Eyes and Ears—Letter to the Editor

Good Morning Chris,

I hope this e-mail finds you well, warm, and in good spirits. My name is Joshua Huppert and I’m currently a pediatric audiologist and member of the Pediatric Balance Team at Children’s Hospital Colorado (CHCO). I will only remain at CHCO for another two or so weeks, as I’ve accepted a position at University of Miami Ear Institute, where I will not only be a pediatric audiologist, but also hold a faculty appointment as well, allowing me to grow, develop, and hone my skills as a clinician AND a future educator.

I wanted to reach out this morning to relay how much I enjoyed your recent article, “Eyes and Ears,” in Audiology Today regarding a closer, in-depth look at the differences between the professions of audiology and optometry with unique perspective on optometry’s success in areas audiology desperately aims to eventually achieve.

There are few points in particular that I wanted to provide additional commentary on, as I think they, in many ways, inhibit the profession of audiology from achieving a status equal to that of optometry. This is all, of course, recognizing that optometry has had many more years to “perfect” their approach; unfortunately, audiology is still, relatively speaking, a fairly young profession.

1. Are we attracting and screening the “right” type of students to audiology?
   As you pointed out in your article, optometry has an entirely separate entrance examination (in addition to prerequisite coursework) that is markedly more “science-focused.” Additionally, optometry licensure is contingent upon passing a National Board Examination. Comparatively, audiology does not require any separate entrance examination outside of prerequisite coursework and our licensure (in MOST states) is contingent upon passing the Praxis, which, if I may be blunt, is hardly a measure of “competency.” As an aside, I find it interesting to note that the failure rate of the Praxis has more than double in the last 2–3 years since the formatting and content changed, when compared to the previous version of the exam.In my opinion, it seems as though we should be attracting more “medically-minded” students to audiology, who value a clinical career path that is deeply rooted in science and invested in continually trying to elevate the profession through science and research; however, we have to recognize the challenge in doing so when the starting salary for an audiologist is not even remotely commensurate with the cost of the AuD.
2. Audiologists need to start embracing their role as and start practicing like doctors.While I’m still fairly “young” in my career as a clinical audiologist, I’ve noted a few trends that, again, if I may be frank, baffle me—
   1. many audiologists cringe and/or laugh at the thought of referring to themselves as “doctor” and
   2. few frequently consult research to help improve upon and enhance their daily practice and delivery of services.

   Having patients and other professionals refer to you as “doctor” is not about caressing an ego; instead, it’s an opportunity for you, as the professional, to raise awareness about and inform your patients about the profession of audiology and let them know that they are being serviced by a doctor of audiology.

   First, you trained and studied hard to retain and utilize the knowledge you have to provide the best possible care and services to positively impact patient quality of life. Second, setting aside a couple hours a week to peruse research and literature regarding the practice of audiology is just as important (if not, more so than) as actually seeing patients.
   As you well know, patients are often well-read thanks to the accessibility of information on the internet, so they WILL come with questions and if you’re not prepared to answer them with sound knowledge, their respect for you, your credentials and your profession falter. That said, it not only negatively impacts your business, but the overall impression of the profession as a whole as well.

3. Globally, we have to stop saying “yes” to inappropriate salaries.Accordingly, to NerdWallet, only 38 percent of newly graduated professionals (i.e., those who graduated within the last 0–10 years) negotiated salary. No company in their right mind is going to offer you their “ceiling.” They want to bring you on for the least amount of money possible.

   In my experience with audiology and in other careers, there’s ALWAYS a $5,000–$10,000 window of negotiation within which most companies can “play.” If you accept a salary of $49,000–$52,000, then you’re telling that company/organization that it’s acceptable to hire on a doctorate-level professional for a salary you could easily make serving part-time at a restaurant (I know this well, as I’ve been there); however, if we negotiate, and they still won’t budge, move on, as there is another organization that will pay you what you’re worth.

   In my opinion, if more people did this, organizations would have to respond because, at least in the realm of rehabilitative services (the department under which MOST audiology departments are housed), audiology brings in the most profit, both with amplification/dispensing and diagnostics (this has been the case in the last three organizations where I’ve interned/externed/worked professionally). That said, if we could better communicate the value and worth of our services as professionals, perhaps less would walk over us.

4. There is great need for standardization across assessing student, preceptor, and residency competency in audiology; furthermore, there are presently TOO many programs to even remotely try and do this successfully and maintain such standardization moving forward.The present disparity across student, preceptor, and residency competency is staggering. There are not adequate measures to ensure all students in X year are roughly at the same place when it comes to clinical and didactic competency. This is a HUGE problem because oftentimes students graduate with lack of competency across the entire scope of the audiologic practice; however, many programs promote that they train “generalists,” professionals who, theoretically, should be able to successfully complete fundamental assessments, etc., across all aspects of our field.

   I’m not saying that every audiologist should be able to do advanced vestibular testing or be experts at CAPD, but you should be able to at least get the conversation started and refer out when necessary. However, as an example, few students graduate being able to successfully administer, let alone interpret a VNG battery. Furthermore, similar disparities can be seen in preceptor qualifications and residency experiences.

   Again, I’m not saying every experience should be the same, but these experiences should ensure that ALL students graduate having met a standardized set of competencies, some obviously with more experience in certain sub-specialties within audiology than others.

   Not only do we not have solid tiers for standardization across these experiences, but we have too many programs to properly regulate accordingly. I think if this is a goal we aim to achieve, we have to stop opening programs. Not only is it a disservice to the students, but, also, to the profession, as God knows we have enough mediocre providers out there doing little to help elevate and enhance the profession moving forward.

I think your article has provided insight about relatively familiar topics, but from a lens of a “different color.”  These two professions have been compared frequently; however, the differences have yet to be as clearly defined and for that, I’m deeply grateful for your article, as I hope it continues to expand upon and strengthen the trajectory of our profession moving forward.

I hope you have a wonderful Friday/weekend, and look forward to our paths crossing soon (perhaps in Nashville?)

With kind regards,

Joshua Huppert, AuD

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Dr. Spankovich,

Hello, my name is Dan Talian and I am an audiologist at Intermountain Healthcare’s Hearing and Balance Center in Salt Lake City, Utah. I recently read your article, “Eyes and Ears,” in Audiology Today and thought that you brought up some interesting comparisons between audiology and optometry and provided the reader with intriguing insights on what we might learn from another profession’s struggles and successes.

Your closing paragraph poses the very interesting question of whether audiology will be the disruptors or the disrupted and begs the reader to ponder where the focus of our efforts should lie in order to have the greatest impact on the advancement of our profession. Should we concentrate on the possible difficulties that OTC devices may present or should we learn from what has worked in other professions and fight for the expansion and refinement of our own? I am inclined to believe that the latter will likely be more beneficial in securing a prosperous future for audiology.

One of the topics that you discussed in the article, board examinations, I feel could have a strong impact on our profession as we move forward. Currently, the Praxis is the only examination in audiology that is used for licensure purposes in many states (I know that at least one state, Colorado, does not require it for licensure).

As a recent graduate, the Praxis is still fresh in my mind and I cannot help but wonder about the quality of the test as a measure of an audiologist’s competencies. A two-hour exam with a mere 120 questions seems to be a relatively short instrument to provide an accurate assessment of the large amount of knowledge we are required to master throughout our training programs. Looking to similar professions, such as optometry, I think it is reasonable to assume that a more structured and rigorous licensing examination could have potential benefits for audiology. For instance, could a more rigorous exam stimulate a higher level of education in audiology programs?

The quality of education and training varies among audiology programs and, for the most part, each individual program is left to create benchmarks for the assessment of its students. If a more comprehensive board exam was implemented, and adequate preparation materials were provided, could we set the bar for audiology education even higher and ensure that clinicians entering the work force are better equipped to handle a multitude of auditory and vestibular disorders?

Surely, an examination is not a substitute for experience but a clinician must have an ample and pliable knowledge base in order to provide appropriate care across the scope of practice. I believe that audiology is moving in the right direction with development of specialty certifications such as the Cochlear Implant and Pediatric Audiology Specialty Certification along with certificates such as the Certificate Holder in Tinnitus Management and Audiology Preceptor. However, I also believe that as a profession we need to elevate the knowledge base that all audiologists graduating with their AuD possess. If only a scant amount of didactic coursework is provided by a program in a specialty area such as vestibular sciences or tinnitus management, can we expect audiologists to feel comfortable in seeking out further education in these areas?

I believe that a board examination is at step in the right direction and could be much more than just a gatekeeper for licensure. It could be a means by which we elevate the knowledge base of our profession and help to spark the interest of budding audiologists as they build their wealth of knowledge. This is only one of the many topics which can be discussed about how to advance our profession. Others such as securing LLP status, expanding scope of practice, better unification in the profession, and post-graduate residencies are all very important and would likely have a strong impact on audiology. Board exams are but one piece of the puzzle and one that, if implemented correctly, I think could have a lasting effect.

I appreciate you taking the time to lay out the similarities and differences between audiology and optometry and brining to light some interesting, often sensitive, topics so that a discussion can begin about how we might continue to advance audiology. I am interested to hear your thoughts on board examinations and, more broadly, what you believe we, as a profession, should be focusing on to ensure our progression.

Kind regards,

Daniel S. Talian, AuD

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Response from the Editor

Drs. Huppert and Talian,

Thank you both for your thoughtful comments on the Audiology Today article “Eyes and Ears.” A common theme across your observations is the role of education in securing and expanding the scope of practice of audiology. The obstacles for education and scope of practice we face are not unlike those of other professions including dentistry, pharmacy, podiatry, and optometry. Even medicine at one time went through its own identity crisis in regulating licensure and raising standards for education (check out Starr, P (1982) The Social Transformation of American Medicine: Harper-Collins).

To secure our future, we must really address two problems. The first problem, consensus, is an internal factor indicative of concord among our professional membership in regards to our goals and objectives. This has been an obvious challenge in audiology. The second problem, legitimacy, is an external factor based on respect of our profession’s authority as the experts in hearing and balance healthcare and to open way to resources and legally sanctioned privileges. These two problems are not independent of each other, as lack of internal consensus can have a negative influence on our external legitimacy.

American medicine and other health professions (e.g., optometry) countered these problems through two primary approaches. The first, consistent with your comments, was education reform. The second was establishing requirements and scope of practice through state licensure reform. Further, we must recognize that persistence is the key. Education reform and change in licensure will take decades. Yet, these are challenges worth pursuing and are the foundation to our scope of practice and future. Our own entry-level exam, expanded curriculum, step-based national exit exam, specialty residencies, LLP status, and scope of practice are all on the table. The question is how do we get consensus from everyone sitting at the table?

If you are in Nashville for AAA, I am happy to chat more and try to answer that question.

Cheers,

Chris Spankovich, AuD, PhD, MPH
Associated Editor, Audiology Today