Where Did All the Audiologists Go? Audiology Workforce Analysis Deep Dive with Dr. Victor Bray

Dave Kemp 0:10
All right, everybody and welcome to another episode of This Week in Hearing today I am joined by Dr. Victor Bray. Dr. Bray has a 40 plus year audiological career including clinical services, audio- r&d, including clinical trials of new amplification devices, senior administration in industry and academia, all of which have been supported with extensive presentations and publications. He is a tenured associate professor and former dean of Salus University, Osborn College of Audiology. Dr. Bray, thank you so much for being here today.

Victor Bray 0:45
David, it’s a pleasure to be here with you. Thanks for the invitation.

Dave Kemp 0:49
Absolutely. Well, I wanted to have you on. I know that you and Dr. Amyn Amlani, have been in the midst over the last few years compiling a number of different analysis, statistical analysis of sort of the audiology workforce. And I know that you’ve been publishing some of your findings of late, and I thought this would make for a great conversation today. So just wanted to set the stage and just kind of establish what it is that we’re going to be talking about. So in this most recent report that you all wrote, I found it to be very enlightening for a number of different ways. And I figured the best place for us to start might be all the way back in 1987, when some of the audiology founding fathers were sitting around at the formation of the profession, and if you want to maybe start by sharing George Osborne’s seven step outline that he proposed for Audiology, to basically have, I thought this might be a good place to, you know, basically establish the context for a lot of the workforce data that you have been compiling and why this is relevant, which is what we’ll get into as the conversation goes.

Victor Bray 2:14
I think that you you bring up a good starting point. This, we’re talking about something that happened 35 years ago, at a national meetings 1987. And you have Dr. Osborne there, Dr. Beck, Dr. Jerger group of the leaders of the audiology community saying, you know, what’s our path forward? And out of that did come really a seven point plan. And I don’t think a lot of people know what the plan is. And I know that a lot of people are not working trying to make the plan help. And I’ve actually got a slide I can share with you that that lists the points and that they do kind of come together in a few talking points. So this there’s an article that George Osborne wrote back in 2004. And there’s actually online a 2003 interview of Dr. Osborne on audiology online describing the current state of audiology, and for any of you who are interested, I advise you to go pull this up and and read this. But the key thing is in 2014, the Academy of Doctors of Audiology recognized Dr. Osborne’s contributions to the AuD transition process and awarded gave him the the Goldstein award. And I, Dr. Osborne deceased at that time, I was able to accept it on his behalf. And we republished the article from 2004 in 2014. And here are the here’s the plan that was put together and this is back in 1987. Become an autonomous profession, become a doctoring profession, obtain limited licensed practitioner status, create our own professional organization, develop and enrich curriculum, enjoy direct access by all patients and develop a new professional structure. And these the seven points are interlocking in terms of the key ideas behind them. Of course, one of it was part of the AuD movement was becoming a doctoring profession. Well, and then you tie in that limited licensed practitioner status, or in reading the article, what may be called today limited licensed physician status, because he writes about operating at the level of Optometry. Now, one thing you have to understand about Dr. Osborne is he was first trained as a dentist who they then went into TMJ work which got him involved in audiology. So he went through the professional school environment, becoming a dentist first. And he wanted that to happen for Audiology. And his vision was that we would have professional schools that taught a biomedical science based curriculum, as you would get if you were going into any of the limited licensed physician categories. Now, the LLP categories are not physicians, but they are people who are recognized at that level within their scope of practice and classic example being Optometry. So the goal was get there. Now, what we’re trying to do today is to get to limited licensed practitioner status, which is a step between where we are today and limited licensed physician status. With the enrich curriculum, the basis of this, the Biomedical Science Foundations is something that just has not happened for the profession. And we’ve not done our educational work to lay the foundation for the movement that was envisioned 35 years ago. The some other parts of this are creating an autonomous profession. That’s a profession that can take care of itself without relying on anybody else to guide it or to rule it. And frankly, that means completely separating from communication sciences and disorders. I have colleagues you know, in the CSD environment, and they they adhere to the philosophy that CSD makes sense because there is, you know, one discipline with two professions that come out of it. And while that may be the historical basis of our profession, it cannot be the future of our profession. Because we can’t look to the model being speech language pathology, we must look to the model being the other profession, which treats a primary sense disorder, Optometry, how are they trained? How are they work, and that was the vision. And so part of becoming an autonomous organization is you have your own association that represents you. You have your own licensing bodies that govern you in the state. You have your own accreditation agency that governs and monitors your training programs, your training programs are autonomous training programs. When you think about these limited licensed physician professions, you don’t go to the School of Dentistry, Optometry and medicine. No, there’s a School of Optometry, there’s a College of Dentistry, there’s a College of Medicine, and these are all autonomous. That was the vision that was laid out 35 years ago, there have been some people have tried to achieve that through the academic route. But frankly, Dave, I will tell you having been there, it is very frustrating to try to get there.

Dave Kemp 8:14
Well, well, what’s really interesting to me, and part of the reason why I really wanted to have this conversation was because it feels as if, as a young person in this industry. Now I’m not an audiologist, but some of this was kind of unbeknownst to me. And I think it’s, it’s really, you know, when you’re looking at the workforce data that we’re going to get into, there’s this is providing so much so much context, you know, so in that seven step plan, it lays out become a doctoral profession. So in 1999, it goes from being a master’s level degree to, you know, in order to become an audiologist, you need to obtain the doctoral level degree. And it’s fascinating that all the way back in 1987, this group of gentlemen have identified the need to obtain practitioner status. Now, what’s the flagship, you know, thing that is trying to be achieved within MAASA, for example, the practitioner status, which will give you direct access to patients. So, you know, in that article that you referenced the George Osborne interview, he’s talking about legislation that was on the floor in 2003, that was going to provide that practitioner level status. So what’s I guess, kind of concerning is that, you know, it’s like you’ve embarked on this path, and you’re actually at the point of no return because you’ve already achieved some of the goals that you can’t reverse. So you’ve already made it such that you have to now get the doctoral level. So you’ve, you’ve added the burden of that additional year and the costs that are associated with it. But because you haven’t achieved the other goals. It’s like you’re in this limbo period. And I just thought that, you know, as I’m looking at the workforce data, there’s so many striking things that come about when you understand that historical context that largely derived from this seven step plan that is still in progress today. That I think is part of the root of some of the issues that our, the audiology community is experiencing is because they have not fully achieved the goals that were initially laid out to become an autonomous profession.

Victor Bray 10:34
You know, you’re picking up on something that is very important. I can give you three examples, firsthand examples where I have watched, I’ve been working on trying to implement the plan. And yet I’ve hit roadblocks. So let’s talk about enriched curriculum. Back as dean in 2014, 2015, our residential program curriculum had been in place for a while, and we did a extensive curriculum review, to update it, revise it improve the curriculum for the college. As part of that, I did a survey of the program directors around the country to get an understanding of what they were teaching in their AuD programs. And what they thought perhaps would be the a model curriculum that we would use that as input into just revising and updating our curriculum. There was a lot of expected results in that, but there was one, one item that just stunned me. And that was that one of the questions I asked and was, of all of these topics that show up in audiology curriculum around the country? Are any of them not needed? Or Are any of them not important enough to include, and there were there were very few things out of the long list that were not included and not deemed worthy of inclusion by the program directors around the country. That item that was deemed not important, was whole body anatomy and physiology. Now, head and neck anatomy and physiology was in all the curriculum, and everybody thought that was important. But whole body anatomy and physiology was not deemed important by the program directors. And again, I was stunned because our program is founded in the biomedical sciences with this vision that we’re going to move the profession up to a level where we’re operating holistically in patient care. I think about today, some of the biggest avenues for opportunity in the profession is understanding comorbidities associated with audiology. If I go back to the 20th century, when I was trained in my master’s training, you know, the ear was this little black box that said in isolation, and now we understand it’s not, and it’s tied into so many parts of the body, the vascular system, especially. And in fact, in some cases, the ear’s health and hearing health and vestibular health is an early warning sign of body health problems that are showing up. But short story being my peer group of program heads around the country saw no need for the biomedical sciences to be part of the curriculum. Yeah, that was a foundational idea back in 1987. Secondly, around 2013, 2014, about the time that I was able to get Dr. Osborne’s seven point plan, republished in ADA’s magazine, I was talking about it on the lecture circuit, and I was at a meeting, it was actually the last meeting of the Scott Hoag Foundation, out in the hill country in Texas, and I, you know, walked through the plan again, and actually called my talk A Revolution Stalled, because we had made it so far, but only halfway through the objectives. And when I talked about achieving Limited License position, or even limited licensed practitioner status, something like that. I had people in the audience who were presidents of AAA from the early years, and after the talk, they came and just basically told me, that was never part of their plan to advance the profession to practitioner or limited licensed physician practice, and it was still not part of the plan. And so there was certainly a problem. The third thing within ADA prior to MAASA, we we worked very hard on the audiology patient Choice Act. And in that was a movement up to limited licensed physician status charted to try to be on par with Optometry. And we could not get a coalition built with ASHA, and AAA to all unify around that objective. MAASA came about when everybody gave something, and what ADA gave up was, Okay, we’re gonna give a limited license physician status, and let’s just work on getting to practitioner status. And just getting there would be a significant advance. But there’s three examples where I know there’s a plan in place that was put there 35 years ago. But I’ve encountered obstacles to implementing the plan over and over again. And I don’t think that the profession even understands the plan has ever seen the plan, or even would agree to the plan today.

Dave Kemp 16:03
Yeah, I mean, I think that this speaks to a lot of the frustration that you know, just as somebody like myself that is just privy to all the conversations that are had in and around the industry, by all the different types of professionals, is the lack of cohesion, the lack of a unified message, I mean, we’re talking about a workforce that’s less than 20,000, even if you include the hearing instrument specialist. So you’re not a big governing body to begin with. There’s not a lot of lobbying power there. And way less so if it’s fragmented. And so here we are, and it seems as if the audiologist, you know, their, their purview, their scope kind of continues to be eroded away. And to your point, I don’t think I’ve ever really had, I haven’t had a whole lot of consistent answers or just feedback in terms of what’s the plan here. And that’s part of the problem is that there doesn’t seem to be I don’t know, a unified answer or mentality of what what it is that we’re seeking to achieve, I think are, I’m saying that as you know, again, as a third party, but what what exactly is this profession trying to achieve? That seems like a big part of the problem is there’s not a consistency in how people would answer that.

Victor Bray 17:21
Well, I think you hit on something that many people are frustrated about. When I, when I look at the scope of practice, which is established at the state level, I the breadth and the scope of practice, from when I was licensed initially, 40 years ago – God that sounds old. Is it hasn’t really budged. Yet, the degree has changed, built around this idea that there’s much more knowledge that needs to be acquired by an audiologist. And the purpose of the degree is to make us a key component of the healthcare system operating at the doctoring profession. With that would eventually come enhance- expansion of the scope of practice. We have a saying here at Salus that education precedes legislation. So the first thing you have to do is educate everybody to be able to operate at a higher level. Once you can prove that, then you can go and work on the legislative activity to let’s get to the higher level. But as you mentioned, we’ve been working on direct access for for 20 years. This year. For the first we got to crack the door open just a little bit through the new CMS Physician Fee Schedule of partial direct access. But the other things we’re looking for having Medicare recognizes at and CMS recognizes at where we want to be that that mismatch just continues to create problems for us. And frankly, it makes you wonder, why do you – why should you put in the amount of work necessary to become an audiologist. If you’re not actually being able to do more things with your degree than we are today. That’s a real problem we have to answer.

Dave Kemp 19:32
Do you- I think this would be a good segue to pull up some of the data that you had, you know, that you had done so. Because I think that it’s here where we can kind of get into you had said to me earlier, you know, one of George’s big premise behind his seven action plan was that and I think that this is like really apparent in the data. With the rise of the hearing instrument specialist is audiology needs to move high or in further up into the medical food chain, if you will.

Victor Bray 20:05
Now, when Amyn, Dr. Amlani and I started looking at this back in 2019. And we’re not the first to look at workforce issues. Doctors Windmill, and Freeman had a great publication a decade ago where they pointed out this issue and there’s been others who have zeroed in on it. But I’m gonna pull up a graph in just a minute and show you the basic thing that catches your attention is what we have the best. The best database that we have for our workforce is the BLS database. In 1997 audiology and speech pathology entered the database as a combined code. Yeah, two years later, in 1999, the two professions were split. So we have from 1999, the BLS data. So that’s 22-23 years of data on what our workforce is. And if you go to that number in 1999, and you go to the number today, the size of the workforce has not significantly moved, at a time when comparable professions to ours. Speech, Language Pathology, occupational therapy, physical therapy, Optometry, have all grown their workforce by 70%. And we haven’t, but let’s look at some data. Here’s the raw data. And some of the analysis that Dr. Amlani and I just published in the Audiology Practices, fourth quarter magazine. And some of this was based upon to a presentation that we made in November, at the ASHA meeting in New Orleans. The so we have a timeline across the bottom, it starts in 1999. It goes out through the last year of the data 2021. The y axis we have the audiology workforce, as reported by BLS. Now, I don’t want to say that these numbers are the size of the audiology profession, because there are other estimates of the audiology profession that say 13,000 14,000 15,000 16,000 people. And certainly the professional association say that, but we don’t have their data that it’s not publicly available data, this is the only thing we have to work with. But if you look at 1999, we’ve got 13,000 audiologists, and you come over here to 2021. And we’ve got 13,200 audiologists. So we’ve grown 200, audiologist in 20 years. So we’re growing it 10 people a year aggregate over the 20 years, as I say, and what I consider our professions very similar ours have grown by 70%. If we grown 70%, there’d be 20,000 or more audiologists by now. But also, when you look at this, the blue lines, the squares and the blue line. It is wonky data, it when I look at data from all the professions, there’s nothing out there that I really see that shows this lack of a steady planned growth in the profession. You have this huge trough that shows up between 1999 and 2008. Hitting with a you know a real low point of below 10,000 audiologists in 2004. That was right smack in the middle of the AuD transition process. And I don’t know what was happening. I don’t I don’t have an explanation. But certainly the data is very alarming. You would hope that in the process of transitioning to a new degree and beefing up your educational structure and having a new vision that the numbers would be going up, not down. But that shows like a 25% loss of the workforce numbers over a five year period. Out of which another five or six years. We’ve steadily climbed back. And then from 2010 and on, we’re starting to see some leveling out of the growth.

Dave Kemp 24:39
Yeah, I like this here because, you know, again, like you mentioned, you know, what happened in 1999. While it transitioned from being a master’s level degree to a doctoral level degree, then you suddenly have this, you know, giant reduction in the workforce down 25%. So I think what’s nice about this I like, you know, aesthetically, this is a great way to map the data because you have three different ways to basically assess it you have, okay, well, do you want to factor in the period of time, you know, directly after the transition? Because that’s going to tell a different story, you know, the Y equals 110, you know, so you’re averaging 110 New audiologists entering into the workforce per year? Or do you want to omit that data 2004 to 2021, where maybe that’s a bit of an aberration? And so you’re gonna look at it that way, then you’re averaging about 152 people? Or are you just looking at the most relevant data, say, the last 10 years, and that’s the green data. But either way, to your point, I think, if you look at from, you know, peak to trough or whatever, you know, from ’99, to ’21, you’re almost flat, in that span of time of where it was, and where it is now for the audiology workforce, which probably segues into the introduction, or the emergence of the hearing instrument specialist and the role that, you know, they played in, I think, ultimately, kind of, maybe because of the transition from the masters to the doctoral, it’s one of those secondary effects of of that, but I know that you compiled a lot of, you know, the workforce analysis that you did is way more comprehensive than just this industry. So maybe there’s some other examples from other, you know, ancillary medical industries that we can look to as to similar, you know, the dichotomy of having doctoral level medical professionals working hand in hand with either associate or master level, you know, support type roles or or something to that effect.

Victor Bray 26:53
Yeah, and you did a nice job of summarizing the graph was, you know, if you’re not familiar with looking at regression equations, there’s three lines on there. The the blue line is the is the 22 year data, the orange line, you say, Well, let’s take the low point at 2004. And come forward. And then you can say, Well, now let’s look at just the last tenure data, which is the green line. They’re showing, from what yeah, as you say, from 110, to 150 to 200, people increase in the size of the profession per year. But that’s not a growth rate, that’s going to overcome the loss. I mean, you would expect, you know that there would be 20- 20,000 to 20,000, or more audiologists. So here’s here’s another way to look at the information. So the blue lines represent the workforce numbers for the profession of audiology and the BLS database. In 2012, there were quite a few health care professions that were added to the database. One of them was hearing aid specialist. And the red line is that 70% growth line that comparable health care professions to ours have followed. And that’s where I get the you know, you would expect to see that if we were to performing on par with a professions like ours, there would be in excess of 20,000 be like 22,000 people. That’s, that would be great to see. But you look at the hearing aid specialist data now that’s that’s being added to the database. And you can see pretty much where the shortfall in audiology is being met by another profession, to meet the needs of the public’s hearing healthcare. The failure of audiology to grow our numbers has many, many consequences. But one thing that is very important is if you don’t grow your workforce, to meet a the growth in the size of the country and the, the graying of America, neither of which audiology is doing, someone else has to step in and do your job. And that’s exactly what we’re seeing in the 10 years that we see the hearing aid specialist data show up in the BLS database, they’ve more than doubled their workforce at a time where ours is increased by about 15%. And if you project those numbers out, in another decade, the two professions will probably be comparable in size. And by the mid 2030s. No, 10-15 years out. Hearing aid specialists will have the actually be a larger profession than the audiology profession, if nothing changes, and I consider it alarming that we have not grown our workforce. I think about just trying to think the things we’re trying to achieve politically getting MAASA through Congress. If we had a profession that had 22,000 people instead of 13,000 people in terms of talking to our legislators about demonstrating that we have the capability to fulfill the needs, that would be great. If you go back a year ago, when Medicare hearing aids were being discussed, there was discussion about well, should it be only audiologists who do this for Medicare hearing aids? Or should hearing aid specialists be involved? Well, the hearing aid specialists were lobbying in on Capitol Hill saying, look at the audiologists who are in the country, they’re in urban areas, but they don’t have enough workforce to meet the needs of the country throughout the state. And we have people in these other areas where audiologists are so combined, what we’re doing is meeting the needs of the country for at least for hearing aids. I don’t want to imply that that’s meeting the needs for Audiology Services. But for fitting and dispensing hearing aids, which is kind of the lowest common denominator for for Audiology, you see who’s who’s, who’s providing the manpower that we’ve created by a lack of growing our workforce.

Dave Kemp 31:33
And when you say that, that what you just said, right, there is I think it goes back to George’s seven point outline, which is, again, moving up the, if you’re going to become a doctoral profession, then you need to move up the food chain, because you’re effectively focusing on the lower complexity tasks that the hearing instrument specialist is able to do as well. And then that sort of calls into you know, I think it’s, it’s, I have a tendency to look at like, well, you know, are audiologists like dentists are they like optometrists, and you know, when you and I were discussing this previously, you made a really good point about, you know, how maybe the analogy of dental sort of falls apart, because of the lack of delineation I guess, of roles. Whereas it’s much more well defined in the dental setting where a dentist has a very clear role. And I guess, like a, you know, battery of different services that only they can perform. Whereas the hygienist, if that’s going to be the analogous role to the the instrument specialist might actually be the one that’s, you know, spending the bulk of the time with the patient. So, it continues to kind of bring into focus this need for those seven steps to be completed. Because if you’re, if you’ve only just moved yourself into the doctoral level, but you haven’t achieved the other steps, it in layman’s terms, it sort of just begs the question, you know, why go the route of, of getting this higher level degree that, again, requires more time and money if you’re ultimately going to be doing the same thing that this other role can do?

Victor Bray 33:34
That’s an that’s a very good question. Last year in my presidential address for the Academy of Doctors of Audiology convention, I made this analogy. If you if you think, again, I modeling on optometry is one of our objectives, I believe, if you think about you’d have the optometrist, you’d have the and you have the ophthalmologist, you have the optometrist, and you have the opticians and they have three very clearly delineated roles. And if you think about the optometrist, are they closer to an optician? Or are they closer to an ophthalmologist? Well, being a limited licensed physician profession, they’re closer to an ophthalmologist because they’re operating at the doctoral level within their scope of practice. They’re not MDs they’re not physicians. They’re not specially trained, but they’re closer there they think of that same continuum. The otolaryngologist, the audiologist, and the hearing aid specialist. How do how are we seen? Are we closer to being to an otolaryngologist or a hearing aid specialist? I maintain that what we are seeing seen as being closer to the hearing aid specialist and being there is a great deal of value to be done and taking care of the nation’s hearing impaired in that role. But that’s kind of the bottom of our scope of practice, what we have to do is to prepare ourselves, one to operate at the top of our scope of practice. And there’s a lot in our scope of practice, which is potential, but not being explored and not being utilized by audiologists. And then, as we ramp up our educational programs on this seven point plan, then we begin to show that we have the capability to expand and meet meet more needs. Then you start coming to the the audiology environment in which we would love to see. And there’s your dentist model coming in dentists are highly effective at running private practices. And they have multiple level of extenders, who different do different functions in and the dentist don’t need to do the basic stuff. I will say it’s probably 15 years ago that I made a presentation that at AAA, I was on the podium with Dr. Margolis. And Dr. Dirks, and we were talking about how are we going to meet the future needs of our country in terms of the role of audiologist and one of the conclusions from our talk was that we cannot do it by manpower alone, we are going to have to rely on assistants and machines. So machine testing, and audiology assistants. And I would add to that now hearing aid specialists. And so for the audiologist to operate at that highest level that they’re seeing the complex patients, and letting other people who work in their practices, take care of the day to day issues and patient care that you do not need an A you do not need an AuD to fit a hearing aid, let’s just be really clear about that. But with an AuD degree and especially some good training in the biomedical sciences, you can do a lot more. That’s where the future of our profession is, I believe. That’s how we separate ourselves create that distance and move to what is a higher place in called the food chain of the medical -the medical hierarchy. Yeah, you have allied health, you have practitioners, you have the limited licensed physicians, you have physicians. We’re at this ‘diagnostic other’ category. And masa, that Medicare audiologist access and Services Act, which we were unable to pass again, in this legislative cycle has three legs to it. How many of the people in the audience know what the three legs are? How many of them have contacted their legislator to say, this is where I want audiology to go. I want direct access, I want my patients on Medicare to be able to come see me without having to have a physician referral. First, I want Medicare to recognize me as having therapeutic value and not just diagnostic role. And frankly, I want to move up. And I want to be recognized as a practitioner, where I can begin to show that I have an autonomous profession that can have more value in the healthcare system. That’s what MAASA is all about. That’s the key to advancing the profession. And every audiologist in this next legislative cycle has got to get on board with this and start to become involved. If audiology as a professional is going to advance, doing those getting those three things done, would be consistent with the big seven point plan to move the profession forward.

Dave Kemp 39:06
I really well said and, you know, just again, to sort of like hone in a little bit on the distinction. And I think that, you know, ultimately, we would be so much stronger. I think as a workforce and as an industry if there was a harmony between the instrument specialists and the audiologists. And I think that again, it’s like this problem has sort of persisted and festered of not moving up the food chain to where now we’ve turned inward in our already small workforce now that there’s like this division of, you know, trying to maintain, you know, your fiefdom, and I think that you’ve used the analogy or maybe the right place to look is optometry and maybe you could speak a little bit to this because I I do think that in I think, in many ways, they probably are one of the best, you know, guides for Audiology, because of the fact that, you know, you look back at Optometry in the days before contact lenses and then, you know, flash forward to Warby Parker, I mean, they’ve had to really weather some pretty significant storms, and they’ve come out doing really well, I would bet that most optometrists are doing great today, you know, respective to maybe some of the doom and gloom that was in that industry. Because you look at like, you know, the role of the optometrist in the past used to be fitting people with their technology. And now it’s more about diagnosing complex medical problems. And it goes back again, to this whole notion of the, you know, having the the aptitude of being this, like biomedical field that is much more medical and oriented in those more complex level problems in letting this, you know, layer of support and extenders like you mentioned, you know, really spend the time tackling a lot of that, and I know that this all sounds great, and stuff like that, but you might be saying, well, the bulk of the revenue today in this industry is around hearing aid sales, I get that I totally get it, but it doesn’t really ever. excuse the fact that, you know, that doesn’t have to be the way that it all, you know, always has to be, you know, I think that it’s part of the challenge of figuring out, you know, it’s easy to say, well, you know, the audiologist needs to move further up into the, the food chain of the medical hierarchy. Well, what does that look like? Like what are the opportunities that that are there? So I kind of want to throw it back onto you, because I know you’ve thought a lot about this of what would that look like and and then how does that then kind of relate to this whole analogy around Optometry?

Victor Bray 42:01
It’s really nice layout of the of the, the history of optometry and what they’ve done, and, frankly, where I think we have to go. optometry, we’re going through right now. We’ll internal crisis, about over the counter hearing aids. optometry went through that. When readers went from prescription devices to over the counter readers. And they recovered just fine. They went through the crisis again, when contact lenses became something that you could get through the internet instead of having to come into the office to get them. And now you mentioned Yes, Warby Parker, you have other people who are entering the device space. And so what what optometry has done is they have dissociated themselves in the definition of their career, from devices, and have made it about the met at the medical services that they can provide that surround vision care, and vision care as part of whole body health. And their Yes, the profession is doing very, very well. And they have people who can work for them doing these other things. But that’s not what they necessarily concentrate on. If audiology continues to focus on devices, in my opinion, that’s a – that’s a path to failure. And the reason is, you’ve got another profession who’s fully licensed to fit in dispense hearing aids, and they do it successfully. We’ve had 20 years of the AuD movement. I still haven’t seen any data that says that an audiologist does a better job than a hearing aid specialist when it comes to outcomes from the patient’s perspective. So that profession to their average wages are $30,000 less than hours. So if I’m, if I’m in industry, or if I’m in retail, why would I hire an audiologist to fit and dispense hearing aids when I can hire a hearing aid specialist to do it, that supports my business model. And that’s and following the device is, I believe a path for failure for the profession. So where do you go? You go you follow the path of optometry you become part of the healthcare system. And we already have a degree that’s what doctors and health care to. You are part of the system again you’re biomedically science trained you are you have to operate peer to peer with the other physician groups. You In medicine, which begins with where even our undergraduates come from, well, not our undergraduates but our undergraduate degrees, we have to become a profession that is attractive enough that we can draw on STEM graduates who want to come in, we can no longer build our profession on the Enlightened refugees of communication sciences and disorders programs, we have to have people who are ready to perform at the level where the profession has to go, in order to have its autonomy, and to be the real profession that has the payoff, for the hard work of getting the doctoral degree. But it does mean thinking about yourself, and how can I be part of the medical system to truly diagnose and treat hearing and balance disorders and the holistic approach in patient care?

Dave Kemp 46:00
And I well said and to, I think, kind of come to a close here, you know, I personally look at the current landscape, and what better over time with everything that’s starting to come out and the science and the research around all of the comorbidities, I mean, there really is, I think, such a gigantic role for this particular kind of audiologists that you’re describing, to really have a significant role. You know, whether it’s winking all of the things with our you know, the brain is that such a frontier that the audiologist plays a massive role in and then down the line with all the comorbidities that are associated with aging, and hearing loss and all of that. So it seems like there’s plenty of opportunity. But again, it it really just boils down to, you know, the, I think the end of the workforce, having a collective unified vision of what they’re ultimately setting out to do, and then having the cohesion as a group to, to accomplish those goals so that they can ultimately reach that autonomy that we’ve been talking about today. Because I do I think that this is a this is not the battle that I think audiology needs in wants to fight is with the hearing instrument specialist. I just think that’s really, it’s, it’s a complete sideshow, the much more important battle is on figuring out where exactly does, like you said, this sort of middle roll, if you will, on the spectrum. And establishing yourself in a way that I think, is future proof, much like the optometrists where you start to disengage from just being associated with the device, you then are perceived as something much different, I think, in the eyes of the patient and the consumer, as a medical professional, that serves a very distinct role that I just think is going to be more and more pertinent as our population gets older. And as we learn more about how interlinked all of our physiology is, particularly as you near the brain.

Victor Bray 48:25
There and the good news is and there is good news, there are audiologist who are already practicing practicing at this level, absolutely, granted, they don’t have practitioner status, they don’t have direct access, they, they still aren’t recognized by Medicare as a rehabilitative experts. But within those constraints, they are practicing at the top of the scope of practice. And they they’re doing some wonderful things. And so, you know, what I would say to the younger audiologist is, if you’re seeking out an extra if you’re in school, and you’re seeking out an externship, or you’re a young audiologist, and you’re trying to figure out where you want to go find those audiologists who are working at the top of the scope of the practice, and go work with them, go learn from them, go get that experience. And I believe that that’s where you will find a great deal of job satisfaction today. And a great future for tomorrow. So there it is happening. We just need it to be global across the profession.

Dave Kemp 49:38
That’s fantastic. Well, Dr. Bray, thank you so much for coming on today, sharing all your thoughts, some of the research and the data. I’m looking forward for the full publication to be published. I think it’s going to be something that a lot of people are going to be reading and talking about. So thank you for coming on. And thanks for everybody who tuned in here. To the end we’ll chat with you next time

Victor Bray 50:02
thank you so much Dave it’s been a pleasure