Supreme Court Decision Sets Stage for Audiology Private Practice
By Kenneth L. Lowder, Au.D., Chair, Audiology Foundation of America
Susan B. Paarlberg, M.S.I.R., Executive Director, Audiology Foundation of America
Tracy A. Harding, Publicity and Development Specialist, Audiology Foundation of America
Few people likely realize that the door to the Au.D. profession in the United States was actually opened by a 1978 Supreme Court decision about engineers. This significant ruling allowed engineers to begin to competitively bid for engineering services without ethical implications. The ruling set a model for the growing field of audiology followed.
Until the late 1970s, there were very few audiologists in private practice. Typically, audiologists would diagnose patients and then refer them to hearing aid dealers for hearing aid purchases. Audiology's primary membership group at this time, the American Speech-Language-Hearing Association (ASHA), held that it would be unethical for audiologists to sell hearing aids for a profit. It assumed a conflict of interest for the audiologist to both diagnose a hearing loss and supply the mechanism for assistance -- that the audiologist would always have one eye turned toward profit.
But audiologists working during those times came to believe that they were better able to provide audiological rehabilitation themselves and wanted to offer a full range of services, including hearing aid fitting, to help their patients.
The Academy of Dispensing Audiologists (ADA) was formed in 1976 to serve as a home for practitioners who found themselves struggling with ASHA's position on the ethics of selling hearing aids. ADA immediately began to offer practical help and advice for audiologists to develop the business and patient-management skills that were critical to their success -- information and services they could not find elsewhere.
Then, in a 1978 ruling that set a remarkable precedent, the U.S. Supreme Court ruled that The National Society of Professional Engineers (NSPE) code of ethics could not be used to prohibit competition and price interference for engineers' services.
"Within days, ASHA dropped its opposition and allowed its member audiologists to sell hearing aids," says David P. Goldstein, Ph.D., Audiology Foundation of America (AFA) Founding Chair.
This ruling set the stage for audiologists to provide full services to patients. By 1981, private practices began to blossom. But as these audiologists continued to practice, they realized they were treating patients and running businesses in much the same way as their optometry and dental colleagues down the hall and across the street. They began to wonder why they didn't have practitioner doctoral degrees hanging on their walls, as their colleagues did, and why they hadn't originally been taught many of the things they had to learn on their own.
Until this point, important topics such as practice management and patient management were self-taught or picked up at ADA conventions -- they were not taught or addressed in the academic environment. Audiologists had only one or two years of study in master's programs, and their clinical fellowship year experience -- a period of time spent "interning" and learning to practice -- oftentimes left them with a skewed view of reality.
Audiologists often spent their entire clinical fellowship year at one site, such as in a pediatrics practice or at a veteran's home. While this gave them a solid foundation in clinical work in their particular area, it also left a void of untaught practical skills in other areas, and rarely covered the entire scope of practice encountered by working audiologists.
ADA and AFA Push the Envelope
The fuel to fire the Au.D. movement came from the initial group of audiologists who were trying to succeed early on in private practice. By 1988, another decade had passed with ASHA continuing to serve as audiology's largest membership group. Many audiologists were still seeking change within the profession -- change in policy, change in philosophy and change in leadership. The American Academy of Audiology (AAA) was founded "of, by and for audiologists," and continues to function in that capacity today.
ADA also hit an important milestone in 1998 when it organized its "Conference on Professional Education," which launched an organized effort to make a new doctoral degree a reality. The published "Proceedings" codified a model Au.D. curriculum, set prerequisites and called for an organization to lead the charge. This organization, the Audiology Foundation of America, was formed soon thereafter.
The AFA's mission was, and still is, to lead the effort to transition the profession of audiology to a doctoral degree with the Au.D. as the unique designator. Dr. David Goldstein, a professor at Purdue University, led the charge and served as the AFA's chair for the first decade. The original AFA board of directors included many other professionals, such as Lucille Beck, Carl Binnie, Leo Doerfler, Loyal Ediger, Carol Flexer, Barry Freeman, Jim Lankford, Angela Loavenbruck, George Osborne, David Citron, Ron Jones, Sharon Lesner and Ross Roeser.
The AFA was initially funded by contributions from individual donors, professional organizations and hearing-industry corporations. The cause was championed by the audiology profession and industry. Support poured in for the first six years as AFA-educated audiologists all over the United States asked about the Au.D. and why AFA was needed. They were curious about what impact the designation -- and the organization -- would have on each practitioner and patient.
In 1995, the AFA organized and sponsored the "Standards and Equivalency Conference" to bring together audiology leaders to formulate Au.D. standards. In addition, the group considered the mechanism by which current practitioners might acquire the Au.D. Equivalency was an important issue, as the group, comprising a mixture of collegians and practitioners, sought to give credit to practicing audiologists for acquired knowledge. Ten audiology organizations ultimately co-sponsored the outcome. ASHA's continued support was noticeably missing.
From the very beginnings of the Au.D. movement, the AFA and most audiologists believed that existing practitioners should be able to participate in the transition and be given credit for their existing knowledge and skills. At the 1995 Standards and Equivalency Conference, attendees voted on many proposals, and in the end, over 60 percent agreed that existing practitioners should be allowed to earn a credential by demonstrating that their expertise and capabilities were the same as doctoral practitioners. In addition, 96 percent of attendees agreed that existing bachelor's and master's degree programs should be phased out.
The resulting strategy was to create an Au.D. credential, earned by practitioners, that would lead to their placement in distance education programs. In this way, they could earn an Au.D. credential during a "transition phase." The AFA was charged with developing this Au.D. assessment and recredentialing process, and the original program, called "Earned Entitlement and Equivalency," was begun in 1996.
The Au.D. credential was met with considerable controversy. Many people were very uncomfortable with the idea of granting credit for experience, preferring that audiologists only acquire the Au.D. by earning the degree. Such fighting within the field only made the struggle toward professional autonomy and independence that much more lengthy and difficult. Other professions, such as dentistry and optometry, transitioned their practitioners to higher degrees much earlier and with encouragement and support from their national membership organizations -- allowing the process of change to move more smoothly than in audiology.
At the Standards and Equivalency Conference in 1995, there was overwhelming support for a new independent accrediting agency, and AAA was assigned to lead the effort. But as the years passed, progress toward this goal was marginal at best. It was not until 2001, when the AFA paid for a study, that the groundwork was set for the creation of a new accrediting body.
One key finding in the 2001 AFA study showed that Au.D. program directors were willing to consider an alternative accreditation program. With that knowledge in hand, AAA and ADA formed the Accreditation Council for Audiology Education (ACAE) in 2002. The AFA also provided $125,000 in seed money throughout 2004 and 2005 to help get the effort on its feet.
The group anticipated that this new accrediting body, through its work, would implement ideas about academic standards, clinical rotation experiences and other outcomes of past collaborations in addition to developing of a new examination.
A decade has passed, and audiology is still without a new process from an independent accrediting agency -- although ACAE is now in the testing phase at two residential Au.D. programs. It is anticipated that the new accrediting program will be open to other programs seeking accreditation later this year.
The Au.D. movement
As spring 2006 graduations push the number of Au.D.s to more than 3,000, it is clear the profession is beginning to take charge of its own affairs. The common title of "Au.D., Doctor of Audiology," will help differentiate audiologists and clarify their role in the healthcare arena in the minds of consumers. This common professional designator will further continue the goal to put audiology on par with other doctoring professions, such as dentistry and optometry, making it easier for audiologists to lobby for direct access to patients, direct billing and other professional necessities associated with limited-licensed practitioner status.
When asked, many audiologists say they will consider the Au.D. transition complete when more than half of the profession holds an Au.D. degree. With a profession that numbers more than 15,500, there is still much work to be done to reach the halfway mark. AFA statistics project that, at current rates, that goal will not be met until after 2010.
State Licensure -- A Major Hurdle
A major consideration in audiology's progress toward autonomy lies in state licensure. While several states, including Ohio, Indiana, New Mexico and Oklahoma, have upgraded licensure to require the Au.D. as the basic standard for practice, others still require only a master's degree. Others are close to making the change, and more than 25 additional states have language that requires a doctoral or master's degree. This year the AFA is emphasizing the importance of state licensure upgrades and will seek to mobilize groups within various states to push for change. The charge must be taken up in every state to incorporate and recognize the Au.D. as the unique and single identifier.
"It is a call to every audiologist to stand behind the profession," AFA Executive Director Susan Paarlberg says. "When the Au.D. is the requirement for practice for every newly licensed audiologist in every state, we will consider our job well done."