Models  |  Listening  |  Caution

What model of diagnosis do you use? This was a question posed to me on the first day of my fellowship. Honestly, I had never thought about it before, and I had never considered its importance. I had studied and then upon graduation began diagnosing and treating patients. As I learned something new, I registered it in the mind, somewhere, hopefully able to draw it up when the time came. I didn’t feel that I was using any particular model. Yet, I had to have been using one since I could not have kept all possible information I had ever heard or read readily available. In some sense, I think I kept a master list of possible diagnoses in my brain and the more often and more recent I had used a diagnosis, the more familiar I became with it. Then, in my fellowship, I was thoroughly inculcated into a model of diagnosis that I had never used before.

A model is a theoretical construction that represents a larger whole. It is probably not possible to know everything that has ever been written on the voice and on the diagnosis of voice disorders, so each person (consciously or not) has a model that they use to diagnose disorders of the voice.

The model used may depend on training. To generalize, voice teachers and speech pathologists may look for and find improper patterns of behavior such as poor breath support or improper usage of the neck musculature. Laryngologists tend to be trained to look for visible lesions of the larynx that can be treated. It is conceivable that both models could lead to a different diagnosis in the same person and could treat the same problem in different ways and result in vocal improvment. Models for diagnosis are not always exclusive.

Models may be based on a decision tree where each question from the examiner eliminates certain groups of diseases and eventually one disease is left. Another model is where the examiner has a complete diagnostic protocol that is performed identically on everyone. After completion, the findings that stand out are organized and a diagnosis made.

Another model that might be used in a busy office is a visual model where the examiner first determines that the complaint is about the voice, as opposed to hearing for example. The examiner evaluates the larynx and matches the visible laryngeal findings to previously seen findings, either from their personal experience or from textbook and journal articles.

The model proposed here consists of three component exams that are performed in some variation on all voice patients: the history, vocal capability tests and the visual laryngeal exam. Each component exam is used to crosscheck the other. The history, performed first, is the most sterotyped exam, where the same questions are asked of almost everyone. The vocal capabilities that are tested, are chosen to crosscheck the history and in turn the visual laryngeal findings are used as a cross check for the vocal capabilities and the history. In actual practice, examiners probably use some combination of models that they have learned during their education. Reviewing the model that one uses for diagnosis. Reviewing the model that one uses is like cleaning house and getting rid of the outdated concepts. A more clear and efficient thought process may emerge that allows a more incisive decision making process. A precise diagnosis allows a precise treatment.

Models  |  Listening  |  Caution