In a debate over audiology’s future, Metz warns against letting the profit-takers take over

Mike Metz

Two weeks ago, Hearing Views published a post by Brian Taylor, AuD, entitled “Let’s make hearing aid dispensing less like Cuba and more like Singapore.” In it, Brian suggested some ideas for advancing and modernizing the profession of audiology, specifically the hearing aid aspect of the profession.

When he read his friend and fellow audiologist’s Hearing View, Michael J. Metz, PhD, disagreed with it so strongly that he decided to write his own Hearing View, which is published here and followed by Brian’s rejoinder. Readers are invited to submit their own comments on the issues raised.

                     David H. Kirkwood, Editor, Hearing Views

 

Hi, Brian

Too bad we cannot have a conversation over a steak and a martini. But, despite this disappointment, I will take some issues here with your October 3 Hearing View.

I think your comments would be appropriate for small business people who are engaged in a profession that is not subject to change—at least not in the foreseeable future. Or for those who intend to attempt to make the past last forever. However, I disagree with your suggestions for the field of audiology, as I think our profession is already undergoing serious change.

 

YOUR POINT 1

You suggest that university training programs forego a curriculum broadly based in speech and hearing and add business and marketing courses in their stead. I am not saying that business savvy is not important in some aspects, but I would have you consider just what would happen to any profession—medicine, dentistry, law, teaching, to name a few—if they abandoned the foundation of courses specific to these professions.

Oh, I suppose many physicians do not depend so much on organic chemistry, but instead get all their drug-related information from the PDR, or whatever passes for the Physician’s Desk Reference these days. And, attorneys need not consider debate, international law, or other ”tangential” bits of information if they decide early on to practice only tax law.

And those dentists—well, I have never liked to use dentists in any comparison, as they are quite easy to pick on. Let me use teachers.

Going to teach high school? Well, you’d better know more than just Spanish or Math if you intend to keep your job in these days of cutbacks.  Also, if you are not in a large city school, you quite likely will be called upon to teach something outside your major. That certainly speaks for a broad foundation in education.

My general point is that no one can tell what will be required of any professional in the future. Therefore, a basic preparation, one that will serve almost all contingencies, is always in order. That basic preparation always involves a broad base upon which to build a specialty. The alternative is to rely on some sort of “savant” who knows some business and nothing about what’s “outside-his-or-her-box” of specialization. Or, to put it another way, how special is knowledge if you can never see beyond your own box (specialty)?

The many AuD programs that emphasize only hearing aids and associated “business” courses have largely been responsible for producing the dilemma we find ourselves in now. Perhaps we should stop digging this hole as a first step toward getting out of it.

 

YOUR POINT 2

You write, “Audiologists…need to explore partnerships with ENTs.” But partnerships with ENTs or other physicians will eventually kill audiology.  The Doctor of Audiology movement was largely predicated on this point, as I recall.

We audiologists should be the “doctors,” right? So, if an ENT looks seriously at hiring (call it partnering if you wish—people take undue advantage of their “partners” all the time) an audiologist for, say, a salary in the mid-$50s versus hiring a dispenser in the mid-$50s, I guess he/she would choose the audiologist? And, then when the audiologist wants to be more “professional” (and make a little more money), what happens? I think we both know that most people in a medical office end up doing that which is most profitable. And, keeping a high school graduate in the mid-$50s is a whole lot easier than keeping an AuD at that measly level.

Besides, what would make anyone think that the coming reductions in health care reimbursement would entice anyone to join a business that, while terrific and profitable today, is headed for a techno-future when the “clinician” is replaced by a “techno-health provider.” Read Clayton Christensen’s book The Innovator’s Prescription for a really good look at a very probable medical (and audiological) future.

Also, if your future students load up on business courses, they sort of cease to be “caretakers” and become “profit takers.” That explains the state that medicine finds itself in today, with private practices being constantly taken over by large health clinics, hospitals, and other private companies.”

 

YOUR POINT 3

Why would engineers forsake a future that will, by all estimates, continue to thrive well into the future, for a profession that will involve getting two to five more years of AuD training? Even if they want to go in that direction, they could much more easily get a dispensing license. But if they go that route, wouldn’t they just be doing it for the money? And, if they just did it for the money, why would they go in a clinical direction where they cannot bill for services without two to five years of AuD training? Unlike you, I don’t know dairy farming, but I do know engineering, and for audiology to look in that direction would be almost fruitless.

We will not attract lots of “outside” people to our field the way it is now. As proof of that, I offer our experience from the past 40 years. If we couldda attracted more outsiders, we wouldda. We had a better chance of attracting high-caliber outsiders into audiology when only a master’s degree was required for clinical licensure.

Also, would you ask that these engineers and scientists also take some business training? Or do they come to us with that trait ingrained in them by some other means. This conflict also speaks to your point 1, doesn’t it?

Maybe we should require some science courses in our AuD programs. Considering how many audiologists do not seem to understand such acoustic things as compression and the decibel, I’ve often wondered why someone, somewhere did not suggest an elementary course in physics as part of basic audiology training. A similar argument could be made for chemistry if audiologists are to understand body chemistry, drugs, and other such clinically important things. I think these basic courses would serve the future of audiology better than any ol’ marketing course.

And this brings us back to point 1: A broad and complete foundation is certainly desirable prior to any “specialization.” I guess that could include some business knowledge. We need to discuss what the priorities should be, and I would expect lots of disagreement on this.

From our prior conversations, I think you and I agree on where this field is headed. I’m not so sure that most people in our field have sufficient foresight to sense this change in direction.

I gave a short talk on a similar topic early this summer in San Diego. At the end of my presentation, a student said to the class that she was very discouraged at my comments and observations. When I asked why, she said that the future of hearing aid sales did not seem bright for audiology. I opined that she was equating audiology with hearing aid sales and that was the mistake.

 

PREPARING FOR THE FUTURE

The future of audiology is quite bright, in much the same ways and for the same reasons that the future is always bright for medicine/law/dentistry/education and other professions that provide services that people will always need.

Professional schools do not and should not teach professionals to make money. They should teach how to help others. Given that the help you render is worthwhile, adequate compensation follows. I think that, to a large degree, audiology has lost sight of this basic principle.

When I helped start a new type of company 14 years ago, I predicted that audiology would change dramatically in the next 5-10 years. I was wrong.  Not about the impending change, but about the time frame.

As a field grows and matures, it must change. Audiology changed in the late 70s and early 80s. We also began a minor change about 15 years ago. Another “change front” is moving rapidly our direction. (Really, every audiologist should read Christensen.)

We can’t stop or alter this change much, but we can prepare for it. But, not with courses from the business and marketing school.

Mike

Michael J. Metz, PhD, has been writing about ethical issues for over 30 years. He served on the American Academy of Audiology’s Ethical Practices Committee for two terms, has authored several chapters about professional ethics in various books and journals, and has frequently lectured on this topic. He owns a private consulting practice in Southern California and has been in this practice for over 35 years. He serves on the adjunct faculty of the University of California-Irvine School of Medicine.

 

BRIAN TAYLOR REPLIES

Mike brings up many valid points. However, I think he misses the larger point I was trying to make, which is that we need to attract individuals from the disciplines of science, business, and caretaking and place them into our existing doctor of audiology programs. Many individuals from these three broad disciplines have the prerequisite academic training and intellect to move directly into an AuD program after obtaining their baccalaureate degree, or, in some cases, with just an associate’s degree.

The current curriculum and educational standards of existing programs are an entirely separate issue, one that certainly warrants further discussion. In fact, I would encourage all audiologists to wholeheartedly support the efforts of the Accreditation Commission for Audiology Education.  No one is doing more than the ACAE to ensure that educational standards within our universities reflect the high standards the public deserves. As Mike would surely attest, we have a lot of work to do in raising the bar on quality, and it starts with having high academic standards revolving around evidence-based practice.

While I completely support the widespread use of evidence-based practice, I also believe in the use of reality-based practice. Reality-based practice means that we need to include hearing instrument dispensers, nurses, and entrepreneurs of all stripes in the delivery of personal hearing health care services lest we be supplanted by the disruptive forces that Clayton Christensen writes so eloquently about.

Mike alludes to a bright future for audiologists and I agree. With higher standards and more rigorous use of evidence-based practice, audiologists can be at the center of a personalized delivery model supported by many of these other smart people.

Mike, let’s start a quality movement over that steak and martini that you mentioned!

Brian



5 Comments

  1. yes, I agree with the Au.D student above. We have blamed and continue to blame ASHA for what the profession is today. If we can stop looking for employment in ENT clinics and think more of private practice, as well as admit students who are have science background, we will be able to compete with other professions. Other things to consider would be: an entry exam in audiology program(not the GRE), addressing oneself as doctor, clearly not allowing hearing aids rep to address us by our first names, or not limiting the profession to hearing aids sell would certainly help elevate the profession that we all love. Last point to make: I work in a setting where I have the freedom to practice my profession, and gently but firmly requested other employees/professionals to address us by our degree title.

    1. Marshall,

      Couldn’t agree more with your sentiments. I think it’s overdue to think we should have a separate exam for AuD students, rather than GRE. Also, the talk of autonomy is wonderful and necessary, but students today have tremendous levels of debt and unfortunately, it seems most private practice owners don’t want to pay audiologist-level salary and would rather pay less for a HIS and make more money. I work in PP and this is an issue people don’t tend to discuss openly, but how will all these new grads help the profession prosper if they aren’t given a chance and work in and learn how to operate a PP?

  2. “The many AuD programs that emphasize only hearing aids and associated “business” courses have largely been responsible for producing the dilemma we find ourselves in now. Perhaps we should stop digging this hole as a first step toward getting out of it.”

    … As a recent 4-year AuD graduate, I cannot think of a single residential AuD program where this would hold true. Most AuD courses have 2 or 3 courses in hearing aids, and probably less than half offer a course on business or practice management. Over 3 years of academic coursework, 3 or 4 courses is really not very many. However, I must agree that we cannot be so dependent upon the hearing aid dispensing model as a primary source of our focus, as this process as we now understand it will likely undergo a significant change within the next decade.

  3. “Given that the help you render is worthwhile, adequate compensation follows. I think that, to a large degree, audiology has lost sight of this basic principle.”

    I agree with this principle, but how has audiology lost sight of this? For those of us in the “trenches” doing our best to help our patients for many years, the compensation has not followed. In fact, audiology is one of the lowest paying clinical doctoral degrees, if not the lowest. This is because our services are not seen as valuable and thus not reimbursed as such. So who’s fault is that? ASHA carries a lot of blame in that regard for not advocating fully for audiology for so man years, but shame on us for not making the case for the value of our services.

    Now with students having to take $100,000 in student loans to get an AuD, reimbursement is becoming a much bigger problem. It’s not about “the money”, but you have to be able to make a living so you can continue doing what you love–helping patients!

  4. You both make equally important arguments. Considering as Dr. Metz clearly points out–paying an AuD audiologist in the mid-50’s isn’t going to keep them around. Well, how are these young AuD grads going to have enough knowlege and confidence to seek brighter pastures without some form of business knowledge.

    We absolutely cannot sacrifice clinical quality and education, but we will shoot ourselves in the foot if we don’t have at least rudimentary knowledge of how business operates. Private practice is the only way audiology is going to get full autonomy and respect from other professionals, in much the way Dentistry and Optometry has historically been focused. But, there’s no way you can operate a successful practice without some basic knowledge.

    Of course, we should never sacrifice clinical quality for the sake of making money. However, business knowledge and evidence-based practice are not mutually exclusive concepts.

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