AMA Scope of Practice. Data Series. Audiologists. demographics. education and training. licensure and regulation. professional organization

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1 AMA Scope of Practice demographics education and training licensure and regulation professional organization current literature Data Series A resource compendium for state medical associations and national medical specialty societies Audiologists American Medical Association April 2009 Disclaimer: This module is intended for informational purposes only, may not be used in credentialing decisions of individual practitioners, and does not constitute a limitation or expansion of the lawful scope of practice applicable to practitioners in any state. The only content that the AMA endorses within this module is its policies. All information gathered from outside sources does not reflect the official policy of the AMA.

2 Table of contents I. Overview....4 II. Introduction...5 III. Audiology as a profession...7 Definition(s)... 7 General duties and responsibilities... 7 Brief history of the profession... 7 Demographics... 8 Number of audiologists in the U.S. work force... 8 Employment types and locales... 8 Salary data IV. Billing for services....9 Medicare... 9 Medicaid... 9 V. Education and training of audiologists Introduction Accrediting bodies in audiology Requirements for program accreditation Council on Academic Accreditation in Audiology and Speech Language Pathology Accreditation Commission for Audiology Education Tensions between accrediting bodies Master s degree programs Didactic curriculum of the master s degree Survey of master s degree curricula Clinical curriculum of the master s degree Master s postgraduate clinical fellowship The Doctor of Audiology degree Background Doctor of Audiology degree programs Didactic curriculum of AuD programs Survey of AuD program curricula Effects of the transition to the AuD on licensure and certification Clinical experience in AuD programs The AuD transition phase for practicing audiologists Earned Entitlement: The AuD credential AuD distance learning EPAC and advanced standing in AuD distance programs Number of schools granting audiology degrees Number of graduates per year Admission requirements for AuD programs Scope of Practice Data Series: Audiologists Table of contents 2

3 VI. Licensing and certification National licensing exam State licensure, regulation and professional certification Certifications available to audiologists Certificate of Clinical Competence in Audiology American Board of Audiology certification Otolaryngologist board certification American Board of Otolaryngology Specialty certification ASHA Specialty Recognition Program ABA Cochlear Implant Specialty Certification Declaration of professional competence: state licensure vs. certification Medicare referral policy VII. Professional organization Professional associations in audiology VIII. Professional journals of interest Appendix Roster of state audiology boards Roster of state audiologist association chapters National association policy concerning audiologist scope of practice Literature and resources Figures Figure 1: State licensure requirements for audiologists Figure 2: State scope of practice for audiologists Figure 3: State audiology board operating information Acknowledgments Many people have contributed to the compilation of information contained within this module. The American Medical Association (AMA) gratefully acknowledges the contributions of the American Academy of Otolaryngology Head and Neck Surgery, the Michigan State Medical Society, the Pennsylvania Medical Society and the Wisconsin Medical Society. Scope of Practice Data Series: Audiologists Table of contents 3

4 I. Overview The American Medical Association (AMA) Advocacy Resource Center has created this information module on audiologists to serve as a resource for state medical associations, national medical specialty societies and policymakers. This guide is one of 10 separate modules collectively comprising the AMA Scope of Practice Data Series, each covering a specific non-physician health care profession. Without a doubt, non-physician health care providers play an integral role in the delivery of health care in the United States. Efficient delivery of care, by all accounts, requires a team-based approach. With the appropriate education, training and licensing, these providers can and do provide safe and essential health care to patients. The health and safety of patients are threatened, however, when non-physician providers are permitted to perform services that are not commensurate with their education or training. Each year in nearly every state and at times on the federal level, non-physician health care providers lobby state legislatures, their own state regulatory boards and federal regulators for expansions of their scope of practice. While some scope expansions may be appropriate, others definitely are not. It is important, therefore, to be able to explain to legislators and regulators the limitations in the education and/or training of nonphysician providers that may result in the substandard or potentially harmful care of patients. Those limitations are brought clearly into focus when compared with the comprehensiveness and depth of the medical education and training of physicians. Issues of access to qualified physicians in rural or underserved areas provide non-physicians providers with what, at first glance, seems to be a legitimate rationale for lobbying for expanded scope of practice. However, solutions to actual or perceived work force shortages simply cannot justify practice expansions that expose patients to unnecessary health risks. In November 2005 the AMA House of Delegates approved Resolution 814, which called for the study of the qualifications, education, academic requirements, licensure, certification, independent governance, ethical standards, disciplinary processes and peer review of nonphysician health care providers. By surveying the type and frequency of bills introduced in state legislatures, and in consultation with state medical associations and national medical specialty societies, the AMA identified 10 distinct health care professions that are currently seeking scope of practice expansions that may be potentially harmful to the public. Each module in the AMA Scope of Practice Data Series is intended to assist in educating policymakers on the qualifications of a particular non-physician health care profession, as well as on the qualifications physicians possess that prepare them to accept the responsibility for full, unrestricted licensure to practice medicine in all its branches. It is within the framework of education and training that health care professionals are best prepared to deliver safe, quality care under legislatively authorized state scopes of practice. It is the AMA s intention that these Scope of Practice Data Series modules provide background information for state- and federal-based advocacy campaigns where the health and safety of patients may be threatened as a result of unwarranted scope of practice expansions sought by non-physician providers. Michael D. Maves, MD, MBA Executive Vice President, Chief Executive Officer American Medical Association Disclaimer This module is intended for informational purposes only, may not be used in credentialing decisions of individual practitioners, and does not constitute a limitation or expansion of the lawful scope of practice applicable to practitioners in any state. The only content that the AMA endorses within this module is its policies. All information gathered from outside sources does not reflect the official policy of the AMA. Scope of Practice Data Series: Audiologists I. Overview 4

5 II. Introduction The American Medical Association (AMA) is pleased to offer this informative module on audiologists, with the intention of aiding physicians in countering advocacy efforts of audiologists to expand their scope of practice to allow for direct access to patients without a physician referral. This information will assist state medical associations and national medical specialty societies in educating legislators and regulators to evaluate audiologists attempts to expand their scopes of practice beyond that which their education and training have prepared them to safely perform. The advocacy movement among audiologists to expand their scope of practice is a byproduct of the Audiology Foundation of America (AFA) effort to transition audiology to a doctoral degree level, to become, as frequently stated in audiology materials, a doctoring profession. Previously trained to the master s degree level, even those licensed, practicing audiologists have been allowed to pursue highly individualized Web-based educational programs culminating in a doctoral degree, the Doctor of Audiology (AuD). With both students of audiology and practicing audiologists seeking this emerging degree, the profession, through its professional associations, now also seeks a significant expansion to its scope of practice, including practice autonomy, as the business model for its practitioners. The profession s push to adopt the AuD as the degree for entry-level audiology practice has had a marked effect on the profession. Modest changes to the curriculum from the master s level to the doctoral level have added little additional content to the traditional campus-based audiology master s degree program. For example, under the previous master s-level audiology program model, two years of academic coursework were followed by a mandatory one-year clinical fellowship. It has been suggested that some programs have simply repackaged this three-year educational model as an AuD. In addition, professional audiology organizations, in concert with certain schools, have created educational shortcuts to the doctoral degree for currently practicing master s-level audiologists. Initially, a process called Earned Entitlement (EE) was adopted by the audiology community through which audiologists could be granted an AuD (and the corresponding use of the title Doctor ) based solely on a review of the candidate s work experience. The EE program evolved into the transitional degree, which awards master s-level audiologists an AuD following completion of certain core course requirements not already fulfilled through either formal education, professional work experience or continuing education. Based on their professional or clinical experience, audiologists can be exempted from certain requisite courses, allowing master s-level audiologists to earn credit towards an AuD degree without ever having to set foot in a traditional classroom, in some cases with minimal coursework completed. The audiologists goal of eliminating physician referral and oversight requirements may increase unnecessary use of audiological services and drive up health care costs. Current Medicare policy requires Medicare beneficiaries to obtain physician referral before seeking audiologist services to assure that beneficiaries are receiving medically necessary services. The Centers for Medicare & Medicaid Services (CMS) supports continued inclusion of the physician referral requirement, stating in a 2007 report to Congress, Clearly, broad removal of the ordering requirement for diagnostic tests as a whole would make it even more difficult to adhere to the statutory command not to pay for medically unnecessary tests and screening tests not authorized by statute. The education and training of audiologists prepares them to provide essential and significant nonmedical and nonsurgical treatment for hearing and balance disorders. It does not, however, prepare them to collect and assess the clinical information necessary to make a medical diagnosis. While patients with hearing problems may seek treatment for one symptom, such as hearing loss or vertigo, such seemingly straightforward symptoms may underlie a more serious medical condition. When undetected by a nonmedically trained practitioner, the delay in medical attention may lead to health complications, adverse outcomes and increased costs for the patient. Scope of Practice Data Series: Audiologists II. Introduction 5

6 By virtue of their extensive medical education on the human body and all its systems, reinforced through years of medical residency training, physicians have the clinical acumen and judgment to identify correlating underlying conditions, as well as prescribe the most appropriate and effective therapy to repair, restore or reduce the negative effects of impaired hearing and/ or balance. Quality patient care is best served by maintaining a physician s medical oversight of the care that audiologists provide to patients. Doing so prevents needless delays in care and ensures that the appropriate treatment is given to patients in a timely manner. We hope that the information contained in this module will allow states and medical societies to present relevant facts and information to lawmakers in response to audiologists efforts to expand their scope of practice to levels unwarranted by their education and training. The AMA holds patient safety as its highest priority, and stands ready to assist state and specialty societies in their efforts to protect the health and safety of patients. The American Academy of Otolaryngology Head and Neck Surgery similarly welcomes requests for assistance or information on audiologist scope of practice issues. By focusing the resources of organized medicine, we can protect patient safety and preserve the highest quality of care for patients. Advocacy Resource Center American Medical Association AMA Scope of Practice Data Series module distribution policy The modules are advocacy tools used to educate legislators, regulatory bodies and other governmental decision-makers on the education and training of physician and nonphysician health care providers. As such, the AMA will distribute the modules to the following parties: (1) State medical associations (2) State medical boards (3) National medical specialty societies (4) National medical organizations In line with the express purpose of the modules being governmentally directed advocacy, it will not be the policy of the AMA to provide the modules to individual physicians. Organizations supplied with the module shall mirror the intent, purpose and standards of the AMA distribution guidelines. Scope of Practice Data Series: Audiologists II. Introduction 6

7 III. Audiology as a profession Definitions The U.S. Department of Labor s Bureau of Labor Statistics (BLS) defines audiologists as health care professionals who study hearing, balance and other ear problems; they identify, assess, treat and help patients manage hearing loss and other auditory, balance and related sensory and neural problems. They help patients with disorders of the ear through treatments such as cleaning the ear canal, distributing hearing aids, fitting and programming cochlear implants, counseling on how to cope with hearing loss and teaching specialized communication skills. Audiologists also address the emotional needs of patients and their family members. 1 An interdisciplinary group of health care professionals devoted to hearing loss, prevention and care defines an audiologist as one who identifies and assesses disorders of the hearing and balance systems of children and adults. Audiologists select, fit and dispense amplification systems, such as hearing aids and related devices; program cochlear implants; and provide services to enhance human communication. A graduate (doctorate or master s) degree is required for practice. 2 The American Speech-Language-Hearing Association (ASHA), a professional organization representing audiologists, notes that: Audiologists are experts in the nonmedical management of the auditory and balance systems. They specialize in the study of normal and impaired hearing, prevention of hearing loss, identification and assessment of hearing and balance problems, and rehabilitation of persons with hearing and balance disorders. 3 General duties and responsibilities Audiologists test hearing and listening ability, fit hearing aids and assistive listening devices, provide training and rehabilitation programs for individuals with hearing and listening disorders and participate on health care and educational teams to plan and provide the most appropriate services. 4 They provide care to individuals of all ages, identifying those with the symptoms of hearing loss and other auditory, balance and related sensory or neural problems, and assess the nature and extent of the problems and help the individuals manage them. Using audiometers, computers and other mechanical testing devices, audiologists measure the volume at which a person begins to hear sounds, the ability to distinguish between sounds and the impact of hearing loss on an individual s daily life. They also evaluate balance disorders using assistive mechanical devices. 5 Brief history of the profession Formal interest in the study of human hearing was catalyzed in the 1920s by the creation of the audiometer, a device designed to measure hearing. The profession of audiology grew exponentially during the 1940s, as soldiers with hearing loss caused by loud noise or mental and emotional stress returned home from World War II. The Department of Veterans Affairs emerged as a leader in the identification, assessment and treatment of hearing problems. Since the 1940s and 1950s, the field of audiology and the hearing sciences has expanded to include new tests to measure and assess hearing, as well as new technologies, including hearing aids and cochlear implants. Today audiologists work in a variety of settings and with all populations Web. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook Edition. Retrieved May 30, Web. International Hearing Society. Introducing America s Hearing Healthcare Team. Retrieved October 8, Introducing_AHHT.cfm. The America s Hearing Healthcare Team initiative is sponsored by the International Hearing Society and the American Academy of Otolaryngology Head and Neck Surgery, and is endorsed by the American College of Surgeons, American Neurotology Society, American Otological Society, Cochlear Implant Association and Deafness Research Foundation. 3. Web. American Speech-Language-Hearing Association. Fact Sheet: Audiology. Retrieved May 30, Web. American Speech-Language-Hearing Association. The History of Audiology. Retrieved July 7, Web. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook Edition. Retrieved July 7, Id. Scope of Practice Data Series: Audiologists III. Audiology as a profession 7

8 Demographics Number of audiologists in the U.S. work force According to the BLS, audiologists held approximately 12,000 jobs in Employment types and locales Audiologists work throughout the United States in a variety of settings, including public and private schools, hospitals, physician offices, rehabilitation centers, residential health facilities, community clinics, private practice offices, health departments, state and federal government agencies, industry (with hearing conservation programs), long-term care facilities, colleges and universities, community hearing and speech centers and research laboratories. 8 The BLS notes that more than half of all audiology positions are in health care facilities hospitals, outpatient care centers and offices of physicians or other health care providers. About 13 percent of audiologist positions are in educational settings, including elementary and secondary schools. Audiologists may also be employed in health and personal care stores, including hearing aid stores, scientific research facilities and state and local governments. A small number of audiologists are self-employed in private practice. They provide hearing health care services in their own offices or work under contract for schools, health care facilities or other establishments. 9 Salary data According to the BLS, the median annual income of audiologists was $57,120 in May The middle 50 percent earned between $47,220 and $70,940. The lowest 10 percent earned less than $38,370, and the highest 10 percent earned more than $89, Results from a 2006 survey by ASHA indicate that the median salary range for an ASHA-certified audiologist in 2006 was $53,000 to $80,000. The median salary for clinical service providers ranged from $55,000 for those working in schools to $60,000 for those working in a hospital setting. Persons in supervisory positions (administration and management) may earn up to $25,000 more than those they supervise. While the 2006 median salary for ASHA-certified master s-level audiologists with one to three years experience was $52,000, the median salary for ASHA-certified PhD-level audiologists was about $90, The BLS forecasts that employment of audiologists will grow 10 percent from 2006 to 2016, about as fast as the average for all occupations Web. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook Edition. Retrieved July 7, Web. American Speech-Language-Hearing Association. Fact Sheet: Audiology. Retrieved May 30, Web. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook Edition. Retrieved July 7, Id. Scope of Practice Data Series: Audiologists III. Audiology as a profession 8

9 IV. Billing for services Medicare Medicare does not cover routine hearing exams or hearing aids, in which cases the beneficiary must pay 100 percent of the costs. Medicare Part B may pay for diagnostic hearing exams, in which cases the beneficiary is responsible for 20 percent of the Medicare-approved amount for services. 13 Medicaid State Medicaid agencies administer their own plans, but must meet federal guidelines set by the Centers for Medicare & Medicaid Services (CMS). As part of current Medicaid standards, states must offer medical assistance for certain basic services to those living under the poverty level. For adults over the age of 21, the states are not required to provide speech-language pathology or audiology services. For children and persons under the age of 21, Medicaid law requires the states to provide hearing screenings and assessment of communication skills and language development as part of the Early and Periodic Screening, Diagnostic and Treatment service. Based on the findings of this screening, the states must provide services and related devices, such as hearing aids, augmentative and alternative communication devices, to treat or ameliorate the condition. 14 The Medicaid program allows direct reimbursement to independent speech pathologists and audiologists rendering services in their offices, clinics or medical rehabilitation facilities, which in turn require states to allow direct reimbursement for coinsurance and deductible amounts associated with services for qualified Medicare beneficiaries, including those dually eligible for Medicaid. In many states, the service requires prior approval both for initiation of therapy and periodically thereafter. The State Medicaid speech, hearing and language disorders coverage for adults table (below) reflects only those instances where states have opted to allow speech pathologists and audiologists to bill directly for services rendered to Medicaid beneficiaries who are not also covered by Medicare. 15 The predominant reimbursement methodology used by states for these services is fee for service. This means the state has established a maximum payment amount for a particular service, or uses the maximum applicable to the Medicare program for the service and pays the lesser of the provider s charge or this amount. Often the payment is capped by an estimate of cost. Some states make payment using a percentage of charge to reflect cost, typically using some documentation of a provider s historical cost-to-charge ratio. 16 State Medicaid speech, language and hearing disorders coverage for adults 17 State Coverage Alabama Alaska Arizona Arkansas None Fee for service reimbursement at 85% of physician fee Prior approval required Coverage limited to Arizona Long Term Care System members Fee for service reimbursement None 13. Web. Medicare: The Official U.S. Government Site for People with Medicare Your Medicare Coverage. Retrieved August 18, Web. American Speech-Language-Hearing Association Medicaid. Retrieved August 18, Web. The Kaiser Commission on Medicaid and the Uninsured. Retrieved June 30, Id. 17. Web. The Kaiser Commission on Medicaid and the Uninsured. The Kaiser Commission gathered its information from Medicaid State Plans and State Plan amendments submitted to and approved by the Department of Health and Human Services Center for Medicare and Medicaid Services (CMS). Additional information was obtained from state web sites. From this information, state-specific summaries were prepared by Health Management Associates and sent to Medicaid officials in the respective jurisdictions for validation. Retrieved June 30, Scope of Practice Data Series: Audiologists IV. Billing for services 9

10 State California Colorado Connecticut Delaware Washington, D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Coverage $1 per visit copayment required Treatment plan required for approval Physician order and rehab potential required, 2 speech pathology visits per month (included in limits with other specified practitioners in any setting) Fee for service reimbursement Diagnostic audiology procedures limited to specified conditions Fee for service reimbursement None Fee for service reimbursement None Limited to services for provision of augmentative and assistive communication systems Fee for service reimbursement None Prior approval required Rehab potential required Fee for service reimbursement Limited to 1 audiological testing and evaluation per year Fee for service reimbursement Prior approval required for services other than to continue therapy provided in previous 30 days on inpatient basis Physician order required for specified services Fee for service or certified cost reimbursement Prior approval required for specified services, including therapy not following hospital discharge Limited to 1 audiological testing and evaluation every 3 years, 30 therapy sessions per month in combination with other therapy providers if ordered by physician prior to hospital discharge Fee for service reimbursement $2 per day copayment required Limited to audiological assessment for a hearing aid Fee for service reimbursement $3 per service copayment required Specified limits regarding audiological testing and evaluation Fee for service reimbursement $1 per visit copayment required Type A: 10 visits per year Types C and D: 30 visits per year; audiometric services not covered for adults Fee for service reimbursement Prior approval required Physician referral required for specified services Fee for service reimbursement Audiological evaluations preliminary to provision of hearing aids not covered Fee for service reimbursement None Fee for service reimbursement None Scope of Practice Data Series: Audiologists IV. Billing for services 10

11 State Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Coverage Prior approval required after initial 80 sessions Fee for service reimbursement None None $2 per visit audiology service copayment required Type A: Audiology services limited to evaluation necessary for provision of hearing aid Type B: Limited to audiological evaluation necessary for provision of a hearing aid essential for employment Fee for service reimbursement $2 or $3 copayment required per visit ($3 per visit copayment if the services are rendered in an outpatient hospital setting) Rehab potential required Fee for service reimbursement Rehab potential required, audiological testing and evaluation requires physician order Fee for service reimbursement Augmentative communication devices not covered Fee for service reimbursement None Type A: $5 per visit copayment required Type B: $7 per visit copayment required Prior approval required Audiological testing and evaluation require physician order Fee for service reimbursement Fee for service reimbursement None $2 per audiological evaluation Fee for service reimbursement Fee for service reimbursement None $3 per visit copayment required Prior approval required Fee for service reimbursement None None None Fee for service reimbursement for frequently performed services, 40% of charge up to Medicare limits for low volume procedures Benefits are covered None Type A: Prior approval required Type C: 1 audiological evaluation for hearing aid per year Fee for service reimbursement None Scope of Practice Data Series: Audiologists IV. Billing for services 11

12 State Virginia Washington West Virginia Wisconsin Wyoming Coverage $1 per visit copayment required (limited to audiology services) Fee for service reimbursement Prior approval required Limited to 12 visits per year Fee for service reimbursement Prior approval required Limited to 20 visits per year in combination with other therapies Fee for service reimbursement $1 copayment required per audiological testing service, depending on payment, up to 30 hours or $1,500 per year across all therapies Prior approval required Fee for service reimbursement Fee for service reimbursement Scope of Practice Data Series: Audiologists IV. Billing for services 12

13 V. Education and training of audiologists Introduction The practice of audiology is regulated in all 50 states, all of which require at least a master s degree for practicing audiologists. 18 Audiologists have traditionally been trained at the master s degree level, with a small percentage going on to acquire doctoral degrees for academic or research careers. However, as of 2008 at least eight states will require a doctoral degree or its equivalent in order to obtain licensure as an audiologist. The change from master s-level to doctoral-level preparation is the end result of audiologists desire for professional advancement and the quest to transform audiology into a doctoring profession. 19 Audiologist organizations support the Doctor of Audiology (AuD) degree, a clinical doctorate (a professional degree not geared toward advanced academic or research study), not only as the minimum entry-level qualification for newly graduated audiologists, but also as the degree currently practicing audiologists should obtain. In order to make a doctoral-level degree as accessible as possible to all currently licensed audiologists, the professional and educational organizations in audiology have created a unique system to allow potential AuD students to earn advanced standing in doctoral programs based on factors such as employment history and continuing education. As discussed later in this section, as existing campusbased audiology programs convert their master s-level content to AuD content, practicing audiologists are concurrently obtaining their clinical doctorates from online programs, supplementing their advanced standing with, in some cases, minimal coursework. Beginning in 2012 the American Speech-Language Hearing Association (ASHA) will require all candidates for ASHA certification to obtain a doctoral degree. 20 Accrediting bodies in audiology Two organizations currently accredit programs leading to professional degrees in audiology. The ASHA Council on Academic Accreditation in Audiology and Speech- Language Pathology (CAA) is the only accrediting body for audiology recognized by the U.S. Department of Education (USDE), and has been continuously recognized by the USDE since The CAA is also recognized by the Council for Higher Education Accreditation (CHEA), a non-governmental organization dedicated to academic quality. 21 A second organization, the Accreditation Commission of Audiology Education (ACAE), accredits only two institutions which award the AuD degree, and is not recognized by either the USDE or CHEA. Much of the information contained in this module pertains only to CAA-accredited programs and/or graduates. Requirements for audiology program accreditation Council on Academic Accreditation in Audiology and Speech Language Pathology The stated purpose of the CAA is to: Formulate standards for the accreditation of graduate education programs that provide entrylevel professional preparation in audiology and/ or speech-language pathology. Evaluate programs that voluntarily apply for accreditation. Grant certificates and recognize those programs deemed to have fulfilled requirements for accreditation. Maintain a registry of holders of such certificates. Prepare and furnish to appropriate persons and agencies lists of accredited programs. 18. Web. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook Edition. Retrieved July 7, Verified with ASHA data October 28, See also American Speech-Language-Hearing Association - State Licensure Trends. Retrieved August 18, Web. Audiology Foundation of American Audiology: A Doctoring Profession. Retrieved August 18, Web. American Speech-Language-Hearing Association The ASHA Leader Online. Retrieved July 7, archives/2007/070529/070529c.htm. 21. Web. American Speech-Language-Hearing Association Council on Academic Accreditation in Audiology and Speech-Language Pathology. Retrieved July 9, Scope of Practice Data Series: Audiologists V. Education and training of audiologists 13

14 The CAA was established by ASHA and is authorized to function autonomously in setting and implementing standards as well as awarding accreditation. The CAA requires its accredited programs to adhere to standards in six discrete areas: (1) administrative structure and governance; (2) faculty; (3) curriculum (academic and clinical education); (4) students; (5) assessment; and (6) program resources. 23 The CAA accreditation standards related to the academic and clinical curriculum of audiology programs require that: The curriculum is consistent with the mission and goals of the program and prepares students in the full breadth and depth of the scope of practice in audiology. Academic and clinical education reflects current knowledge, skills, technology and scope of practice. The curriculum is regularly reviewed and updated, and the diversity of society is reflected throughout the curriculum. The scientific and research foundations of the profession are evident in the curriculum. The academic and clinical curricula reflect an appropriate sequence of learning experiences. Clinical supervision is commensurate with the clinical knowledge and skills of each student, and clinical procedures ensure that the welfare of each person served by students is protected, in accordance with recognized standards of ethical practice and relevant federal and state regulations. Clinical education obtained in external placements is governed by agreements between the program and the external facility and is monitored by program faculty. The clinical education component of the curriculum provides students with access to a client/patient base that is sufficient to achieve the program s stated mission and goals and includes a variety of clinical settings, client/patient populations and age groups. The program must provide evidence that all curriculum standards are met, regardless of mode of delivery. 24 In support of ASHA s requirement that candidates for certification earn a doctoral degree by 2012, in 2004 the CAA declared that for the period of it would continue to accredit graduate programs in audiology that offered a minimum of 75 semester credit hours of education pertinent to the field of audiology and that culminated in either a master s or doctoral degree. 25 In other words, all CAA-accredited audiology programs would need to meet the academic and clinical credit hour requirements of a doctoral program according to CAA standards although the degree granted might still be the master s. 26 In response, the USDE, as well as other professional organizations, raised serious questions regarding the appropriateness of the CAA s transitional accrediting process. 27 The sentiment was that the application of doctoral-level accreditation standards to programs that grant master s degrees was inappropriate. 28 The CAA subsequently rescinded its transitional accreditation plan and ceased accrediting master s degree programs as of Dec. 31, Master s degree programs accredited as of January 2007 will remain accredited until the end of their regular accreditation cycle period, essentially eliminating a master s degree as a terminal degree. Accreditation Commission for Audiology Education The ACAE is an independent, nonprofit organization formally established in 2003 by representative members of the American Academy of Audiology (AAA) and the Academy of Doctors of Audiology (ADA), formerly known as the Academy of Dispensing Audiologists. 23. Web. American Speech-Language-Hearing Association 2007 Audiology Standards. Retrieved July 9, accredmanual/section3.htm. 24. Id. 25. Web. American Speech-Language-Hearing Association Revised Eligibility Policy for Accreditation of Audiology Programs. Retrieved July 9, Id. 27. Id. 28. Id. 29. Id. Scope of Practice Data Series: Audiologists V. Education and training of audiologists 14

15 According to the ACAE, the purpose of accreditation is to recognize, reinforce and promote high-quality performance in AuD educational programs through a rigorous verification process to produce evidence that AuD programs have prepared graduates who are qualified to be doctoral-level audiologists. 30 The ACAE is recognized by neither the USDE nor CHEA. Without USDE recognition, students at ACAEaccredited schools or programs are unable to receive federal financial aid. The ACAE standards require AuD programs to use a system of competency-based assessments (outcome measures) to quantify a student s proficiency in stated areas related to evaluation, diagnosis, treatment and management within the audiologist s scope of practice. The standards are divided into five segments: general standards for AuD programs; administrative structure; planning and evaluation; specific curricular standards; and faculty. 31 The ACAE s curricular standards include multiple methods of instruction and evaluation; required knowledge and competencies (foundation, diagnosis and management, communication, professional responsibility and values); clinical environments and populations; externship; and student research and scholarly activity. 32 According to the ACAE website, as of August 2008 only two AuD programs hold ACAE accreditation: Central Michigan University and the Washington University School of Medicine Program in Audiology. 33 Both of these schools also maintain their CAA accreditation. 34 Tensions between accrediting bodies Beginning in 2004 the Council of Academic Programs in Communication Sciences and Disorders (CAPCSD), an independent coalition of academic leaders in audiology and the communication sciences, 35 hosted a series of meetings on the topic of program accreditation. In 2006 the ACAE and the CAA jointly developed a white paper entitled Framework for Development of a Single Accrediting Body for Audiology, which outlined the issues to be addressed before the profession could advance toward having a single accrediting body for the education of audiologists. 36 However, the two groups disagreed on the mechanics of designing the most appropriate accrediting organization and procedures. Not surprisingly, the CAA expressed its belief that, in the best interest of both graduate education programs and students, the CAA should remain the single accreditor for clinical doctorate programs in audiology. 37 While the ACAE noted conditional support for the CAA as the single accrediting body, it also voiced its concerns over necessary modifications to the structure of the new CAA, the relationship between the new CAA and professional organizations in audiology, a merger of CAA and ACAE accreditation processes and standards, and the relationship between accreditation and certification. 38 Despite these responses, or perhaps because of them, in August 2007 the CAPCSD executive board issued a resolution that it would no longer actively encourage further collaboration between the CAA and the ACAE. 39 The CAPCSD stated that it would only support the activities of the CAA Web. Accreditation Commission for Audiology Education - About ACAE. Retrieved July 10, Web. Accreditation Commission for Audiology Education Accreditation Standards for the Doctor of Audiology Program. Retrieved July 10, Id. 33. Web. Accreditation Commission for Audiology Education For Academic Programs. Retrieved August 21, Confirmed by phone calls to both schools. October 8, See CAPCSD website for more information Web. Council of Academic Programs in Communication Sciences and Disorders. CAPCSD Response to White Paper August Retrieved July 17, Web. CAA Response to White Paper. Retrieved September 3, Web. Council of Academic Programs in Communication Sciences and Disorders. Accreditation Commission for Audiology Education: Framework for Development of a Single Accrediting Body for Audiology (August, 2007). Retrieved September 3, paper_ pdf. 39. Web. Council of Academic Programs in Communication Sciences and Disorders. CAPCSD Response to White Paper August Retrieved July 17, Id. Scope of Practice Data Series: Audiologists V. Education and training of audiologists 15

16 Master s degree programs A master s degree in audiology, no longer offered as a viable course of professional study, generally required two years of graduate study in audiology, followed by a 36-week clinical fellowship. The vast majority of licensed, practicing audiologists obtained a master s degree as their first professional degree. The master s curriculum included a variety of courses in the sciences, counseling, mathematics and audiology. Students also participated in several practicum learning experiences, culminating in the postgraduate clinical fellowship. 41 As discussed earlier in this module, the master s degree in audiology is being phased out in favor of the AuD degree. 42 Though the formal mandate for the AuD requirement does not go into effect until 2012, most existing audiology programs are no longer enrolling new master s degree students. Didactic curriculum of the master s degree The didactic program of the master s degree was typically front-loaded, meaning that students took their classroom courses before beginning clinical rotations. While programs varied in their curricula, every accredited program had to meet the CAA minimum requirements for accreditation. Under the 1999 CAA standards, master s-level programs in audiology needed to include a minimum of 36 graduate semester credit hours. At least 30 of the 36 semester credit hours of professional coursework had to be in audiology, including at least six hours in hearing disorders and hearing evaluation; at least six hours in habilitative and rehabilitative procedures with individuals who have hearing impairment; and at least six hours in speech-language pathology. 43 Survey of master s degree curricula 44 The curricula at several audiology programs were compiled to demonstrate the range of credit hours a master s student may have received in any given subject area throughout the program. The presence of a 0 in the Credit hours required column indicates that at least one school did not provide a course in that subject area. 45 Course Credit hours required Research methods/mathematics 0 3 Research methods and design 0 3 Research seminar 0 3 Audiology-specific courses Speech and hearing science 0 3 Amplification 0 6 Language disorders in children 0 3 Language development of deaf/ 0 3 hearing-impaired individuals Advanced aural rehabilitation 0 3 Advanced clinical audiology 0 6 methods and procedures Psychoacoustics and 3 9 instrumentation Differential diagnosis of 6 7 auditory disorders Pediatric audiology 0 6 Auditory pathologies 0 3 Advanced hearing aids and 0 3 instrumentation Audiological assessment 0 16 Sound and vibration 0 3 Aging and audiology 0 3 Developmental speech 0 3 perception 41. Web. Wichita State University Master of Arts Program in Audiology. Retrieved October 26, Web. Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook Edition. Retrieved October 25 and 26, Web. American Speech Language-Hearing Association - Comparison of 1999 (Current) and 2008 Standards for Accreditation of Graduate Education Programs in Audiology and Speech-Language Pathology. Retrieved July 18, BCB/0/AccreditationStdsComparison0307.pdf. 44. Web. Adelphi University. Search term audiology. Hofstra University. Search term audiology. University of Pittsburgh Communication Sciences and Disorders. All retrieved October 25-28, As of July 2008, these programs no longer offered Master s degrees, and therefore the curriculum is no longer available to be viewed on these websites. 45. Note, however, that is does not necessarily indicate that the student did not receive instruction in that particular subject area. Some schools may not organize their curriculum by discrete subject topic, may embrace non-descriptive course titles, or for other possible reasons. 46. Some schools include some of these audiology-specific courses in their electives. Scope of Practice Data Series: Audiologists V. Education and training of audiologists 16

17 Survey of master s degree curricula (continued) Course Topics in audiology 0 6 Clinical procedures laboratory 0 6 Management of hearing 0 3 problems Practice management 0 2 Clinical management 0 2 Electives 0 6 Credit hours required Clinical curriculum of the master s degree All master s programs required their students to participate in clinical experiences while in school. While programs varied in their clinical experience requirements, every accredited program had to meet the CAA minimum requirements for accreditation. Under the 1999 CAA standards, the graduate-level clinical curriculum required a minimum of 250 clock hours of supervised clinical practicum in audiology, including at least: 40 clock hours in the area of evaluation of hearing in children 40 clock hours in the evaluation of hearing in adults 80 clock hours in the selection and use of amplification and assistive devices (including a minimum of 10 hours related to children and a minimum of 10 hours related to adults) 20 clock hours in the treatment of hearing disorders in children and adults 20 clock hours in speech-language pathology 47 Master s postgraduate clinical fellowship Under the 1993 ASHA standards, all applicants for the Certificate of Clinical Competence in Audiology (CCC-A), the audiologist s professional certification, were required to successfully complete a postgraduate clinical fellowship following formal master s degree (or doctoral) schooling, as well as pass the national Praxis Examination in Audiology. 48 The postgraduate clinical fellowships typically consisted of 36 weeks of full-time (at least 30 hours per week, of which 24 hours had to be in direct patient contact) audiology clinical training. 49 Under the 2007 ASHA CCC-A standards, however, there is no longer a requirement for a postgraduate clinical fellowship. 50 The 2007 standards were based in part on results from a study indicating that the skills necessary for audiologist practice were to be gained while the individual was enrolled in a graduate program. 51 The 2007 standards increased the number of clinical practicum hours required during the AuD program from 250 hours of clinical experience during formal schooling plus 36 weeks of post-graduate fellowship (previously required for ASHA certification) 52 to 52 weeks of clinical practicum training (at least 35 hours per week, which can be satisfied through direct patient/client contact, consultation, record keeping or administrative duties relevant to audiology service delivery). According to the CAA, the increase in clinical practicum hours made the postgraduate clinical fellowship unnecessary. 53 The new standards do not specify a particular number of hours for patient- or condition-specific rotations. Individual programs may therefore determine the number of hours that their students will spend in each setting and/or clinical rotation. 47. Web. American Speech Language-Hearing Association - Comparison of 1999 (Current) and 2008 Standards for Accreditation of Graduate Education Programs in Audiology and Speech-Language Pathology. Retrieved July 18, BCB/0/AccreditationStdsComparison0307.pdf. Note that these clock hour requirements do not total Web. American Speech Language-Hearing Association Membership and Certification Handbook. Retrieved July 18, membership-certification/handbooks/aud/aud_clinical_fellowship.htm. 49. Id. 50. Web. ASHA. Frequently Asked Questions About the 2007/2012 Standards in Audiology. Retrieved July 21, membership-certification/2007audfaq.htm. 51. Id. 52. Id. 53. Id. Scope of Practice Data Series: Audiologists V. Education and training of audiologists 17

18 While some states have no postdoctoral training, supervision or practicum requirements prior to obtaining licensure, others may require audiologists to have up to nine months of postgraduate professional clinical experience. All but three states (Colorado, Maine and Virginia) currently require clinical fellowship training for audiologist licensure. It is likely the profession will seek to amend the licensing laws to conform to the new CAA clinical practicum standards. The Doctor of Audiology degree Background The AuD is intended to supplant the master s degree as the professional entry-level degree for audiologists. According to ASHA, clinical doctorate (AuD) programs are designed to prepare graduates for clinical practice. 54 PhD programs in audiology and/or related scientific disciplines also remain an option for students, though the PhD places greater emphasis on academics and research than clinical practice. 55 The clinical doctorate represents an educational terminus that, in the eyes of its recipients, demonstrates parity between emerging doctoral professions, such as audiology, and other health care professions whose doctoral-level education is well established, such as optometry (OD) or dentistry (DDS/DMD). 56 Professional audiologist organizations have suggested that the public, specifically patients, would benefit from the quality of care resulting from the additional knowledge imparted by the AuD programs. 57 AuD graduates would additionally be able to adopt the title Doctor, and audiologists who held the AuD degree would enjoy the recognition, acceptance, prestige and economic rewards associated with a doctoring profession. 58 However, one critic of clinical doctorate programs noted that such motivation suggests that the degree, rather than the profession commands respect and recognition. 59 The extent to which the audiology clinical doctorate inspires confidence in the contents of its curriculum is discussed in detail in the sections below. In 1988 the ADA initiated an organized effort to make the AuD the minimum standard for entry-level audiology practice. 60 The ADA created a model AuD curriculum, set prerequisites and called for the creation of an organization to spearhead the extensive efforts to establish, gain popular acceptance of and seek accreditation of programs leading to the AuD degree. The Audiology Foundation of America (AFA) was formed in 1989 to accomplish these tasks. 61 In 1995 the AFA convened leaders in audiology education to formulate standards for the AuD degree. 62 The issue of equivalency that is, awarding a practicing audiologist advanced credit or academic standing toward an AuD degree in an amount equivalent to their professional work experience emerged as an important issue. Only about 60 percent of those polled at the conference believed that credit for existing knowledge and skills was an acceptable mechanism to transition an audiologist to the clinical doctoral level Web. American Speech-Language-Hearing Association (ASHA) Strategies for Entry into Graduate Schools in Communications Sciences and Disorders. Retrieved August 22, Id. 56. Web. Audiology Foundation of America. Career Brochure: Audiology A Doctoring Profession. Retrieved July 17, Profession.pdf. 56. Id. 57. Web. Audiology Foundation of America. Career Brochure: Audiology A Doctoring Profession. Retrieved July 17, AuDProfession.pdf. 58. Web. Review A Clinical Look at Clinical Doctorates. The Chronicle. Retrieved July 17, Web. Academy of Doctors of Audiology. About AuD. Retrieved July 7, Web. Audiology Foundation of America. Supreme Court Decision Sets Stage for Audiology Private Practice (Originally Published in Feedback 2006). Retrieved July 7, Id. 62. Id. 63. Id. Scope of Practice Data Series: Audiologists V. Education and training of audiologists 18

19 Nonetheless, nearly a dozen audiology organizations ultimately cosponsored the decision to form distance education programs to facilitate master s-level audiologists earning an AuD degree during a transition phase. 64 ASHA s support and endorsement of the distance education program was noticeably absent; furthermore, the AFA again met opposition from within the profession regarding the idea of granting educational credit for standard professional experience. 65 During this time there was also overwhelming support for the creation of a new independent educational accrediting agency. 66 The ACAE was founded in 2002 as a competitor to ASHA s CAA. 67 Doctor of Audiology degree programs As mentioned previously, the primary focus of AuD programs is to produce audiology practitioners. By contrast, a PhD in audiology is traditionally considered an academic or research-oriented degree, meant to provide the basic scientific and statistical foundation necessary for scholarship and independent research associated with the science of audiology. A nontransitional AuD degree generally requires four years of graduate study. Some existing AuD programs require only three years of graduate study, a source of much contention and debate in the audiology community. 68 The then-president of the AAA touched on program length at the 2004 AAA convention, saying, there is growing concern about a handful of academic programs that appear to be repackaging their master s curriculum with a clinical fellowship year and calling it an AuD program. 69 Though the AuD degree has now become the educational standard for audiologists, critics continue to question the profession s regulation of AuD educational quality. James Jerger, PhD, who oversaw the first AuD degree program at Baylor College and was the founder and first president of the AFA, has expressed disappointment over how the AuD movement has unfolded. Dr. Jerger has indicated that he expected a smaller number of schools to offer the AuD in the hopes that this would provide for richer curricula and more experienced faculty. He has found instead that nearly every school that had a master s program closed it up, renamed it and jumped on the AuD bandwagon. 70 Some do not see this as a long-term problem, claiming that market pressures will eventually force the poorer-quality programs to shut down. Jerger is not convinced, stating, It s not a free market in university programs. If there s any competition at all, it s for the students, and as long as you re willing to accept students of marginal quality, there s an unlimited supply of them. 71 Other critics have focused on the rigor of CAA AuD program standards. One of those critics is Angela Loavenbruck, EdD, a former AAA president, an early advocate of the AuD and chair of the ACAE. Dr. Loavenbruck has stated, What the CAA has done in requiring only 75 credit hours is to make it easy for academic doctoral programs, PhD programs, to meet accreditation standards. [T]hey ve made it possible for many of the master s degree programs that the CAA now accredits, with virtually no change in their curriculum or requirements or faculty or facility, to simply change into an AuD program by incorporating the one year of clinical practice at the end of their master s degree program and call themselves doctoral programs Id. 65. Id. 66. Id. 67. Id. 68. Web. Northwestern University School of Communication. Frequently asked questions. Retrieved July 17, programs/doctor_audiology. 69. AuD Movement: The Tide is Turning. Advance for Audiologists. Vol. 6, Issue 5, p. 27. Retrieved August 25, search/aviewer.aspx?an=aa_04sep1_aap27.html&ad= (referencing: Audiology Today An Independent Audiology, May/June 2004, p. 7). 70. Web. AuD is transforming audiology, but growing pains persist. The Hearing Journal. Vol. 58 No. 5 (May 2005). Retrieved September 19, Id. 72. Id. Scope of Practice Data Series: Audiologists V. Education and training of audiologists 19

20 Didactic curriculum of AuD programs Doctoral-level coursework in AuD programs focuses most heavily on audiology-specific coursework, including acoustics, calibration, instrumentation, screenings, pediatric hearing and language considerations, hearing aids, auditory pathology, balance and rehabilitation. 73 Standards for AuD programs, developed by the CAA in 2008, require a curriculum that allows students to achieve knowledge and skills in the following relevant areas: Foundations of audiology practice Prevention and identification Evaluation Treatment 74 It is notable that while the standards require that the program must provide sufficient didactic coursework, most commonly over four years, there is no stated minimum of calendar time, semester credit hours or academic terms required to meet this standard. 75 The lack of specificity in CAA standards for AuD programs is seemingly mirrored in the 2007 revisions to ASHA requirements for the Certificate of Clinical Competence in Audiology (CCC-A) certification. Specific coursework requirements for certification, 76 present in the 1993 standards, were removed in 2007 to allow individual programs to assess whether or not certain courses would provide the appropriate and adequate prerequisite skills and knowledge. The new standards, therefore, emphasize the acquisition of knowledge and skills, not completion of specific coursework or hours in a classroom. 78 Survey of AuD degree curricula 79 Course Biological sciences 0 9 Anatomy and physiology of 0 3 hearing mechanisms Neuroscience 0 3 Microbiology and pharmacology 0 3 for audiology Research methods/mathematics 3 15 Research methods and design 0 3 Clinical research 0 12 Calculus for the biological 0 4 sciences (or calculus) Statistics 0 4 Audiology-specific courses Acoustics, calibration and 3 6 instrumentation Measurement of hearing/ 2 3 Screenings Auditory and clinical 0 7 electrophysiology and assessment Amplification 0 9 Pediatric amplification/audiology 2 4 Hearing science and 0 4 speech perception Hearing aids and repair 0 10 Pathology of the auditory system 0 3 Hearing loss and speech 0 6 understanding Credit hours required 73. AuD Movement: The Tide is Turning. Advance for Audiologists. Vol. 6, Issue 5, p. 27. Retrieved August 25, search/aviewer.aspx?an=aa_04sep1_aap27.html&ad= (referencing: An Independent Audiology, Audiology Today May/June 2004, p.7). 74. Web. American Speech-Hearing-Language Association - Comparison of 1999 (Current) and 2008 Standards for Accreditation of Graduate Education Programs in Audiology and Speech-Language Pathology. Retrieved August 25, D0A4916BCB/0/AccreditationStdsComparison0307.pdf. 75. Id. 76. Under the 1993 ASHA standards for CCC-A certification, at least 27 of the 75 required credit hours must have been in basic sciences; at least 36 of the 75 credit hours must have been in professional course work, with the remaining 12 hours to be distributed between the two areas. Basic science course work required at least six credit hours in the biological/physical sciences and mathematics; at least six credit hours in the behavioral and/or social sciences; and at least 15 credit hours in the basic human communication processes, to include coursework in each of the following three areas of speech, language, and hearing: the anatomic and physiologic bases, the physical and psychophysical bases, the linguistic and psycholinguistic aspects. The professional course work required at least 30 of the 36 semester credit hours be completed in audiology, with at least six of the 30 credit hours in hearing disorders and hearing evaluation and at least six in habilitative/rehabilitative procedures with individuals who have hearing impairment. It also required at least six of the 36 semester credit hours be completed in speech-language pathology, with at least three of the six in speech disorders and at least six in language disorders. 77. Id. 78. Web. American Speech-Language-Hearing Association Frequently Asked Questions About the 2007/2012 Standards in Audiology. Retrieved August 26, The three top-ranked AuD programs as noted by U.S. News and World Report (2008): Vanderbilt University (#1) php?site=dhss_graduate_studies&doc=4471; University of Washington (#2) University of Iowa (#3) Retrieved July 11, Some schools include some of these audiology-specific courses in their electives. Scope of Practice Data Series: Audiologists V. Education and training of audiologists 20

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