Choosing your doctor

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It is always difficult to know how good your physician is going to be. I have a list of physicians on this site, though I do not know all of them personally. I know that they have in some way hung out their shingle and said “I do voice work.” That gives every physician who wants to do voice work somewhat of an even chance at starting a medical practice, but doesn’t help the consumer.

Word of Mouth

This is not an unreasonable way of checking out your doctor. If they are in an academic institution, the residents or nursing staff may have the most insightful view of a particular physician.

Patient referrals by someone who has visited and been examined and treated by a physician seems to carry a lot of clout. It is evident to me that a physician’s bedside manner is more effective in making patients happy than actual technical or diagnostic skill. So in the end recommendations are representative of how nice a person the physican is and perhaps not always reflective of his/her technical skill.

Judging your visit after the fact

I believe it is reasonable to expect the following from your physician - though you likely will not get all of this in one person. Perhaps these thoughts will help you evaluate your own physician.

Timeliness

The physician sees you promptly. This is a small quality indicator and really should only be considered along with many other characteristics Physicians who overbook, may be making efficient use of their time, possibly at the expense of yours. There are certainly plenty of reasons for a physician to be behind - the office should keep you informed.

Time spent with you

To some extent the more time you have with the physician, the more likely your problem will be correctly identified. Some physicians are rushed. Others delegate a lot of your life to testing and evaluation by others. While you spend a lot of time at the office, it is not with the person doing the trouble shooting. Don’t let these other activities smokescreen your reason for being there - the diagnostic skill of the physician. If the diagnosis is wrong, it will not matter how great or technically skilled a surgeon your physician is.

History

The physician should interview you and find out your most important concerns. This is the beginning of the physician coming to understand your problem or putting the puzzle together. Most voice problems have a typical pattern to their development.

Examination

  • Listening
The physician should listen to your voice and request that you do a variety of things with your voice. View this as you would a cardiac stress test. If you had chest pain and the emergency room doctor told you that your EKG was normal, would you accept that as an explanation in full or would you go to the heart specialist? At the heart specialist, they would ask you to perhaps exercise on a treadmill to see if they can reproduce the symptoms. Who is more likely to have the most precise answer for you? I find that a combination of soft and loud speaking, brief singing, a loud yell, checking high and low pitches, seeing how long one can make a sound - these vocal activities help an astute listener - the physician - identify another piece of the puzzle. There are other vocal tasks that can aid the trained ear in identifying a voice problem.
  • Looking
While your voice physician may start with a mirror exam of your throat, it should progress to using the endoscopic equipment that can view your vocal cords in detail. See example photos.
  • Equipment
Endoscopes
These instruments may be passed through the mouth or through the nose (after appropriate numbing). and can be looked through or attached to a camera. The camera can then greatly magnify the size of the voice box for detailed viewing on a monitor.There is a fairly large difference between the fiberoptic endoscope and the chip endoscope and this year (2010) there are HD endoscopes becoming available.
Video recording equipment
Things happen fast in the vocal folds and the human eye cannot always catch them. It is helpful to record the movements along with the sound so that if necessary the same task can be viewed, listened to and correlated several times if necessary. See example video. Additionally, after a brief orientation to the pictures of your vocal folds, you should understand how yours are behaving and why they are not behaving properly.
Stroboscope
While the vocal folds open and close fast to change from breathing to speaking, when producing sound they vibrate really fast, hundreds of times per second. A strobe light can slow down the apparent high speed of vibration and very detailed movement can be seen as well as a crisp picture of what the edges of the vocal folds are doing during their vibrations. Think about that disco dance in the 1970’s (if you were around) and how every thing seemed to be happening in slow motion when the strobe light was on.
Digital equipment
Todays digital recording technology allows video to be reviewed at various speeds without streaks or lines across the screen interfering with the structures of interest. It is a clearer picture.

Explanation

Your physician should be able to take the time to review the video photos with you and come up with a plausible explanation of what your problem is and how to treat it. It should make sense, even to you. The physician should be able to tell you things about your voice and you should feel, “ah ha”, he/she understands my problem. The voice box is really not mystical, it is mechanical and mechanical things make sense. All the pieces of the puzzle should fit together.

Second opinion

Don’t hesitate to get one. Especially if you are not clear on things. Especially if your physician doesn’t specialize in voice issues. Especially if recommended treatments are not helping you. Especially if your physician doesn’t want you to get one and you are worried - get one. Feel free to review the ideas on this and other web sites about surgery and treatments.

Signs of concern

Vocal cord stripping

If your physician uses these words - vocal cord stripping - in the context of your vocal cords, finish the visit, thank the doctor and then look elsewhere for care for your vocal cords. You do not want anyone stripping off the delicate lining of your vocal cords. You might also be concerned about variations on this word, like scraping. Words like delicate trimming, precise excision might be more reassuring.

Your physician saw a bump but cannot reasonably demonstrate how that bump is impairing your voice. That is a “Red Herring”. Bumps are not always the cause of a vocal problem. That is the problem with looking and not listening. A bump in a given place, will cause a given change in your voice.

The Team Approach

Many institutions and some clinics have instituted the “Team approach”. Yes, there are times when many minds are better than one, though there are times when one mind is better than many. To use the analogy that your disease is a puzzle, I think a puzzle might be more rapidly put together by a group of people. That is, the belief of the clinic where one person gets your history, another person looks at your vocal cords, another person runs a group of tests on your voice and a physician comes in at the end and summarizes everyones recommendations as a plan for you.

I think the game of chess might be a better analogy here to voice problems. I suspect a game of chess is seldom better played by a team than by a single astute player. With complex problems, like chess and like the voice, one person seeing the whole problem often leads to a correct insight into the strategy of the opponent or in this case: the cause of the vocal problem. Putting together peoples behavior patterns, audible changes in the quality of the voice and understanding the complex movements of the muscles and lining of the voice box takes a bit of insight. There are still a great many unknown things and partially known things about the voice that require intuitiveness to ferret out. Additionally, when the main person listens to the patient, analyzes the voice and looks for the problem; they learn what groups of things go together and their knowledge is constantly growing and changing.

Like chess, perhaps someday, someone will be able to program a computer to check out a great many details about the voice, process the results and be a better than average “diagnostician”. For now though, you want a good physician with a great deal of interest in your voice.