Date Published: October 11, 2016
Publisher: Springer US
Author(s): Martina Scharitzer, Peter Pokieser, Michaela Wagner-Menghin, Ferdinand Otto, Olle Ekberg.
Clinical assessment of swallowing disorders (dysphagia) requires accurate and comprehensive medical history-taking to further tailor the diagnostic work-up, but functional health care questionnaires show a large variability and various limitations. The aim of this study was to assess the way in which international swallowing experts from various disciplines asses swallowing problems in order to improve the radiologist´s ability to take a thorough medical history in this specific patient group.
A two-step Delphi method was used to collect swallowing experts’ ways of taking the medical history in patients with swallowing disorders. The questions obtained in a first interview round were pooled and structured by dividing them into general and specific questions, including several subcategories, and these were scored by the experts in a second step based on to their clinical relevance.
Eighteen experts provided 25 different questions categorized as general questions and 34 dimension-specific questions (eight attributed to ‘suspicion of aspiration,’ 13 to ‘dysphagia,’ six to ‘globus sensation,’ four to ‘non-cardiac chest pain,’ and three to ‘effect of life.’) In the second interview round, the experts´ average predictive values attributed to those questions showed the varying importance of the presented items. Seven general and 13 specific questions (six of them attributed to ‘effect on life’ and seven ‘others’) were also added.
This collection of questions reflects the fact that a multidisciplinary approach when obtaining the medical history in patients with swallowing disorders may contribute to an improved technique for performing a symptom-oriented medical history-taking for radiologists of all training levels.
A two-step Delphi method  was used to determine swallowing experts’ ways of taking the medical history in patients with swallowing disorders. In such a structured communication process, an expert panel first provides opinions about a key question. These opinions are then pooled and structured by the researchers and the result is fed back to the expert panel. In a second step, the expert panel rates each statement’s importance for answering the key question.
Step 1—Answers to key questions; directed content analysis.
The goal of this study was to obtain a range of answers from a widespread, diverse group of experts from different disciplines about how to take a medical history in patients with swallowing disorders. Previously, various studies have revealed the relevance of the medical history for making a final diagnosis and showed a high agreement between the diagnosis made after taking the history and reading the referral letter and the final diagnosis [8, 9]. In a study from 2005, Graber et al. found that the majority of cognitive errors in internal medicine occurred due to premature judgment from incomplete data . Clinical evaluation of swallowing is a subjective evaluation to identify possible causes of deglutition disorders, evaluate the risk of aspiration, and decide on further diagnostic tests. As early as 1959, when evaluating dysphagia due to lower esophageal rings, Schatzki stated that, by obtaining a careful history, a strong suspicion of the correct diagnosis could be obtained in 80% to 85% of cases . The role of different swallowing disorders in determining the various causes of dysphagia still remains a challenge. Patients’ subjective experiences of dysfunction are impossible to measure objectively. However, these subjective experiences can be narrated, and selected symptoms and clinically easily assessable variables can help to discriminate different causes of dysphagia . Particularly in the work-up of this patient group, skilled history-taking may lead to differences in planning the diagnostic procedure and in guiding further diagnostic testing.
This survey presents a collection of the methods used by interdisciplinary experts to perform the clinical interview in patients with swallowing disorders and a weighting of varying questions as an approach to this complex clinical challenge. It may contribute to improve the technique of radiologists of all training levels to take the history in patients with swallowing disorders in order to tailor the examination protocol of the individual symptomatic patient. Although radiologists often do not take a full history in an interdisciplinary setting, it is still important to know the relevant questions across the boundaries of individual disciplines to tailor the radiological investigation optimally and correlate the symptoms to the radiological findings.