The Current State of Audiology: A Profession in Transition

FORWARD: A Profession in Transition ... Revisited
Author: Victor Hugo Bray, M.S.C., Ph.D.

It was a great pleasure to see George S. Osborne posthumously honored with the David P. Goldstein Outstanding Audiologist Award for “promoting audiology’s transformation to a doctoral degree with the Au.D. as its distinctive designator” at the ADA 2014 Annual Convention. Thank you to the Academy for the remembrance of Dr. Osborne with this honor.

In 2004, an article authored by Dr. Osborne was published in ADA’s Feedback magazine and it remains one of the most important documents in our profession’s evolution. The paper, reprinted a decade later in today’s ADA’s Audiology Practices, was “The Current State of Audiology: A Profession in Transition.” The article listed seven objectives to be met by the profession. They were - and remain - that audiology:
  1. become an autonomous profession;
  2. become a doctoring profession;
  3. obtain limited license practitioner status [today termed LLPhysician status];
  4. create its own professional organization;
  5. develop an enriched curriculum;
  6. enjoy direct access by all patients; and
  7. develop a new professional structure.
Where do we stand today on these seven objectives? The fourth objective was met twenty-five years ago with the formation of the American Academy of Audiology (AAA). Now the largest audiology-only organization in the country, AAA is the umbrella organization for the Accreditation Commission for Audiology Education (ACAE), the Student Academy of Audiology (SAA), and the philanthropic AAA-Foundation. The second and fifth objectives were sealed ten years ago with ASHA’s Council on Academic Accreditation in Audiology and Speech Pathology (CAA) requirement that the clinical doctorate become the entry-level degree for the practice of audiology in the U.S.

The third and sixth items are in progress, with almost fifteen years of AAA advocacy for direct-access legislation and the new ADA-led advocacy for LLPhysician status legislation on Capitol Hill. Once goal number six - which includes goal number three - is met, we will transition from a “doctoral-in-title-only” profession to a true doctoring profession with appropriate rights, responsibilities, and rewards. The final step in audiology’s journey will be the seventh objective - creation of a new professional structure - to finally achieve an autonomous profession, the foundational objective in Dr. Osborne’s article.

It is critical that all audiologists understand that our transitional work is not complete; we have only partially advanced along the seven-step path of audiology’s objectives. It is for this reason that the Osborne 2004 article is required reading for every student in our training program and should be for all audiology students in every Au.D. training program. I hope that you will take the time today to re-read Dr. Osborne’s comments and share his vision with the entire audiology community.

To review the time-line, the first step was the establishment of AAA to contest with ASHA for control of audiology (a decade after ADA was established “by and for audiologists”). The second step was the transition to the clinical-doctorate degree (the ADA-led “Au.D. movement”). In retrospect, it was ADA’s leadership generation of master’s degree audiologists, some with research doctorates, who were the pioneers to blaze the trail towards these significant achievements. We were fortunate to have had visionaries such as Dr. Goldstein and Dr. Osborne lead us through the first half of our professional journey.

As we move from our internal battles of the past, we will endure more difficult encounters. We must unite in new, external battles against forces – some hostile - that intend to stop our professional advancement. The third step is to achieve Medicare-recognition for audiology as a point-of-entry for hearing health care services. This includes patients’ direct access to, and reimbursement for, audiologists’ diagnostic and rehabilitative services. It is clear that this is again ADA leadership (“the 18 x 18 movement”), specifically the Au.D. Distance Education generation, who are now walking the walk and talking the talk.

The (future) fourth step is to create the new professional structure (e.g. audiology-only training programs; audiology-only training program accreditation body; audiology-only state licensure laws, and audiology-only state monitoring boards). This most likely will only come about with (future) leadership from the emerging generation, the residential program Au.D. students and graduates, who ADA is actively mentoring today. Only after all seven steps have been accomplished will we achieve the long-sought status of audiology as an autonomous profession.

The road is long, our travels have been hard, and the path forward will continue to be difficult, especially without the full and active cooperation of ADA, AAA, and ASHA. Let’s use this opportunity of the Goldstein Award recognition of Dr. Osborne as an earnest reminder that our profession’s original, multi-stage plan is still in play and that it will continue to take multi-generation memory, effort, and collaboration of all of us to accomplish these seven shared objectives.

The Current State of Audiology
Author: George S. Osborne, Ph.D., D.D.S.
Dean, PCO School of Audiology

The transition of audiology to a professional degree, eventually elevating the status of audiologists to that of limited license practitioners, entails much more than simply changing the entry-level degree to that of a doctorate (Au.D.). Although our leadership knew early on that it would be necessary for audiology to move in the direction of medicine, dentistry and other professional healthcare providers, the academic community resisted. Carhart, as early as 1976 stated, “…as long as either ASHA or clinical audiology are satisfied to accept this definition [the ccc/a and/or the Masters degree] as describing competence in clinical audiology the field cannot expect to be recognized as equal to professions that hold the doctorate as one of their inviolate requirements.”

A panel discussion on “The Future of Audiology” was held at the 1987 ASHA conference. More audiologists gathered in one room than had ever gathered in one place before. Panelists included Jim Jerger, Lou Beck, Jim Hall, Richard Talbot, and yours truly. The consensus of the presenters was that audiology would:
  1. Become an autonomous profession;
  2. Become a doctoring profession;
  3. Obtain Limited License Practitioner status;
  4. Create it’s own Professional Organization;
  5. Develop an enriched curriculum;
  6. Enjoy direct access by all patients; and
  7. Develop a New Professional Structure.
Let's take a look at how we're doing, some 16 years later. In retrospect it is clear that the call for becoming autonomous sounded great but the realities of autonomy were not fully understood. Specifically, to become an autonomous profession means that we will have the right or power of self-government, that we can carry on without outside control, and that we would be capable of existing independently. It is clear that gaining the right of self-government is much more difficult than we envisioned, and that no-one exists in the healthcare arena without outside controls of some sort. We will always need to satisfy the influences of third party payers, patients, and politicians.

However, we have learned that it is important that audiologists demand that decisions affecting the future of the profession are made by audiologists; not by physicians, politicians, or speech language pathologists. As of this writing, there are 42 residential Au.D. programs and approximately 35 additional masters programs that have made application for Au.D. status. Based on the initial objective to transition a critical mass of audiologists to the Au.D. Degree, the “unwritten agreement” is for the distance education Au.D. programs to accept students through 2005-2006 with the expectation that the distance opportunity will phase out in 2009. As an attempt to discourage students from entering masters degree programs, the PCO School of Audiology will not admit anyone into the distance education program who received their masters or doctorate degree in Audiology after September 1, 2004. In my opinion, there is no justification for advising a student to enter a masters program today and to do so borders on unethical behavior.

Our second vision was that audiology would become a doctoring profession. The ADA took up the mantle to make this vision a reality. It is interesting to note that the ADA was founded by Dr. Leo Doerfler (and others) in 1976, the same year Carhart made his plea for audiology to move in a professional doctorate direction. Doerfler was one of Carhart's first doctoral students. The ADA, always the energizing force for change in audiology, is “dedicated to leadership in advancing practitioner excellence, high ethical standards, professional autonomy, hearing technology and sound business practices in the provision of quality audiological care.” In 1988, under the leadership of then president David Citron, the ADA hosted the Conference on Audiology Education in Chicago, a landmark meeting that changed audiology forever. An ad-hoc committee, which subsequently became the Audiology Foundation of America (AFA), was formed and charged with transforming audiology to a doctoring profession. Members of that committee included: (no surprise) Leo Doerfler, David Goldstein, David Cieliczka, David Citron, Angela Loavenbruck, Susan Whichard, Tom Zachman, and yours truly. It has taken 16 years to convince the profession that audiology is not only worthy of being a doctoring profession but the body of knowledge and technology is so great that we must require significant curricular enhancements over the masters degree to meet the needs of our hearing and balance impaired citizenry. Further, if patients are to be able to afford quality hearing and balance services it is imperative that the patterns of access to qualified practitioners’ change. Third party agencies will not recognize a group of providers as being independent unless they have Limited License Practitioner status. More on that later. The profession has clearly accepted the Au.D. as the entry level credential to practice audiology. We are close to the AFA’s objective of transitioning a critical mass of audiologists to the Au.D. Degree, and all future audiologists will earn the Au.D. Degree. Specifically, the projected Au.D. numbers by 2007 are:
Residential to date: 173
Distance to date: 1,527
Residential Estimated by 2007: 625
Distance Estimated by 2007: 2,970
Totals: 5,295

I anticipate that by the end of the distance education Au.D. “bridge” opportunity in 2009 we will have over 8,000 Au.D. audiologists.

We need to consider the proper use of the Au.D. title. This is a serious issue as our misuse of the title might very well lead to devastating effects, as licensure boards ponder our changing role in the healthcare arena. First, it is my opinion that students in Au.D. programs should refrain from using the “Au.D. Candidate” designation. There is no guarantee that an audiologist or student who is accepted into a program will, in fact, complete the program. Professional students do not “advertise” themselves as M.D., D.D.S., or O.D.“Candidates”. There is no precedent for this “wannabe” behavior - it is a vestige of graduate education and both inappropriate and embarrassing. Once the degree has been granted, it is important we use it correctly: i.e. John Q. Smith, Au.D. I also advocate that audiologists qualify the Au.D. by placing “DOCTOR OF AUDIOLOGY” in small caps below their name on business cards and stationary, simply to let folks know what Au.D. stands for. When using the formal title it should always be qualified: i.e. “Dr. John Q. Smith, Audiologist.” Using the formal title without the qualifier suggests that we are advertising as physicians, is misleading and, in my opinion, unethical.

The vision of obtaining Limited License Practitioner status is a bit more complex than we imagined back in 1987 and is indeed, our most lofty goal. Medicare reimburses four types of non-physician health care professionals who are classified as “limited license practitioners”. Those healthcare specialists include: optometrists (O.D.), dentists (D.D.S.), podiatrists (D.P.M.) and chiropractors (D.O.C.). Note that each of these specialists are represented by a single designator (with minor variations - Harvard’s D.M.D. etc.). Recall that audiology has no fewer than 22 different designators (degrees). It is important that all audiology practitioners eventually are identified by the designator Au.D.

Medicare recognizes the limited license practitioner as a physician when they furnish those specific services for which the law considers them physicians, those services for which they are trained and which are included in their scope of practice as defined by their license to practice. Limited license practitioner status will allow patients to seek the services of audiologists without a physician referral and allow audiologists to bill third parties directly for those services using the audiologists UPIN number.

The need for us to create independent state licensure boards should be obvious. Speech-language pathologists who have little understanding of our transition to professional education and eventually, limited licensure practitioner status, control most of our State licensure boards. Changing state statutes is a very time consuming and arduous project. It will require dedicated audiologists step up to the plate and become involved in their state organizations and licensure boards. Our detractors will view attempts to change licensure statutes as “self-serving” and it will take the good works of many to convince the powers of the legis- latures that independent licensure statutes for audiology are in the very best interest of the public we strive to protect, both professionally and fiscally.

Another of our goals was to create our own professional organ- ization - by, of, and for audiologists. In January of 1988, only a few months after the ASHA panel, Dr. James Jerger invited 30 prominent audiologists from across the country to convene in Houston, TX. The rest is history! The AAA, the formal home of the profession of audiology, boasts beautiful offices in Reston, VA with an exceptional executive team and competent staff to guide our doctoring profession well into the next century. Each year, for sixteen straight years, the membership of the AAA has grown, to over 9,000 members today. This goal has been achieved. Some might say that, living in denial, our parents don’t realize we have moved.

The goal of developing an enriched curriculum is more complex than simply adding one or two courses to an existing masters curriculum and charging tuition for a “CFY” placement. One of the major challenges is to raise the standards of all programs through an improved and appropriate accreditation process. A joint funding effort of the ADA and AAA a new academic accreditation process unique to Au.D. programs is underway. The Accreditation Commission for Audiology Education (ACAE) is in its second year and building an accreditation process that will adequately reflect the professional nature, experiences, and expectations of education programs for audiologists. It is only through raising the standards will we overcome the shortfalls of marginal training programs.

The transition to become a “doctoring” profession mandates major changes to existing audiology curriculum. Our Au.D. training programs must be on par with the best of the other professional training programs (medicine, dentistry, optometry) and incorporate a strong biomedical foundation into both pre-requisite and basic science requirements. Including the diagnosis and treatment of balance disorders within the scope of practice of audiology places a significant responsibility on our training programs to gear up and provide the necessary bio-neuro-muscular knowledge to appropriately deal with all aspects of the vestibular system. No longer will a single lecture or weekend demonstration course on electronystagmography suffice.

I believe the transition will necessitate moving Au.D. programs from “graduate” schools to “professional” schools. Limited license practitioner programs are not located in graduate schools. In fact, the degrees granted to professional graduates are classified as “first professional degrees” and not “graduate degrees” by the U.S. Department of Education.We must be willing to accept the changes that this move will make on funding sources for students and resist designing our programs to “fit” antiquated education models of funding. Through advocacy and demonstration we will be able to make a strong case for changing the models to accommodate our new training paradigm.

All of the goals mentioned are part of a long-term strategy to provide patients direct access to audiologists. However, we have an astonishing opportunity that could really move this issue forward in HR-2821, the Hearing HealthAccessibility introduced into the House of Representatives on July 22, 2003. S-1647 is the Senate companion to this legislation, which if passed, will allow Medicare beneficiaries the option of going directly to a qualified audiologist for hearing and balance diagnostic tests. It is incumbent on every audiologist to write to their legislators requesting support of these bills. Additional information can be found on both the ADA and AAA websites.

The last of the future visions outlined 16 years ago was a new professional structure. This vision is slowly becoming a reality. It is interesting to note that the following “vertical” structure appears to be emerging. Characterization of the development as vertical is contrasted with the “horizontal” structure of the past with the AAA, ADA, ASHA, ARA, EAA, etc all working independently for members and programs. The AAA is becoming our National umbrella organization, with State affiliates (i.e. Pennsylvania Academy of Audiology); the ADA is showing signs of becoming our practitioner organization; a new accreditation body to assure a high standards for training programs, the ACAE, has recently been formed; and the Council of Au.D. Programs (CAuDP) is currently being reconfigured to eventually represent our academic pro- grams. Wouldn’t it be nice if - in our attempt to “brand” the profession, we had one logo, an (“A”) overlying a map of the US for the AAA, each State used the same logo overlying an outline of their State, and every State Academy had a similar URL (i.e. - check it out). Feel free to contact the developer of our PA website to copy the format (and logo) for your State Academy (IL has and it looks great).

Finally, our transition from “education/ technician”education to “professional/doctor” training requires new vocabulary to describe many of our activities. Specifically, clinical training modules that take place within, or closely associated to, an academic institution during the first 1-3 years should be referred to as “clerkships”, training for extended periods of time off-campus should be referred to as “externships or rota- tions” and the student referred to as an “extern”. The doctor providing the externship experience is a “preceptor” (clinicians and supervisors train technicians). We are a relatively young and small profession and the term “residency” is inappropriate for us at this time, for in professional education a resident is one who is engaged in a 3-7 year specialty program “after” graduation (i.e. a dentist in an oral surgery residency). Interns are usually considered to be doctors in their first year of residency. Board Certification is reserved for a doctor who has successfully completed a nationally recognized specialty examination after finishing a residency program. A fellow describes those doctors in subspecialty programs (versus residents in specialty programs), or in Graduate programs, that are beyond the requirements for eligibility for board certification in the specialty. The Consensus Conference on Audiology Fourth Year Training, held in Reston in January 2004, endorsed many of this new terminology.

The future of the profession of audiology is very bright, as the demographic changes of our country, and the world, require greater attention to the hearing and balance needs of an aging population. As audiologists we are very fortunate to be engaged in a profession that makes a decided difference in the single most human component of the lives of so many. Each day the difference you make for those you serve brightens the future for those who will follow.    
Dr. George S. Osborne completed a Ph.D. in Audiology and Speech Pathology and then a D.D.S. degree and 2 years of periodontal training. One of the first private practitioners, he was a long-time advocate for the autonomy of audiology. In addition to serving on many committees of the ADA, Dr. Osborne was a founder and charter board member of the AAA; co-founder, chair, and director of the AFA; founder and president of the PAA; director of the new Accreditation Commission for Audiology Education; and was Founding Dean of the George S. Osborne College of Audiology at Salus University.

Dr. Victor Bray, Dean of the George Osborne College of Audiology at Salus University, holds a Ph.D. degree in Speech and Hearing Science from The University of Texas at Austin, a M.S.C. degree in Audiology from Auburn University, and a B.S. degree in Biochemistry from The University of Georgia. He has more than 30 years of experience in audiology and the hearing device field, including clinical experience involving direct patient care in medical and retail environments, hearing aids, cochlear implants, and instrumentation. His management experience includes executive staff, research and development, auditory and clinical research, regulatory affairs, and quality assurance. His publication experience includes authoring three book chapters and numerous technology papers. Dr. Bray can be contacted at [email protected]