International Student Placement 2013

I arrived in Chennai, India on June 16^th and was instantly taken aback by the differences in sights, smells, animals, foods and dress. My placement site was at a prestigious medical college called Sri Ramachandra Medical College (SRMC). It is on the outskirts of the city and its green campus is where I called home for 10-weeks. During my initial meeting in the speech-language pathology department at Sri Ramachandra Medical College I felt like I was being welcomed into a family who was there not only to guide me academically, but also through life in India for the next 10-weeks.

I started my internship with the assumption that I would be working in a voice and fluency clinic, but the variety of clinical experiences I had over the course of the placement was invaluable. With various faculty members and student clinicians at SRMC I was able to see patients in the paid and free hospital ward, outpatient rehabilitation clinic, fee-based rehabilitation clinic and multidisciplinary specialist school, Vidya Sudha. The patients I saw ranged in age from premature infants in the neonatal intensive care unit to elderly patients, and all those in between. I was able to observe, discuss and work hands-on with clients in a wide range of disorder areas including acquired language, dysphagia, fluency, voice and articulation. I worked in areas that many students don’t get exposure to in Toronto, including infant feeding and cleft lip and palate. Working with local speech-language pathology student clinicians was a great experience. They acted both as translators and friends throughout my 10-weeks in India. We often worked together sharing ideas based on our unique clinical experiences. In these situations the learning was definitely bi-directional. I learned a lot about assessing children and adults informally using whatever resources were available at hand and formally, using instrumental assessment methods like nasoedoscopy (during assessment of children with cleft lip and palate) and stroboscopy (during assessment of voice patients).

I was not only exposed to a wide variety of disorder areas and unique programs within the clinic at Sri Ramachandra Medical College (SRMC), but was given the opportunity to experience different rehabilitation sites and programs outside of Chennai. They added to my learning experience and allowed me to compare speech-language pathology services within South India and to those available in Toronto.

Thirvannamalai Transforming Faces Cleft Lip and Palate Camp is a multidisciplinary outreach program organized by speech-language pathologists from SRMC. I got the chance to travel to Thirvannamalai for the day where we assessed and referred patients to the appropriate health professional (i.e. orthodontics, plastic surgery, articulation therapy through community workers) based on their needs. I learned how to act quickly, yet be thorough during an assessment and make the necessary decisions quickly so that all patients could be seen that day.
I visited the State Resource Training Center, which is an organization that conducts audiological screenings in order to determine the disability status of Indian citizens. Here I learned about the process of obtaining disability status in India and resources that were made available to those that qualified. I had wondered why speech and screenings weren’t being done and was saddened to learn that having a speech or language disorder is NOT considered a disability in India!
I travelled to the East Coast Road where the National Institute for the Empowerment of People with Multiple Disabilities (NIEPMD) is located. Over 2-days we were given a tour of the facility and met all the different members of the interprofessional team. NIEPMD is a governmental organization whose vision is for people with multiple disabilities to have equal rights and to have a better quality of life. The programs offered were extensive ranging from an early years special education school to vocational training. Housed in an environmentally inclusive building, NIEPMD was an inspiring environment filled with knowledgeable and welcoming clinicians.
In Bangalore, India I visited the National Institute of Mental Health and Neurosciences (NIMHANS), which is a multidisciplinary academic, research and health care institute that emphasizes the relationship between neurology and mental health. During our 2-day visit, I was able to shadow respected speech-language pathologists and work collaboratively to assess a client with dysarthria. I saw clients from all over India and surrounding countries who came in order to get services at this nationally renowned center.
Perhaps the most emotional experience during my 10-week placement was a 3-day Laryngectomee Camp located in Chennai. Here I worked directly with patients who had undergone a laryngectomee surgery in order to give them a voice. The 3-day intensive therapy camp focused on teaching esophageal speech because it is the most financially feasible option for most patients. Supported financially and organized by the Cancer Research and Relief Trust, patients were given a unique opportunity that included housing, food, speech therapy, medical consultations, meditation therapy and perhaps most importantly group support. I was able to see so many patients make significant gains in their voicing abilities and levels of confidence. At the end of the camp, one of the patients I worked with daily gave a speech using esophageal speech and explained how happy he was to once again have a voice.

Living in a country so remarkably different from home has required me to open my mind to the uniqueness of India and be flexible while adapting to my surroundings. I have become aware of cultural differences that exist between India and Toronto in the organization of the system, the way speech-language pathology services are administered and interactions with clients. I learned about the importance of making your assessment materials both culturally and linguistically relevant so that you don’t misdiagnose differences as disorders. I also had to make individually feasible management plans taking into account the influence of culture on the understanding of disability and families’ financial situations. For example, there was a limited use of augmentative and alternative communication techniques and other assistive devices because of the associated stigma. The importance of family involvement and support was seen through intensive demonstration therapy and caregiver accompaniment in special education schools. The interplay between traditional Ayurvedic medicine versus the current medical model and its impact on health services and clients reaction to recommendations was a particularly interesting phenomenon. This was also brought up during the Transforming Faces outreach camp where initially a lot of work had to be done in the community to detach the stigma related to cleft lip and palate and the introduction of a modern medical management approach. I think that this is a really interesting cultural phenomenon and one that plays into the holistic approach to care. Despite the cultural differences that I soon became accustom to, the theoretical understanding of speech-language disorders was the same half way across the world. Integrating my theoretical knowledge and understanding of disability into the beliefs and customs of a different culture is a skill developed here in India but is equally applicable and important in Toronto.

From the outset I attempted not only to expand my clinical knowledge base but also immersed myself in the culture by exploring Indian life outside of the College. I wasn’t able to buy a completely new wardrobe for my 10-week stay but I dressed conservatively both for work and leisure and bought a few traditional shirts they call “Kurtha Tops”. I attended a daily Yoga course for the first half of my placement and learned of its significance to Indian culture while trying to perfect this art of the body. I travelled to different sights including temples, churches, a beach and shopping areas during my free time. I learned to navigate the public bus system, bargain with “auto rickshaw” drivers and eat with my hands. However, it was when I felt comfortable dodging cars, motorcycles (2-wheelers) and cows while crossing at an intersection that I had truly adapted to my surroundings! I have enjoyed being immersed in such varied clinical experiences. I’ve not only increased my clinical skills but have learned to appreciate a different culture and how to adjust my assessment and treatment techniques to suit these differences. This clinical experience has solidified my understanding of the importance of being not only clinically but also culturally competent as a speech-language pathologist.

Asha Shelton