The State of the State of Audiology: Audiology Education

I wrote on this topic back in 2022 and am reframing my thoughts based upon continuing audiology access issues and changes happening on the ground. I actually am stealing from my 2022 piece because my thoughts have remained unchanged. Again, much of what I am writing is controversial but extremely important to acknowledge, address and discuss. I do not pretend to have all the answers but am willing to out something out there for discussion.?

We need to define what is the practice of audiology, what services that entails, and what type, level, and amount of education is required to be licensed in and practice at each level of education. In this process, we also need to take a long look at audiology and hearing aid dispensing and define where “hearing aid dispensing” and “testing for the sole purpose of fitting and modifying hearing aids” and “the practice of audiology” begin, end and merge.

We need to acknowledge some harsh truths and issues:

• The practice of audiology is more than hearing aid dispensing.
• Many AuD audiologists never practice to their education, scope of practice and/or top of license.
• Audiology and audiology private practice existed before audiologists were legally allowed to dispense hearing aids in 1978.
• It does not require an AuD to dispense a hearing aid.
• There is no evidence that audiology delivered hearing aid care provides superior outcomes to hearing aid dispenser delivered care or self-fitting of hearing aids. In other words, it is more about the individual provider than it is the class of provider or delivery.
• Every hearing test does not require the skills of a doctoral level audiologist.?
• There is evidence supporting self-assessment of hearing loss using phone applications, websites, and specialized equipment.
• There are technicians who can currently perform, under direct physician supervision, otoacoustic emissions and vestibular assessment and who often perform evoked potential testing.
• There is a shortage of audiologists in the US.
• The current audiology educational model is expensive, time consuming, and often a poor return on investment for the student.
• The current audiology educational model is inconsistently delivered and yields varying outcomes across program and graduate.
• We rely too much on unaffiliated and unvetted (off campus preceptors) and quasi-affiliated (adjunct faculty) to deliver clinical, practical, and classroom education.
• We do not commonly utilize technology, specifically, clinical simulation, in our AuD programs,
• Our off-campus clinical education programs and processes are fraught with issues and inconsistent care delivery and supervision. ?
• If WE do not acknowledge and address all of the truths above, the market and healthcare will address them, with technicians, expanded scope of hearing aid dispensers, and more direct to consumer alternatives. We must evolve or risk becoming irrelevant and replaceable.

My first idea, which is not novel as an Indiana University alumnus, is that there should be undergraduate degree programs in audiology. Period. If you have never read the Humes et all article from 1993, I encourage you to do so. Much of what I learned in my communication sciences undergraduate program has had little to no bearing on my day-to-day practice as an audiologist.?Instead, these audiology programs should require undergraduate coursework in anatomy and physiology, general, organic and biochemistry, microbiology, physics, statistics, and psychology.?Students should be able to opt out of some of this coursework, such as general chemistry, physics, and psychology if they have passed Advanced Placement testing with scores of 4 or 5 in high school.?Within their undergraduate curriculum, students should receive additional coursework in acoustics and psychoacoustics, language acquisition, cognition, measurement of hearing, introduction to amplification, research, auditory rehabilitation, and anatomy and physiology of the auditory and vestibular systems, as well as coursework to prepare them to take a hearing aid dispensing examination. Their program should include a minimum of 30 hours of clinical observation. Ultimately, after four years of undergraduate education, they should graduate with a Bachelor of Science degree in audiology and the tools to attend graduate school, become an audiology assistant (step one in the care continuum) or obtain their hearing aid dispensing/trainee license (step two in the continuum). We, as a profession, will have provided graduates with employable skills and a means of making a living, in the event that they do not want to pursue post-graduate education. This will create a trained extender workforce to support current audiology practices.? This will also make them more attractive graduate students as this approach will allow for more thoughtful selection of audiology as a career and allow them to enter post-graduate education with basic foundational skills as well as a better understanding of the profession and their options within it.?THIS approach affords us the opportunity to create a more foundational and comprehensive educational pathway to hearing healthcare as well as improve and enhance the level of education available to hearing aid dispensers.

Graduate school should be a tiered educational process (more consistent with medicine), with multiple options along the continuum. The third step would be a full-time, year-round, 12-to-18-month Master’s program.?There should be a pathway/track to transition interested hearing aid dispensers into this pipeline.? This pathway would expand into intermediate coursework in pathologies, pediatric assessment, amplification, cerumen management, pharmacology, cognition, auditory rehabilitation and counseling, hearing conservation/industrial audiology, ethical/legal considerations, and business practices. This pathway would also include 350 hours of on and/or off-campus clinical practicum, both live and simulated, and completion of standardized written and practical qualifying examinations as a graduation requirement. In order to obtain permanent licensure, the graduate would have to complete a nine-month, post-graduate paid fellowship.?While these graduates could practice independently, the scope of practice of Master’s degree professionals would be limited to screening, identification, measurement, testing, interpretation, habilitation, rehabilitation and instruction related to peripheral audiologic disorders, and selecting, fitting, modifying and servicing air conduction or non-implanted amplification devices.?

If the Master’s program graduate wanted to pursue a more advanced degree with a more expansive clinical scope of practice, an additional option could be the pursuit of a clinical doctorate in audiology, or an AuD degree. This pathway would require an additional 12 to 18 months of full-time, year-round study and include expanded, advanced coursework in pathologies, amplification, implantable technologies, evoked potentials, vestibular evaluation and management, tinnitus evaluation and management, neuroscience, including imaging, pharmacology, central auditory system and auditory processing, counseling, supervision, and business/entrepreneurship, as well as completion of a Capstone research project. This pathway would also include an additional 350 hours of on and/or off-campus clinical practicum, both live and simulated, and completion of standardized written and practical qualifying examinations as a graduation requirement.?In order to obtain permanent licensure as an AuD level audiologist, the graduate would have to complete a one-year, post-graduate paid residency, with an established timetable, common application, and matching system.?The scope of practice of these graduates would be more expansive and reflective of a doctoral level professional.

Both the Master and Doctoral tracks should be developed as competency based educational models. This educational model is gaining traction and acceptance, especially in healthcare disciplines.?In other words, the student progresses at their own pace, based upon their personal ability to master a skill or competency. Conversely, if they are unable to master a skill or competency, they are unable to progress.?If after multiple failures they cannot master a core competency, they would be dismissed from the program. Period. This would allow for the student to better control their timeline and resulting expenses and for the profession to produce audiologists of a more consistent skill and competency level.

Courses could be developed in both live and recorded formats.?This model would allow for larger class sizes and more expansive clinical opportunities because graduate students would not be tied to a singular geographical area for clinical placements. Also, because every entrant into either the Master’s or AuD track would have, at a minimum, a hearing aid dispensing license, every student in the continuum would have an employable skill and could work during their training program. This should help alleviate, to some degree, the return-on-investment issue.

Finally, all off-campus clinical placement sites would have required training in ethics and supervision and would be vetted for competency and adherence to research evidence-based practice. They would also be afforded adjunct faculty status by the parent institution and, possibly, some form of compensation for their role in clinical education. Every student, regardless of their place within the program, would be allowed some degree of clinical independence in off-campus clinical placements because of the existence of, at a minimum, a hearing aid dispensing license. Both the clinical fellowship, for the Master’s level audiologist, and the clinical residency, for the AuD level audiologist, would be paid positions, regardless of the work setting. The only unpaid clinical practicum would be those that occur during the degree program itself.

For all their good intent, while ASHA hosted an AuD Education Summit in 2016, it took them three years (yes, this is not a typo) to produce a report from that meeting. Many of the hosting committee are now either retired or, sadly, no longer with us. Nothing significant or substantial has emerged from this summit as a result. AAA has done even less to evolve audiology education. Inertia is an endemic in audiology and few are interested in a vaccine. The only way this changes is if preceptors, adjunct faculty, employers, and, most importantly, students push back and require change. They truly hold the power.

I appreciate that what I am proposing is completely revolutionary and will be panned and dismissed by many, including those at the Accreditation Commission on Audiology Education, the Council on Academic Accreditation in Audiology, in academia, and from the founders of the AuD movement. I am, as always, prepared for the backlash. But here is my response to the naysayers: “While you hate my ideas, what are YOURS?”. I least I am willing to out myself out there and create and share ideas for discussion. It is more than I can say for most stakeholders.

Let my thoughts be a jumping off point for real, substantiative discussion, productive engagement, and legitimate change. Time is running out.

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