Feeding Pod is Back: Growth, Changes, and Cringe
Brianna (Bri) Miluk: Welcome back to The Feeding Pod. I am so, so excited because this is kind of the like, kickoff, intro, episode to not only a new season, but transitioning The Feeding Pod entirely to bring on Tovah Feehan as a co host and I'm so excited because, not only to like introduce you all to her, but also just share our journeys and have somebody else to really bounce ideas, thoughts, interpretations of everything off of.
And I think that having more than one insight on something is so important. So with that being said Tovah and I are going to spend today kind of reintroducing I'll kind of reintroduce myself very briefly. Tovah is going to give you a more of an introduction to her, but we're also both going to go through just like our journeys to where we're at now.
So kind of going through the process of what got us to practicing where we are now, and then also diving into some of the ways that we've changed as clinicians. Kind of some of the things that we have had to rethink or reframe based on our journeys. So kind of diving into some of the like uncomfiness of like, here's how I started out and the way I thought about things, but like, here's how I do it now.
And I think Tovah, you know, you and I would probably both agree that like, I hope that I also cringe at myself now in like 10 years about something that I'm doing because that ultimately means that we're continuing to learn, we're continuing to change in the face of evidence.
Tovah Feehan: Yeah.
Brianna (Bri) Miluk: Okay, so let's start out with our journeys and I'm gonna let Tovah give like brief introduction to herself first and then we'll both like dive into where we started. I feel like we gotta start back at the like the, the beginning, beginning, like grad school.
Tovah Feehan: I was like, I was born in West Philadelphia.
Brianna (Bri) Miluk: I was born at eight pounds, five ounces and yeah, so we'll, okay, we'll, but I think like starting there would be a really good point.
Tovah Feehan: Yeah.
Brianna (Bri) Miluk: Because it kind of just sets the framework, but Tovah, why don't you give like just a quick intro of like who you are right now, and then we'll go back in time. Does that sound good?
Tovah Feehan: Yeah, time travel. Okay. I'm Tovah Feehan and Right now I am a speech pathologist. I specialize in pediatric feeding and swallowing and I have my own practice and then I have a unique setup where I'm able to do swallow imaging at a local hospital when I need to. And I'm a professor and I'm a mom. I have two kids six and three years old. We were potty training this weekend, so it feels really good for my house to be quiet right now and to just talk to you. It was very stressful.
Yeah. And I guess my journey, so I didn't study speech in undergrad, and I really had no clue what I wanted to do. And I started working in the arts in New York City, and my mom got a brain tumor, and as part of that, she lost hearing on one side. And so I ended up taking an audiology course just out of curiosity of, you know, how I might be able to help her and what I might expect.
And then that professor said, you should consider going to school to be a speech pathologist. And so I started taking prerequisite classes with the mindset that I wanted to work with adults and I wanted to work in a medical setting. And I went through grad school. My first job was in research and I was working with adults to help with the head and neck cancer population, but we were doing high speed MRIs of the swallow in healthy subjects. And I loved the team that I worked with, but it became very clear that that was not my path.
Brianna (Bri) Miluk: And this was right after grad school?
Tovah Feehan: Yeah. Well, so I started the job during grad school and then it turned into my job.
Brianna (Bri) Miluk: Okay. Okay. So even during grad school, you were still fully like thinking...
Tovah Feehan: Oh...
Brianna (Bri) Miluk: Like
Tovah Feehan: 100. Like, I don't want to work with kids. I only want to work with adults. Yes.
Brianna (Bri) Miluk: Oh my gosh, that's so funny. Okay, so I'll give my like school part and then we'll..
Tovah Feehan: Yeah yeah yeah.
Brianna (Bri) Miluk: I think we just like alternate the journey.
Tovah Feehan: I love that. Yeah.
Brianna (Bri) Miluk: Okay. So for undergrad I also went in undecided originally I thought like I was either going to be a teacher or a pediatrician. Like those were my two so I was always like I want to work with kids But I didn't know in what realm like I didn't know which way that was going to look and so when I first started out I went into like biology pre med knowing that like, I didn't know which one it was, but I was very interested in the medical side.
So like you said with the dolls, like the medical sides, what intrigued me. And so I started out doing that. And my mom is actually the person that brought up speech language pathology. Like I had no clue that it was a field, a thing like and looking back now I'm like, oh yeah, I remember like, a friend of mine would actually get like pulled out and sometimes I would be like her communication partner and I'd get to go with her to like practice or play games or do whatever.
And I'm like, oh, that was totally the speech language pathologist. I was like working with her. But didn't know that at the time. So my mom was like, why don't you shadow a speech language pathologist and just like, see what you think? And she was like, cause I feel like that might kind of fit in what you're thinking about of like an in between of like, I want to work with kids and I want to be medical, but like, I don't think I want to be a pediatrician, but like, where else could I kind of land?
So and my mom's a physician, so I think that's where she was more familiar with the allied healthcare professional. So I observed someone at a hospital who actually did both peds and adults. So they would do like adult inpatient in the morning and then pediatric outpatient in the afternoon. Like that was kind of their schedule through this hospital.
And immediately I was like, oh my gosh, I love this. Like this is, this was, this was great. So I switched majors. And then went to grad school and I actually, which is interesting because I think this still comes a little bit from the like the way I was kind of like, I don't know, maybe I'll also be a teacher early on, was I was actually really interested in deaf studies and like the deaf and hard of hearing population.
So while I was in school, I actually took courses at the community college alongside the grad program in American Sign Language, so that I could learn that language. And I, like, I will say now, I'm like, I can hold, like, a basic conversation. I haven't practiced in a while, but, like, for the most part, I can pull it out.
It's more like the reception. That is harder. I feel like. But I thought that that's what I want to do was like work at a school for the deaf and but while I was in grad school, again, medical side was really interesting to me and like we started dysphagia classes and the anatomy and physiology and I was like, oh wait, I actually really like these topics.
And then I got a grad placement where I got to see some pediatric feeding patients and that's where it kind of like was like... okay, that is what I want to be doing. And so I shifted gears. And then from that moment forward, like, you know, kind of my, my first job ended up being, I feel like this happens for a lot of people in pediatric feeding.
And so I want to be like transparent to others. And it's like, it's not like I jumped in and I had a hundred percent like pediatric feeding and swallowing caseload. Like the odds of that happening are probably, next to zero. But I started out with getting a few pediatric feeding disorder patients, but I still had like your artic, your language kid, you know, when you first graduate, you're like, just fill my like caseload. I need to be able to see patients. So I started out in a position where I was in a school two days a week. And then I was also doing home visits and outpatient visits.
Tovah Feehan: Oh wow.
Brianna (Bri) Miluk: It was really busy. It was really busy.
Tovah Feehan: I feel like that would be a really steep learning curve because you're trying to learn so many different settings and ages and population.
Brianna (Bri) Miluk: Yeah, I know. It was a lot because I had, like, I had to understand the, like, school logistics of, like, IEPs and, like, attending those meetings and all of that side of it while also, like, being in the early intervention side of stuff when I was in the home. And then the outpatient was probably the the least learning curve of school. But yeah, it was, it was a lot. It was also like somewhat isolating because of the fact that like I had to be at so many different locations. I wasn't really touching base with like a supervisor very frequently.
Tovah Feehan: Oh, like during your clinical fellowship year.
Brianna (Bri) Miluk: Mhm.
Tovah Feehan: Interesting.
Brianna (Bri) Miluk: Yeah.
Tovah Feehan: I, so, so I mentioned I was living in New York and I was getting married after grad school. And we were going to live in Philadelphia and the research job was in New York. So I was commuting back and forth and I also needed to start a fellowship. So I started interviewing. I, I got one adult hospital interview and talk about cringe. Oh my God. I could not have bombed worse. There's just, I don't know of any way that I could have possibly bombed worse to the point where I look back and just, I feel like they, they felt sorry for me, how bad I was bombing. Anyways, I interviewed at a bunch of places and I did get some job offers, not at that place, but I didn't feel like anywhere I interviewed, like they really cared about my growth.
Brianna (Bri) Miluk: Mmm yeah.
Tovah Feehan: Or skills, except for an interview that I almost didn't even go on for early intervention. When I went to that interview, it was the only one where I felt like they were invested in me as a clinician.
And I like loved my mentors who would be my mentor so much. He and I just like clicked and I could tell I would learn a lot from him. And so I ended up doing a 180 and starting out in early intervention. And I am so thankful that I started out there because you, it's so humbling to see how people live, even whether you're in a brownstone and you have like a night nanny and a day and an au pair, or you live in the project, like it's humbling.
It's humbling to see how different people live, how they grapple with information about their child and diagnoses and how they communicate. And I mean that, oof, it was, it was really, really helpful. And I noticed in early intervention, I w- I was in Philadelphia that there was this big divide between what would happen in the medical setting.
And then from the medical setting to home, there was, there was, this gap. And so after a few years in early intervention, I switched and started working at a pediatric hospital in hopes of being able to bridge that gap. And so it was interesting because they did a long orientation process at the hospital which is amazing.
And, but I would listen and hear well meaning and very wonderful clinicians, but, you know, they would be making recommendations for like high chairs or talking about different foods to get. And I would be thinking in my head, like, This family might only have lawn furniture. Like we need to.
Brianna (Bri) Miluk: Yeah, like um?
Tovah Feehan: Ask more questions and yeah.
Brianna (Bri) Miluk: They don't have a dining room table at all. Like, that's, that's not where they're going to be sitting. So bringing a high-, you know.
Tovah Feehan: Yeah. So to have that lens of of what things might look like at home was really, really helpful when transitioning into that setting and then starting to take a deeper dive into the, the medical side of things. And so I was at that hospital for about eight years and same as you, I feel like over time I specialized more and more in pediatric feeding and swallowing, but it wasn't out the gate. And I'm thankful for that too, because I think it's helpful to have that, that broad lens, the same as it's helpful to know how somebody operates at home versus the clinic. And I was thankful to have that foundation of development, like that birth to three development before transitioning to the hospital too. Yeah. So I feel like at the, for the last probably like four or five years at the hospital, it was mostly pediatric feeding and swallowing, swallow imaging before transitioning to my practice and teaching.
Brianna (Bri) Miluk: Yeah, yeah, that's awesome. I, my mentor in my CF was, was wonderful. Like as a person, but in terms of like supervising and seeking mentorship on pediatric feeding, I really didn't get that piece during my CF as much as I would have liked. I was finding myself like reaching out to others that weren't even like my direct supervisor just to like seek some support and get some, some feedback and like being able to just like even discuss like, hey, I have this case.
I would love to talk more about it and go through that. And so, but I think it was just kind of like you said, the way, unfortunately in my interview, they made it seem very much like they wanted to support and like guide me on my way and help with this and that. And it ended up kind of being like, oh, wait, you're hired now.
Just like, well, we'll figure it out. It was kind of, unfortunately not. It was not, I won't say it was a bad experience because I did learn a lot because I was kind of just thrown to the wolves. But I would not recommend as a CF going into something where you're in like three different locations and like don't have, don't feel like the point of contact is going to serve exactly what you want to serve.
But I was just like excited to have a job and I was in Asheville, North Carolina for that one. So I was not where I am now in Greenville, but after that I wanted a job again that was like, okay, I want to go to a somewhere that is going to focus more on pediatric feeding and swallowing. Like I want the clinic to be very like, it's very, very clear that that, that they work on that there.
And so I ended up searching like towards the end of my CF for like other jobs. And originally I wasn't planning on like moving anywhere. But one day I like put in searching of like pediatric feeding clinics and a place in Greenville popped up and I was like, okay, like they, they definitely have a pediatric feeding program here.
Like, I can tell that they're, you know, doing different things and working on again, feeding and swallowing. And I was just like, I just want to go somewhere where I can learn more from somebody. So I came to the clinic that was in Greenville. I interviewed, I really, really liked the team. Everybody was so welcoming and so nice.
And it was all outpatient at this point. So that was also like a huge drawing for me from going from like, I was all over the place and all these different settings, like, what do you mean I just come to work and like every patient just comes to me? It just felt like wow, that would be incredible because right now I'm was spending so much time in in my car doing the in between stuff and I feel like because now i'm in home and community based primarily so it's not the matter of just like being in your car to go to visits.
It was the matter of like sometimes I would have back to back at a clinic, sometimes I would have a bunch of groups at a school, and then I was also driving in between there, so like, the, that was what made it tough. But anyway, I, I interviewed, and I'll, oh, this is also kind of like an interesting part of the story, I feel like, and something that I've done with basically every job I've had, like, so I even did this with my CF, is there was not a job listing posted.
I just reached out, like I just emailed and said like, hi, I came across your clinic. It seems like it aligns with some of the like goals and values that I'm like, I have as a clinician, blah, blah, blah. Like I know you don't, I don't see any job postings listed. However, I would love to just like have a conversation or hear about opportunities if they come up in the future.
Like very just like. Sometimes I look back and I'm like, who did I think I was? But I just wanted to know, you know, like, I don't know. Maybe they were about to post something. And sure enough with this one, that's what they were. They were like, actually, we were going to be looking to hire very soon. And so like, we'd love to just talk. So anyway, I feel like I have to, like, shorten. I'm such a yapper, such a yapper. But anyway.
Tovah Feehan: I feel like when I was sharing, I was all over the place. Did it make sense?
Brianna (Bri) Miluk: It made sense to me. Yeah.
Tovah Feehan: Okay, cool. Well, you always follow me on my
Brianna (Bri) Miluk: Your journey.
Tovah Feehan: Tangents.
Brianna (Bri) Miluk: No, it was good. So anyway, I went to this clinic and I accepted the job, moved to Greenville. My I, yeah, started working there and for the first like little bit, I was very like, I was like learning so much. And it was wonderful and I had a supervisor and mentor there who was kind of teaching me along the way. And it was probably like a year and a half or two years into it where I was like starting to seek mentorship from others as well. So I was like seeking outside of my clinic and that was when I really also started to be like, okay, I want to prioritize learning more through the research and like pulling articles more forward. And so like, I feel like those first like couple years for me were like, just like scrambling, right?
Like you graduate and you're just like, here's a caseload and like, go do the things. And you're like, I don't really know anything yet. And I'm going to listen to this person and I'm going to go over here. And like, it was just like chaos. And then finally, once it was like, okay, I feel like I can, like, I can breathe for a minute.
Like I've got my routine. I know what I'm doing. Like quote unquote doing I'm giving quotation marks. I know what I'm doing. And was when I started to be like, hold on some of the things that I've been learning. I'm not finding are aligned with research, or it doesn't really make sense to me. Like when I look at like ASHA's practice portal and like, you know, clinical guidelines and like systematic reviews of specific techniques that like, this is how we should be doing these things.
And at that point was when I started to kind of like, push back a little bit. So one of the things that I liked about this clinic was that we had weekly meetings, weekly team meetings, where we could just like discuss what's going on, what questions you have, you know, and like love that aspect of it.
And so I started to bring up, like, I read this thing, or, you know, could you further, could you further explain, like, why you use that type of strategy or like, is there something that I could read more about this type of strategy? And I'll talk about the strategies when we, you know, talk about how we relearned and rethought some things in a minute.
And I just noticed that there was just like no answer to it. It was very much the like, well, that's how I've always done it. And like, I've seen progress with my patients. So like, that's why we do these things. And like, that's how we just approach it. And it just kind of felt like. Icky. Or I was like, hold on, wait, like I, I, and honestly, like, that's part of the reason that like I got on social media and started doing all this stuff because like, it just like lit such a fire under my butt where I was like, I can not believe that I did not question the authority of this person earlier.
Like that, I just didn't take the time to be like, oh, could you like explain that more? Could you provide the research behind that? Like from the moment I started learning from them. And again, like I was just that, that's a cognitive bias, right? Like it was like a person who talked with authority and confidence and I thought they knew what they were doing and they were, you know, kind of running the show.
And so I just defaulted to like, of course they're going to be telling me the things that align with exactly how I should be doing stuff. And also I feel like early on you're kind of like, could you just tell me exactly what to do? Like..
Tovah Feehan: Yeah.
Brianna (Bri) Miluk: Book of like, okay, yeah. And I'm just going to do exactly like you do because that seems to be working okay versus like after a couple of years, you're like, wait, I feel like I have a little more autonomy over this because I like, I can actually critically think through these experiences a little better now. So anyway, that happened for a little bit, and then they left the practice. And so when they left the practice.
Tovah Feehan: Did they leave the practice?
Brianna (Bri) Miluk: Mm hmm. Yes. To start their own. To start their own practice. Yes. And so at that point, I moved up to like the director of feeding at this location. We basically like 180'd. Like, I like held in services on like, so for example, I'll give a spoiler to some of the things we're going to talk about. oral motor exercises and like tongue tie.
And I like gave a couple in surfaces on the research for it to kind of like bring everybody together to have like discussions. And then we started those weekly meetings ended up being like, we each took turns picking a research article to review and talk about how it actually like applied to our caseloads and could apply to future caseloads and how to like interpret the information.
So we kind of like 180'd it. So I was there for, let me think, four years, I think before I kind of shifted to wanting to do something where, well, I wanted a position that was going to allow me more flexibility to do some of my courses and like podcast and Instagram and like be able to like also take on this part that I was finding that I really, really liked because because of my experience.
And so, and during that process too, like I sought out mentorship from So many other people and other sources and I feel like I took like so many, there was like a period of time, this was early on, but I don't know if you were the same way, but there was a period of time where I took like every feeding course I could possibly come across.
Like it was just like, oh, there's like one hour lecture on this thing or this too, this, what, like, it was just like, yeah, let me just like, let me just hear, let me just listen, let me just like pull it, pull it all in. But yeah, so I, I left to go to something more flexible. So then I started contracting with a company, so it allowed me flexibility in my schedule so that I would have time for some of this other stuff.
And that was kind of like a, that was primarily community home based, but I had a few patients that I saw inpatient at their like brick and mortar location. And then. Yeah, that's, that's, that's where I kind of ended up until now I'm, you know, due in a month and hoping to transition to my own thing entirely.
When I for clinically I've been doing my own thing from a business standpoint of like courses and stuff, but clinically when I kind of returned back in the spring. So that was like long winded, but I feel like I had to put that in there because like, I didn't have like the best, most amazing experience early on.
Tovah Feehan: Yeah.
Brianna (Bri) Miluk: We didn't know it at the time.
Tovah Feehan: You don't know what you don't know.
Brianna (Bri) Miluk: Mm mm.
Tovah Feehan: Yeah. I would, I would listen to my mentor talk about things in appointments and I would write down word for word what he was saying. Because,
Brianna (Bri) Miluk: yeah. Right? Because we're like, yes, okay.
Tovah Feehan: Yeah. And even like, four years in, I guess I would say like at the hospital I would, you know, follow different people during that orientation period. And I was, it was so interesting to hear how different clinicians communicate the same message and then to see how that message was received or how they explain something or analogies that they use. It was really valuable and similar to you, you can have an amazing mentor, but it's still really good to learn different things from different people or different disciplines.
And it's interesting now because you get to a point with a mentor. Well, I don't know. I'm still very close with the people who closely mentored me and now we can even challenge each other and
Brianna (Bri) Miluk: Yeah, that's how I found myself too. I feel like that's when you know you have a good mentor because when you do bring up like, hey, I started to think about this that way, or like, you know, I know we've talked about this before, but I was thinking of it from this like new lens and I feel like when they're receptive to those conversations like that tells you like, oh, I found a good one.
Like, like this is the type of person like that I want to be mentored from and mentored by because like they are still now open to like conversations and the nuance. So yeah, I would say definitely that.
Tovah Feehan: Can we talk about cringes.
Brianna (Bri) Miluk: Yes. Blah. Blah. Blah. So cringe. Oh, can you hear my chair squeaking? I don't hear it at all. Okay, that's good because it is like, I need to like WD 40 it. It's like so, so squeaky. But I'm glad.
Tovah Feehan: What I will say though. Sorry. What were you going to say? Oh, okay. Well, so we're talking about mentorship and we're talking about kind of like, you don't know what you don't know.
And that learning curve. And even 10 years in, when I started my practice, I had so much fear because my identity was very much tied to the facility that I worked at, and my confidence was tied to an institution versus the skills that I had worked so hard to build. And what I had to offer, like everyone has a unique offering, even if we're all providing feeding therapy, we have a unique way of doing it.
And so that was, a really, really scary transition and a huge learning curve for me. To just be like flying free and still very much like, you know, I text you, we have like our, our squad, you know, where you, you have like phone a friend and you text different people for different things. I will always, I will always, always need that. And if I don't need that, then I'm going to have to do some self reflection and possibly retire. I don't know.
Brianna (Bri) Miluk: Yeah. That's what I was going to say. Like, if I get to the point that like. I'm not reflecting and not like checking in with others saying, hey, how would you interpret this? Would you approach it that way?
And like also being receptive to when they say, I probably wouldn't have done it like that, actually, you know, then it's like, well, I should probably just go show me the door because I probably shouldn't be doing this anymore. But yeah, I totally agree. And having like building that network, I think is so, so important.
And with that being said, like. Yes, I had this experience where we're going to talk about like, I learned some of the things that I now cringe over, but also because of that experience, like, I have been so humbled to be like, okay, you're going to admit that this isn't, you know, best practice of, you know, now, right like it was probably considered, you know, considered best practice at one point in time by and obviously certain people. But.
Tovah Feehan: I didn't even hear what you just said. It was like "blah blah blah"
Brianna (Bri) Miluk: By certain people. But like to have that humbling experience to be like, I'm literally going to change my practice now. Like in the face of new information of like, and, and when I say new information, I feel like also recognizing like new information to you.
It's like absolutely okay to be like, oh my gosh, I didn't know that, even though like the research was published on it like five years ago, or there's like been a body of evidence that you just haven't visited. Like, that's okay. Like it's new to you. But what's important is that when we get that new information, we're not just ignoring it and being like, okay, interesting, but that doesn't really fit with the agenda of how I've been going about things.
And I think like you said, Tovah, the When you start to find like, okay, I have more autonomy over how I'm practicing, or you find yourself in a situation like working for yourself, or I would even say like in early intervention and home health, a lot of the times it's kind of like feeling like a silo, like you're kind of on your own there versus like falling back on like, well, hospital policy and, you know, practices say this, so I can kind of fall back on that or the out, the outpatient clinic.
Like we do have certain criteria or outlines of stuff that like we follow because yes, those are good from like safety standpoint and regulation standpoint, but also knowing that like you do still have autonomy over your practice ultimately. But it can be scary to be like, I can make the decision on it.
Tovah Feehan: Yeah. And what if I mess up? But I think that you and I are similar in the sense that I, I like challenging the status quo, even if it's just in my own brain, like asking myself, like, why am I doing this? Or why is it done this way? And I think that's actually really healthy, but sometimes it makes me sound like a toddler. Like why, why, why?
Brianna (Bri) Miluk: Yeah. No, I think it's good. And that's like, I mean that's part of the reason, probably a big part of the reason that like I wanted you to co host this with me because like as we go through topics like I only think about it from my lens and my experiences and my interpretations and like the research that I've come across and having another viewpoint is always so important.
And there's even been times that like I texted you and I was like, what about the, like, cause I don't do swallow studies. And like very recently in conversation, I was like, what does this mean? The frames per, I literally don't even remember like what exactly.
Tovah Feehan: It was the frames per second. And we were talking about what's the optimal number.
Brianna (Bri) Miluk: 15 or 30 or 45.
Tovah Feehan: Yeah.
Brianna (Bri) Miluk: I literally don't even remember.
Tovah Feehan: Yeah. We went down a rabbit hole with that one, but yes, 30.
Brianna (Bri) Miluk: Yeah.
Tovah Feehan: We'll talk about that....
Brianna (Bri) Miluk: I was like. I was like, is this concerning? Cause I was like, I don't do them. I don't know like the best practices surrounding that. Until I like come across something that sparks an interest and then I, you know, start researching it.
But initially like I was like, okay, I'm, I'm searching like, I think it was 15 frames per second to start out. And I was finding a few articles that were like, that should be enough. You know, you don't need to like blah, blah, blah, blah, blah. But then I went on the 30 side and it was like, this should be best practice. Like these, it was 30, right? Am I saying?
Tovah Feehan: Yeah, 30!
Brianna (Bri) Miluk: I'm like, look here. I'm like reading your face. Like am I saying it right?,
Tovah Feehan: No, no, no. You're right. You're right. *talking at the same time* I'm trying not to interrupt because I get excited, you know. No you're good.
Brianna (Bri) Miluk: But I was like, and then it was like 30 frames per second. Exactly. And so I feel like that was a perfect example though, where like, if I'm just searching like 15 frames per second, pediatric swallow studies, I will probably come across research that says that could work.
But you have to go like further, right. And like pay attention to how you're looking at that information and interpreting it and considering it. Cause yeah, that one was like a big rabbit hole. You were like, no, no, Bri, not 15 30. I was like, huh, but what about this article? And I was like sending them to you, but that's not, we, that's, you should do that, you know, because it helps us better understand and like, that was just one that recently came up. There's so many. There's so many.
Tovah Feehan: Yeah.
Brianna (Bri) Miluk: So, okay. Well, for the sake of time, on, on this first episode let's just like share a couple things that like make us cringe and I literally like my oh I can already like feel it like i'm having like a physiological response to things.
Tovah Feehan: Oh tell me.
Brianna (Bri) Miluk: Okay all right you want me to go first? I'll go first okay.
Tovah Feehan: Oh no it doesn't matter but yeah if you're ready.
Brianna (Bri) Miluk: Okay. All right. I'll give one. There's so many. I'm just kidding.
Tovah Feehan: Are you sweating?
Brianna (Bri) Miluk: Yeah, I know. I'm getting hot. Am I getting red?
Tovah Feehan: No, you're not, but it could also mean that you're really pregnant.
Brianna (Bri) Miluk: Yeah, I am. Okay. So, I will, let me think of one to start. Okay, I would say one that, one that we had at the, at the clinic was the idea of strength and like building strength and warming up the mouth in kids.
So we would have these like triangle shaped like chewies and like there was like a skinny little prong at the one end and then like a thicker prong on the other end and we were like basically like would use those to build strength in the jaw. And do like warm up exercises for like, kids that have like, hypotonicity, like, you know, that was like, the idea was like, oh, they need to like, awaken their muscles.
And so I would have, and we had goal banks, that literally like, you would just pull oral motor goals from, that said like, child will chew bilaterally on like a non food item. I can't remember what it said exactly, but like, I don't even think it said like the tool that you were using with it, which is also like a little like, but it said like, child will chew bilaterally 10 times on each side without stopping to like, you know, build strength or whatever.
And so I would use those things and this is like, this is the one where I'm like, this was so, excuse my language, like fucked was we would have these tools, and then they sold them in the clinic for parents to then buy for $20. For one chewy triangle and we're like educating the family on like, okay, and then do this before like every meal time, which is a whole different like ethical issue that I have now about like, right, reducing the burden onto families.
So like anything we're asking of families should definitely have benefits and efficacy to say why we're asking them to do the thing. And this absolutely does not. And so I cringe when I think about it from like so many different levels. And I do remember early on, like, whispering to families, like, yeah, I know we sell these here, but, like, you can get it on Amazon for, like, eight bucks. You know, like, and I was, like, already telling.
Tovah Feehan: That's like a double markup. That is so predatory.
Brianna (Bri) Miluk: Oh, it was, like, it was horrific. So that would be, like, probably one of my big ones is because, like, I thought that that, like, made sense. Like, well, we need a lot of strength for it. And we would use it for things like, I remember learning the one strategy where the kid, you would hold the triangle, like, on the side of their mouth, and you'd have them bite, and then move their tongue and tap it, and then bite and move their tongue and tap it, and bite and move their tongue and tap it, and that was supposed to, like, help form the movements of, like, managing a bolus, which, like, we now know, we'll talk about in so many other things, like motor learning and neuroplasticity tells us like that's probably not gonna carry over to just like managing a bolus now. But that's one that really makes me cringe. And -
Tovah Feehan: That's a really good one. I forgot that I did that. And the goals of warming up the mouth. I did it too girl.
Brianna (Bri) Miluk: I'm like, I'm so, I'm so sorry. I'm so sorry. I made families do that. But I promise I changed it when I knew better, and that's the key. That's what keeps me sane.
Tovah Feehan: Yeah. So, when I transitioned to the hospital setting and started working with some school aged children who had feeding challenges, I was like, the, the go to protocol were these, oh my god, they were these eight by 11 laminated sheets with Velcros on them. And then we even had baggies with different themes of the pictures that you could put on them for every time you took a bite or licked something or did something.
And I remember having like, yeah, all my like mini baggies and my superhero baggies and oh, yeah, that was a big one. And honestly, my Spidey sense talking about superheroes I had in my gut, it never felt good. I was never excited to do those sessions. Because I think I felt like something felt out of alignment for me even before I knew.
Brianna (Bri) Miluk: Yeah.
Tovah Feehan: Research or other strategies. Yeah, that was a big one for me.
Brianna (Bri) Miluk: I think that gut feeling is so important because I had the same thing. I have another one I'm gonna share as my second one that like literally makes me want to roll over and die.
Tovah Feehan: Oh.
Brianna (Bri) Miluk: But it like during it, the whole time was very like, I just don't feel like this is right. Like..
Tovah Feehan: Yeah.
Brianna (Bri) Miluk: Gut feeling of like, this is just not, but like not knowing what else to do either.
Tovah Feehan: Yes. And also there's something about like, when that's what you, when you're on the newer side or even like, I would, like I said, I was already like three, four or five years in, but this is what. It was a new population for me.
And this is what I saw everyone around me doing. So I'm like, this is what we do. I don't, I don't know anything else to do. So this is what I'm going to do. But what's yours. I want to know what made you want to die.
Brianna (Bri) Miluk: Okay. I'll tell you my second one. This one, I don't think I've ever told you this.
Tovah Feehan: Ooh.
Brianna (Bri) Miluk: Like I like, I'm a little nervous. Okay. So the place.
Tovah Feehan: My heart's racing.
Brianna (Bri) Miluk: Okay. So the place that I was working at was very, very tongue tie happy. Like, very, very tongue tie happy. Like, we have almost all conversations, like, surrounded how a tongue tie impacts, you know, a whole laundry list of things. You end up feeling like that's all you see.
Like, you see it everywhere. Because that's all that's being talked about, and you're taught that it can impact so many other things. And you're also taught it in a way where it's like, well yeah, they may have reflux, or they may have laryngomalacia, and they could still have a tongue tie. So you, it like never left the table as being a conversation.
And so, like, a lot of like, the training and what I learned was like surrounding that topic. And we were encouraged that if a patient did have a tongue tie release to do like the active wound care after and like trained on how to teach families on how to do it. And the way that we were trained was that they had to do it six times a day for at least two weeks until they like, checked, made sure it had healed appropriately, you know, not reattached, blah, blah, blah.
And in order to do it, you had to basically like, you would lay the child down to where like their head was kind of like between your legs. And then you would like bring your fingers in their mouth and you wouldn't touch the wound. And they'd be gloved hands, but like you'd put their fingers in their mouth and then you'd elevate their tongue and like hold that up for five seconds.
So we taught families how to do that. But for kids who had teeth, we had bite blocks to keep their mouth open so it wouldn't bite you, so you could still do the stretch. And it literally, like, kids would be screaming. like, Tears, screams, like, and like, I was so under the impression that like, this was absolutely essential to their healing, and to like, in order for this to work and make progress and not have to undergo it again, and like, all of this different stuff, and like, I remember, like, and again, the clinic sold the bite blocks that the families could get to be like, here's how you use it.
And it's literally like this little block that you like stick in the side of their mouth, like by their molars. So that like, if they wanted to try to bite down to like block you from getting in their mouth, they can't. And like, we would literally teach parents to like, if the child wouldn't open their mouth to start, how you hinge it open to stick the bite block in there, then you could do it.
I mean, like barbaric, absolutely barbaric. It makes me like want to cry. I have cried about this before. Because like, again, was under the impression that like this was essential, like it wasn't-
Tovah Feehan: Yeah.
Brianna (Bri) Miluk: Like a question that this is part of like, and that was what, like, I was taught there. That's what like the preferred provider dentist would tell you to do.
And so like you have, I had this list of professionals saying that you had to do this. And I remember every time being like, this just feels so icky. And like, that was one of the big ones that when I started reading into the literature and seeing like, there is truly no documentation of like a difference between doing nothing, like just allowing the child to like eat and talk and breastfeed like the frequency as needed for range of motion for healing being enough like there's not anything that says like stretching it or massaging it or doing any type of those protocols is more beneficial I just immediately stopped because I will not because I hated it. I hated every aspect of it And yeah, that's that was a big one for me
Tovah Feehan: Yeah, I definitely, I never did the bite block. I will say that's next level of commitment, but but I do like, I really did think that when I was recommending wound care and even if the baby was upset, I really was doing it out of the, like the best interest. What I thought was the best interest at the time, because I was afraid for them to go through this procedure and then have reattachment. So yeah, it was, it was with the best of intentions for sure.
Brianna (Bri) Miluk: Yeah, and I think that about like all of this like even like I'm like, oh, it's not a good experience because I had a mentor and supervisor team. I truly think everything they taught me was well intended. Like, I don't think that they were telling me anything to try to like mislead me and like, you know, teach me practices that they didn't actually believe were efficacious and beneficial and like, and I don't think that's the intention majority of the time, but that's why like. I think it's also hard to say like, well, maybe that still wasn't right.
Tovah Feehan: Yes, I will say to like part of- Oh, did I cut you off?
Brianna (Bri) Miluk: Uh uh.
Tovah Feehan: Okay. Part of I think so I was operating with the knowledge that I had at the time, right. But also, I think, if I would have been a little bit more humble and a little bit more open, I probably would have learned those lessons sooner.
Because I can remember getting pushback from ENTs and getting pushback from other SLPs or other providers and instead of self reflecting and being like, oh, like they have different experience, like maybe they have something that maybe I can learn from them and their experience. It was like, that goes against what they just don't know what they're talking about was, was my reaction.
And that's why even now there are certain things that I feel like really strongly about, but I do try as much as I can to like keep an open hand about it because I'm always learning something new. And, but it is one of those things where it's like, the more that I saw how that whole journey with whether it's like tongue tie wound care, all that stuff, how it was impacting the, the family, like how it was impacting parents.
And like when, when we would talk about the stretches, just like you could see the tension in their bodies. And knowing we do have all this evidence about responsive feeding and trauma and all this stuff, like, trauma is perception. And so if I'm not sure if something is right or not, but I have like all this evidence on this side to say like, it could be really damaging or it might help. I'm going to go with the side that's saying like, we could do real damage here until, until I learn otherwise.
Brianna (Bri) Miluk: Yeah. The risk and benefit analysis is so important in situations like that, because it's like, you know, people will argue like, well, there is the potential for it to help, right? It's like, how strong is that potential in comparison to like the strength of the risks occurring, like oral aversion or interruption in caregiver, you know, attachment and the guilt that a caregiver feels in that situation.
Or, I mean, I feel like there's so many feelings that report, like it was terrible, like I didn't want to do it. And then of course, if, if they, you know, were like, I didn't do it, you know, very frequently or as frequently as I was reported to or told to or whatever, then like they're blamed if something goes wrong, like it's, well, like you didn't follow the protocol.
And I think too, there was a, there was an article on, I'm not gonna be able to quote it off the top of my head who the author was for it but it was on, like complications post frenectomy, and one of the things they said was like, we also have to consider, like, the ethical implications of asking families to do something such as wound care that does, like, it's, which is typically done in a very like structured medicalized setting, you know, and thinking about how that even plays a role into it.
So, but yeah, I, I also agree with you and like, kind of like wishing I learned earlier to be like significantly more open and stuff because I do remember there being like, oh, like we don't refer to that ENT because he just like doesn't agree with like the process and instead of like, and then instead of being like, well, why doesn't he like, should I call him?
Can I talk to him? Like instead of doing that, just being like, oh, okay. Like just accepting that as like, oh, guess they just don't understand. They're not well trained in it. Or, you know, they haven't taken the continuing ed to be versed in it and blah, blah, blah, you know, kind of like that whole agenda.
Tovah Feehan: And I mean, both things could be true.
Brianna (Bri) Miluk: Yeah, for sure, for sure, but I remember like *talking at the same time*
Tovah Feehan: Feedback and I'm like, oh, okay. Like we just see things differently.
Brianna (Bri) Miluk: Yes, yeah.
Tovah Feehan: Different things you know?
Brianna (Bri) Miluk: But it's helpful to still hear those perspectives. And like, that was one of the things too, that I remember, like after she left and kind of like did the 180, I was very like, I'm calling those providers now.
Like I called the alternative providers that were like the ones that we were supposed to like, oh, don't talk to them because they're just gonna, you know, dismiss it. They don't understand or they don't know or whatever. And it was like, those conversations helped me so much, like significantly more in, in actually understanding like, wait, there's other perspectives to this.
And like those perspectives actually are aligning more with the research and the medical consensus on some of these topics. So.
Tovah Feehan: Yeah, I think another big one for me that you touched on was the one about like the burden that we place on caregivers, like what we're asking them to do in anything with intervention and therapy.
And in the beginning of practicing, just like, it was more about me, like, wanting to have all the answers than knowing how to be helpful, if that makes sense, like, I would just give them a laundry list of, like, here's all this homework that you can do, because I also wasn't sure yet what to prioritize and what was at the surface, or what would be the most helpful for them, because we weren't really having, like, a collaborative conversation, it was more me telling them, like, here's the, like, this list of things that you should do and I would say that that's something that shifted with learning more and more experience and also being able to like synthesize a lot of, cause with feeding, there's so many puzzle pieces, so being able to synthesize and see like, well, what's at the surface right now that we need to like attack first, but also becoming a mom. And I'm so curious for you on this journey. Like, I'm so excited for-
Brianna (Bri) Miluk: We've already talked about it. I'm like, my brain's already starting to rewire itself,
Tovah Feehan: Yeah but also like I would be asked to do the simplest things with my daughter. And I would find it and everybody's different, but I would find it so overwhelming.
I mean, I was like YouTubing how to give her a bath and like the best way to give her a bath. Like I was overwhelmed by the simplest tasks. And so if I would have been given that laundry list, I feel like I would have been paralyzed. It's so overwhelming. And I mean, every parent's different. Like some parents are like, give me, give me, give me like all of it, all of it, you know, but just like trying to feel out, well, what's going to give you, like, how can we make this fit into your day and be like, so functional for you? And where are we going to get the most bang for our buck with like, how we're attacking this with our plan?
Brianna (Bri) Miluk: Yeah, no, I agree. I think that's a big one. And I think early on, it's kind of like, for me at least, I was like, almost like compensating for like, lack of experience and lack of knowledge and lack of know by being like, oh, well, let's do like this, this, this, this, this, you know, and versus now being like, okay, it's probably only like a fourth of that that even matters.
And of that fourth, which piece of it can we actually apply to like this specific family? It also reminds me of that, that other podcast episode, shouting out another podcast with The Rare Life, where they did the episode on like, What I Wish My Therapist Knew, I think was the what it was called.
Tovah Feehan: Ooooh.
Brianna (Bri) Miluk: And it's two caregivers of medically complex kids. And they're talking about like, what I wish I could tell my therapist. And it's a lot of, it's about like, the carryover and the homework that we provide them. So that's.
Tovah Feehan: Because also like, we are, forgetting sometimes that they're a parent first. And so when we're asking them to do things, like even the way that we, even the way that we give ideas for them of how they can do things at home and the words we use can shape how they view themselves as a parent and how they view their child and their child's disability. Like our words and the way that we say things is also just so, so, so important.
Brianna (Bri) Miluk: Yeah, that's a great point. I feel like we could just go on for hours, like find a stopping point for us. No, I think that's good. I think that's, you know, and, and for everyone, you know, listening, like our goal is to like, keep having conversations like this, where we kind of revisit things that we've rethought and kind of like share the evidence behind and then also, of course, you know, bring in other people's perspectives so that we can learn from their perspectives as well and their trainings and experiences. And so I hope that was helpful. And I hope that you know, this gets you excited to continue listening and Tovah, I'm just so thankful that you're, you're going to help me on this journey and continue forward with the, the podcast, because having your perspectives and experiences alongside it, I think we'll just make it. So much, like, it will hopefully make the value and enrichment of the content that much better.
Tovah Feehan: Oh my gosh. Thank you for asking me. I'm excited. I was really nervous, but I'm excited, too.
Brianna (Bri) Miluk: It's gonna be so- *talking at the same time*
Tovah Feehan: I'm gonna learn, too.
Brianna (Bri) Miluk: Yeah, that's a big part.
Tovah Feehan: We're having people on that I want to like, there's things that I want to learn and that, yeah, I wanna talk about.
Brianna (Bri) Miluk: Yeah. We're actually like selfishly choose topics and people so that we can learn. I'm like, oh, cause like, I really want to hear more about this, please. But yeah, so I think, you know, we'll, we'll kind of close out today's intro episode. So some of the topics that let's let's let's just share a couple of the topics that we're both excited about so I have a couple coming up we're going to have an episode that talks about like appraising misinformation on social media and posts and contents and using that CRABS framework with Dr. Jessica Stokes Parish and then also really excited about the episode that's gonna dive deeper into tongue ties and specifically kind of like deciphering the New York Times article that came out with it last year. What are you, what are, what are two you're looking forward to?
Tovah Feehan: I am really excited to talk pharmacy and meds because, and it came about because I was having questions about thickening meds. So I'm excited to learn more about that and how meds impact our practice with a pharmacist. And then also super excited to talk about swallow imaging. Because Kristin and I we both do them, but we have, we have a lot of things that where we're aligned and then we have things that where we do things differently. And I learn from her constantly. And she's so awesome about providing all the latest research and everything.
Brianna (Bri) Miluk: Yeah I'm excited about both of those too. I'm excited about all of them.
Tovah Feehan: I'm also really excited so to talk with caregivers.
Brianna (Bri) Miluk: Yeah.
Tovah Feehan: And learn from caregivers because some of that, this is the last one that I'll be excited about, but I would say like, that's the number one thing that has shifted for me in my practice is like really being open to learning from caregivers and really trusting them as the experts on their children. And so I'm excited for those episodes too.
Brianna (Bri) Miluk: Yeah. I'm excited about that. And I'm also excited about the little like mini series we're going to like sprinkle throughout.
Tovah Feehan: Oh yes yes yes!
Brianna (Bri) Miluk: So we're going to have a couple different mini series of like fake news. That's what we're calling it. Fake news and PFD. So like basically things we've seen on the internet and like talking through, like kind of debunking the information and providing the research to support like other ways to think about it. And then also doing some like Q and A episodes where people can, you all like listeners can actually submit questions about different things and then Tovah and I will cover those. And so I am really excited about those little, like, kind of like short, shorter, but like fun episodes that will be sprinkled throughout too.
Tovah Feehan: Me too. Especially because a lot of times it's products that I've seen and, and I'm probably getting targeted, but I'm like, oh, and so my gut is like, oh, that's crazy. And I'm like, but is it crazy? Like, what if it's super helpful? And then. Yeah.
Brianna (Bri) Miluk: What if it is- *talking at the same time*
Tovah Feehan: Actually a picture of it?
Brianna (Bri) Miluk: So not just like saying like, hey, I saw this thing. Oh my gosh, it's crap. But being like, okay, let's think through this, you know, like let's, let's bring the science in and like critically appraise what we saw. So hopefully that will be helpful to keep doing it, moving forward. For us, too. For us, as well, to kind of check in. And maybe we'll find some things that we're like, hey, I was actually kind of surprised that, like, part of this made sense, you know?
And going through that, so. But anyway! I'm so excited. This is going to be so much fun. And we hope that you all will kind of enjoy the shifting and changing and the episodes to come. So thanks for listening and see you next time on The Feeding Pod.
Tovah Feehan: Bye.
