Saturday's Afternoon Panel Discussion 1

Panel Moderator Paul Kiesgen
Panel Members Mona Abaza, Kate Emerich, Graham Welch, Leon Thurman, [Harm Schutte], Bill Reilly, Linda Carroll, Karen Wicklund, Deidre Michael (left to right in following picture.)
Picture of Panel
Statement from Harm Schutte. Regarding the remark that ‘it is unreliable to derive the frequency position of formants from a spectrogram’………click on the Audio link for the statement. Audio link.
Panel Introduction by Moderator Paul Kiesgen - Introduction of panel format. Audio link.

In the professional voice team - including the singer, singing teacher, choral director, speech pathologist, singing-voice specialist and the laryngologists - What is the role of each member of the team? And what is the communication of the team? Audio link.
Mona Abaza – A Laryngologist is actually a fellowship-trained ENT doctor who spent additional years training. I think that’s an important thing to remember because there are a lot of people who are ENTs who’ve had long-term interests, and certainly keeping in mind that the majority of fellowships are 10-15 years old, the longest one is about 15 years old. There are not a lot of people running around with actual training who took a year and spent it with somebody. So you may not actually have direct access to a laryngologist. There are a lot of people who are now starting to get appropriate laryngology training, as more and more laryngologists end up at academic centers. So I think it is important to have someone at least with an interest and an understanding that a professional singer, professional voice user is not the same thing as your grandmother singing in her church choir, although it may be as important to her, the issues, the technical issues in surgery and treatment are very different. Somebody who has a grasp of that and finding somebody you can work with who is also willing to learn from the people around them. I’m not a singer, but during my fellowship I was required to take singing lessons, and it gave me an understanding of the patients I was going to treat, and it helped me to be able to ask what they were doing with their singing teacher and understand what that meant. So the person you work with doesn’t have to be world-class everything, but they do need to have the desire to learn from you and other people around, I think every member of the team has something to contribute. I tend to be the face they look at to tell them the answers, but I don’t necessarily have all the answers, but I’m willing to be educated by those around me that do. Audio link.
Kate Emerich – The speech language pathologist and singing voice specialist aids in sometimes differential diagnosis. If Dr. Abaza or the laryngologist you are working with cannot get a flexible or rigid endoscopy done, then oftentimes, I will do some trial therapy to get the larynx in a position where she can get a scope in to visualize the vocal folds. I also am the person who does the acoustic assessment some of the time in the voice lab setting, and also the voice assessment, singing voice assessment and treatment if it is appropriate. Dr. Abaza takes care of the medical treatment. I will create a treatment plan for the singer (if I’m working with a singer), then depending on the vocal folds that I’m dealing with, we’ll create a treatment plan with both speech and singing voice exercises. That can be 3-4 months or longer, depending on the problem. Audio link.
Graham Welch – My comment is not from any of those perspectives, but from visiting various clinics, including my first visit to the NCVS in Iowa, and the developments that have gone on in the UK over the last 10 years. I referred this morning to Engeström’s work in activity theory. This grew out of hospital/clinical studies in Scandinavia, particularly Finland, where they discovered that there were multiple perspectives in what the patients needs were. [….remaining in audio link….]. Audio link.
Leon Thurman – My context is that I am employed in a hospital setting/medical center. There is an entity called Fairview Voice Center that’s part of rehabilitation services at Fairview-University Medical Center. My colleague at other end (referring to D. D. Michael) is at the university campus and I’m at the riverside campus. My speech-pathologist colleague and I work with people with diagnosed voice disorders, diagnosed most of the time by ear-nose-throat physicians, sometimes primary care physicians, and referred to us. I’ve seen the people who are singers or actors, people who, shall we say, "use their voice in athletic ways", clergy, etc. I participate under the guidance of a speech pathologist; I participate in the therapeutic care of those patients. And at the same time I do what we refer to as voice education – singing or speech lessons, etc. My title is specialist voice educator. Specialist in the sense that a voice educator, so-called "non-specialist" voice educator might be a person that might not have a background to work in a quasi-therapeutic type setting. […click on the audio link for remaining text…]. Audio link.
Karen Wicklund – Just briefly, coming at it from the view of just a singing teacher, although I almost have a masters in speech pathology now, but there are singing teachers only who assist the team as well. They may be singing teachers who really rely on what the SLP and otolaryngologists are helping them with. They also are the point of entry; the singing teacher is often the person that hears the voice first and says ‘gee, I think you need to see the doc’. Also you should know if you are a singing teacher and do not have an SLP background, your services are not reimbursable, and the singer has to pay out of pocket, at least at this point, that is one other reason I’m getting my SLP degree. Audio link.
Bill Reilly – Just to more clearly define what our teams are…all headliner research scientist do study voice, and several has been to my studio and taken a lesson. Our team structure is that the point of entry is the laryngologist’s office. All who want to go through this voice regime are required to work with both a speech pathologist and a voice trainer, usually me, often others. The other team members include physical therapists, massage therapists, acupuncturists; psychotherapy is required for many of them and hypnotherapy is very helpful in other cases. […listen to audio link for full answer.] Audio link.
Linda Carroll – I wanted to go back a little bit to some of the other things that the team is critical with an individual that is having a voice disorder. Think about the environment that a patient goes to when they first go to the laryngologist's office and they admit yes, they’re having a problem. The lighting is severe and so is their reaction sometimes. I think that sometimes it’s difficult for a laryngologist in the brief time they typically have in their schedule to see the patient to get a full profile as to what’s really going on with this patient to find out "are there any other factors that precipitated this voice problem?" [….listen to audio link for full answer…] Audio link.
Deidre Michael – I don’t have a whole lot to add to that. As the singing teacher and the speech language pathologist on our team, I actually do gather all of the history. That history does include all of the medical stuff and also the little repertoire things. I’m the one that can get to the ‘oh, it is that phrase that is getting to you, I understand what that is’ and the otolaryngologist doesn’t need to hear that, I know how to truncate that for him and say ‘this is what is up’. The singer can spend ½ hour giving that to me, and I can give it to him in one sentence. The other thing that happens is in the course of treatment, then, things do come up and I become the liaison for all those other team members; that also can include the GI Specialist, a visit to the TMD Clinic, the Feldenkrais specialist, all of those, and I’m the one to invite the singing teacher to "please come in to sessions and watch what we are doing and let me talk to you about where do we go" in the terms of the singing lesson from the singing lesson. Audio link.
Mona Abaza – The patient probably believes it’s me, but it isn’t me, because quite honestly, I have the least amount of time in my schedule to see them. They come in; this is a big admission: “I’ve got a voice problem, I was sent here.” I stick this large thing down their nose, and I stick a rigid object in their throat, and they’ve got a monitor, and they’re staring up and they’re not blind and they see ‘the mass’ or ‘the problem’. They see that, and nothing else out of my mouth do they hear, quite honestly they hear every third word out of my mouth, so I need someone else to take the history, gather information, coordinate things, and who hopefully the patient will confide in. […listen to audio link for full answer]. Audio link.
Kate Emerich – The nice thing about being in such close contact with the team, is that as a speech pathologist and the singing voice specialist, I see these patients weekly. So I can find out ‘how are you doing with your reflux meds’ and ‘how are you doing in general’. Because they see me on a weekly basis, they have confidence in me and trust me. [Listen to audio link for full answer..] Audio link.
Bill Reilly – Actually, not all of us are in close proximity. When I was working with Dr. Gould, I was actually in his office, but now I’m working more with another doctor and I’m not in her office, but we do communicate several times a week. We have to teach the patient to assume an active role in communication. Whenever a patient visits me, I make sure I’m calling the doctor during that session so the patient gets a confidence to know that we’re in communication. The doctor will pick up for me when I call since I have built a team with relationships that work well. Audio link.
Leon Thurman – Just a quick comment – one key element about a team concept is that all members of the team listen to each other, trust each other and take into consideration the various perspectives about every patient and so forth. I’ve been associated in certain circumstances when that has not been the case and it is not helpful to anyone including the people called patients. Audio link.
Commentary, Paul Kiesgen – I think it seems clear that building relationships seems to be the strongest message out of all of this, and I think you would all advise to build the relationship before we need it. To get to know the people in the community, just introduce yourself and get to know them so that when you need them you can make that contact. Audio link.

Filipa Lã - I saw a lot of specialists working in this team, I think this is great, but I was wondering why you don’t also include an endocrinologist? Because 25% of voice disorders are related to hormone inbalances, and there are women with hypo-thyrodism function that causes the voice disorders, I think from my point of view, as a singer it would be very important also to have an endocrinologist on the team. Because the problem is not always in the source; it could be in other parts of the body. Audio link.
Linda Carroll. Audio link.

Lynn Helding – What happens to the person when they are no longer a patient? That leads me to the question of where we are with the singing voice specialist as a subfield? We all know that therapy is short-lived, it is often covered by insurance, but usually only 4-6 visits; then, if the professional voice user goes back to the same teacher or same situation, they are likely to show up in another year with the same problem. Audio link.
Linda Carroll. Audio link.
Mona Abaza. Audio link.
Karen Wicklund. Audio link.
Bill Reilly. Audio link.

Irene Feher – I think also, too, as a general education, we at McGill University, the Music faculty has established a wonderful relationship with the McGill University Health Center. We have a vocal area meeting where two prominent laryngologists from Montreal came and educated and spoke with the students as a group. The more I’m seeing this, I’m thinking this is a good relationship to establish with universities or faculties; do your groups do these kinds of things as well? Audio link.
Deidre Michael. Audio link.

Comment, unidentified audience member – Just a comment, built out of personal experience, when I first started to teach at my university, the health services would not even listen to me. They wouldn’t even grant that I was doing anything. Gradually, they came to trust the voice teacher. Now, I keep telling them “I’m not a doctor, please sent that person to this laryngologist”, or whatever. Last year, our health services at the university tried to get me to speak at the Association of College Health Services, and that association deemed it ‘not a worthy subject’. So if anybody in this room has pull to get anybody knowledgeable in that to start to talk to the college health services, especially if they have theatre and music departments, they have to be on board here, that’s a critical area. Audio link.
Deidre Michael. Audio link.

[Comment] unidentified audience member – No matter how elaborate the team, it all boils down to the fact that the most important member is the patient, and if they’re not compliant, then it’s all for naught. Maybe that boils down to education as well. Audio link.