speech Pathology Australia Code of Ethics).

2. Who owns progress notes?

Generally, as a matter of law, principal speech pathologists own their file notes. Sole practitioners have full ownership of their notes. Employers own the progress notes of their employed speech pathologists. In most cases, the hirer/principal owns progress notes relating to clients served by independent contractors (although this is a bit of grey area and should be documented in the contract between the hirer and the independent contractor).

In group practices, and practices with a high turnover off staff, the analysis of who owns a specific progress note (and who owes legal obligations to retain and protect it) can get complicated quickly.

3. Who, apart from the speech pathologist, has access rights to progress notes?

Clients have statutory access rights to progress, including under the Privacy Act 1988 (Cth) (“Privacy Act”).

Progress notes can also be subpoenaed by a party to litigation, e.g. in Family Court custody disputes or where there is an allegation of professional negligence.

4. For how long do speech pathologists need to keep progress notes?

This varies, State by State. But it’s longer than many people think. In NSW, the ACT, and Victoria, for example, you are required to keep progress notes until a child client turns 25, and, for adults, for seven years from the date of the last service.

You may also need to keep progress notes in some States if you anticipate litigation.

5. What are speech pathologists’ key privacy obligations with respect to progress notes?

For the purposes of the Privacy Act:

  • speech pathologists in private practice – big or small – are “health service providers”; and
  • our file notes and reports contain “health information”, which is one of the most sensitive categories of personal information.

This means that, compared to non-health related small businesses, we need to take extra steps to protect our clients’ privacy.

First, we need consent to collect health information. We also need to tell clients how we handle their information, including how we will store and protect it. The most common way of doing this is through a privacy policy and a written notice at or just after intake.

Speech pathologists must take reasonable steps to protect personal information from misuse, interference or loss; and from unauthorised access, modification or disclosure. If we are sending personal information offshore, we must take reasonable steps to ensure no privacy breaches will occur.

Since 22 February 2018, the Privacy Act has imposed a mandatory breach notification requirement on health providers for some data breaches, including breaches that health providers believe are likely to result in serious harm to patients. (You can read more about this here.)

6. Progress notes stored in practice management systems

The laws above apply regardless of how you write progress notes or where you store them. Storing progress notes in a cloud-based practice management system raises a few additional issues speech pathologists need to think about.

To help make the discussion as practical as possible, I looked at the Cliniko and HealthKit Terms of Use as of 9 July 2018. I don’t currently use either service in my practice, but I know both are reputable services used by many speech pathologists.

(a) Who is responsible for complying with Australian laws that regulate progress notes stored on practice management systems?

The speech pathologist.

Health service providers, including speech pathologists, cannot delegate their legal obligations to service providers. Most practice management system companies make this very clear in their terms of use. For example:

  • Cliniko’s terms state that the speech pathologist using the service “must comply with all applicable rules and regulations, including without limitation privacy laws, and must not infringe or violate third party rights”; and
  • HealthKit’s terms state that a speech pathologist using the service warrants that they “manage Personal Information in accordance with Australian Privacy Principles….”.

(b) Does the speech pathologist still own their notes?

Probably, though it’s best to check before using a practice management system to store progress notes. For example, Cliniko expressly claims no intellectual property rights over the data or other material speech pathologists provide. HealthKit’s Terms of Use appear to be silent on this point.

(c) Do you need client consent to store progress notes in a cloud-based practice management system?

In our view, yes. And, in their terms, some providers appear to agree with us.

For example, HealthKit’s terms state that speech pathologists using the service must warrant (promise) that they “have disclosed to and obtained the consent of patients that their personal and non-personal data, including health records and payments information, are stored on [HealthKit]…[and] further warrant that [they] have disclosed and obtained patients’ consent for the possible uses of the information stored on this site”. HealthKit’s terms go on to state that speech pathologists using the site warrant that, “where in your reasonable belief the patient is physically or mentally incapable of consent, you have disclosed and obtained the consent of the patient’s guardian, next of kin or other relevant party”.

(d) What happens if the practice management system loses or deletes your progress notes, goes down, if your service is suspended or terminated, if the provider goes out of business, or if the service is otherwise discontinued?

The speech pathologist remains on the hook for the privacy, health record retention and other obligations in respect of progress notes. Even if the management system deletes or otherwise loses your data.

Most practice management system companies are very clear on this. For example:

  • the Cliniko terms provide that use of their service is at the speech pathologist’s sole risk and that the speech pathologist is solely responsible for any damage resulting from use of their service; and that the entire risk arising out of use, security or performance of their service remains with the speech pathologist. They also make it clear that if there is loss or damage to your data, your only remedy will be for the company to “use reasonable commercial endeavours to restore the lost or damaged data from the latest back-up of such data” maintained by the company. They also make it clear that they do not promise to provide an uninterrupted or error free service.
  • the HealthKit terms provide that the service is provided on an “as is” and “as available” basis and that they may (among other things) “discontinue this web site and its services or delete the data you provide, whether temporarily or permanently”.

(e) With whom can the practice management system company share progress notes containing health information?

This varies from company to company. For example:

  • the HealthKit terms state that “sometimes we may transfer information to persons outside Australia (e.g. a contractor located in another country who provides us with services). By giving us your personal information, you consent to such disclosures”. They also state that they can share information with Medicare, the Department of Veterans’ Affairs and “our SMS provider and other third parties that we contract or with whom we integrate for the for the purpose of identifying you”.
  • the Cliniko terms state that users consent to the company “transferring your data to third party IT providers, including our website host and back-up service provider, outside Australia”. Cliniko’s Privacy Policy states that their use of data that is personal information relating to third parties (including clients) is limited to providing support and technical assistance.

In practice, this means you need to look carefully at the specific provider’s terms of use and privacy policy. In particular, you need to check that the service provider does not claim the right to use your clients’ data for direct marketing, or to sell it to third parties for commercial purposes.

(f) What happens if the practice management provider suffers a data breach involving your progress notes?

The speech pathologist is responsible to their clients and the regulator for compliance with the Privacy Act, including the mandatory notification requirements for serious breaches. To do this – obviously – you need to know that a breach has occurred and speech pathologists should check that their service provider will notify them in a timely fashion that a data breach has occurred. Cliniko, for example, states in their Privacy Policy that they will notify users within 72 hours of discovering a breach.

Bottom line

Storing progress notes on a cloud-based practice management system is an attractive proposition for many speech pathologists. Storing progress notes in the cloud raises compliance issues, including with respect to client privacy and the retention of health records. Regardless of how speech pathologists write and store their progress notes, they are responsible for complying with Australian laws that apply to the creation, storage, use and disclosure of health records.

Disclaimer: The information in this article is for general information purposes only and is not legal advice. This article is current as at the date of its publication. This article does not constitute any kind of legal advice, opinion or recommendation about rights, obligations, remedies, defences, options, or strategies. It cannot be relied on by any person for any purpose. If this article raises any issues for your practice, you should seek independent legal advice based on the facts and circumstances of your situation.

Related articles:

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Speech pathologists, therapy assistants, digital platforms, and the gig economy: some ethics and compliance issues

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Over the last five years or so, there’s been a lot of chatter about how speech pathologists can or should outsource “non-core services” to others – e.g. to therapy assistants or software service providers – to help more clients achieve their goals for less money.

It’s going to happen, whether we like it or not.

Outsourcing is confronting. But it’s nothing new for many professions.

For example, while working for law firms and banks in the early 2000s, I watched the rise and rise of Legal Process Outsourcing (LPO). LPO is now a very big business, where law firms and companies in high cost locations like the US and the UK subcontract some of their client/legal work to other companies in the same country or (more usually) in low cost jurisdictions like India, Chile, the Philippines and Sri Lanka.

In the early days, much of the work outsourced was very low level grunt and churn work. But, as companies and clients got used to the benefits of LPO, and as the LPO providers got more experience and skills, many LPO providers started offering higher value (and higher fee) services that, for some work, threatened to replace the need for in-house lawyers and external lawyers in high cost countries altogether.

LPO is only one kind of a much larger industry called Knowledge Process Outsourcing (KPO), which can occur across borders or within them. To different degrees, KPO has affected a whole host of professions in high cost countries, including tax and accounting, marketing, medical and life science research (including clinical trials), data analysis, business intelligence, engineering and finance.

Is speech pathology work vulnerable to outsourcing?

Yes. At least some of it is.

We tend to think of speech pathology as “outsourcing resistant”. The theory goes that we offer a personal service that requires a qualified speech pathologist to interview, assess, plan, then deliver all aspects of therapy to clients in a room, face-to-face.

But is all our work outsourcing-proof?

In practice, low profit margins are probably the biggest disincentive to the large-scale KPO of speech pathology. But, over the last few years:

  • many practices have their resources and even client data “in the cloud”, often using a range of low cost subscription-based platforms to do so;
  • many small practices have started to use virtual assistants and automated (or semi-automated) platforms to handle processes like client intake and bookings;
  • clients are increasingly looking to access basic information about speech pathology needs via YouTube, blogs, social media, e-courses, or e-books;
  • many of us are assessing and treating clients via telehealth using low cost or free services like Zoom and Skype;
  • aided by mobile payment and other cloud-based systems, many of us are delivering mobile services without bricks and mortar clinics;
  • aided by increased competition in some parts of the market, clients and other service “payers” (like the NDIA) are increasingly expecting that “commoditised”, low-value services will be provided for free or at a very low price that is not worth professional time;
  • more and more SLPs are opting for (or being forced into) independent contracting work. Some – particularly Millennials – are seeking flexibility and work-life balance. Some are doing it because they want to be their own boss. Others are doing it because they can’t find stable employment;
  • digital platforms like HireUp have developed to match clients with service providers who can help them (including speech pathologists);
  • health review sites have sprung up to give consumers more transparency and information about our strengths, limitations, services (and waiting lists);
  • the evidence base has established that some conditions, like childhood apraxia of speech or hypokinetic dysarthria, require more frequent and/or intensive treatment than we’ve traditionally been able to provide one-to-one; and
  • more universities have started speech pathology programs and more adult colleges have established speech pathology assistant courses, increasing the size of the para-professional workforce with at least some knowledge of speech pathology services.

Some key ethics and compliance issues to consider when outsourcing work to a service provider or assistant

Fundamentally, what separates qualified speech pathologists from assistants like students or therapy assistants is not simply knowledge, but the wisdom about how to apply it appropriately in the best interests of our clients. Being a professional mandates that, in any outsourcing arrangement – big or small – we think carefully through issues like:

  • client confidentiality and the privacy of health records;
  • client care and costs information;
  • informed client consent;
  • “reserved speech pathology activities” that are too important to be carried out by assistants and service providers who are not speech pathologists; and
  • contractual arrangements and indemnity and other insurances to address foreseeable risks/events like data breaches and negligence.

None of this is easy – in the legal sector, lawyers have been struggling with these issues for well over a decade. And, to complicate matters, “speech pathologist” is not a protected title in some countries (like Australia), meaning that it’s sometimes very difficult to establish what “reserved speech pathology activities” might mean in a given context, outside of the rules regulating rebates and insurance payments.

What matters most is – of course – the best interests of our clients; and making sure we satisfy our legal and ethical duties to clients, the profession, and to the general public.

In outsourcing professional work to others, we cannot delegate our ethical and legal obligations to clients or the profession.

Disclaimer: This article contains our opinion on some legal and ethical matters in the field of KPO of speech pathology services. Nothing in this article constitutes legal advice.

Related articles:

Principal background references:

Ross, M. (2011). Legal Process Outsourcing: Ethics and Compliance. Legal Information Management, 11, 97-101.

Shuk-Ching Poon, T. (2018). Independent Workers: Growth Trends, Categories, and Employee Relations Implications in the Emerging Gig Economy, Employment Responsibility Rights Journal, (published online, 5 June 2018).

Noronha, E., D’Cruz, P., Kuruvilla, S. (2016). Globalisation of Commodification: Legal Process Outsourcing and Indian Lawyers. Journal of Contemporary Asia, 46(4), 610-640.

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The No-Prep Mumble-Buster: for children who mumble and mutter

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“What did you say? Can you say that again?”

Mumbling and muttering are significant barriers to good communication and can have a big impact on a child’s social and academic participation. This “no-prep” program is designed to help mumbling children to speak clearly. Featuring a colourful cast of Speech Legends and various play worlds, the pack incorporates 41 pages of social stories as well as drill-play language games and fun activities designed to improve the student’s:

  • awareness of mumbling and its social effects;
  • ability to discriminate mumbling from clear speech;
  • understanding of the key elements of clear speech, including rate, volume and good articulation;
  • response to cues from therapists, teachers, parents and others; and
  • general intelligibility, first in the training sessions and then out in their “real world”.

Note: this program is designed primarily for typically developing children who mumble and mutter – either all the time or intermittently. Many of the strategies in this pack may also benefit children with speech sound issues. However, children with significant speech sound disorders (e.g. speech featuring age-inappropriate phonological processes or articulation errors) should be referred to a qualified speech pathologist for assessment and treatment. You can read more about speech sound disorders and their treatment here.

To download the pack, go here. Then simply print the pack, and associated materials and go!

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