Title: Understanding differences in practices and preferences during videofluoroscopic swallow studies: A survey of radiologists and speech language pathologists in the United States
Authors: Hermann, Donaker, Salmon, & Mervak
Journal: Clinical Imaging
Year of Publication: 2022
Design Type: Anonymous survey
Purpose: “The purpose of this study was to (a) examine the interprofessional relationship between radiologists and speech-language pathologists (SLPs), and (b) explore viewpoints and practice patterns of each profession regarding a videofluoroscopic swallow study (VFSS)”
Population: U.S. radiologists & speech-language pathologists performing videofluoroscopic swallow studies
Inclusion criteria: a) credentialing as a speech-language pathologist or radiologist, including radiology residents, fellows, or attending radiologists, and b) currently performing and interpreting videofluoroscopic swallow studies within a clinical practice setting at least once weekly
Exclusion criteria: Respondents who did not complete the survey or who skipped > 6 items
“Could we just…” “I’d like to….“
“No.” “We don’t do that here.” “We can’t do that.“
Do you ever get spooked having this short back-and-forth in your setting?😱 While it can be related to many things, one common conversation is often heard between an SLP and Radiologist.
If we’re ever gonna get along, we need to know just what it is we disagree (or agree) with!🤥 This article is just a start in helping both sides see the other’s point of view and find some surprisingly common ground in order to provide the best services to our patients.
- Only got a sec?
- SLPS & Radiologists may have differences ideas on everything for VFSS except having a standardized protocol, but we need more responses across the professions to dig deeper
- Only for a minute?
- “Despite the commonality of dysphagia in the U.S., our study shows a significant discrepancy in opinions and practice patterns between radiologists and SLPs. Specifically, radiologists and speech-language pathologists had significantly different opinions on all but one statement in this survey, with the groups agreeing that a standardized protocol for VFSS should exist“
- “Statistically significant differences between SLPs and radiologists were seen with responses related to the following practice patterns: performance of an esophageal sweep, ideal fluoroscopy time <5 minutes, termination after aspiration event, role of SLP in describing swallowing physiology, inclusion of anterior-posterior view, primary purpose of VFSS, use of VFSS to assess all the phases of swallowing, and frame rate“
- “Recent publications in the American Journal of Speech-Language Pathology (AJSLP) as well as Applied Radiology outline the importance of not simply using the VFSS as a pass/fail tool for identifying aspiration and, when safe, to continue the assessment despite aspiration to further assess swallow physiology and functional outcomes. If the study is stopped due to an aspiration event, the understanding of causation and the determination of preventative strategies are incomplete“
- Got more time? Keep Reading!!
Why there are plenty of other papers that delve into the history of performing these radiographic tests, the authors make a pretty compelling point that “dysphagia be recognized as one of the ‘geriatric giants’ in healthcare” according to Smithard (2016). Add that to the fact that there’s been ample research looking at other professional collabs for nursing, physicians, and other allied health, and it should be a win-win, right? But SLPs and Radiologists? Sometimes it seems we can appear as that suprising (I dare say it) awkward couple you might be wondering what forces brought us together and make it work?🤨
With some collabs in the works and a handful of increasingly used standardized protocols for VFSS, the authors set forth to learn more about how we work separately while being jammed together and just what each side values or prefers when it comes to VFSS.
After perusing existing literature, adding information from a breakout session at a 2019 continuing education event through a poll of 100 SLPs, and knowledge from more commonly used standardized protocols (MBSImP & MDTP), the authors distributed a final “Interprofessional Collaboration in Fluoroscopy Suite” survey consisting of “7 multiple-choice demographic questions, 13 statements with a continuous Likert scale from 0-100 to measure level of agreement, one numeric reetext entry, and one fill-in-the-blank for contact information.” Even better, you can check the full form out in the original article😉.
Since there were no incentive rewards for teh survey and all particpants did so at their own own/interest, the authors had a bit more burden to bear in order to obtain an adequate sample size from both professions in the following various ways and platforms:
- Society of Abdominal Radiology
- American Speech-Language & Hearing Association Special Interest Group Sig 13 (Swallowing) forum
- Professional groups within social media platforms
- Individual emails to 2,696 radiologists registered with Bracco Diagnostics, Inc.
- >200 invitations to radiologists via LinkedIn Mail
The authors had lots of data to sort out to try to make sense of the interesting dynamic between our fields, and out of a total of 362 survey responses that were accepted for analysis (after some being thrown out due to being incomplete), guess who had the most surveys returned?
Yep. We SLPs keep holding onto that Type A-get-it-done title because there were 316 SLP responses compared to the final 46 Radiologist survey responses returned. The authors are quick to mention this little bias since the majority of them are SLPS too! Needless to say it’s always a bit easier to get those same birds of a feather together instead of having to go against the grain.🙃
Both groups had a wide range of experience, with more SLP participants in the 0-5 year category, as well as a broad range of number of weekly VFSSs completed (anywhere from 1-5 to >15) with both groups having the most responses in the 1-5 range. And an interesting (but not surprising) detail was the gender disparity between the 2 groups with 30/46 Male radiologists and 284/296 Female SLPs🚻).
Get ready for the breakdown:
“Statistically significant differences between SLPs and radiologists were seen with responses related to the following practice patterns: performance of an esophageal sweep, ideal fluoroscopy time <5 minutes, termination after aspiration event, role of the SLP in describing swallowing physiology, incusion of anterior-posterior view, primary purpose of VFSS, use of VFSS to assess all the phases of swallowing, frame rate.” p.147
I know, pretty much most of what we all knew to be true, unfortunately. I want to say I was at least a little suprised at the following:
“There were also statistically significant differences noted in the perceptions of radiologists and SLPs on the following items (Q17–Q19): description of pathophysiology and kinematics, most valuable information obtained from study, and training requirements.” p.147
Hold tight, because it’s about to get bumpy folks😬….
“When asked to select the role(s) of the radiologist during VFSS, 91% of radiologists selected ensure patient safety per ALARA guidelines, 78% selected identify structural or functional abnormalities, 74% selected operate videofluoroscopic equipment, and 48% selected guide assessment of patient’s swallow function.”
“When asked to select the role(s) of the radiologist during VFSS, 73% of SLPs selected ensure patient safety per ALARA guidelines, 86% selected identify structural or functional abnormalities, 67% selected operate videofluoroscopic equipment, and 10% selected guide assessment of patient’s swallow function.” p.147
The authors then found out from further statistical analysis that “statistically significant differences for the following 2 items: a) ensure patient safety per ALARA guidelines and b) guide assessment of patient’s swallow function,” and were really what stuck out as important.
The authors share some key areas that were so different between Radiologists and SLPs that they want to make sure we don’t just start giving the silent treatment or frustrated sighs but rather try to come up with solutions to reach some common ground:
Initial Aspiration Event
Yes it’s clear there is disagreement, but how can we go about changing these preconceived perceptions?
That’s the more important thing the authors are nudging us all towards by sharing some great insight (which you might also wanna jot down during your next trip down to fluoro😉):
“Recent publications in the American Journal of Speech-Language Pathology (AJSLP) as well as Applied Radiology outline the importance of not simply using the VFSS as a pass/fail tool for identifying aspiration and, when safe, to continue the assessment despite aspiration to further assess swallow physiology and functional outcomes. If the study is stopped due to an aspiration event, the understanding of causation and the determination of preventative strategies are incomplete.”
“The American College of Radiology (ACR) Modified Barium Swallow Practice Guidelines also support continuation of a study following an aspiration event if the aspiration is not severe, stating that, “if aspiration occurs, the patient’s response to aspiration and ability to clear the aspirated materials and his or her response to protective and therapeutic maneuvers should be assessed wherever possible. The examination may need to be terminated prematurely if the patient demonstrates severe aspiration (such as aspiration below the sternal notch) and does not respond to protective or therapeutic maneuvers.” p.147
As we’ve been saying for who knows how long: We have to see things more than once and test various hypotheses as safely appropriate in order to best identify and treat any swallow pathophysiologic dysfunction. Doing so when put into a larger context for holistic, person-centered care (e.g. quality of life/goals of care, medical prognosis, medical history, etc.) is really the only way we can do more that just yell from afar “aspiration” or “penetration” and call it a day.
Since they also include a recent 2020 article for “Best Practices in MBSS” by some other greats, you can just use this instead😉:
“As outlined in a recent article regarding best practices during VFSS, “radiologists must assess the volume of aspirate; the ability of the patient to clear their airway; and, importantly, the underlying condition and reserve of each patient. It is only with this entire complement of information that the radiologist can adequately evaluate the ongoing safety of the examination” p.147
What we probably knew to be true: SLPs prefer to get that sweet A-P view more often than Radiologists.
While this is something I probably could’ve made an easy bet especially since standardized protocols and journals within both fields even argue for this addition as best practice, the authors still provide some additional ways to promptly push for the AP view, or at least give a Radiologist a lil nudge to turn forn and center😉:
“Radiologists may benefit from learning other reasons an AP view can assist their SLP colleagues, including: assessment of bolus flow symmetry, pharyngeal contraction and residue, and multiplanar visualization of the esophagus. As noted by the ACR, this projection is also valuable to further assess potential anatomical abnormalities and can improve referral patterns.” p.148
Yep, you guessed it: SLPs are the majority again on this one! The authors again shed some light into why this piece of the puzzle is often MIA:
“Although it should be stressed and documented in the radiology report that the esophageal sweep is not designed or intended to replace a full barium swallow for complete evaluation of the esophagus. Nonetheless, an esophageal sweep can lead to appropriate referrals to gastrointestinal specialists for evaluation and diagnosis of suspected esophageal dysfunction, and assess timing and symmetry of bolus clearance.” p.148
With recent evidence even pointing the finger to this critical piece out including a recent 2021 systematic review on the subject, it’s worth having the (albeit possibly uncomfortable or awkward) conversation to better help our patients a) not waste money or time on things that potentially don’t help their problem and b) get the answers they more necessarily need from more appropriate professionals.
SLPs for the win! We’ve known for a while now the critical impact having a reduced frame rate can have. Admittedly, the authors do clarify that some participants may have naturally confused the terms use in the survey, stating “While it was intended to indicate pulses per second…The confusion between pulses per second and frame per second, prone to misinterpretation, has been discussed in the literature” with references to match.
Even so, we still have previous evidence pointing us and our Radiology colleagues hopefully in the right direction at some point so we can see eye to eye:
“A 2013 study found that decreasing the frame rate from 30 to 15 frames per second reduced diagnostic accuracy in 37% of swallows and changed treatment strategies in 47% of those patients. Another study found that 15 fps increased the risk of missing episodes of penetration.” p.148 [Bonilha et al. (2012); Cohen (2009), respectively]
I know it may feel like carrying the heaviest weights on your way down to fluoro to possibly yet again get rejected for any of the above SLP desires. But don’t get too discouraged because it turns out there is actually something we can find common ground on after all!🤯
“There was no statistically significant difference in the ratings of radiologists and SLPs on whether a standardized protocol should exist.” p.147
Who woulda thought that both worlds actually want to have more standardized procedures?! Hey, I’ll take an ally for this push anywhere and any day!!
Before we go marking our territories throughout the hospitals, here’s where we need to really take a leap of faith to discuss what this all means, and what it really doesn’t…
For starters, this article finally proves that we’re not crazy thinking that our SLP way of thinking feels drastically different from that of our radiology colleagues’!
So what do we do with this powerful info? Do we shove this in our radiology friends’ faces and say, “Ha! Told you!” Or start barricading off the barium until we all agree on these important points?
Especially since we should probably get more research on this little niche area of interest since it directly impacts both professions along with the outcomes of our patients. We need more participation from more Radiologists to really gain a better, more expansive and in depth reflection of this profession we work so closely with (yet have so drastically different opinions!). We also don’t know how many SLPs/Radiologists chose not to participate in such a survey, and if so why!? (always a conundrum when it comes to this method😕).
Personally, I’m looking forward to learning more about this disparity as well as seeing more collaboration (like Dr. Martin-Harris’ presentation across the aisle for “Society for Abdominal Radiology (SAR) 2022 Annual Meeting to highlight the necessary collaboration between disciplines when conducting Modified Barium Swallow studies.“
But for the rest of us SLPs bringing down the barium and packets of pudding, for now we can at least use this as a discussion point with all of our colleagues to start creating a common path for change.
“Our hope is that this study can promote awareness of guidelines from national organizations and tools like the above which can improve patient care by offering a more comprehensive assessment, beyond simply the presence or absence of aspiration, and assist clinicians as they establish a patient’s baseline within the larger framework of a treatment algorithm.” p.147
Hermann, L., Donaker, M., Salmon, K., & Mervak, B. (2022). Understanding differences in practices and preferences during videofluoroscopic swallow studies: A survey of radiologists and speech language pathologists in the United States. Clinical Imaging, 83, 144-151. doi: 10.1016/j.clinimag.2021.12.016