The Last Layer is Peeled Away

Holly Hosford-Dunn
November 21, 2017

Harvey Abrams PhD

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


This will be my last post as part of the “Peeling the Onion” series. When I first began these articles, I felt its name was an apt metaphor for the issues facing hearing healthcare in general and the audiology profession in particular – I still do.

Over the past years I’ve written on a number of professional, economic, educational, research and legislative issues. Each revealed a complex interplay of factors which, when peeled back revealed yet another layer of factors leading inevitably to where we currently find ourselves.


At the Center, Another Layer


And where, exactly, is that? We are, at our roots, a rehabilitation-focused profession born in the military and VA hospitals following the end of WWII and, over the subsequent 70 years, have become a repository, perhaps THE repository, of knowledge and skills  associated with hearing and balance disorders and their treatments across the life span.

We are a relatively small group of professionals struggling to be recognized as an autonomous profession by legislators, regulators, third party payors and, most importantly, the public. Yet, we can’t seem to speak with a unified voice as evidenced by a disturbing level of discord among our major professional societies. Could we be an example of Sayre’s Law?  – “In any dispute the intensity of feeling is inversely proportional to the value of the issues at stake.”1

We are a doctoring profession that trains students in over 70 programs but graduates only about 10 students a year at each, the result of which is an unchanging supply of professionals serving a growing number of individuals with hearing and balance disorders. Our training model is inconsistent across those programs – some requiring 3 years of study; others requiring 4. Unlike other healthcare training programs, audiology students in their final year, with rare exception, complete externships (as a student? as an employee?) at clinics and facilities that hold no certification nor are held to any professionally developed or agreed-upon set of criteria that provide reasonable assurances of a quality training experience.

After graduation, many of those graduates will work at practices in which hearing aid sales represent an important, if not the primary, source of revenue.  Those hearing aids will be sold at a bundled price where the value of our considerable professional knowledge and skills will, at its best, be obscured and at its worst (for regulators and legislators) be invisible.  Despite compelling and growing evidence demonstrating the benefits of a “best practice” approach, many audiologists will fail to administer standardized needs assessment intake measures, develop comprehensive treatment plans, select hearing aids and features based on those needs and plans rather than simply the audiogram, verify fittings using probe microphone measures, validate treatment success using standardized outcome measures, and provide post-hearing aid fitting rehabilitation services. Bundling our fees and failing to exercise best practices make the audiologist indistinguishable from other hearing healthcare professionals engaged in hearing aid sales. Furthermore, we resist cost efficiencies such as participating in buying groups and the use of automation and support personnel that have long been a practice among other healthcare professions, placing us at an even greater disadvantage when competing against large retail chains.


Seeds of Change


One might ask why the profession has not yet collapsed under its own weight given the issues I outlined above.  I could posit several reasons. From the academic and hearing aid perspectives, until recently, there has been no reason to change the status quo. Training programs are continuing to get more applicants than they can admit; most private practices do quite well with their current business model.

But remember, “every system is perfectly designed to get the results it gets”.2 Those “results”, however are subject to change if the system generating them does not adapt to changing external economic and regulatory forces. Will students be willing to carry $100,000+ in student debt to train to be an audiologist if they can earn more and owe less by training to be a physical therapist or optometrist, for example? Will a practice be able to sustain itself selling 20 hearing aids a month at $2,500 per hearing aid if Costco is selling hearing aids for half that price or if potential patients are able to purchase hearing aids over-the-counter for a tenth of that price?


At the Center, Our Core Strengths


Another reason the profession hasn’t collapsed is that there are some services that only we, as audiologists, provide and we provide them incredibly well. One example is pediatric audiology. The knowledge base and skill set of pediatric audiologists are unique. What other professional can competently diagnose the degree and type of hearing loss in a 2-week old infant or fit a hearing aid to a 6-month old? 

Another example is the audiologist specializing in cochlear implants. Yes, the surgeon implants the device but the audiologist through their knowledge and skills makes it come alive. It is fitting that specialty certification is offered for both pediatric audiology and cochlear implants. Other opportunities to autonomize the profession include the diagnosis and management of tinnitus and balance disorders.


A New Onion Patch


I recently attended the 50th Anniversary Celebration of the establishment of University of South Florida’s Communication Sciences & Disorders Department. I’ve been a part of this program in various capacities for most of those 50 years. It was an interesting experience, seeing this 50-year arc of progress – the impressive accomplishments of former students, the physical and academic growth of the program, its contributions to research and to the local and professional communities. 

At the conclusion of the ceremonies, we were introduced to the current students. I couldn’t help but wonder what their future holds given the major economic and regulatory forces facing the profession. I’m an optimist by nature and I see excellent career opportunities for these bright students but only if we respond intelligently and effectively to those forces and expand our scope of practice to include, for example, co-managing chronic conditions that have been linked to hearing loss and refocusing our efforts on the roots of our profession – rehabilitation.  

In his autobiography, “Peeling the Onion”, Nobel laureate Günter Grass ends his first paragraph of the opening chapter by asking, “But can something that had a beginning and an end be pinpointed with such precision? In my case it can.3,4   I believe it can in my case as well because the challenges facing the profession today will mark either the beginning of the end, or the beginning of a reimagined and bright future for audiology.







Harvey Abrams, PhD, is a consulting research audiologist in the hearing aid industry. Dr. Abrams has served in various clinical, research, and administrative capacities in the industry, 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 .

Images from Ross Land/Getty and askideas


  1. Thanks for many interesting and pertinent articles over the years. And, thanks for this final blog. I hope we continue to “hear” from you on this site. I look forward to your continued thoughts.

  2. Harvey,

    Your Peeling the Onion series has provided readers of HHTM with a wealth of thoughtful and important insights, always clearly expressed. I’m sure that Holly and all the editors of HHTM–present and past–are grateful for your contributions.

  3. Harvey, how about a guest article every now and then? We value your insights and there will be more layers to peel…

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