The ‘Big Picture’ Diagnostician When we focus only on technology when diagnosing, we lose valuable insights from lifestyle information, behavioral symptoms and our own expertise. From the President
From the President  |   February 01, 2017
The ‘Big Picture’ Diagnostician
Author Notes
  • Gail J. Richard, PhD, CCC-SLP, is former department chair, professor emeritus and director of The Autism Center at Eastern Illinois University.
    Gail J. Richard, PhD, CCC-SLP, is former department chair, professor emeritus and director of The Autism Center at Eastern Illinois University.×
Article Information
Professional Issues & Training / Language Disorders / From the President
From the President   |   February 01, 2017
The ‘Big Picture’ Diagnostician
The ASHA Leader, February 2017, Vol. 22, 6-7. doi:10.1044/leader.FTP.22022017.6
The ASHA Leader, February 2017, Vol. 22, 6-7. doi:10.1044/leader.FTP.22022017.6
A few years ago I caught a cold that lingered, escalated and led to difficulty breathing, with consistent coughing and wheezing. My physician diagnosed bronchitis and prescribed antibiotics and a steroid. My blood pressure was also elevated—a big concern to the doctor. After completing the prescribed medication regimen, my coughing and wheezing weren’t better, but the doctor was focused on the blood pressure. He prescribed three different medications for blood pressure, but nothing for the consistent coughing and wheezing.
The blood pressure responded to medication, and gradually medications were removed until I was on only one blood pressure medicine. Still, I received nothing for the coughing or wheezing, which were hindering my ability to converse, sleep and function. I requested a referral to a pulmonologist because of my concern about the breathing difficulty.
The pulmonologist ordered a boatload of tests and restricted my diet. He never examined me, didn’t listen to my breathing and wheezing, and didn’t really ask questions to build a case history. After I completed all the tests, I waited an hour to discuss the results with him. He said he hadn’t had time to review any results (some were completed six weeks prior), and advised me to make another appointment.
At my next appointment, the pulmonologist said he didn’t have results yet, so I handed him a CD of the results that I’d obtained from the hospital. He said the results suggested maybe borderline asthma, but I would just need to live with it and could get a breathing machine to help. Still, he did not examine me and only reviewed half the tests.
Now you might be thinking I encountered incompetent or simply impersonal physicians. But what I believe occurred was an interaction with the new generation of technicians versus diagnosticians. This physician was so focused on technology that he abandoned use of personal detective skills. Because the tests were inconclusive, he made no attempt—based on examination and case history—to fill in missing pieces with lifestyle information, behavioral symptoms or his own impressions.
The test results are definitely important. Advances in technology have contributed to improved accuracy in evaluation of possible causes for symptomatic issues. But the test results need to be one piece in fitting together the diagnostic puzzle and determining the big picture. In fact, the theme of the 2017 ASHA Convention in Los Angeles is “Focus on the Big Picture”—a call to broaden our perspectives related to our professional lives and practice. Within our professions, advances in technology have significantly improved our ability to meet the needs of clients with communication disorders. But we also need to remember the personal touch and importance of putting all the components together to achieve the best outcome for our clients.
My fascination with communication disorders has always stemmed from playing detective. I enjoy fitting together all the puzzle pieces and actively seeking opinions from adjunct professionals (such as audiologists, psychologists, physicians and occupational therapists) to expand my understanding of contributing and mitigating factors. Neuroscience helps me relate a behavioral symptom to brain structures responsible for mediating that characteristic.

Remember the personal touch and importance of putting all the components together to achieve the best outcome for clients.

When working on a university faculty to educate future clinicians, I have always been adamant that graduate students do more than just report test scores. I want them to be able to explain how and why a test score was realized. They also need to consider other aspects that might influence the test scores, such as attention, hearing loss, visual impairment, motor skills and more. How do all those scores fit together to arrive at a complete picture of the communication disorder? How have developmental and medical involvement affected communication?
To finish my personal saga, it took two years and a different pulmonologist to determine that the problem was a hiatal hernia and reflux, which is now under control. I found a professional who listened carefully to the evolution of the problem, examined me, evaluated all the test results together, and engaged in a ruling out/ruling in diagnostic process. He used the physiological tests and technology, paired with careful clinical insight, to guide the diagnosis and treatment.
In our professions, we need to guard against becoming overly dependent on technology. It is a tool. Careful clinical observation is imperative to effectively evaluate a communication disorder. Many of our clients, because of their communication problems, are not able to accurately explain all the issues they may be experiencing. We need to take the time to discover all aspects of the communication disorder to accurately diagnose and prescribe treatment.
Experience helps us fill in missing pieces that are suggested by a test result. Technology is important and certainly adds confidence to our diagnostic conclusions, but we need to ensure a personal factor of overlaying clinical impressions on the test results. Embrace the challenge of being a diagnostic detective by using the technology, paired with clinical knowledge and insight. And remember to keep the big picture in mind!
February 12, 2017
Patricia Mayro
Critical Thinking and Client Care
Thank you, Dr. Richard! I could not agree more that it is essential for us as CSD professionals to always remember that client care demands all of our attention and resources. We are not technicians who merely report data; we are professionals who hold the care of her clients paramount. Part of that care means that we will engage in critical thinking which demands time and effort from us, in order to best realize competent care for our clients.
February 27, 2017
Maria Noel
Clients are More Than Just Scores
Thank you for this excellent editorial. We so often work under tight deadlines and restrictive guidelines that sometimes get in the way of making appropriate diagnoses. While I don't disagree with having testing results reported in a timely manner or using guidelines to determine eligibility, we must adopt a wholistic approach in order to reach conclusions that will inform our interventions. I feel that diagnostics is both art and science, and wonder if that would be appropriate as a specialty area or SIG.
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February 2017
Volume 22, Issue 2