FC and the Practice of Internal Medicine. How Would That Work, Exactly?

The recent promotion of Facilitated Communication (FC) at Penn State, UPenn, and Harvard Extension School reminded me of an article that was published in the Tampa Bay Times about a year ago.

The article, by Jeffrey S. Solochek, featured  a fourteen year-old student using a letter board who was, purportedly, dreaming of studying internal medicine at Harvard Medical School. As reported, the student exhibited unreliable speech, motor difficulties, and attentional challenges (e.g., difficulty focusing on tasks, tiring easily when spelling). According to one observer, the student could, with facilitation, answer questions quickly and without seeming to pay attention. (emphasis mine)

A student is being subjected to Facilitated Communication in high school education classes. (Tampa Bay Times 12/3/2021)

A video included with the article clearly showed the student being facilitated in the style most commonly associated with Spelling to Communicate (S2C) and Rapid Prompting Method (RPM). In these variants of FC, a facilitator holds the letter board in the air, providing physical and verbal cuing, while the student points towards letters on the board. 

To date, there is no empirical evidence that S2C or RPM users exhibit independent communication and organizations like the American Speech-Language-Hearing Association (ASHA) and American Association on Intellectual and Development Disabilities (AAIDD) strongly advise their members not to use the technique.

While I heartily support individuals with disabilities in the pursuit of all types of careers and interests, I have questions about an individual’s reliance on a facilitator holding a letter board in the air as their sole form of communication at Harvard Medical School (or any educational setting, for that matter). How would the individual fare in such a high-pressured educational environment? Who would actually be completing the coursework? How would this impact the patients? And, what of the professors who doubt the authenticity of the typed messages after witnessing FC in their classrooms?

Internal medicine physicians are “specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness.” (see American College of Physicians)

 Harvard Medical School’s four year program includes studying communication skills, conducting physical exams for patients, learning about the molecular, cellular, and genetic basis of medicine, understanding the structure and function of the human body, studying the mechanisms of defense and disease, and so much more. In addition to general classes, students participate in workshops and large group sessions, as well as Standardized Patient Encounter/Objective Structured Clinical Examinations. From what I understand, this is only the starting point for a career in internal medicine. Additional study, in the form of a 2-3 year residency is required. In addition, some individuals choose to specialize (e.g., in cardiology, endocrinology, gastroenterology), which, again, requires an additional 2-3 years of study.

Considering the rigors of the program requirements, both in terms of classroom participation and years of practical hands-on experience a number of questions arise:

1)    Wouldn’t the “application of scientific knowledge” also apply to FC, which has been scientifically discredited? Not acknowledging this fact or ignoring the body of evidence against the technique, for me at least, would erode credibility in any physician adopting FC as a primary form of communication.

2)    How would course instructors, colleagues, and patients be sure that the FC-generated messages were the thoughts and opinions of the student physician (e.g., the person with disabilities) and not those of the facilitator—especially if the student did not appear to be attending to the activity while the typing sessions were being conducted? For me as a patient, it wouldn’t instill a lot of confidence if, for example, my doctor wasn’t paying attention to the letter board as the words were typed out.

3)    How would confidentiality issues be addressed? Assuming the facilitator wasn’t the person who was actually earning a degree, it seems like a breach of confidentiality to allow a lay person in the examining room and/or to be a part of the treatment process. Since the written language abilities of individuals being subjected to FC decreases significantly when their facilitator is not in the room with them, how would these activities be carried out?

4)    If the typing remained a “laborious” process, as reported in Solochek’s article, how would the student physician keep up with a fast-paced learning and work environment? What if, during a routine examination, a patient had a medical emergency that couldn’t wait for the student to hunt-and-peck a typed response for treatment?

5)    In proponent literature, FC has been described as a “fragile phenomenon” with the technique working with some facilitators (some of the time), but not with others. Naïve facilitators (those unfamiliar to the student) may or may not have success working with that individual because of a lack of established trust between the pair. What if the student physician’s usual facilitator got sick, moved to another city, or was otherwise unavailable to participate in classes? What happens to the reliability of the FC-generated messages then?

6)    Proponents claim FC-generated messages should not be tested because questioning the person being “FCed” stresses them out and causes them to be unable to identify pictures, one-word answers, or information known to the client but not the facilitator (e.g., message-passing tasks). The rallying cry of proponents is to presume competence, not question the typed answers, and ignore or minimize spoken words or non-verbal communication. Just looking over the Harvard curriculum and taking a cursory glance at the requirements of becoming a physician of internal medicine, I think I can safely say that testing is an integral part of the process, as is conferring with colleagues, making quick decisions, and successfully completing all licensing requirements. In addition, patients are encouraged to ask questions of their physicians and, sometimes, patient-doctor interactions can be stressful. How professionally reliable is the student physician if they crumble under pressure situations to the point they can’t correctly recall even one-word answers?

It may, on the surface, feel good to read about an “FCed” individual dreaming about obtaining a college degree. But Solochek’s story fails to address some significant issues, not the least of which is who is completing the course work and whose goal is it—really—to attend college? The evidence weighs heavily on the side of the facilitator and not the person with disabilities. And, finally, what are the professional and ethical ramifications of using a discredited technique in the classroom? I’d like to see a follow-up story addressing the questions I’ve raised in this article by The Tampa Bay Times that, like other newspapers, has, wittingly or not, ended up promoting FC.