“Because diagnosis is so imprecise, it follows that treatment will be haphazard.”
Richard Smith, MD, former editor of the British Medical Journal, made this statement in 2012. This is not what we want for our patients with dysphagia.
Imagine this scenario:
“Henry,” a resident at a skilled nursing facility, has had difficulty with solid foods getting stuck and needs an outpatient dysphagia evaluation. Henry goes to Gold Hospital, where the speech-language pathologist always evaluates dysphagia in outpatients with a videofluoroscopic swallow study.
Since the SLP is forced to squeeze the entire evaluation process into a half an hour, she performs an instrumental exam with a basic protocol that includes only barium liquids, barium pudding, and a cracker in the lateral view with one brief esophageal scan at the end with thin liquid.
Based on the SLP’s findings from this exam, Henry is told that he has minimal oropharyngeal dysphagia. The SLP speculates that maybe his tongue base retraction to the pharyngeal wall is a bit weak and recommends some lingual exercises. The SLP does not make any additional referrals or recommend additional testing.
Weeks later, Henry is admitted to a different hospital, Platinum Hospital, with odynophagia, persistent dysphagia to solid foods, regurgitation, and weight loss. The SLP at Platinum Hospital performs a thorough chart history and patient interview. Discussions are held with the SNF, the medical team, and Henry’s family. Platinum Hospital’s SLP realizes that an upper GI study is likely the best next test for Henry and speaks directly with the radiologist who is completing the study. Based on her thorough evaluation, her suspicions also lead her to refer Henry to a GI doctor for an endoscopy to rule out an obstructive process.
Unfortunately, the final diagnosis is an esophageal tumor. All the tongue exercises in the world would not have helped Henry.
The Value of Thorough Chart Review
While SLPs don’t have x-ray vision, we are able to form diagnostic hypotheses based on thorough chart reviews, interviews, and bedside swallowing examinations. This is the art of our profession.
In a 2015 Dysphagia Research Society (DRS) lecture, former DRS President Dr. Kulwinder Dua asked, “If technology fails, will you be lost?” He was stressing the importance of the art of good history taking and a keen sense of observation. With today’s focus on technology, we may be losing these skills.
Even when a new patient comes to you for an outpatient videofluoroscopic swallow study, you must think critically. Your chart review and interview should help you customize your evaluation. While an instrumental evaluation follows a protocol, the protocol can be tweaked to answer the questions you have about each unique patient’s needs.
When you are working with inpatients in a hospital or acute rehabilitation setting, you may have more time to consider your hypotheses, allowing you and the medical team to fashion an evaluation process that best fits the needs of your individual patient.
Making the Switch to a Platinum Standard
Thinking critically, forming hypotheses based on thorough evaluations, and customizing treatment for dysphagia is the platinum standard, a term coined by myself and Theresa Richard of Swallow Your Pride and presented at ASHA’s 2018 convention. It is not a one-size-fits-all approach, in which every patient receives a “gold standard” exam and is then sent on their way.
One person may benefit most from a video swallow study while another may require a fiberoptic endoscopic evaluation of swallowing (FEES). Other patients may benefit from a gastroenterology or otolaryngology consult for endoscopy. Often, the initial exam is just the starting point, and multiple examinations may be needed to best answer all the clinical questions in a personalized approach.
- Smith, R. (2012). Stratified, personalized, or precision medicine. British Medical Journal Opinion. Retrieved from https://blogs.bmj.com/bmj/2012/10/15/richard-smith-stratified-personalised-or-precision-medicine/
- Sheffler, K. & Richard, T. (2018, November). Revolutionize the gold standard! How about a new platinum standard of personalized medicine for instrumental dysphagia evaluations? Session presented at American Speech-Language Hearing Association Annual Convention, Boston, MA.
- Langmore, S. E. (2017). History of fiberoptic endoscopic evaluation of swallowing for evaluation and management of pharyngeal dysphagia: changes over the years. Dysphagia, 32: 27.