Medical Speech Pathology

Curiosity, Dialogue, and Knowledge

The Importance of Being Earnest (in diagnostic testing)

Earnest- (adj.)

1. serious in intention, purpose, or effort; sincerely zealous: an earnest worker.

2. showing depth and sincerity of feeling: earnest words; an earnest entreaty.

3. seriously important; demanding or receiving serious attention.

Many of you are already earnestly seeking precise diagnostic information before you begin treating your patients.  Some of you are not.  I have worked with people and been trained by people who found this part of patient care to be a necessary evil rather than a key to maximizing patient performance.  Sadly, I’ve glossed over it myself at times.   I was taught correctly by my professors at school.  I can’t blame them.  But that isn’t the “real world” is it?  In clinic we spent all day preparing lesson plans, gathering materials, reviewing tests, and being microscopically analyzed by multiple clinical instructors.  When I started working with adults in the medical field, I quickly realized that I didn’t have to do all those standardized tests anymore; even if I was so inclined, where was the time?  There is no requirement that a patient score 2 standard deviations below the mean on 2 standardized tests to qualify for services (there is such a requirement with the schools or something similar).  With adults at the hospital, the only requirement for services is that they have a doctor’s order for evaluation and treatment.  That’s it.

Because of this more permissive atmosphere, many SLPs that work with adults in the hospital settings (Rehab, SNF, Acute, LTAC, etc.) have adopted a dangerous mentality towards the use of diagnostic materials.  At the eight places I’ve visited or worked at (PRN included), I’ve yet to run across even one that uses a standardized test in a standardized way.  More specifically, I mean that they all had standardized tests but none of them actually gave the full tests with any regularity.  All of the places also had their own version of a “cog eval” or a “communication eval” that was cut and pasted from several other standardized tests.  Why would they do this?  The answer (I know from personal experience) is simple:  many of the standardized tests fall into one of two categories; they are horrid or they are dreadfully long.  I love the SCATBI, but it takes a minimum of three 45 minute sessions to give (and another 20 minutes or so after work to score).  I can’t stand the MMSE or the RIPA.  The first is too broadly applied given very little information, and while the second one can be given during one session, it cannot be used to answer most of the clinical questions you have about the patient.

Think back to grad school with me for a moment.  If your professors were like mine, you might have spent upwards of a weeks worth of therapy time (3-6 hours) doing a battery of tests for each and every client that you served.  In an inpatient rehabilitation hospital, our average length of stay for neuro patients is roughly 18 days.  If I followed the same model I was taught in graduate school, I would eat up a full week of patient treatment with testing.  I don’t think that is a good solution.  However, I also don’t think relying too heavily on home-grown assessments really fits the bill either.  As federal dollars for medical care become increasingly scarce, there will be tighter regulation on who does and who doesn’t deserve therapy.  We need tests that are well researched and applicable to our clients.  Some of the tests out there for testing patients with encephalopathy (like the RBANS), are well designed and have a short test time, but are really intended for use by persons with a background in psychology- they are not available to SLPs unless you have a PhD.

In the inpatient rehabilitation world, we really need a test that is thorough enough to look at multiple areas without taking up more than one session to administer.  It also needs to mesh well with the documentation we already have to use to grade a patient’s level of independence (the FIM instrument).  This test, to my knowledge, doesn’t exist.

The challenge, then, is to find tests that do fit.  A couple of cognitive tests that are a bit more of what I’m looking for include the Cognistat and the Montreal Cognitive Assessment (MOCA).  There are options out there for dysphagia as well (thanks to researchers like Dr. Giselle Carnaby  who created the MASA).  And, I would be neglectful if I didn’t allude to our relative wealth of good language and articulation tests: the Frenchay Dysarthria Assessment, BDAE, WAB, Apraxia Battery for Adults-2, and others.  As we push for more credibility within the medical field we must keep in mind the fact that we will be judged on the level of evidence we present for our findings; we must use instruments that are reliable, valid, and specific to the patients we are testing.


4 comments on “The Importance of Being Earnest (in diagnostic testing)

  1. Michael Hoeft, MS, CCC-SLP
    October 5, 2012

    Though I relate and agree with the practical challenges to obtaining “precise diagnostic information” – of which there are many – I would add that the very notion of this concept as it relates to cognitive functioning is a bit of a Quixote-like hunt for the Golden Chalice. The psychometric challenges of comprehensive standardized testing within the medical setting — heterogeneity of medical status, test conditions, and rater reliability should call into question the cost, practicality, and the very validity of the quest itself. After all, even the “best” testing tool is but one component of an assessment process whose primary purpose is to establish a functional baseline from which to judge future progress. No wonder we do indeed find ourselves often gravitating toward our quicker, more familiar “home-grown” tools. Establishing a functional baseline doesn’t demand a formalized battery from which to draw questionable normative comparisons. It does demand expediency and relevance to the actual plan of care – the treatment targets and methods undertaken. Yes, having a good profile of deficits facing our client should lend to a more focused treatment approach, which then should produce a better outcome. But the reality is that it may not. Not unless we the clinician know the best practices and/or proven techniques for actually improving the very function that we so earnestly diagnosed with great precision. In short, I propose that as a profession, our earnest be more productively focused on treatment efficacy. We may want to wow our medical colleagues with our diagnostic brilliance, but until we can match it with outstanding treatment outcomes, our relevance will always be questioned. As humbly reminded again and again in conversations with physicians, I often hear the following. “ I see…that’s interesting; now what can you do about it?”

    • Admin
      May 4, 2013

      Nice points Michael. I agree with your point about moving forward in therapy, but I still worry about what I’ve seen some clinicians do with patients: they spin their wheels trying different modalities and interventions that will likely produce poor results when a session or two of diagnostic evaluation would steer the ship in the right direction. It’s not wasting time to do a proper evaluation. You mention completely valid concerns about test conditions, the multitude of different patients, etc., and these are all real challenges to good diagnostics. But, I don’t think it’s “quixotic” to aim for accurate assessments that have some degree of statistical backbone to them- scientific is the adjective I would choose.

  2. Jennifer F Beadling
    January 15, 2017

    I know this is an older post, but I hope you can still respond. It looks like your advocating for “standardized assessment” but the MOCA is considered a screening tool. Can you please clarify? I greatly appreciate the information and guidance you provide. I am a CF and the only SLP in my facility. I do use the MOCA regularly but was looking for something more in depth to better guide my treatment plans.

    • Admin
      March 31, 2017

      Great point, Jennifer. I think there are better assessments out there, but time is a huge factor as well. There is the Rivermead for memory, the Boston naming for anomia, the WAB for aphasia, BDAE for in depth language, the RICE tests for right hemisphere issues, and more. I use a combination of these as appropriate. The time issue, as you know, is a real barrier. Average LOS for an IRF is 12-14 days; of which we might have 8-10 actual therapy days where we see them 1-2x a day.

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