Dear SLP- The Top 15 Things You Need to Do Before, During, and After FEES Competency Training

Author: Ainsley Martin, MS, CCC-SLP Edited by: Heather Bolan, MA, CCC-SLP

Becoming competent in flexible endoscopic evaluation of swallowing (FEES) was a definite career goal of mine. I always said it was "on my list of things" and figured it would be somewhere down the line in my career. However, when I was offered the opportunity to independent contract for a well known and reputable mobile FEES company in my area, I couldn't say no! I soon found myself on the fast track to reaching one of my ultimate professional goals! Within one week, I found myself on a plane to Northern Louisiana where I completed my competency training with Hillary Cooper of North Louisiana Swallow Solutions. I can say without hesitation that my FEES training was the most difficult, anxiety inducing, educational, and rewarding thing I have done in my professional career. I have since reflected on my FEES journey and hope to share with you the real of FEES competency.

Before FEES Competency Training:

1. Take a 2-day basic FEES Course: The first step to achieve FEES competency is to attend a two day course where, at a minimum, you are introduced to; the components of a FEES system, contraindications for FEES, anatomy of the nose, laryngeal anatomy and physiology, pros and cons of modified barium swallow studies (MBSS) and FEES as well as anatomical variants, salient findings on FEES exams, application of FEES in various patient populations, interpretation, and scoring rating scales such as the Reflux Finding Score or Yale Pharyngeal Residue Rating Scale. Usually the second half of day 2 is hands-on and devoted to working with competent FEES trainers to practice actually passing the scope. The hands-on portion is crucial as it allows you to become comfortable with manipulating the scope, body-mechanics, and the variants of normal laryngeal anatomy as you scope your peers. A head model is also usually available for those who want a little extra practice before scoping a live one. There are many high quality basic FEES courses available including; Dr. Eric Blicker's Basic FEES course, Dr. Susan Langmore's Foundations FEES course, SA Swallowing Services, and Carolina Speech Pathology to name a just few. Naturally, each course instructor brings in their own expertise, clinical experience, and presentation style. I personally attended Dr. Blicker's FEES course for my 2-day basic training in 2017. (Be sure to stay tuned for a review of both Dr. Blicker's Basic and Advanced FEES courses.) Since then, I have regularly returned to his courses as a volunteer and to get in some extra practice. Now, the 2-day course does not a competent FEES clinician make. After the 2-day course, you need to...
   

2. Find a competent FEES mentor to complete your supervised passes: FEES is not for everyone much less competency training. You want to find a mentor who has been performing quality FEES studies and has a solid track record not only in diagnosing and managing swallowing and swallow disorders, but also in teaching. A person can have all the knowledge in the world, but if they don't know how to modify their instruction methods to the needs of their students, it won't be very effective. When selecting a mentor, be discriminating, ask questions, and make sure it is a mutually beneficial fit. The instructor for your 2-day course should be able to provide you with suggestions for FEES mentors. In addition to making sure your mentor knows their stuff, you also want to make sure that you vibe well with your mentor on a personal level. During your competency training, you will be spending hours upon hours with your mentor, especially in mobile FEES. During my competency training, Hillary and I spent sometimes 14 hour days together between drive time, evaluations, and report write ups. You will likely meet your mentor's family, spend time in their home, and certainly spend time in their car. I am so grateful to have had Hillary as my mentor. She knew how to tailor her approach and provide extra support as needed based on my unique needs. This is so valuable in a mentor! Also, when we weren't scoping, we enjoyed some fine Louisiana food and beverages, including Drive-Thru Daiquiris (picture below).
   

3. Study, study, study: After finding a mentor, you will want to brush up on laryngeal anatomy and physiology, salient findings, contraindications for FEES, and compensatory strategies. There is already so much to learn during FEES training, that having this background knowledge ahead of time will put you ahead of the curve. Your mentor will also provide you with material to study in preparation for your training. Helpful resources during my training included The Manual of Dysphagia Assessment in Adults by Dr. Joseph Duffy and Endoscopic Evaluation and Treatment of Swallowing Disorders by Dr. Susan Langmore. Dr. Blicker also strongly recommended work by Dr. Peter Belafsky, Dr. Joe Murray, Dr. Greg Postma, and Dr. Jonathan Aviv.
   

4. Don't plan on doing anything else during your competency except FEES: Seriously. You will NOT have time or energy.
   

5. Practice: If you are anything like me and know there will be a gap between your 2-day FEES course and your competency training, keep your skills sharp by volunteering at FEES courses and practice passing the scope. Even if you are only passing on people with normal anatomy and physiology, you will be able to fine tune your body-mechanics, anchoring, and using different scopes.

During FEES Competency Training

1. Keep an open line of communication with your mentor: Before you even begin scoping on patients, your mentor will likely have you scope them a few times before actually letting you loose on a patient. At that point they can assess what needs to be improved as far as technique and provide you with the appropriate instruction. They will also introduce you to their FEES equipment, protocols, and system for documentation. While a good mentor should be able to determine your strengths and weaknesses and where you need more practice, it is also up to you to advocate for yourself to get the most out of your FEES training. Ask for feedback on what you can improve and when your mentor provides you with feedback, be sure to listen!

2. Body mechanics: Competency training is different for each person, but body-mechanics was where I really struggled initially. In my case, my diagnosis of (mild) spastic cerebral palsy made maintaining one position for a long period of time excruciating. You know how you hear stories about mobile FEES providers having to climb over bariatric beds to get a study done? Yeah, I had to do that. I'd be lying if I said I didn't doubt if I'd be able to make it through that study. When I woke up in the morning, my calves were tight, my wrist was sore, and my back hurt, BUT, I wanted to do FEES, and I needed to find a way to figure it out. Even though you may not have the same physical limitations I experienced, finding a posture where you are comfortable performing the study and where you are able to maintain the position for 15-45 minutes is huge in being successful with FEES. If your attention is on how uncomfortable you are, you're not paying as much attention as you should to your patient.

3. Get out of your HEAD and get in the ZONE: I may have mentioned that my competency week was the most anxiety inducing period of my professional career (yes, including grad school). That was not hyperbole. I wish someone had explained to me beforehand, like I am explaining to you now, how intense FEES training is. Initially, it's physically and mentally taxing. My FEES mentor compared managing passing the scope, maintaining the view while being mindful of your posture, anchoring, directing the person assisting in feeding to provide specific trials, and trialing compensatory strategies at the same time to juggling knives in the dark while you're set on fire. That too was not hyperbole. (Ok, maybe a little). On top of that, my personality is very type A (I'm admitting it) and I have high performance anxiety combined with even higher expectations for myself. There's no one harder on me than I am and my mentor picked up on that right away. I had to learn to not be hard on myself, learn from my mistakes, and improve. I also had to learn to give myself grace, which was not easy to do. Each person's FEES journey will be different and I had to learn to accept that I could not compare my journey to others. Some people just have their FEES brain click right away. Others take a couple competency weeks before they catch on. And that is totally ok! Something I found really helpful was engaging in activities that made me feel relaxed. The night before my I was to perform an exam independently, I went swimming to clear my head. That morning, I spent time outside, just breathing. And on the way to the facility, Hillary gave me an awesome pep talk and played songs from her "you're a badass" playlist. If it's listening to music, yoga, using an alter ego, whatever, figure out what it is that help you get out of your head and into the superstar scoping zone.
   

4. Bring extra deodorant: Trust me- the FEES sweats and FEES funk are real.

5. Practice: Each FEES exam you perform is an opportunity to improve your skills and implement feedback from your mentor. Practice may also include scoping a head model or scoping your mentor. The picture below is Frank, the head model. Frank and I spent some evenings together practicing anchoring and working on positioning for my free hand (the hand not holding the scope) after scoping all day. The night before the last day of my competency, my mentor offered me extra practice scoping her to work on my posture and anchoring. We had a long day, I was tired and she was tired, but when your mentor gives you an opportunity for more practice, you take it. That was one of the most intense training sessions I ever had, but the most useful! We practiced anchoring the scope, so that even if your patient moves around during the study, you can maintain your position and view, without causing discomfort to the patient. She whipped her head left and right, back and forth, and even got up to walk around! All the while I had the scope in place and didn't move. That was a huge boost to my confidence and was extremely helpful as I had a patient the very next morning who was anything but still.

After FEES Competency Training

1. Celebrate: What you have accomplished is no small feat! Grab your favorite drink, get a massage, or sleep for 12 hours if you need.

2. Continue Learning: Competency is really just the beginning of your journey as an endoscopist. You will never know everything and can always learn more to increase your efficiency in report writing, interpretation, and recommendations. Advanced FEES courses such as those offered by Dr. Blicker, Dr. Langmore, SA Swallowing Services, and Carolina Speech Pathology are helpful. As with anything in our field, you never stop learning.
   

3. Develop a FEES network: As a FEES provider, you will come across laryngeal abnormalities and even variants of normal anatomy that you've never seen before. Even if you have been performing FEES for years, you can still be thrown for a loop or not know how to word something just right. Having a network of other FEES providers who you can bounce ideas off, text images to, and get advice from is crucial.

4. Be confident: Being a FEES provider also places you in a position of authority and influence. Patients and other speech pathologists will look to you for answers. Not just about the diet or pathophysiology, but also sometimes how to manage the dysphagia. When you make recommendations, you must be confident in your sound and evidence-based rationale. If you waffle on your recommendations, you lose credibility.

5. Practice: You should begin to see a theme here. Practice, practice, practice. You will never be perfect in performing FEES, but you can always improve in your journey to becoming the best endoscopist you can be!

I did not write this with the goal of frighten or scare anyone away from FEES training. But, I wish when I started, someone had explained to me how intense it really was so I had a better idea of what I was getting into. I practiced and worked hard, and by the end of it all, during my 'final exam,' my FEES brain clicked. I remember the actual moment it happened. Something just switched. I was calling out trials, trying compensatory strategies with the patient, and maintaining the money shot view all while the facility SLP and her graduate student were in the room with me. I was so comfortable in my position too, I could have hung out and had lunch there!

FEES challenged me in ways that I have never been challenged before. But there was no greater reward than seeing myself make improvements day after day, gain even more knowledge and clinical experience, and at the end of it all, receiving a letter (with a big ol' hug) from my mentor stating I had met the requirements for my competency.

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If you are interested in pursuing FEES training, please review the additional resources provided. Special thanks go to Dr. Eric Blicker, Theresa Richard, and Hillary Cooper. Without their instruction, mentorship, and support, I would not be the FEES competent clinician I am today.

Additional Resources:

• http://ceualliedhealth.com/

• https://www.mobiledysphagiadiagnostics.com/dont-hire-nancy-knownothing-to-be-your-fees-trainer-an-overview-of-training-to-fees-competency-for-assessing-swallowing-disorders/

• https://www.langmorefeesllc.com/

• https://www.sasspllc.com/

• https://carolinafees.com/