Are We Best Served by a Medical Audiology Model?

Harvey Abrams PhD

“Peeling the Onion” is a monthly column by Harvey Abrams, PhD  

In last month’s post, I spoke of Audiology’s origins as a rehabilitative discipline and its transition to a doctoring profession. How did we get to where we are?

Without peeling back too many layers of the onion, arguably, the major driver was the desire to separate and distinguish ourselves from our speech-language pathology colleagues with whom we were grouped under the ASHA umbrella.  That motivation resulted in an official recommendation by an ASHA Task Force in 1984 to create a professional doctorate and the subsequent creation of a professional organization founded 4 years later “of, by, and for audiologists” – the American Academy of Audiology.

The Doctoring Drive

The strong desire to be recognized as “doctors” is not a surprising one considering how the profession evolved after World War II. The development and proliferation of a myriad of diagnostic tests such as tone decay, SISI, ABLB, PB-rollover, tympanometry, reflex decay, ABR, OAE, ASSR, ENG, VNG, and VEMP created a profession with effective tools to assist physicians in differentially diagnosing hearing and vestibular disorders.

Note that I say “assist physicians” since, in the end, no matter how skilled the audiologist is in administering and interpreting these tests, the diagnosis and treatment of the patient are ultimately the responsibility of the referring physician. It is the physician who can order additional tests, prescribe medication, cut out the disease, and cure the patient, and who is perceived by the patient as the hero and can bill the insurance company.  In this model, the medical audiology model, we are an important but, nevertheless a supporting, player.

But being a “doctor” was, is, and will continue to be a very seductive professional goal. If we peel back this layer of the onion, we would have to admit that at least part of our motivation for becoming a doctoring profession are the positive emotions that are associated with wearing the white coat, and being addressed as “Doctor” by patients, their family members, and other medical staff.  The use of hearing aid fitting formulae or “prescriptions” in our practice further solidifies our self-perception as doctors – after all, doctors write prescriptions don’t they?

Not All Doctors Are Created Equal

Unfortunately, unlike medical doctors, medical audiologists continue to face obstacles in terms of direct access and billing for services. These issues are currently being addressed through the  “18 x 18” initiative which aims to

…amend Title XVIII of the Social Security Act to provide for treatment of Audiologists as physicians for purposes of furnishing audiology services under the Medicare Program, to provide for a broadened scope of audiology services available for coverage under the Medicare program and to enable Medicare beneficiaries to have their choice of qualified audiologist.{{1}}[[1]]Audiology Patient Choice Act[[1]]

Legislation was introduced in the last session of Congress, which, if passed and signed into law, would have resulted in the implementation of the provisions of the 18 x 18 initiative (considerably sooner than 2018, which is the stated goal for its passage).  Unfortunately, Congress failed to take up the legislation prior to adjournment so the process will have to begin anew in the 114th Congress (note the absence of audiologists among its members).

The More Things Change, the More They Stay the Same

So where do we stand as a doctoring profession in 2015? Frankly, not in a much different place from where we stood when the first three Doctors of Audiology graduated from Baylor College of Medicine in 1996. Are we better educated? Are we better trained? Are we better skilled? Are we better prepared as Doctors of Audiology in 2015 than we would have been as master’s degree-trained clinicians?

Those are questions open to debate; however, from regulatory and policy perspectives, not much has changed. With the notable exception of the Federal Employees Health Benefits Program, direct access for audiology services still remains an unrealized goal, as does direct billing for audiology services without a physician’s referral.  What are the prospects for direct access, direct billing, or enactment of the 18 x 18 initiative in the short term?

My sense is that these will continue to be difficult obstacles to overcome, particularly in the face of well-funded physician opposition, an emerging healthcare landscape that values physician-led managed care organizations, and a more conservative Congress.

Back to Our Roots for Nourishment

Is all lost? Is there no hope? Do not despair, my friends. While we will likely continue to have a difficult time competing in the ‘medical’ space, I’m not suggesting we abandon the medical audiology model. The contributions we’ve made in the areas of hearing and vestibular diagnostics have been nothing short of breathtaking.  It is a legacy of which we should be justifiably proud and one in which we will continue to have a profound influence.

However, there is another space within audiology that we should rightfully call our own; one in which we are the experts and in which our physician colleagues assume a supporting role. Ironically, it’s a place where it all began for us – rehabilitative audiology.  You might well ask, “Don’t we do that already? Aren’t we practicing rehabilitative audiology when we fit hearing aids?” Well, the answer to those questions depends on how you fit hearing aids and the part they play in the treatment process:

• Under a medical audiology model, hearing aids are a prescription device, the parameters and features of which are based on a diagnostic test – the audiogram, similar to prescribing medication based on the results of a diagnostic test of blood cholesterol levels, for example.  Unfortunately, this is the model practiced by many audiologists who dispense hearing aids.
• Under a rehabilitative audiology model, the hearing aids are but one of many tools that are used to resolve the patient’s problems – problems that go far beyond what an audiogram can reveal.

In my next post, I’ll peel back the onion to explore the delicious rehabilitation layer of our profession and the opportunities that rehabilitative audiology presents to us.

This is Part 2 of the Peeling the Onion series.  Click here for Part 1 or Part 3.

Harvey Abrams, PhD, is currently Principal Research Audiologist at Starkey Technologies. Dr. Abrams has served in various clinical, research, and administrative capacities with Starkey, the Department of Veterans Affairs and the Department of Defense. Dr. Abrams received his master’s and doctoral degrees from the University of Florida. His research has focused on treatment efficacy and improved quality of life associated with audiologic intervention. He has authored and co-authored several recent papers and book chapters and frequently lectures on post-fitting audiologic rehabilitation, outcome measures, health-related quality of life, and evidence-based audiologic practice.  Dr. Abrams can be reached at [email protected]

feature image by Ross Land/Getty Images