Dysphagia Detectives: How Storytelling Enhances Patient Care

In the fascinating world of speech pathology, we often encounter patients with complex medical histories and puzzling symptoms. Like medical detectives, we must carefully gather clues, analyze the evidence, and piece together the story to arrive at an accurate diagnosis and effective treatment plan.

Dr. Lisa Sanders' book, "Every Patient Tells a Story," beautifully captures this spirit of medical sleuthing. She highlights the importance of listening to patients, observing their symptoms closely, and considering all possible explanations before jumping to conclusions.

The patient interview is the oldest tool in the medical toolbox. While its widespread use is fading, it has proven incredibly effective. Dr. Sanders reports that interviews result in a correct diagnosis 70-90% of the time. That beats out most of the high-tech, innovative medical tools we’ve grown accustomed to using the last few decades. And it’s just from talking. No radiation, no knives, and no transfers to other facilities. Just some old-fashioned gabbing.  

Each patient presents a unique puzzle, and it's essential to approach each case with an open mind and open ears in order to uncover the problem and in order to find the best path forward.

The case of the mysterious chest pain and dizziness

I once saw a patient who came to the hospital with a complaint of chest pain and dizziness. Let’s call her Molly. Molly appeared to have no difficulty swallowing, but the team wanted an SLP to evaluate her due to her concern about dizziness and a possible CVA. A quick assessment would have shown that Molly’s speech, language, and swallowing were completely normal. No issues? It's time to get to the other patients who need help, right? 

But I decided to dig a little deeper. I asked Molly to tell me what brought her into the hospital. Then, I listened. I tried my best not to interrupt (Not as easy as it sounds for an SLP!), and each time after the patient seemed to be finished, I asked, “Is there anything else I should know?” After doing this two or three times, Molly appeared to be finished with her story. All in all, it was about a three-minute discussion. But in those three minutes, I noticed something interesting that wasn’t in her medical chart. She said the symptoms started in the middle of the night after she woke up coughing violently. She said this happens occasionally, but this was the worst. She had a large meal the night before and had a few glasses of wine. 

“Do you have a history of reflux?” I asked.

“Oh my goodness yes,” Molly answered. I”ve been on Omeprazole for years.” “Do you think that could have something to do with my chest pain?” 

Instead of simply checking off the box with Molly, I uncovered a very important clue to the source of her complaints. She may have had a large reflux episode in the middle of the night and aspirated on the stomach contents, causing aspiration pneumonitis or the beginning stages of aspiration pneumonia. The dizziness did not appear to be due to any neurological cause but by the dehydration, Molly had after alcohol consumption. Normally, a careful review of her story would have enabled the team to document this information in the H&P, but this time, it was missed. I quickly informed the medical team of my findings and made a referral to the gastroenterologist to assess further. I also gave some basic education on reflux and preventative strategies.  

The Importance of Storytelling

We are privileged to hear stories such as this in speech-language pathology. These stories provide valuable insights that other interdisciplinary team members can often overlook or miss. We can gather crucial clues that guide our assessment and treatment by actively listening and paying attention to the details.

As you can see with Molly, it typically doesn’t take that long, either. The issue is that the medical professional often dominates the discussion. For example, Dr. Sanders reported that doctors interrupt patients over 75% of the time and, on average, only 16 seconds after they start talking. Some even interrupted as quickly as three seconds into the patient’s story. To put this into perspective, a simple introduction takes about ten seconds. Did these patients even have time to say their names? 

What’s the result of being interrupted so much? 

• Fewer than 2% of the participants in this study could complete their stories.

• The doctor and the patient often didn’t agree on the purpose of the visit.

• The doctor and the patient agreed on the chief complaint as low as 25% of the time. It’s like debating the significance of the ending of a movie with a friend and only realizing after the fact that you’re mistakenly talking about two entirely different films. 

The kicker? This data comes from a study when both parties knew they were being recorded. These doctors were on their best behavior! One could only imagine what these discussions would look like in private. 

Do we have patience for our patients?

And this study showed that when doctors interrupt patients, it happens so quickly that it’s probably not from a lack of time but from a lack of patience. And trust me, it’s not just doctors. SLPs and other medical professionals are guilty of this as well. We want to help, but that urge to help comes in the form of filling in the blanks when the patient is the one who is most qualified to do so.  We are giving them the answer before the question has been fully formed.

And jumping to conclusions has life-altering implications for the patient. An eye-opening piece from 2000, “To Err is Human,” revealed that medical errors account for 98,000 yearly deaths. That’s the equivalent of a jumbo jet going down every single day. We can and must do better.

To combat the urge to interrupt the patient, Dr. Sanders emphasizes the importance of "thinking slow" and considering all possibilities. We must approach each dysphagia case with a thoughtful and inquisitive mindset.

Here are four key takeaways from "Every Patient Tells a Story" that can enhance our practice as SLPs:

1. Listen attentively:

Pay close attention to the patient's narrative, their descriptions of symptoms, and their concerns. Don’t look for what you’re trying to find. Listen, ask questions, and then listen again. You may find something completely different from what you were originally looking for. Don’t have the time? Trust me, this will save you time in the long run.

2. Observe closely:

Look for subtle cues, patterns, and connections that might provide diagnostic clues. Sometimes, simply taking a step back and looking at the patient can give you a better idea of their status than spending the whole assessment closely examining the patient’s mouth and face. The more assessments you do, the better you will get at pattern recognition. Don’t have the experience yet? Bounce ideas off a colleague who does.

3. Consider all possibilities: “What else could this be?” When you jump to conclusions, you leap past the right path. Explore various diagnoses and treatment options before settling on a plan. Dr. Sanders mentions that, by far, the most common medical error is from premature closure. Meaning, we settle on something and no longer explore alternatives. This is why a diagnosis of dysphagia or aspiration pneumonia can be easily made but not easily dismissed. Sometimes, these diagnoses may even follow a patient for years when that initial diagnosis may not have been correct.

4. Collaborate: It takes a village. So use it. Work closely with the patient, the family, and other healthcare professionals to gather information and develop a comprehensive treatment plan. Take the information you’ve collected and talk it out with a colleague. This might reveal a hidden connection you wouldn’t have otherwise made. 

By embracing the principles of medical storytelling, we can become more effective and compassionate clinicians. We can unravel the mysteries of dysphagia, provide personalized care, and empower our patients to regain the function and quality of life they deserve.

You made it to the end, congratulations! Now, it’s time to put this information to work. How can you use these concepts to help your patients today?

Share your experiences and insights in the comments below!

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