A Guide to Voice Care Providers
Optimal voice care is delivered by an interdisciplinary team consisting of physicians and nonphysicians. The physician may be an otolaryngologist (a specialist who practices all aspects of ear, nose, and throat medicine) or a laryngologist, who specializes in voice and swallowing disorders. The physician commonly collaborates with other professionals, such as a speech-language pathologist, singing voice specialist, acting-voice specialist, nurse, and others who constitute the voice care team. Under the best of circumstances, all of the members of the team have received special training in not just the general aspects of their disciplines but also additional training in care of the voice. Although even the best training does not guarantee clinical excellence, it does improve the probability that a practitioner will provide superior, modern voice care. This chapter reviews the typical training and qualifications of the professionals associated most commonly with voice care teams.
The Voice Care Team
A voice care team is ordinarily under the direction of a physician who is usually an otolaryngologist or laryngologist. In addition to the physician who diagnoses and provides medical treatment for voice disorders, the team includes the speech-language pathologist, who provides voice therapy and attends to problems that affect the speaking voice; a phoniatrist in countries without speech-language pathologists; a singing voice specialist; an acting-voice specialist; a nurse and/or a physician’s assistant; sometimes a voice scientist; and consultant physicians in other specialties. It is helpful for patients to understand the background and role of each key member of the voice team, as discussed below.
Otolaryngologist / Laryngologist
The leader of the voice care team is ordinarily a physician (otolaryngologist). Otolaryngologists are physicians (surgeons) who specialize in problems of the ears, nose, and throat (ENT). Laryngologists are otolaryngologists who specialize in care of disorders of the larynx (particularly voice problems) and, in some cases, related problems such as swallowing. To practice laryngology, one must first complete training as an otolaryngologist. To become an otolaryngologist, a person completes college, 4 years of medical school, and 5 or more years of residency in otolaryngology head and neck surgery. In the year following completion of residency, the physician takes a national, standardized board examination given in 2 parts (written and oral) to become a “board certified” otolaryngologist. Certification by the American Board of Otolaryngology, or the equivalent organization in other countries or for osteopathic otolaryngologists, is an important indicator of mastery of basic knowledge in otolaryngology and is considered a basic, minimum qualification. The only exception is “board eligibility” in the case of a physician who has finished residency but has not yet successfully passed the board examinations. Board certification is not granted until a physician has had about 1 year of clinical experience following residency and demonstrated competency on the oral and written board examinations.
Most otolaryngologists’ clinical practices include many or all components of the specialty, such as otology (disorders of the ear and related structures), laryngology (disorders of the voice and upper airway structures such as the throat and trachea), head and neck cancer, head and neck neoplasms (masses including benign or malignant lesions), facial plastic and reconstructive surgery, allergy and immunology, bronchoesophagology (lower airway and swallowing disorders), rhinology (nose, sinus, taste, and smell disorders), and pediatric otolaryngology (ear, nose, and throat disorders of children). Most otolaryngologists and laryngologists care for patients of all ages from early childhood through advanced years. Some otolaryngologists subspecialize, caring for disorders in just one or two areas of otolaryngology. This subspecialization can either be a keen interest in a specific area while still providing a broad range of ear, nose, and throat care, or the focused practice of only one or two of the subcomponents of otolaryngology. Laryngology is one such subspecialty.
Most of the senior physicians specializing in laryngology today did not receive laryngology fellowship training. That is always the case as a new field develops. Modern laryngology evolved out of an interest in caring for professional voice users, especially singers. The first comprehensive article guiding otolaryngologists on care of professional singers was published in 19811; the first major modern American otolaryngology textbook with a chapter on care of the professional voice was published in 19862; and the first comprehensive book on care of the professional voice was published in 1991.3 So, most of the senior laryngologists practicing at the turn of the 21st century were involved in the evolution of the field before fellowships were developed. Most fellowship training programs started in the 1990s, although a few informal fellowship programs existed in the 1980s and earlier. It is reasonable to expect most voice specialists who finished residency training in the 1990s or later to have completed a fellowship in laryngology. There are approximately 2 dozen laryngology fellowship-training positions in the United States, and they are highly competitive. At present, completion of a fellowship is a reasonably good indicator of superior knowledge and clinical training in laryngology. Most laryngology fellowships include training in the diagnosis and treatment of voice disorders in adults and children, neurolaryngology (neurological problems that affect the voice and larynx), swallowing disorders, airway reconstruction, and laryngeal cancer. The training includes both medical diagnosis and treatment, and sophisticated laryngeal surgery. Typically, laryngologists care for both routine and complex problems that affect the voice. Such problems include voice dysfunction associated with something as simple as a common cold, especially when it affects the voice of a professional singer or actor. However, laryngologists also are called on to diagnose and treat structural lesions such as nodules or polyps, prolonged infections of the vocal folds, cancer, traumatic injury from fracture or internal trauma (intubation injuries from anesthesia, vocal fold injuries from previous surgery), neurological disorders, and other voice problems. The laryngologist is responsible for establishing a medical diagnosis and implementing or coordinating treatment for the patient. The laryngologist may prescribe medication, inject botulinum toxin, perform delicate microsurgery on the vocal folds, or operate through the neck on the laryngeal skeleton. He or she is also usually responsible for initiating evaluation by other members of the voice team and for generating referrals to other specialists as needed.
Laryngologists may practice in university medical centers or private offices, and in major cities in the United States, they are usually affiliated with a voice team including at least a speech-language pathologist, a singing voice specialist, and sometimes an acting-voice specialist. Laryngologists also should have, or have access to, a clinical voice laboratory with equipment to analyze the voice objectively and a stroboscope to visualize the vocal folds in slow motion. They also should be familiar with physicians in other specialties who have an understanding of and interest in arts-medicine. Even for patients with a voice disorder who are not singers and actors, such knowledge and sensitivity are important. Just as nonathletes benefit from the orthopedic expertise of a sports-medicine specialist, voice patients receive more expert care from physicians trained to treat singers, the “Olympic” athletes of the voice world.
Currently, there is no official additional certification for those who have completed a laryngology fellowship. However, there are organizations (medical societies) with which many of the leading laryngologists are affiliated. Essentially all laryngologists in the United States are fellows of the American Academy of Otolaryngology-Head and Neck Surgery (http://www.entnet.org), and laryngologists in other countries are members of their nations’ analogous organizations. A few are also members of the American Laryngological Association (ALA), the most senior otolaryngology society in the United States (http://www.alahns.org). The ALA also accepts “associate members” from other countries. Some laryngologists belong to the American Bronchoesophagological Association (http://www.abea.net), and the Voice Foundation (http://www.voicefoundation.org). The Voice Foundation was founded in 1969 and is the oldest organization dedicated to voice education and research. It provides seed grants for research, sponsors an annual symposium on care of the professional voice that started in 1972, and fosters voice education through conferences, educational videotapes, books, and publications such as the Journal of Voice and the Voice Foundation Newsletter. In recent years, several countries have developed organizations similar to the Voice Foundation, such as the British, Canadian, and Australian Voice Foundations. Laryngologists in such countries are usually members of their national organization, and many are also members of the Voice Foundation (Philadelphia, Pennsylvania). Although membership in these organizations is not a guarantee of excellence in practice, it suggests interest and knowledge in laryngology, particularly voice disorders.
A speech-language pathologist is a certified, licensed health care professional, ordinarily with either a master’s degree (MA or MS) or doctorate (PhD). After college, speech-language pathologists generally complete a 1- or 2-year master’s degree program, followed by a 9-month, supervised “clinical fellowship,” which is analogous to a medical internship. At the conclusion of the clinical fellowship year, speech-language pathologists in the United States are certified by the American Speech-Language-Hearing Association, and use the letters “CCC-SLP” after their names to indicate that they are certified. Like otolaryngology, speech-language pathology is a broad field that includes care of patients who have had strokes or other neurological problems affecting speech and swallowing, undergone laryngectomy (removal of the larynx), have swallowing disorders, have articulation or stuttering problems, have craniofacial disorders, or have other related fluency disorders of speech, or have disordered swallowing. Some speech-language pathologists subspecialize in the care of voice disorders. The speech-language pathologist affiliated with a voice team is usually such a subspecialist and may call himself or herself a “voice pathologist” rather than a speech-language pathologist, although “voice pathologist” is not a term recognized officially by the American Speech-Language-Hearing Association, yet. Relatively few speech-language pathology training programs provide extensive education in voice, and there are virtually no voice fellowships for speech-language pathologists. Many speech-language pathology training programs do not require even a single course on complex medical voice disorders. Thus, it cannot be assumed that all speech-language pathologists are trained in or comfortable with caring for individuals with voice problems. Most acquire the subspecialty training they need through apprenticeships, extra courses, and symposia, or by obtaining doctoral degrees that include voice-related research.
Speech-language pathologists are responsible for voice therapy and rehabilitation, which is analogous to physical therapy. The speech-language pathologist analyzes voice use and teaches proper voice support, relaxation, and voice placement to optimize use of the voice during speaking. A variety of techniques are utilized to accomplish this goal. Speech-language pathologists do not ordinarily work with the singing voice, although they are involved in the treatment of speaking voices of singers.
Speech-language pathologists may be found in universities, private offices, or freestanding speech and hearing centers. In the United States, most are members of ASHA (the American Speech-Language-Hearing Association), and its voice-related special interest division (SIG-3), which can be accessed on the Internet. Many speech-language pathologists with special interest in voice in the United States and elsewhere are also members of the Voice Foundation. Like otolaryngologists, speech-language pathologists who subspecialize in voice provide more incisive, state-of-the-art treatment for voice disorders than most general speech-language pathologists who care for patients with various problems encompassing the entire field. So, it is worthwhile for patients with voice disorders to seek out a subspecialist to improve the likelihood of a rapid, excellent treatment result. Referrals to speech-language pathologists specializing in voice usually are obtained through a laryngologist or otolaryngologist.
Phoniatrists do not exist in the United States, but they provide voice care in many European countries. The phoniatrist is a physician who is in some ways a hybrid of a laryngologist and speech-language pathologist. Phoniatrists receive medical training in diagnosis and treatment of voice, swallowing, and language disorders, including voice therapy, but they do not perform surgery. In countries with phoniatrists, surgery is performed by otolaryngologists. In many cases, the phoniatrist and otolaryngologist collaborate as a team, just as otolaryngologists and speech-language pathologists do in the United States and elsewhere. A physician who has completed training in phoniatry is generally well qualified to diagnose voice disorders and provide nonsurgical medical care, as well as voice therapy.
The singing voice specialist is a singing teacher with special training equipping him or her to practice in a medical environment with patients who have sustained vocal injury. Most singing voice specialists have a degree in voice performance or pedagogy, although some have only extensive performing and teaching experience without a formal academic degree. Nearly all have professional performance experience, as well as extra training in laryngeal anatomy and physiology of phonation, training in the rehabilitation of injured voices, and other special education. The singing voice specialist must acquire knowledge of anatomy and physiology of the normal and disordered voice, a basic understanding of the principles of laryngology and medications, and a fundamental knowledge of the principles and practices of speech-language pathology. This information is not part of the traditional training of singing teachers. Moreover, so far there are no formal training or fellowship programs that assist singing teachers in becoming a singing voice specialist. Their training is acquired by apprenticeship and observation. Many take courses in speech-language pathology programs, but usually not as part of a formal degree or certification program.4 There is no certification of singing voice specialists. A few of the best singing voice specialists are also certified, licensed speech-language pathologists. This combination is optimal, provided the speech-language pathologist has sufficient experience and training not only as a performing artist but also as a teacher of singing. In patients with vocal injuries or problems, the fundamental approach to training the singing voice is different in important ways from that usually used with healthy students in a singing studio. Hence, even an excellent and experienced voice teacher may harm an injured voice if he or she is not familiar with the special considerations for this population. In addition, many voice teachers do not feel comfortable working with a singer who has had a vocal injury or surgery.
Virtually all singing voice specialists are affiliated with voice care teams. Most are members of the National Association of Teachers of Singing (NATS), or the equivalent organization in another country, and of the Voice Foundation. In many cases, their practices are limited to work with injured voices. They work not only with singers, but also with other patients with voice disorders. As a member of the voice treatment team working with nonsingers, they help teach speakers the “athletic” techniques utilized by singers for voice production. Singing is to speaking as running is to walking. When rehabilitating someone who has difficulty walking, if the person can be helped to jog or run, leg strength and endurance improve and walking rehabilitation is expedited. The singing voice specialist applies similar principles to voice rehabilitation in collaboration with the speech-language pathologist and other voice care team members.
Singing Voice Specialist
Acting-voice trainers also are called voice coaches, drama voice teachers, and voice consultants. Traditionally, these professionals have been associated closely with the theater. Their skills have been utilized as part of a medical voice team only since the mid-1990s.5. Consequently, only a few acting-voice trainers have any medical experience, but their contributions have proven invaluable.
Acting-voice trainers use a variety of behavior modification techniques designed to enhance vocal communication, quality, projection, and endurance in theatrical settings. They train actors to speak or scream through 8 shows a week, and/or theatrical runs that may last years, without tiring or causing injury to their voices. They also teach techniques for adding emotional expression to vocal delivery, and they work with body language and posture to optimize vocal delivery and communication of information. They may be a great asset to the voice team in teaching people how to apply the many skills learned through the speech-language pathologist and singing voice specialist to their everyday lives. Acting-voice trainers are especially valuable for people who speak professionally such as teachers, lecturers, politicians, clergy, sales personnel, and others concerned with effective vocal delivery and with vocal endurance.
There are no formal programs to prepare voice coaches to work in a medical milieu. Those who do receive training generally do so through apprenticeships and collaboration with medical voice care teams under the direction of a laryngologist.
Acting-voice trainers interested in working with voice patients are generally members of the Voice and Speech Trainers Association (VASTA) and the Voice Foundation.
Nurses are indispensable assets in medical offices, and they are important members of the voice team in many centers. Nurses who work closely with a laryngologist generally have vast experience in the diagnosis and treatment of voice disorders. They are wonderful information resources for patients and frequently provide much of the patient education in busy clinical settings. These nurses usually are members of the Society of Otolaryngology-Head and Neck Nurses (SOHN). Nurses with advanced knowledge and skills may be certified (by SOHN) as otolaryngology nurses and are identified as such by the initials “CORLN” (certified otolaryngologic nurse) after their names.
Nurse practitioners are advanced practice nurses with master’s or doctoral degrees, who are licensed to provide independent care for patients with selected medical problems. They are identified by the initials “CRNP” (certified registered nurse practitioner). They work in conjunction with a physician, but they can examine, diagnose, and treat selected problems relatively independently. A few nurse practitioners pecialize in otolaryngology and work with voice teams. They ordinarily receive special training “on the job” from the otolaryngologist, and they provide care within their scope of practice. Nurse practitioners also can become members of SOHN, become certified through examination by SOHN, and upon certification will also use the certification CORLN after their names.
Physician assistants, like nurse practitioners, function in association with a physician. Physician assistants graduate from a training program that usually lasts 4 years and teaches them various aspects of medical diagnosis and physical examination. They use the initials “PA” (physician assistant) after their names. They practice in conjunction with physicians but can perform examinations and treat patients independently. They are licensed in many states to write prescriptions. A few physician assistants specialize in otolaryngology, and a smaller number have had extensive training and experience in voice care. In collaboration with a laryngologist and voice team, they are qualified to evaluate and treat patients with voice disorders.
Physician assistants should be distinguished from “medical assistants” who have less training and are qualified to assist in medical care and patient education but generally not to diagnose and treat patients independently. Medical assistants generally are trained to perform tasks such as phlebotomy (drawing blood) and electrocardiograms. In a laryngology office, a good medical assistant can be trained to perform many other tasks, such as taking histories, assisting with strobovideolaryngoscopy, and assisting during the performance of surgical procedures in the office, participating in research, and other activities.
Physician Assistants and Medical Assistants
Otolaryngologists often refer voice patients for consultation with other medical professionals. Other specialists consulted commonly include neurologists (nerves), pulmonologists (lungs), gastroenterologists (stomach and intestinal system), psychologists, and psychiatrists. However, physicians in virtually any medical specialty may be called on to care for voice patients. Traditional and nontraditional ancillary medical personnel may be involved in voice care, including nutritionists, physical therapists, chiropractors, osteopaths (for manipulation), acupuncturists, and others. Within virtually all of these fields, there are a select few professionals who have an interest in and an understanding of arts-medicine. Just as caring for voice professionals (especially singers) involves special considerations and challenges for the otolaryngologist, caring for hand problems in pianists or ankle problems in dancers poses challenges for the orthopedic surgeon. Orthopedic surgeons, neurologists, pulmonologists, and others who are accustomed to working with performing artists (dancers, wind instrumentalists, etc) are most likely to have the insight, sensitivities, skills, and state-of-the-art information needed to provide optimal care to voice professionals. Many such physicians tend to be associated with arts-medicine centers or are performers themselves. There is no certification or broad-based national or international organization that helps to identify such physicians, although some are members of the Performing Arts Medicine Association (PAMA). In most fields, there are no formal arts-medicine training programs or associations. Physicians acquire such training through their own interests and initiative, and through apprenticeship or observation with colleagues. If there is no arts-medicine center in the area in which a patient is seeking care, arts-medicine physicians are identified best by word-of-mouth or through arts-medicine-related websites. Referrals can be obtained through the local laryngologist or voice specialist or by consulting with eminent performing arts teachers in the community. For example, the leading private university and conservatory violin and piano teachers often know who the best hand specialists are; the wind instrument teachers often know whom to see for neurological and pulmonary problems that affect musicians; and dance teachers know the best foot-and-ankle physicians.
Consultant Medical Professionals
Voice care has evolved into a sophisticated, well-organized medical science. Patients with voice disorders are served best by a comprehensive voice team that coordinates the skills of professionals trained in various disciplines. It is important for health care professionals to assemble interdisciplinary teams and to affiliate with arts-medicine specialists and other disciplines in order to provide comprehensive care for voice patients. It is also important for patients to be educated about the kind of health care that is now available for voice disorders and how to evaluate and select health care providers.
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3. Sataloff RT. Professional Voice: The Science and Art of Clinical Care. New York, NY: Raven Press; 1991.
4. Emerich KA, Baroody MM, Carroll LM, Sataloff RT. The singing voice specialist. In: Sataloff RT, ed. Professional Voice: The Science and Art of Clinical Care. 2nd ed. San Diego, CA: Singular Publishing Group; 1997: 735–753.
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