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Inside SLP is a limited series podcast that reveals how our profession came to be and why it functions the way it does. Most clinicians work inside a system they were never taught to see, shaped by decades of history, policy, economics, and unspoken assumptions. This show offers lightbulb moments that bring clarity to the structures beneath our everyday work and opens space for thoughtful, grounded understanding of the field we share.
Welcome to Inside SLP. This is a limited series podcast about how our profession came to be and where it's heading. Most of us work inside a system we were never taught to see. Inside SLP offers a way to understand that system with more clarity, calm, and context. Each week, we explore one idea that helps illuminate the structures, histories, and tensions shaping our field.
Megan Berg:This podcast is not about outrage or quick solutions. It's about understanding a complex profession so we can navigate it with more confidence and curiosity. I'm Megan Berg. Let's look inside. This series makes the most sense if you start at the beginning.
Megan Berg:Each episode builds on the last. In the last episode, we looked at our patchwork of regulations and licensing standard, which shined a light on how our clinical training structure makes it challenging to have unified definitions of competence across the country. Today, we're stepping into one of the most defining structures in our profession: our training pathway. If you've listened from the beginning, you've probably noticed a theme emerging. So much of what we take as normal in SLP was not designed with intention.
Megan Berg:It was inherited. And nowhere is that more clear than in the path each of us walked to become a clinician. Today, I want to tell you a story about six professions. Imagine them lined up at the starting line of their careers: audiology, occupational therapy, physical therapy, clinical nutrition, nursing, and speech language pathology. Everyone puts on the same backpack at the beginning: coursework, foundational sciences, the early pieces of clinical reasoning.
Megan Berg:And then something very predictable happens. For almost all of these professions, the backpack gets heavier inside of the degree. Audiologists complete all of their clinical training inside the AUD. OT and PT students complete all of their fieldwork before graduation. Nurses complete supervised clinical rotations before sitting for boards.
Megan Berg:Dietitians complete their supervised practice within coordinated programs. It's all wrapped together. The degree contains the supervised clinical training and then you take a national exam and get your state license. It's a single integrated pipeline. But when you look at SLP, the backpack gets split into two.
Megan Berg:Inside the degree, you get coursework and a portion of clinical hours. Sometimes robust, sometimes thin, sometimes tightly supervised, sometimes loosely structured. It varies widely and programs technically only must provide the opportunity for clinical hours but do not uniformly guarantee completion. Some students graduate with three seventy five hours, some graduate with many more, and a small number finish with fewer often because their career goals are not clinical. But then after graduation comes an entirely different stage.
Megan Berg:The clinical fellowship year, the CFY, our rite of passage, our cultural norm, our shared vocabulary, the part we rarely question. And yet, this structure is astonishingly unusual. Based on everything we know, SLP is the only allied health or education adjacent profession in The United States where the bulk of supervised clinical training happens after graduation, under a provisional license, funded by an employer, and overseen by a national association whose certification is optional in most of the country. This is the part of the profession where the story gets interesting and complicated. Because we've normalized the CFY, we've unintentionally normalized a whole ecosystem around it, including minimal required supervision.
Megan Berg:Over nine months, a CF only needs thirty six total hours supervision. That's an average of one hour a week. Some members go far beyond this and many do not. Additionally, the employer pays the trainee. This is the opposite of nearly every other healthcare training model.
Megan Berg:In OT, PT, nursing, dietetics, and psychology, students pay tuition while completing their supervised clinical work. The university owns the training. In SLP, we place the cost including financial, logistical, and emotional on employers and supervisors. Supervisors are often unsupported and uncompensated. Many CF mentors carry full productivity expectations with no protected time for teaching.
Megan Berg:Supervision is often treated as an add on, not a core responsibility. The CF is hired as staff and is not seen as a learner. This creates a philosophical tension. Are they here to work or to be trained? Most settings treat the answer as both, even when being both is nearly impossible.
Megan Berg:Managers who hire across disciplines run into contradictions. A rehab director once told me, If I hire an OT new grad, they're fully trained and fully licensed. If I hire a PT new grad, same thing. If I hire an SLP new grad, I'm inheriting a nine month training program I'm not equipped to run. Many settings don't realize the CF is not just a paperwork step.
Megan Berg:They think it's a formality, a period of observation, not actual training. And that misalignment causes real problems for safety, supervision, and expectations. Additionally, provisional licensing complicates billing and policy. SLPs in their CFY often hold a provisional license when one is available. And in many states, that provisional license restricts billing.
Megan Berg:Sometimes CMS or the Centers for Medicare and Medicaid Services changes its interpretation of who can and cannot bill and the profession scrambles. We saw that chaos unfold in 2025 and all of this stems from the same root. Our clinical training is not integrated into the degree. How did this become normal? Partly, it's the structure we inherited, partly because the CCC became the historical container for clinical training long before states regulated practice, and partly because when you live inside a system long enough, you forget that it was built and that it could be built differently.
Megan Berg:Audiology used to look like SLP. You needed a master's degree, you had to complete a postgraduate clinical fellowship, and then obtain an optional certification. But audiologists spent about fifty years reshaping their pathway. They created the AUD, they built an alternative accreditation body, they wrapped all of their clinical training into the degree and they removed themselves from dependence on the CFY CCC model. Whether or not that system is perfect is not the point.
Megan Berg:The point is, it's possible for a profession to rebuild its training pipeline on purpose. SLP has never meaningfully done that. When I started researching this topic years ago, I thought the CFY was just outdated. Just abolish it, I thought, fold it into the degree like everybody else. Problem solved.
Megan Berg:But the more I learned, the more I understood how deep the contradictions run. You can't collapse the CFY into the degree without restructuring everything from university accreditation, the financing of clinical placements, supervisor training requirements, state licensure laws, national certification models, the economics of graduate education, and the expectations of employers. Every lever pulls another lever. Every change ripples outward. And that's why the system hasn't changed.
Megan Berg:Not because people don't care, but because it's incredibly interconnected. The way we train clinicians affects workforce shortages, burnout, supervision quality, billing compliance, patient safety, career mobility, equity in graduate education, and the sustainability of the profession. And yet, most SLPs have never been taught how unusual this pathway is. When we can't see the system, we can't ask better questions of it. Speech Language Pathology didn't arrive at this training model because it was the best option on the table.
Megan Berg:It arrived here because it was the option that worked well enough at the time and then it just stayed in place. Once clinical training moved outside the degree, the rest of the system adapted around that gap. Certification absorbed it, employers inherited it, states regulated around it, and students learned to treat it as a rite of passage rather than a design choice. And for decades, that structure held. Not comfortably comfortably or elegantly, but consistently enough that we stopped asking whether it still made sense.
Megan Berg:What often gets lost in these conversations is that other professions faced the same pressures. Limited university capacity, evolving scopes of practice, uneven regulation, and they made different choices over time. Like we've covered, audiology used to look a lot like speech language pathology. And then slowly and deliberately and with a lot of internal conflict, they changed their training pipeline. It doesn't mean that their system is perfect.
Megan Berg:It does tell us something important. The structure we're living inside is not inevitable. So the question isn't just why is our training model so unusual? The harder question is why? After more than seventy years of knowing it was unusual, did the degree itself never change?
Megan Berg:And that's where we're going next. In the next episode, we'll step back into the history of speech language pathology and look at how a temporary workaround became permanent. Not because anyone decided it should be, but because redesign turned out to be far harder than adaptation. If you want to take this deeper, I invite you to learn more about the PACT survey, a large scale research project examining how SLPs, audiologists, employers, educators, and consumers experience the system we all work inside. Learn more at pactsurvey.com, and you can reach out to me anytime at therapy insights dot com slash inside SLP.
Megan Berg:Thanks for sitting in the complexity. I'm Megan Berg. This is inside s l p. This podcast reflects my own research, analysis, and interpretation. It is not affiliated with, endorsed by, or produced in collaboration with ASHA or any other professional association.
Megan Berg:Association. Historical information referenced in this episode is drawn from publicly available sources, including the book The First seventy five Years: An Oral History of History of the American Speech-Language-Hearing Association (1999), by Russ Malone, former Public Information Director for ASHA, along with publicly available legislative records and archival materials. Any errors or interpretations are my own.