Abstract
Purpose of Review
Dysphagia has significant negative impact on health outcomes and hence evidence-based assessment and management of impaired swallowing is central to quality healthcare.
Recent Findings
Approaches to the Clinical Swallowing Examination (CSE) vary considerably. It has been suggested that the patterns of item use within a CSE are non-random, and are influenced by the clinician’s decision making and reasoning processes relevant to each specific clinical scenario. These observations are in line with current models of diagnostic reasoning in the health professions and may reflect a dual process of analytical and intuitive decision making that allows clinical decisions to be made in situations of high cognitive load, limited resources, and dynamic workloads. As such, it may be the robustness of the clinical decision making process, not necessarily dogmatic adherence to item-based assessment protocols, that ensures quality CSE assessment processes, and ultimately, of the clinical care processes it informs.
Summary
We provide an overview of the relevant literature on the cognitive psychology of human decision making and reasoning, and summarize existing research as it pertains to reasoning and decision making in the CSE. We draw connections between these exciting fields of research and offer our own considerations for future directions in research and scholarship in this area.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: •• Of major importance
Altman KW, Yu GP, Schaefer SD. Consequence of dysphagia in the hospitalized patient: impact on prognosis and hospital resources. Arch Otolaryngol Head Neck Surg. 2010;136(8):784–9.
Smithard DG, O’Neill PA, Parks C, Morris J. Complications and outcome after acute stroke. Does dysphagia matter? Stroke. 1996;27:1200–4.
Ekberg O, Hamdy S, Woisard V. Wuttge–Hannig A, Ortega P. Social and psychological burden of dysphagia: its impact on diagnosis and treatment. Dysphagia. 2002;17(2):139–46.
Bonilha HS, Simpson AN, Ellis C, Mauldin P, Martin-Harris B, Simpson K. The one-year attributable cost of post-stroke dysphagia. Dysphagia. 2014;29:545–52.
Facione NC, Facione PA. Critical thinking and clinical judgment. In: Facione NC, Facione PA, editors. Critical thinking and clinical reasoning in the health sciences: a teaching anthology. Insight Assessment, The California Academic Press: Millbrae CA; 2008. p. 1–13.
Threats TT. Use of the ICF in dysphagia management. Sem Speech Lang. 2007;28:323–33.
Incident Management in the New South Wales Public Health System (2008), NSW Department of Health, Sydney. http://www.cec.health.nsw.gov.au/data/assets/pdf_file/0006/258270/incident-management-2008_07to12.pdf accessed 16.04.2018
Wilson R. The quality in Australian Health care study. Medical Journal of Australia. 1995;163:458–71.
Kahneman D. Thinking fast and slow. 2011. Farrar, Straus, & Giroux.
Evans JSBT, Stanovich KE. Dual-process theories of higher cognition. Persp Psychol Sci. 2013;8:223–41.
Norman GR, Eva KW. Diagnostic error and clinical reasoning. Med Ed. 2010;44:94–100.
Tversky A, Kahneman D. Judgment under uncertainty: heuristics and biases. Science. 1974;185:1124–31.
Dawes RM, Faust D, Meehl PE. Clinical vs. actuarial judgment. Science. 1998;243:1668–74.
Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775–80.
Marcum JA. An integrated model of clinical reasoning: dual-process theory of cognition and metacognition. J Eval Clin Prac. 2012;18:954–61.
Gigerenzer G. Why heuristics work. Persp Psychol Sci. 2008;3:20–9.
Wilson TD, Schooler JW. Thinking too much: introspection can reduce the quality of preferences and decisions. J Personal Soc Psych. 1991;60(2):181.
Pretz JE. Intuition versus analysis: strategy and experience in complex everyday problem solving. Memory & Cognition. 2008;36(3):554–66.
Benner P, Tanner C. How expert nurses use intuition. Am J Nurs. 1987;87:23–31.
Klein G. Sources of power. Cambridge, MA: MIT Press; 1998.
Crandall B, Getchell-Reiter K. Critical decision method: a technique for eliciting concrete assessment indicators from the intuition of NICU nurses. Adv Nurs Sc. 1993;16(1):42–51.
Linden P, Kuhlemeier KV, Patterson C. The probability of correctly predicting subglottic penetration from clinical observations. Dysphagia. 1993;8:170–9.
Splaingard ML, Hutchins B, Sulton LD, Chaudhuri G. Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical assessment. Arch Phys Med Rehabil. 1988;69:637–40.
Linden P, Siebens AA. Dysphagia: predicting laryngeal penetration. Arch Phys Med Rehabil. 1983;64:281–4.
Vogel B, Cartwright J, Cocks N. The bedside assessment practices of speech-language pathologists in adult dysphagia. Int J Speech Lang Pathol. 2015;17(4):390–400.
Bateman C, Leslie P, Drinan MJ. Adult dysphagia assessment in UK and Ireland: are SLT’s assessing the same factors? Dysphagia. 2007;22:174–86.
Martino R, Prin G, Diamant NE. Oropharyngeal dysphagia: surveying practice patterns of the SLP. Dysphagia. 2004;19:165–76.
Mathers-Schmidt BA, Kurlinski M. Dysphagia evaluation practice: inconsistencies in clinical assessment and instrumental decision-making. Dysphagia. 2003;18:114–24.
•• Mc Allister S, Kruger S, Doeltgen SH, Tyler-Boltrek E. Implications of variability in clinical bedside swallowing assessment practices by speech language pathologists. Dysphagia. 2016;31(5):650–62. This study explored the decision making process in expert clinicians during CSE in the context of type1 and type 2 reasoning.
Carnaby GD, Harenberg L. What is “usual care” in dysphagia rehabilitation: a survey of USA dysphagia practice patterns. Dysphagia. 2013;28:567–74.
Archer S, Wellwood I, Smith C, Newham D. Dysphagia therapy in stroke: a survey of speech and language therapists. Int J Lang Comm Dis. 2013;48:283–96.
Langmore SE, Pisegna JM. Efficacy of exercises to rehabilitate dysphagia: a critique of the literature. Int J Speech Lang Pathol. 2015;17(3):222–9.
McCurtin A, Clifford AM. What are the primary influences on treatment decisions? How does this reflect on evidence-based practice? Indications from the discipline of speech and language therapy. J Eval Clin Prac. 2015;21:1178–89.
Jones O, Cartwright J, Whitworth A, Cocks N. Dysphagia therapy post stroke: an exploration of the practices and clinical decision-making of speech-language pathologists in Australia. Int J Speech Lang Pathol. 2018;20(2):226–37.
Groves-Wright KJ, Boyce S, Kelchner L. Perception of wet vocal quality in identifying penetration/aspiration during swallowing. J Speech Lang Hearing Res. 2010;53(3):620–32.
Warms T, Richards J. “Wet voice” as a predictor of penetration and aspiration in oropharyngeal dysphagia. Dysphagia. 2000;15(2):84–8.
Rangarathnam B, McCullough GH. Utility of a clinical swallowing exam for understanding swallowing physiology. Dysphagia. 2016;31(4):491–7.
•• Gonzalez-Fernandez M, Sein MT, Palmer JB. Clinical experience using the Mann Assessment of Swallowing Ability for identification of patients at risk for aspiration. Am J Speech Lang Pathol. 2011;20:331–6. This study documents that when engaging in a global clinical reasoning process, speech pathologists can reliably identify patients at risk of aspiration.
Logemann JA, Rademaker A, Pauloski BR, Antinoja J, Bacon M, Bernstein M, et al. What information do clinicians use in recommending oral versus nonoral feeding in oropharyngeal dysphagic patients? Dysphagia. 2008;23:378–84.
•• Ward EC, Sharma S, Burns C, Theodoros D, Russell T. Validity of conducting clinical dysphagia assessments for patients with normal to mild cognitive impairment via telerehabilitation. Dysphagia. 2012;27(4):460–72. This study documents that clinicians reach comparable clinical decisions regardless of assessment modality.
Odderson IR, Keaton JC, McKenna BS. Swallow management in patients on an acute stroke pathway: quality is cost effective. Arch Phys Med Rehabil. 1995;76:1130–3.
•• Croskerry P. A universal model of diagnostic reasoning. Acad Med. 2009;84(8):1022–8. Seminal paper on human diagnostic reasoning.
Hammond K. Human judgement and social policy: irreducible uncertainty, inevitable error, unavoidable injustice. New York, NY: Oxford University Press; 2000.
Le Maistre C, Paré A. Whatever it takes: how beginning teachers learn to survive. Teaching and Teacher Education. 2010;26(3):559–64.
Day SB, Goldstone RL. The import of knowledge export: connecting findings and theories of transfer of learning. Educational Psychologist. 2012;47(3):153–76.
Thorndike EL. Mental discipline in high school studies. J Educat Psychol. 1924;15:83–98.
How people learn: brain, mind, experience, and school/John D. Bransford…[et al.], editors; Committee on Developments in the Science of Learning and Committee on Learning Research and Educational Practice, Commission on Behavioral and Social Sciences and Education, National Research Council.—Expanded ed. Accessed on 16.04.2018 https://www.nap.edu/read/9853/chapter/1#ii
Braithwaite J, Westbrook J, Coiera E, Runciman WB, Day R, Hillman K, et al. A systems science perspective on the capacity for change in public hospitals. Israel Journal of Health Policy Research. 2017;6(1):16.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
The authors declare that they have no competing interests.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Additional information
This article is part of the Topical Collection on Swallowing Disorders
Rights and permissions
About this article
Cite this article
Doeltgen, S.H., McAllister, S., Murray, J. et al. Reasoning and Decision Making in Clinical Swallowing Examination. Curr Phys Med Rehabil Rep 6, 171–177 (2018). https://doi.org/10.1007/s40141-018-0191-z
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40141-018-0191-z