Telehealth Best Practices: Dr. Cate Crowley of Smile Train On How To Best Care For Your Patients When They Are Not Physically In Front Of You

Relationship building is key for speech therapy. Even in a remote setting, it’s important to connect with patients in a comfortable setting. For example, we worked with a teenager in a remote area of Peru who wasn’t excited about doing the speech therapy his mother wanted us to give him. We found that when he took his phone into his room and could close the door, he initially at least reluctantly worked with us. But once he could hear the benefit of the therapy by his own improved speech, he became self-motivated.

One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors wish patients knew in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?

In this interview series, called “Telehealth Best Practices; How To Best Care For Your Patients When They Are Not Physically In Front Of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewing Dr. Cate Crowley.

Dr. Cate Crowley is a speech and language pathologist with a focus on comprehensive cleft care. Specifically, Dr. Crowley’s work with Smile Train and other cleft partners enhances the quality of services for children and adolescents around the world by training students who aspire to be speech therapists.

Residing in New York, she brings an international focus to her cleft palate speech support work and has developed the Cleft Palate Speech Training Project which provides workshops for parents and colleagues who work with children with repaired cleft palates. While Dr. Crowley enjoys her in-person time with her students and patients, she’s grown fond of the opportunities that tele-health has offered throughout.

Can you share the most interesting story that happened to you since you began your career?

The most influential moment, and one that put me on a new professional trajectory, was the first cleft speech therapy training I led in Guatemala City. I created the training with my colleague Dr. Miriam Baigorri, and we put a lot of work into it, but it had never been done before. We didn’t know if we could spend five days in a country doing interactive teaching in the morning and then providing supervision for clinical application in the afternoons to make a sustainable impact. We hoped to train people and change children’s speech during the five days so that when we left Guatemala, the trainees and the parents of the children would have enough skills and knowledge of how it works and what to do next.

One of the families who came was a father and his 3-year-old son who was born with a cleft palate that had been surgically repaired when he was one. As with many children with repaired cleft palates, this boy needed speech therapy. Even at this young age, his father told us how worried he was about his son because children were already bullying him and mocking him for his speech.

During our five-day training, the father came each day with his son. In just a few days he could make four sounds he couldn’t before. The father had found the path for his son that would change his son’s life’s trajectory. I was so moved to a part of this.

The story of this father and son has stayed with me and continues to motivate me to do this work.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

“The unknown is lush and bountiful.” It is a reminder to be less afraid of going in a direction I’ve never been before. Now, I embrace new things in every aspect of my life.

I am so fortunate that work allows me to connect with people from a variety of backgrounds and cultures. When I travel or virtually connect to train teams around the world, I am open to learning about the cultures, perspectives, and experiences of the people in the countries where I am working.

As such, one tremendous, and somewhat unexpected benefit, is the deep personal relationships and friendships I have developed with people all over the world as we join together in our common goal to improve the lives of children born with cleft lip and palate.

Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?

I’ve worked in West Africa for a long time and have had the pleasure of working with Smile Train’s program director for West & Central Africa, Nkeiruka Obi (NK). We have a similar vision, and she can see the potential impact we can have around cleft care and speech in Africa. We are both thinking about how to improve the lives of children born with cleft lip and palate and our individual strengths become synergistic.

NK is a leader and a visionary, and I am so thankful for having the opportunity to work with this incredible person.

Can you articulate for our readers a few of the main benefits of having a patient in front of you?

The main benefit of having cleft patients in front of us for speech therapy is being able to perceive the sounds they’re making when they speak. The core of our work is listening with a fine-tuned ear to hear sounds to help guide our therapy recommendation based on what specifically needs to be addressed.

For us, we’re often working with children and their parents as well. This in-person time is also critical to teach the parent about what sounds to listen for and how to apply certain therapy methods at home.

Another benefit easier to establish in person is the relationship-building aspect — the bond of trust and commitment between the therapist, child and family is foundational to effective speech therapy. However, in fact, I now feel like this is less of an issue. Telehealth has become more commonplace, and therapists have gotten better at ensuring the work is exciting and engaging. People are learning how to develop strong trusting relationships that before could only be established in person.

Based on your experience, what can one do to address challenges within tele-health?

One thing I’ve learned from Trevor Noah is to look in the camera rather than looking down at the image of the person on the screen.

In this virtual world, I have to do what I can to be as present to the person I am talking with online. When I look at the camera, the person sees me as looking directly at them, establishing a more direct and intimate relationship. It was a bit odd to get used to in the beginning, but now it is natural for me to look in the camera, knowing that this makes a stronger connection.

This is something that I’ve incorporated both in my telehealth sessions and for the cleft speech therapy training, and even my graduate-level courses that I’ve been teaching remotely. For speech therapy to be successful, it’s important to make connections so the patients and parents feel the value of the work and ask questions when they don’t understand something or talk about their concerns with progress or approaches. The more connected I am with them, the more likely they are to raise questions and concerns, and that is how progress is made. That direct eye contact helps create a more personal connection.

We also have found that the best way to hear those sounds is by turning off our computer sound and having the parent hold the smartphone close to the child’s mouth. We listen with headphones so we hear the sound the child produces as if we were there. We also help the parents acquire the perceptual skills to hear what the child is producing and understand if there’s air coming through the nose when it shouldn’t be. Over time we have learned how we can provide optimal services through tele-health.

What are your “5 Things You Need To Know To Best Care For Your Patients When They Are Not Physically In Front Of You? (Please share a story or example for each.)

1. Relationship building is key for speech therapy. Even in a remote setting, it’s important to connect with patients in a comfortable setting. For example, we worked with a teenager in a remote area of Peru who wasn’t excited about doing the speech therapy his mother wanted us to give him. We found that when he took his phone into his room and could close the door, he initially at least reluctantly worked with us. But once he could hear the benefit of the therapy by his own improved speech, he became self-motivated.
   In a short period of time, we were able to correct his speech completely. Without the tele-therapy option, it is very doubtful that this teenager would have been willing to come to a speech clinic, surrounded by many much younger children who also needed speech therapy, let alone be fully engaged in the therapy to attain such great results.
2. Provide material to support your recommendations. Over the years, we have been creating cleft palate speech therapy materials in close to 30 different languages that cover all stages of the cleft palate speech therapy hierarchy. The languages we offer mostly are developed by students and trainees so there are materials in the local languages where we have trained people including Ndebele, Shona, Amharic, Spanish, French, Mandarin, Korean, Igbo, Hausa, Yoruba, Bahasa, Kiswahili, Ga, etc.
   These materials are all available for free download and copying at my website leadersproject.org. We also have instructional videos showing how to use the materials if the parents or children forget between visits. We make sure our families know where to access the materials and how to use them no matter where they are and even if “my dog ate the homework!”
3. Adapt to what is most beneficial for the child and their family. We tend to schedule tele-health appointments on a regular basis, once or twice a week, or every two weeks, depending on availability.
   We can also send very short videos reminding them of the particular strategy they are focused on for the week or what we will be looking for them to be doing at the next appointment. We do whatever works best for the family including instant messaging, WhatsApp, private messaging on Facebook, etc.
4. Eye contact is key. Again, from my Trevor Noah lesson, look at the camera because by doing so the child and family will feel you are looking at them directly. This is especially true when working with children who really need that eye contact, but don’t we all?
   The eye contact tells them that you are directly connected to them and fully engaged. Children are getting used to virtual learning, but we have found that to motivate children and families, we need to do everything we can for them to feel connected to us.
5. Mail things to the children and families. If we cannot do therapy in person, we can certainly snail mail various materials to the families. It is fun for the children to receive envelopes or small packages through the mail. These packages might include full-color therapy materials on card stock, including the cleft palate practice books from Leaders Project.
   We can send mirrors that parents can use to see if any air is escaping from the nose when it shouldn’t be. We can send the Smile Train coloring books to give them fun activities even just a couple of index cards. We even send some treats like candy or gum, with the parents’ permission. Anything that fits in an envelope or small package so they can feel that physical connection to us and to the work we do.

Can you share a few ways that tele-health can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?

When I have trained people in Africa, the Philippines, Indonesia, and Latin American, there are children with surgically repaired cleft palates who simply cannot travel the distances to meet up with providers who know how to address cleft palate speech therapy.

While the surgeries can be done with a single visit, this is not the case with speech therapy. Cleft palate speech therapy can be completed in a matter of months, but the therapy does require regular visits to address the different sounds. Telehealth provides access for all the children who need the services, not simply those who live near a provider or whose parents can take the time off from work to travel long distances on a regular basis for the therapy.

What’s more, this tele-health allows mentoring for those therapists who need additional support, as we all do as we learn new information we are applying to our work.

I receive videos through WhatsApp and questions often accompanied by videos in Facebook private messages, instant messages on my phone, and much less frequently email, asking me for advice on a particular child’s speech. It is exciting to watch the capacity build and know that this means that more and more children with cleft palate speech receive the speech services they need.

You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be?

The movement I would like to inspire is to reduce the length of copyright protections for peer-reviewed articles and chapters in my field and others.

While it may seem like heresy to academia and with scientists, I think scholars and researchers should consider using their power to negotiate time limits for the length their work remains under copyright protection.

While the system on its surface appears to be beneficial, encouraging people to produce innovative content, it actually creates an enormous barrier to the flow of information and knowledge globally.

The copyright law creates inequities in the world of health care. Those who have access to the content, usually by being attached to a university or other learning institution, acquire the newest research and clinical approaches. But those without those resources simply don’t have access. Yet, the copyright prohibits access without payment for decades and decades.

This is why I’ve made all the resources on the Leaders Project website are available for anyone to copy, download and distribute. The use of the free material on the Leaders Project website is beyond anything I had imagined. In fact, just last month we had 26,400 views from 142 countries.

How can our readers further follow your work online? Social media or beyond.

The best way to connect with my work is through our website and our social media pages

• Twitter: @leadersproj
• Instagram: @leadersproj
• Facebook: The Bilingual Extension Institute — LEADERSproject or Cate Crowley
• YouTube: LEADERSproject
• Website: https://www.leadersproject.org/

Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.