In my previous article, “Personalizing Dysphagia Evaluation: The Platinum Standard,” I demonstrated the power and value of personalized medicine. Both Theresa Richard (of the Swallow Your Pride podcast) and I refer to this customized approach as “The Platinum Standard.”
Now, I’d like to dig deeper into what we mean when we’re talking about personalized medicine and offer a real-world look at how SLPs can incorporate the platinum standard of dysphagia care into their own practice.
Personalized Medicine: A Primer for SLPs
Personalized medicine has been a hot topic in the medical world for years, especially in the field of oncology. The part that’s new—and that makes personalized medicine a feasible option—is the access to the tools needed to provide an individualized approach to care.1
1. Stratified medicine groups patients by clinical biomarkers, matching diagnostics and therapies. For example, genetic information can be used to predict a given subgroup’s response to a particular drug.
2. Precision medicine tailors diagnosis and treatment to the individual. This term is used by the US Institute of Medicine and is most advanced in oncology. Examples include:
- Use of genomic information of a tumor
- Use of molecular taxonomy of a disease
- Delivering the optimal dose of the right drug to a specific patient with a very specific condition
3. Personalized medicine is an all-encompassing term for delivering medical care tailored to the individual, using new tools for diagnosis and treatment.5 In addition to the use of new genomic medicine, biomedical discoveries, and big data from advances in medical information technology, this includes:
- Patient empowerment
- Patient-centered/patient-directed medicine
- Lifestyle and environmental influences
- Preventative medicine
- Evidence-based therapy based on each patient’s specific profile6
Recently in audiology literature, Gutenberg et al showed how big data can be used to advance healthcare policy-making in hearing health,7 noting the ways in which data can contribute to problem identification, public awareness of the health issue, and policy formulation through implementation. Big data can be a catalyst in implementing truly evidence-based medicine.
Per this infographic from the University of Illinois at Chicago, personalized medicine strives to provide the right patient with the right drug in the right dose at the right time. We can easily branch that over to the rehabilitation fields. We want to provide the right patient with the right examinations, helping us target the right treatments to the right people at the right time, in the right way, and at the right frequency.
Sound familiar? This concept is similar to the many principles of neuroplasticity, particularly:
- Treatment should be specific (tailored or targeted).
- Treatment should be salient (important with a clear purpose).
- Treatment intensity and repetition matter.8
What Does Personalized Dysphagia Medicine Look Like?
In dysphagia therapy, an imprecise diagnostic process can lead to:
- Ineffective treatment
- Poor outcomes
- Poor patient motivation and adherence
- Maladaptive behaviors
- Serious negative consequences such as choking, aspiration, aspiration pneumonia, and death
When adequate testing hasn’t been completed, SLPs may tend toward an overly cautious approach. An example of this might be leaving patients on honey-thick liquids. This could lead to negative consequences like urinary tract infections or dehydration. A patient who is left on honey-thick liquids when they are still aspirating could have an elevated risk for pneumonia, as the highly viscous liquid cannot clear out of the lungs.9
Applying the Platinum Standard: A 3-Step Approach
1. The first step in applying the platinum approach to dysphagia is to make less imprecise diagnoses by performing instrumental evaluations and not simply relying on a bedside evaluation to guide treatment. As we transition to the platinum approach of personalized medicine, we no longer simply choose a single “gold-standard” exam. Instead, we choose the exam or exams that best fit our clinical questions after a thorough swallowing evaluation, which also includes a thorough chart review and interviews.
2. The next step is to make appropriate referrals. This may include referring your patient for a FEES if you started with a VFSS, or vice versa.10 You might recommend a therapy trial with a repeat swallow study, or you might refer your patient for an upper GI/barium swallow study or manometry.
3. You should also consider referrals to specialists in otolaryngology, neurology, or gastroenterology, just to name a few. A holistic approach to dysphagia management will likely have you asking the primary team about medications that may cause dysphagia and dry mouth, as well as discussing weight loss risks with the dietitian. Weight loss could put a person at risk for loss of muscle mass and muscle wasting (sarcopenia), which in turn could increase the dysphagia.
A multidisciplinary or transdisciplinary approach to swallowing is best practice, and SLPs can lead that glutology team. This is what we mean when we talk about the platinum approach or the platinum standard of personalized medicine for dysphagia.
- Raza, S., Blackburn, L., Moorthie, S., Cook, S., Johnson, E., Gaynor, L., & Kroese, M. (2018). The Personalised Medicine Technology Landscape (report). Cambridge, UK: PHG Foundation.
- Brice, P. (2015). Obama’s precision medicine initiative: the future of healthcare? PHG Foundation. Retrieved from https://www.phgfoundation.org/blog/obamas-precision-medicine-initiative-the-future-of-healthcare
- Pokorska-Bocci, A. (n/d). Many names for one concept or many concepts in one name? PHG Foundation. Retrieved from https://www.phgfoundation.org/documents/311_1358522182.pdf
- Smith, R. (2012). Stratified, personalised, or precision medicine. The BMJ Opinion. Retrieved from https://blogs.bmj.com/bmj/2012/10/15/richard-smith-stratified-personalised-or-precision-medicine/
- Millenson, M. L. (2017). When ‘patient centred’ is no longer enough: the challenge of collaborative health: an essay by Michael L Millenson. British Medical Journal, 358: j3048.
- Millenson, M. L. (2006). Personalized medicine: finding the patient’s ‘doctor within.’ Medscape General Medicine, 8(2): 32.
- Gutenberg, J., Katrakazas, P., Trenkova, L., Murdin, L., Brdarić, D., Koloutsou, N., & Ploumidou, K. et al. (2018). Big data for sound policies: toward evidence-informed hearing health policies. American Journal of Audiology, 27(3S): 493–502.
- Martin, R. E. (2009). Neuroplasticity and swallowing. Dysphagia, 24(2): 218–29.
- Robbins, J., Gensler, G., Hind, J., Logemann, J. A., Lindblad, A. S., Brandt, D., & Baum, H. et al. (2008). Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial. Annals of Internal Medicine, 148(7): 509–18.
- Langmore, S. E. (2017). History of fiberoptic endoscopic evaluation of swallowing for evaluation and management of pharyngeal dysphagia: changes over the years. Dysphagia, 32(1): 27–38.