Annual Vocal Physical: PART 1 - the History
In medical school, we are taught that history-taking is the most important part of a patient visit. We are instructed (endlessly) that by asking targeted questions, you can create a reliable framework for that person’s problem and are more likely to get to the right diagnosis.
Fast forward through four years of med school, five years of residency, a year of fellowship, and a good decade of practice and you’ll find that most doctors have trimmed down on the thorough and exhaustive steps of a patient visit.
This is a huge mistake, especially for vocal athletes. If doctors who treat professional voice users rush through the history, they risk missing the true cause of the voice problem. They often do so because they believe the scope can provide the answer. But this results in missed diagnoses, delayed treatment, and unnecessary medications most of the time.
I’ll give you the perfect example. I saw a voice actor in my office who complained of voice fatigue. I spent 20 minutes with him just describing his symptoms, and I asked him to go back to the beginning … twice. As he described his issue, I found I had more questions and so we went back to day one. He stated he had seen another doctor who advised him to take reflux medications. The patient did have some reflux symptoms and so he tried it without success.
Why didn’t the reflux medications work?
By digging into the story, it was easy to see that while he had reflux symptoms, they weren’t the cause of his voice symptoms. A patient can have a disease like reflux … and still not have it be the cause of their voice problems.
The elements of the history taking that help guide my care are:
Timing of the voice symptoms- acute or chronic. Later, after I examine the patient, I will ensure my diagnosis ties into their timing. For example, reflux won’t cause a very acute (sudden) voice change unless it’s severe in which case…
Associated symptoms - they report a sudden bout of reflux, heartburn, diet change, etc. When I ask about other symptoms, I want to know about things that may seem irrelevant. Even the car accident that you were in around the time of the voice problem is significant. Tell me everything!
The real impact on voice - Don’t just tell me your voice is hoarse. Tell me about professional voice use vs speaking voice. Tell me about how long you can work until symptoms start. Tell me about recovery time and compare it to before your voice symptoms. Tell me about pain, loss of range, and areas of your voice that are impacted.
Surgery, medical problems, and social habits like smoking, drinking, vaping, drug use
Diet and hydration
Exercise habits
Vocal habits including warm-ups and cool downs, training and coaching
For my patient, these types of questions led me to suspect a slight paralysis and that is exactly what I found.
This patient had been struggling for a year, with a delayed workup, because of careless history-taking. The temptation to skip to the scope is real. It feels so easy, like the scope will tell us the answer. But this approach means diagnosing something that not be the cause of the symptoms, ensuring that the patient doesn’t improve.
I did find mild reflux in this patient, and referred him for treatment because I didn’t want to start medications for something so mild. But I knew that a bunch of Pepcid was not going to fix his voice problems and he’s on his way for a few more tests before we get our answer. It’s okay not to have the answer on the first round of care, as long as you are careful not to jump to a quick, wrong answer.
The history-taking is the most important part of my exam. As an added benefit, it helps me to understand my patients, their preferences for treatment, their personality and their fears. It’s an opportunity to built trust and rapport and nothing helps more to ensure a good outcome.
Interested in working with the best professionals in LA for voice care and rehabilitation?
Meet Dr. Gupta, the top voice doctor in LA, and Tressa Cox, the leading voice therapist specializing in voice rehabilitation.
Learn more about their expertise and services at the Center for Vocal Health.