Digging for Dysphagia: Combatting our own cognitive bias

By George Barnes MS CCC-SLP

“You have to have dysphagia to have dysphagia” said the great Dr. James Coyle. This statement is packed with more wisdom than meets the eye. As swallowologists, dysphagia is always top of mind. We sleep, breathe, and eat swallowing (pardon the pun). So when we are consulted for a dysphagia evaluation, it’s pretty much all we are thinking about. It textures the way we look at the chart, our time with the patient, and our discussions with the interdisciplinary team. So much so that it may cause us to see it when it’s not even there. In many ways, it’s natural to have tunnel vision for dysphagia. It’s what WE DO for cripes sake! Except for one small issue: not everybody has dysphagia. You have to have it… to have it. 

Confirmation Bias

As an avid fan of math’s superstar celebrity, statistics, I am always looking for ways to recognize and combat cognitive bias (Which is the antithesis of statistics (you can use that tongue twister in your next speech session)). We all have cognitive bias and if we don’t at least acknowledge it then we risk making decisions against our best interest (or in this case, our patient’s interest). There are many different types of cognitive bias, but the one most relevant to this article is called “confirmation bias.” 

You know that avid sports fan that knows their team is the best no matter what you tell them? That’s confirmation bias. Or the political enthusiast who only sees the good in their party and the bad in the other. “It’s a war! Pick a side!” Confirmation bias. Or the person who knows they have some terrible disease and searches the internet until they finally find the one article that confirms it. Confirmation bias (And yes it’s ok, we’ve all done that last one).

It would be nice to live in a world that is filled with straight lines and symmetrical reasoning, especially when it fits in so nicely with our own knowledge and understanding. But that’s not the way the world works (sucks right?). Confirmation bias is when we take all the information that challenges our beliefs and throw the bathwater out and all the babies that come with it. 

What we pay attention to matters. If we are paying all of our attention to one thing, we are surely missing others. So confirmation bias is kind of like the little devil on your shoulder telling you to pay too much attention to one thing and distorting your reality. Except, you don’t even know he’s there and you think what he’s telling you is just your own thoughts. Yeah, you’re basically a walking zombie and you didn’t even know it. Dysphagia management is no different. Dysphagia is the coolest kid on the symptom block so why pay attention to anything else? Coughing? Must be dysphagia? Globus? Must be dysphagia? Watery eyes, runny nose, poor gag reflex, and throat clearing? There you are dysphagia, right where I always knew you’d be. So if confirmation bias is the devil on your shoulder, who is the angel?

It’s a bird, it’s a plane… No, it’s thoughtful reasoning! Sounds simple, but remember, our brains are programmed for bias so we really have to be thoughtful about being thoughtful (And now I’m being meta about being meta). Here are some simple tips to combat confirmation bias in your daily practice:

Have a system

Approach every patient the same way every time so that we don’t miss any key information. Review your chart the same way, perform your oral motor exam the same way, and yes, conduct your MBSS and FEES exams the same way. Every time. No exceptions. Ok?! Sorry, it’s just that it’s important to stick to a routine so that we don’t veer off course when our bias kicks in… “He has pneumonia? Must be aspiration...NPO.” “This person has been NPO for 2 years, there’s no point in re-checking now!” Or on the other side of the equation… “She came in on a regular diet, must be fine- no reason to check further.” Don’t let that little devil get the best of you. Confirmation bias can work both ways- we can be biased for or against dysphagia. It’s the being biased against being the biased thing that we are striving for. By doing everything every time with everyone in a strict procedure-like routine, you are less likely to let your biases get the best of you.

Look at the whole picture

Do a thorough chart review looking at everything from vitals to imaging to lab work and DO NOT forget the progress notes (It can be a lot to mine through, but you’re bound to find little golden nuggets of information that you would have missed otherwise). Talk to the IDT to see what’s been going on with the patient, the current trends, how stable is the patient, and how the patient is tolerating PO currently. Remember, there doesn’t always have to be a problem. You may find that the patient is stable and is having no significant difficulties, but that an evaluation is part of a stroke protocol. Or that the patient had confusion which has now resolved. Or that the baseline diet is simply unknown and the team wants to double-check with the expert (that’s you).

What question are we answering? 

Why were you consulted for the evaluation in the first place? Talk to the doctor and find out what the concern is with the patient’s swallowing or if she is just trying to rule out another factor that could be leading to some sort of aerodigestive issue. Odynophagia? Increased coughing? OR increased risk due to comorbidities and nothing to do with physiology? The only way we can get this information is by going directly to the source: The MD who ordered the evaluation in the first place.

Broaden your scope (and use one too)

Instead of jumping to conclusions, get grounded in evidence. This is to avoid a knee-jerk reaction... “The patient was coughing so it must be dysphagia.” A cough can be from any number of causes. Using this example, let’s zoom out and examine all possibilities: a cold, the flu, pneumonia, asthma, COPD, bronchitis, GERD, postnasal drip, fibrosis, heart failure, laryngitis, cancer, pulmonary embolism, tuberculosis, emphysema, sinusitis, etc. The list goes on. Seriously. 

By assuming there is dysphagia we may jump to an intervention that may, in itself, cause negative effects (e.g. thickened liquids lead to reduced intake and changes medication breakdown). So we better know FOR SURE if the patient has dysphagia before we start meddling. Even if a patient is coughing DURING intake, this does not confirm aspiration (I, myself have seen many patients coughing during a FEES with no penetration or aspiration). If dysphagia is suspected, get an instrumental study and quickly. Try not to make a decision at the bedside because you can be doing more harm than good and nobody has that as a career goal. 

Be biased against your bias

So, yes, we are all biased. That devil has been in our brains for far too long to get it out now. To tame it we must accept it, systemize our clinical approach, look at the whole picture, break down the purpose of the assessment, and broaden our scope. If we are constantly looking for dysphagia we are bound to find it. Heck, if you followed me around for long enough you’ll find I clear my throat and cough occasionally during meals. Remember, you have to have dysphagia to have dysphagia. And the only fool-proof way to determine this is an instrumental study. Whether you have direct access to one or not, does not change this fact. But the worst thing we can do is pretend we know more than we do, make unfounded judgments, and provide blind intervention that stirs up a storm of changes for the patient. There are many things we can do in any given clinical scenario, but first, do no harm. 

Please contact us if you need help getting access to instrumental studies in your area. Here to help. 

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