We Must Return to Our Rehabilitative Roots: Part I

Hearing Health & Technology Matters
October 30, 2013

Author’s Note: My profound appreciation to James Jerger, Audiology’s most prolific scientific contributor and intellectual leader of the profession. His comments, suggestions, corrections made this article what it is and I am most appreciative of his working with me on its final preparation.

Miller pic

Dr. Maurice Miller

By Maurice H. Miller, Ph.D.

I write this article from a serious and profound concern for the future of audiology as I have known it and served it for well over half a century. A major problem exists: audiologists have concentrated so much on the “testing” and “fitting” aspects of hearing aids that many of our practitioners feel less comfortable than speech/language pathologists in performing long-term rehabilitative services; this despite the inclusion of auditory rehabilitation under various designations in course work and practica at so many of our universities.

The present state of performed (or not performed) audiologic rehabilitation services by audiologists is alarming!  ASHAs 2012 survey of 2,000 ASHA-Certified Audiologists from a variety of work settings found that only 17% provide “auditory training” and 4% provided speech reading/lip reading. There is much current focus on the instrument and so little on the rehabilitation of the user.

Let me stress at the outset that this discussion focuses only on adults, primarily the “elderly.”  Children are often served by a “team” that includes audiologist, speech/language pathologists, otolaryngologists, pediatricians, social workers, psychologists and others which, at its best, provides diagnostic findings and makes joint recommendations for the diagnosis, therapy and other indicated interventions.

Looming Problems 

Some practicing audiologists (many of whom I have trained) tell me that the difference in hearing aid prices between Costco and similar operations is that the hearing-impaired patient is welcomed by the audiologist to revisit after the trial period as many times as he wishes at no additional cost.  But this is a totally ineffective way of providing the audiologic rehabilitation that these patients, especially the elderly, and especially those with associated cognitive problems, desperately require.

I fear that unless we provide the audiologic rehabilitative services and associated services (counseling–often long-term, situationally determined use of amplification) on an organized, scheduled, initially in-person basis, our future and that of those we serve is in deep jeopardy. Increasingly the technology for hearing testing and hearing aid fitting can be performed equally well by the audiologist or the dispenser, or by a technician or even by appropriate technology.  And we are left with a huge increasingly elderly population whose auditory problems are both peripheral and central.

Amplification can benefit those with peripheral auditory impairments to varying degrees, but less so in the case of central processing disorders, unless it is accompanied by necessary individualized rehabilitation services. Moreover, charging 3-4 times more than some massive distributor services and telling the patient after the hearing aid(s) is sold to come in if you have a problem is not an appropriate or defensible recommendation.

Much has changed in Audiology since WWII

Much has changed in Audiology since WWII

In the World War II era, we could require a comprehensive total rehabilitation program.  But our present primarily elderly population is not subject to the same controls that military audiologists could exert over their patients.  In the absence of insurance coverage, and with an orientation that after paying many thousands of dollars for hearing aids they should resolve all hearing problems, we are left with many expensive, fully digital, carefully programmed hearing aids in the proverbial dresser drawers of this generation.

How Did This Situation Evolve?

The rapid evolution of Audiology as an independent and sustaining specialty occurred during and after World War II.  The object was to rehabilitate individuals who had sustained service-connected hearing loss. In this role, in addition to diagnostic services, audiologist then provided a host of rehabilitative services, including hearing aid selection and use, speech (lip) reading and auditory training (often in group classes), patient counseling and support in understanding and adjusting to the hearing loss.  In providing these services, we were acting as case managers rather than technicians or diagnosticians.  Mark Ross has correctly stated that regardless of how well we administer and interpret sophisticated diagnostic procedures, we basically remain technical support persons for the medical profession.

It is when we are the profession responsible for evaluating and managing the communication disorder and handicap imposed by a hearing loss that we fully come into our own as independent professionals.

The practice and progression of audiologic rehabilitation, Ross states, was not comparable to the growth of the medical/ diagnostic role when the field moved into academia and into the world at large after World War II.  Instead of audiologic rehabilitation being a core and defining activity, it has moved into the distant periphery of the profession. In many academic programs it has been relegated to one or two courses in speech reading and auditory training and often assigned to the lowest ranking professionals in the department. For example, speech reading and auditory training are often taught by master’s level audiologists while the doctoral level professors teach primarily in the diagnostic area.  We still pay lip service to audiologic rehabilitation and claim it philosophically as our own, but we in academia “just don’t do it.”

The Reimbursement Issue

There are ongoing and much needed efforts to reimburse audiologists for “aural and vestibular rehabilitation” in addition to diagnostic services under Medicare. If enacted, the proposed Medicare Services Auditory Enhancement Act (HR-2300) will, hopefully, provide the necessary impetus to move audiologists into the rehabilitation arena that our patients so desperately require and that we alone can provide if willing and trained to do so.

Scope of the Problem

Data on the prevalence of hearing loss in adults are striking. According to the World Health Organization, over 360 million people, or about 5% of the world’s population have some degree of disabling hearing loss. In the United States, the figure often quoted is 28 million, although this is probably a significant under-estimate. Yet the number of persons who receive competent rehabilitative care remains disappointingly low. In part this is because most adult hearing loss occurs gradually, without pain or noticeable discomfort, making it a condition easy to deny and to delay care.


The conclusion of Dr. Miller’s Hearing View will appear here next week.

Maurice H. Miller
, PhD (Columbia, 1956), is Professor Emeritus of Audiology, New York University Steinhardt School of Culture, Education and Human Development. Throughout his career, he has directed programs in Communication Disorders at some of the nation’s leading medical and academic institutions and spent over 40 years as the Chief Audiological Consultant to the New York City Department of Health. He is the author of five books, over 120 articles in peer-reviewed journals and numerous monographs and chapters in widely used audiology textbooks. Dr. Miller  was the second person ever to receive the Lifetime Career Award from the American Academy of Audiology.


*Feature Image Courtesy Antioch University

Leave a Reply