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.
Hi, everyone, and welcome back to Inside SLP. This series is about how our profession came to be and where it's heading. Most of us work inside a system we were never formally taught to see. This podcast is about slowing down enough to understand that system with clarity, calm, and context. I'm Megan Berg.
Megan Berg:Let's look inside. In late twenty twenty five, I started hearing rumblings about something strange happening in Oregon. The rumor was that the state licensing board was considering completely removing the conditional license for new graduates. This would mean that new graduates in Oregon could become fully licensed without completing the CFY or its equivalent. And online, people had big reactions.
Social media person #3:Honestly, good for Oregon. The CF is just an excuse for employers to pay new grads less for doing the exact same work.
Social media person #2:Six years of coursework, three hundred seventy five clinical hours, and we still don't have agency over our own careers.
Social media person #3:Wait. So if Oregon removes it, do we still have to do the CF to get our CCC? I just worry. What incentive do employers have to offer mentorship if it isn't required?
Social media person #4:They aren't motivated to mentor us even now.
Social media person #5:Maybe the CF should just be optional? Relying on corporate employers to look out for new grads out of pure goodwill is a terrible idea.
Social media person #6:Wait. So if a state removes the conditional license, does that mean you can just skip the CF entirely?
Megan Berg:Before we explain what actually happened in Oregon, I just want us to sit in that confusion for a minute because the confusion is the story. If you're an SLP, you probably went to grad school, completed clinical hours, worked with supervisors, did a CF, got your CCC, and got licensed. And because all of those things happen one after another, it feels like a single, coherent pipeline. But it's not. Your graduate degree is one system, your state license is another, the CF is another, the CCC is another, and over decades, speech language pathology has layered those systems together so tightly that many clinicians no longer know where one ends and another begins.
Megan Berg:So when Oregon proposed eliminating the conditional license, it didn't just spark a debate about administrative rules. It exposed a deep friction within the profession about what the CF actually accomplishes. And the deeper question underneath all of that debate was much bigger. Where is clinical training actually supposed to happen? That's what this episode is about.
Megan Berg:To understand how we got here, I sat down and talked with three leaders from the Oregon Speech Language Hearing Association or OSHA.
Teigan Beck:Hi, my name is Teigan Beck. I'm an SLP and the Vice President of Government and Legislative Affairs for the Oregon Speech Language and Hearing Association.
Dr. Jordan Tinsley:I'm Dr. Jordan Tinsley, current President of OSHA and Clinical Associate Professor at Pacific University.
Dr. Kerry Mandulak:And I'm Dr. Kerry Mandulak, immediate past President of OSHA and Professor and Chair of the Graduate Admissions Committee at Pacific University in the School of Communication Sciences and Disorders.
Megan Berg:And when we all sat down to talk, it became clear very quickly that this story didn't start with a philosophical debate about higher education. Like so many existential crises in healthcare, this story started with money, specifically Medicare reimbursement. In 2025, the Centers for Medicare and Medicaid Services or CMS dropped a bombshell, a change in interpretation that would prevent clinical fellows from billing for Medicare Part B services.
Teigan Beck:So in the springsummer of twenty twenty five, CMS changed or reported that they were going to change their interpretation of clinical fellows being able to see Med B patients.
Dr. Kerry Mandulak:And we were about to graduate, 35 new CFs, as well as the other two programs in Oregon,
Megan Berg:and it felt like a major crisis. If a clinical fellow can't bill Medicare, employers won't hire them. Facing a massive workforce bottleneck, the state licensing board looked for a workaround. They realized that if they just eliminated the conditional license and granted full licensure immediately upon graduation, these new grads wouldn't be classified as trainees by Medicare. They could bill, get hired, and the crisis would be averted.
Dr. Kerry Mandulak:Approaching this from a solution focused, right, problem solving solution focused lens, I was like, well, if the compact is never gonna pass, likely, in Oregon, the compact requires a conditional licensure. If we're never gonna pass the compact, then maybe we don't need a conditional license. Could we not have a conditional license so that in the future, you know, our students would be able to practice immediately after and bill and all of that, thinking about the future of our and being in a higher ed space, thinking about the future of our students and where they could work and get jobs and all of that, I, you know, said, hey. Should we talk to the board about this?
Megan Berg:This is where nuance matters. The board wasn't trying to gut clinical standards. They were trying to solve a bureaucratic puzzle. But once the proposal became public, clinicians didn't see a clever workaround. They saw either an escape hatch from the burden of the CCC or a terrifying drop in safety standards.
Dr. Jordan Tinsley:For to them, their mindset was like, oh, well, this is great for people where they're having a hard time hiring and we get more people in here. And I'm like, so you're gonna have a brand new grad who doesn't have adequate training, get hired in a rural hospital or, you know, be put somewhere out in the middle of nowhere in Oregon with no mentors that are like on not that they're always on-site anyway. We know there are problems, you know, in the current model, but, you know, with no oversight and expect them to be able to stand up to their manager or to people to say like, no, I can't do that. I don't have the training in that when they're brand new. And, of course, they're gonna say, absolutely, I can do that.
Dr. Jordan Tinsley:I am, you know, happy to work for you here and and work for you, you know. Yeah.
Megan Berg:When I sat down to talk with the leaders of OSHA, I realized that this sudden collision between a Medicare billing rule and a state license was forcing all of us to confront a fundamental confusion. Most of us moved through our early careers without ever having to fully zoom out and look at how this entire machine is built. We mistake sequence for structure. We assume ASHA, the universities, and state licensing boards are a unified front, but Oregon exposed just how blurry those boundaries are and how much the people running the systems are learning on the fly.
Dr. Kerry Mandulak:Also, what I've learned is the separating out conditional licensure from CF, that they are not the same, but they very much overlap in a way that's made me kinda go, right, this national versus state level overlap, a CF I mean, sorry, a conditional licensure happens during the CF. So there was definitely something, you know, that has happened historically that has made that come together. And then to get the c's gives you, like, the privilege to supervise. That's the way that we can send students is if they have their c's. And all of that, like, again, that makes wait a minute.
Dr. Kerry Mandulak:Like, that's where I sort of took a step back and was like, wait a minute. Because we've we've lost supervisors that are so excellent because they chose to not have their c's anymore. So that that is something that's also made it, I think, Megan, when you asked the question about, like, the CF and the c's, and that's something I've really had to cognitively pull apart this past year is how those things have interacted. And I think I've just been, like, existing in a world of it is the way it is. And so to have really look deeper into it, I that's been a it's a really been a period of learning for me.
Dr. Kerry Mandulak:And I got my c's in nineteen ninety eight, ninety nine. And I've just been like, well, that's just the way it is. And so when you're forced to think about how it's not just the way it is, that's a really interesting that's been a really it's a bit of place
Dr. Kerry Mandulak:of learning for me, and I appreciate that even when it's complicated and it's hard. To what you've talked about in the podcast, Megan, you're like, we were never trained to be like lawyers or advocate, you know, I mean, advocates in a way of like state legislature and like federal legislature and law and how this so I think everyone's like trying to learn the best they can on the fly.
Megan Berg:Once you pull back the curtain, the deeper question emerges. If graduate school is only the foundation, where exactly are clinicians becoming clinically competent practitioners? Because the reality inside higher education is incredibly strained. Over the last fifty years, the SLP scope of practice has exploded. We cover everything from pediatric feeding to geriatric dysphagia, from AAC to cognition, but graduate programs still only have two years or oftentimes less to teach it all.
Dr. Kerry Mandulak:Well and I think when when we we often get a little, I'll say, a little disgruntled when we see graduate students who, you know, who graduate and get out in the world, and they say, well, I never learned about this in grad school, and I was never trained to do this. And legitimate like, I think I I understand it's frustrating. But now as an educator, having worked here for fourteen years, I also realize, like, I have such little time to make full fully formed, super competent clinicians in all of the things we're required to teach. In stuttering, which is one of the courses I teach, I'm like, what's, like, the base knowledge? What's the foundational most important thing I can teach you so that when you leave, you can remember that and then work from there and then develop.
Dr. Kerry Mandulak:And there's so much that we learn through our clinical practice that you just can't get in class. We're just giving you the foundation.
Megan Berg:One of the themes running through this entire podcast series has been the growing disconnect between who the profession assumes is responsible for clinical training and who is actually structurally responsible for it. Universities are often criticized for graduating clinicians who do not feel fully prepared for independent practice. But the degree itself was never designed to contain a complete transition to practice training model entirely within the graduate degree. Instead, much of that responsibility has historically been absorbed by employers through the CF process. In practice, the profession evolved around a distributed training model.
Megan Berg:Universities provide academic education, foundational clinical exposure, and supervised opportunities, while employers, supervisors, mentors, and the CF structure take on much of the responsibility for real world clinical formation after graduation. And over time, many clinicians began to experience that entire pathway as one seamless educational system, even though the responsibilities were actually spread across multiple institutions with very different incentives, pressures, and priorities. So when Oregon discussed removing the conditional license, it didn't just raise questions about licensure, it exposed uncertainty around where the profession believes clinical competency is actually supposed to develop.
Dr. Kerry Mandulak:We put so much on community supervisors to teach our students. I mean, much responsibility, and that is a lot to ask. And at the same time, how can we make that a really good how can we optimize that model? How can we support community supervisors? And often community supervisors are like, we can't take students.
Dr. Kerry Mandulak:We're too busy workload. And I understand it's so much work to take a student. But then when the students go to apply for jobs, they're like, we don't have medical experience. And it's like, well, we couldn't get the medical placements to get the medical experience so they could work there to you know? And so there's a bit of that also happening behind the scenes.
Dr. Jordan Tinsley:I'll say, like, as a person who coordinates placements for our I mean, I think that's just that is such a huge barrier. And, like, we're just running into, you know, SLP burnout. I think our students are feeling burned out faster than, I don't know, if, like, we're just recalling it that now, and maybe we felt like that too for sure. I don't think there's, like, anything, like, inherently different or, like, wrong with our current suit. But, I mean, I just think that, like, we're living in a time where, like, the world is really heavy.
Dr. Jordan Tinsley:Like, just being a human is being burned out right now, I think. And so I think that's different. And and people, it's just, like, are doing their best to just get through their day. And then I think when you think about adding a student to that as many good intentions as we have and as much as we want our field to thrive, like, that is an extra. And I think until either the schools and ASHA and people can, like, find a way to create some sort of incentive, more incentive maybe for supervisors rather than just like you're a really great human and, like, here's your subscription to, like, speech therapy PD for a year, which is also great.
Dr. Jordan Tinsley:You know? I mean, but, like, I just people are like, cool. Now I am gonna have time to, like, learn more. I don't know. I just I I am glad we can do things like that for it, but I just I don't know what the solution is, but I think that there I think people we need to work with the like, with the employer, like, systems for people to be, like, given a little extra time, you know, as supervisors to, like, meet with their student to, like, slightly reduce their productivity rate perhaps.
Dr. Jordan Tinsley:Or, you know, I don't know. I just there's yeah. There's a lot of things going on, and and we're just running into issues with, like, getting more supervisors. And so then that's probably also where from, like, some people's standpoint, they're like, well, great. Then just, like, throw people out into the world.
Dr. Jordan Tinsley:But, like, that's not the solution. And I don't think that students would feel good about that either.
Megan Berg:But community supervisors are exhausted. Productivity expectations are high. Placements are harder and harder to secure. And the more conversations I've had with SLPs across the country, the less this feels like a story about bad actors or big bad wolves. It feels like a profession built around a training model that has quietly shifted responsibility across multiple systems over time.
Megan Berg:Students go through graduate school believing they are being prepared for clinical practice, but structurally, much of the profession has continued relying on employers, supervisors, and the CF process to actually complete that transition into independent clinical competency after graduation. Universities are trying to provide academic education, foundational clinical exposure, and supervised opportunities within limited time and resources. Meanwhile, employers are often onboarding brand new clinicians who are still developing real world clinical judgment, confidence, and competency through mentorship and supervised practice. And as we saw with the CMS changes in 2025, there are situations where clinicians may not yet be recognized as independently billable providers until they complete that postgraduate clinical training process and obtain full licensure. And as we've discussed throughout this series, speech language pathology is relatively unique among allied health and education adjacent professions in that much of the transition to practice clinical training process has historically been structured around employer based mentorship experience rather than being fully embedded into the graduate degree itself.
Megan Berg:But Jordan, with the amount of time that you spend finding placements, the question I always have for people in your position is like, OT and PT do the same amount of work at the university level to find those placements. Their placements are just a little bit longer. Mhmm. And so the degree itself doesn't always end up being four years. It could be two and a half years, a little under three years.
Megan Berg:Like, you're just extending that placement, and you're wrapping the clinical training into the degree. And then the university is responsible rather than the licensing board or the employer for holding those supervisors accountable. So, like, is that like, just when you think about that, is that something that could be doable? Because every time I look at the situation, I'm like, everybody's backed into a corner. Like Mhmm.
Megan Berg:ASHA can't give up their financial stability. Students don't wanna give up being paid for their training. Universities are definitely in a corner as far as, like, trying to teach this vast scope with limited resources with universities that are more and more looking at, like, revenue baseline to make decisions. Mhmm. So I'm like, what can actually budge that's, like, realistic
Megan Berg:Mhmm.
Dr. Jordan Tinsley:That would I would love to think that if you have a supervisor who's willing to take a student that you know, we're at Pacific, we're a little different than the other schools here. So U of O and Portland State are on ten week quarters, and we're on a fifteen week semester. And so sometimes we run into supervisors who have only had the other, like, ten week students, and they're like, oh, fifteen weeks. Like, that feels really long, you know, because, like, they're used to the ten weeks, and maybe that's, like, the workload they wanna take on and when they think about 15. But all of the supervisors that I work with who work with our students are, actually, fifteen weeks is really great because maybe, let's say, you take the first five weeks of that placement and the students really just, like, getting up to speed on like, what the caseload is, how you do the things, what is this place, you know, and then the last five weeks, they're like, helpful.
Dr. Jordan Tinsley:Exactly. The last five weeks, maybe they're more helpful in that, you know, it's like less burden on the supervisor and a little bit more like the student is kind of taking some of that responsibility in the lead. Then so then if you have five more weeks, it's like, even more benefit, know, so it's like there is to me, like benefit to longer clinical placements where the student, like, really gets to settle into a location and, like, learn that and work with the supervisor.
Megan Berg:And so because our model is so unique and because we don't officially require universities to provide any training hours other than the, quote, opportunity to obtain three seventy five hours that can count toward the CCC, we rely on the CFY. I
Dr. Jordan Tinsley:think the CFY is doing us favors, but I think it's very variable. Like, I think there are good models for CFYs. And I think that there are people who have good CFY experiences. And I don't wanna invalidate folks because I absolutely know that there are people who have ridiculous CFY experiences that are, like, literally only that in name and are barely, you know, meeting the hours requirement, you know, or or are just, like, the bare minimum. And so, I mean, I'll say, like, my my experience was very different from Tegan's where it was at I was at the Portland VA hospital.
Dr. Jordan Tinsley:They run, like, a CF every year. They take one or two, and it's very structured. It's twelve months, like, instead of nine, and it's, like, the first three months you're in, like, with one supervisor learning in the hospital, acute care. The second one, I was in Vancouver, and we were at their kind of long term care facility and inpatient rehab. And so I was learning in that, you know, setting.
Dr. Jordan Tinsley:And then the third quarter was in, like, back in the hospital and, like, head and neck cancer unit. And then for the fourth quarter, at that point, I could apply for my Cs because I had all the like time and hours, but I went back through one month in each of those and was much more independent. So the first three, you know, was like I was still able to practice more independently than when I was a student, but it was very structured. And for me, like that was lovely. And you know, especially in a setting, a medical setting where I was dealing with some things that could be a little bit more life or death or a little bit more, if not life and death, like result in, you know, or could result in like a medical issue if things went south.
Dr. Jordan Tinsley:You know, think having that level of support was helpful.
Megan Berg:The truth we don't like to talk about is that the CF is a lottery. Some clinicians get deeply structured mentorship. Others are thrown into independent practice as cheap labor left to sink or swim. And when Jordan talks about supervision requirements, I think it's important to put those numbers into context. Under the current CF requirements, ASHA requires a minimum of eighteen hours of direct supervision and eighteen hours of indirect supervision over the course of the entire nine month fellowship.
Megan Berg:For a clinician working full time, that averages out to roughly two hours of direct observation for every one hundred and sixty hours worked within a month. That doesn't mean many supervisors aren't providing far more mentorship than that, many are, but it does highlight an important the quality of a CF experience often depends far more on the culture of the workplace and the commitment of the supervisor than on the minimum requirements themselves.
Teigan Beck:I was thrown into my CF. I did have a mentor, but it was kind of a CF farm. Like, I mostly had other CFs, and I was very independent. I was doing, like, breastfeeding work very, very quickly because my mentored, like, tongue tie, and, like, I was just thrown into that, like, if she was out of town or something.
Social media person #3:Like, here you go. And so I don't think that my program, prepared me for that, but I still survived.
Dr. Kerry Mandulak:I'll speak from my completely my own perspective. I absolutely think that the CF has incredible value. I know for me, it was it was the bridge for me between, you know, graduate work and practice. I did not feel like I was clinically prepared to work when I started, and I had that safety net.
Megan Berg:When Carrie calls it a safety net and Tegan talks about just surviving, it highlights the ultimate vulnerability of our field. We have distributed the responsibility of clinical competency across so many systems that everyone has assumed someone else was holding the ladder. The deeper I got into our conversation, the less this felt like a debate about Oregon politics and the more it felt like a collective awakening. Oregon was just the fault line where the pressure finally broke through.
Teigan Beck:And, yeah, we should probably, reflect back on that public meeting, which I didn't attend, but I have a lot of notes from it, where then we went with the board and we provided public comment and said, maybe this is a good idea, but we are not ready for this. Please don't do this yet. I think one of
Dr. Jordan Tinsley:the concerns that we had, you know, to getting rid of, like, the conditional licensure, like, getting rid of that and, like, is that right now, it feels like that's one of the only ways that we're, like, making sure that people like, employers will offer this opportunity. Because if all of a sudden you say, like, no, you're fully licensed when you get up there, like, what incentive do employers have to offer really, like, dedicated mentorship? You know, I'm not saying that SLPs wouldn't make that decision, but it's like the employer who's maybe giving more support to their CF mentors who's, like, in some places paying them $1 extra per hour that they're like a preceptor, you know, or something like that. Because they would be like, oh, you're fully licensed when you get out, like, here you go. And would it then be on the SLP, like the new grad and like SLPs in the field to like uphold that level of supervision and training when when employers are saying no, like the state is saying you're fully licensed, so you're good to go.
Dr. Jordan Tinsley:Like, you just go out there. And and I'm not saying that's what potentially would happen. But I mean, I think when you're thinking of it from, a financial standpoint and not from, a patient safety standpoint, I am very concerned that if we were to, like, get rid of that oversight at the state level, that you would have employers who are trying to make money who are like, cool. Like, great. You're fully licensed.
Dr. Jordan Tinsley:Like, go ahead. And that's very concerning to me.
Megan Berg:The question was never simply, should we get rid of the conditional license? The deeper question is, what structure actually protects patients, supports clinicians, and creates competent practitioners in the modern reality of health care. And right now, I don't think the profession fully agrees on the answer. Facing that reality brings up a lot of complicated emotions for those of us who love this field.
Dr. Kerry Mandulak:Yes. It's nuanced, and thank you for doing this work and for bringing, you know, these conversations to light because I think that, they're really important, and I am a optimistic person. I when I when I become cynical, that's when I know I'm burned out. So I really try to stay in a place of optimism and assuming best intentions. But this past year or two, it's been that has been really challenged for me.
Megan Berg:Yeah. Yeah. And I think I did that episode on, like, just professional grief. Like, I think there's a lot of grief in, like, this is not what I thought it was.
Dr. Jordan Tinsley:Yeah. I was gonna say one last thing I would say, and it kinda goes off of what Carrie was talking about with, like, having these passionate students who are entering the field, is that I am recognizing also on social media. I think that not that we want to, like, lie to students or have anything, but, like, the burnout that SLP's are feeling and, like, I think the act the emotions are getting in the way and people are, like, pushing that onto students and they're making students really scared. And I I I think there is some truth in, like, systems are not perfect and here's some of, like, the world that you might be walking into and we don't wanna paint rosy pictures and rainbows when there are issues, but also I wanna remind people, like, what did you feel like when you were entering the field? And, like, let's not take away that passion and excitement for the field from our students.
Dr. Jordan Tinsley:Like, I think we need to be more thoughtful about the way that we're having these conversations and, you know, not putting out their spark before they're even in the field.
Megan Berg:I don't think Oregon exposed a profession that doesn't care about training. I think it exposed a profession carrying enormous complexity inside systems that evolved over decades without many people stopping to ask, why is it structured this way? And maybe that discomfort is actually the beginning of a more honest conversation. I'm Megan Berg. This is Inside SLP.
Megan Berg:If this is the first episode you're listening to, I invite you to go back and start from episode one. There is so much rich history woven throughout this series and understanding that history gives us a different lens through which to view the conversations happening in our profession today. I think this episode makes much more sense when you understand the historical context that led us here. And finally, I just wanna thank everyone who has connected with me online and in person to share what this podcast has meant to you. It means a lot that you trust me to hold these conversations in our field.
Megan Berg:Over the last few years, I've learned some hard lessons about what it means to hold a microphone responsibly, about the importance of factual accuracy, intellectual humility, and creating space for conversations that are complex, emotionally charged, and sometimes uncomfortable. I don't take lightly the fact that people spend their time listening, thinking, questioning, and engaging with what I'm creating here. So thank you. If this series is bringing up questions for you, I invite you to reach out and ask them. I'm still learning too, and I plan to continue making episodes as I learn new things and encounter new perspectives.
Megan Berg:And I also want to say thank you to the University of Memphis Mid South Conference for inviting me to speak at their annual student run initial chapter sponsored conference in Memphis next February. I'm really looking forward to that conversation. And later this month, I'll also be speaking with an Austin based private practice and leading a discussion with them. One of the most meaningful parts of this project has been watching these conversations move beyond the podcast and into real classrooms, workplaces, conferences, and professional spaces. So if these conversations are resonating with your graduate program, workplace, or state association, I'm always open to continuing them in person as well.
Megan Berg:I care deeply about creating space for thoughtful, grounded discussions about the history, structure, and future of our profession, especially conversations that make room for complexity, disagreement, curiosity, and reflection. If you'd like to connect with me, you can find me at therapyinsights.com/ inside SLP. There's also a link in the show notes.