How Has Education in Audiology Evolved?

Audiology’s professional roots date back to days following World War II, when veterans experienced blast trauma, noise-induced hearing loss, and other challenges. This new profession shared common threads with professions of otolaryngology, psychology, rehabilitation, speech-language pathology, and others. Audiology has evolved to the status enjoyed today, where audiologists play an instrumental role in prevention, assessment, and management of hearing loss. Audiologists treat patients across the entire lifespan, from newborn through geriatric populations. This age span is widening, as the infant mortality rate diminishes and as the country experiences the “graying of America,” with Baby Boomers beginning to experience deficits in hearing acuity.

The scope of practice is ever expanding, including comprehensive diagnostic evaluation, evaluation of auditory processing disorders, tinnitus assessment and treatment, misophonia and hyperacusis assessment and treatment, hearing aid and cochlear implant evaluation and fitting, vestibular function testing, aural (re)habilitation, electrophysiologic assessment, intraoperative monitoring, hearing assistive technology, and much more. Educational requirements for audiology practice have also developed greatly, in line with professional growth. The Academy of Dispensing Audiologists promoted the concept of a clinical doctorate as the entry-level degree for audiology in 1988. The American Academy of Audiology (AAA) released a position paper in 1991 that supported the Doctor of Audiology (Au.D.) degree, along with a recommended framework for academic and clinical study. In 1992, the American Speech-Language-Hearing Association (ASHA) supported the Au.D. degree as the entry level degree for practice. Affiliated accreditation bodies engaged in much discussion and modified standards to which academic programs must adhere. Professional organizations mandated that the entry level for practice in 2007 was the Au.D. degree. ASHA mandated that audiologists seeking the Certificate of Clinical Competence (CCC) after January 1, 2007 must hold the Au.D. In similar fashion, the American Board of Audiology’s (ABA) Certification, affiliated with the AAA, required a clinical doctoral degree as a prerequisite for application. Prior to that time, a master’s degree was required, with graduates completing a clinical fellowship year under supervision, following graduation and prior to licensure and permanent employment.

What Is Currently Involved in Au.D. Education?

The Au.D. is considered to be a clinically oriented doctoral degree and there are ∼75 Au.D. programs in the United States. Some foreign countries have progressed to an Au.D. degree requirement to practice while most employ a bachelor’s or master’s degree model. There is a great variability among programs here in the United States and efforts have been initiated toward greater standardization, as well as overall assessment of the current model. While undergraduate students may apply to an Au.D. program from myriad backgrounds, most have an undergraduate foundation in the Speech and Hearing Sciences (SHS). Many undergraduate programs offer such majors or minors in SHS or Communication Sciences and Disorders, with graduates then seeking additional graduate education in speech-language pathology, audiology, or a similar field. While optimum undergraduate education for entering the audiology profession is still being considered, many agree that a heavy foundation in math and the sciences is beneficial. Some students who originally seek a premedicine major learn about related health professions such as audiology, occupational therapy, physical therapy, and others. These students may seek a career path that is an alternative to a career path in medicine.

Au.D. programs engage in a rigid admissions process that involves submission of materials such as personal statement, graduate record examination scores, official undergraduate transcripts, personal interview, and letters of recommendation. Many programs are highly competitive, with average class sizes of 8 to 12 students. Numbers are kept small, in view of one-on-one mentorship with clinical practicum supervisors (preceptors) and research mentors. Most Au.D. programs are 4 years in length, although some may require students without a background in SHS to take prerequisite courses that could lengthen the program. Conversely, there are 3-year programs in existence and there are also consortium models, whereby several universities in one state may combine resources toward implementation of a program.

Early in their curricula, most programs incorporate scientific foundational courses such as anatomy and physiology, neuroscience, psychoacoustics, hearing and vestibular disorders, and others. Courses reflecting scientific underpinnings are complemented by clinically oriented courses, such as clinical audiology, a hearing device sequence, an electrophysiology sequence, vestibular assessment, aural rehabilitation, hearing conservation, and others. Laboratory-based, hands-on experiences are critical components of such courses, so that the student may apply concepts learned in the classroom and also “bridge” between the classroom and the clinical settings. Statistics and research methods courses are also crucial, so that students may learn consumerism of the literature and skills necessary to study the evidence and apply those principles to daily practice.

A very important component of an Au.D. curriculum is the clinical practicum component, whereby students actually see patients under supervision so that they may apply knowledge learned and skills gained in real-life settings. Au.D. programs vary with regard to when students begin experiencing their clinical placements, with the fourth year (or final year, in the event of a 3-year program) typically considered the full-time clinical externship year. Practicum sites are varied, just as job settings of an audiologist are varied. Audiologists may complete practicum or work in such settings as clinics, hospitals, universities, research laboratories, manufacturing, private practices, not-for-profit organizations, school districts, schools for children who are deaf or hard-of-hearing, and countless other types of facilities. Practicum sites affiliated with an Au.D. program may vary in scope and number, depending upon factors such as the university’s geographic location and whether the program is located in a rural versus urban area. Students often obtain clinical practicum experience within the program-housed clinics prior to being placed off-campus or at a site in another city. Appropriate supervision is crucial and is provided in graduated steps, as the student gains more experience and becomes more independent. It is important to ensure quality of sites and supervisors (preceptors) and to coordinate clinical practicum experiences with coursework that the student has completed.

The fourth year externship characteristics also may vary among programs, although many students embark upon the externship after completing coursework, earlier practicum rotations, and any research project that may be required. An externship search and application process is initiated during the fall of the third year of study (sooner if there is a 3-year program), followed by interviewing and making/accepting of offers. The timeline for this process across the country and across sites is highly variable, although AAA has published a recommended timeline for programs, students, sites, and supervisors (preceptors) to follow. Some externs may prefer to stay in the city that houses their program, whereas others may choose to extern at a varied array of sites across the country. The spirit of the externship is toward a depth and breadth of clinical experiences. Just as audiologists may specialize, externs may choose to begin making inroads toward specialization via the externship and example areas may include pediatrics, hearing aids, cochlear implants, adult settings (such as with the veterans administration), and others. Employment options are plentiful, once the student graduates upon completion of the externship and fulfillment of all other graduation requirements. Some students are offered employment, following externing at a particular site. The mentored externship search serves as an admirable “trial run” for the eventual job search. In addition to the variable timeline inherent within the search process, other challenges may include variability in stipend awarded to the student; some sites are able to pay while other sites do not pay. The extern is still a student, as opposed to an employee, and unable to bill for services or collect revenue.

What Is Accreditation and Why Is It Important?

Most professions are in a position to seek accreditation for their educational programs. Benefits are to protect consumers, ensure programs are meeting specified standards, promote standardization among programs, and strive toward the highest quality of education for students. The Council of Academic Accreditation (CAA) is a body affiliated with ASHA that accredits programs in audiology and also in speech-language pathology. Standards are developed by a body of experts, are peer-reviewed prior to adoption, and are revised regularly so that they remain current.

The current CAA Accreditation Standards for Audiology may be viewed at http://www.asha.org.easyaccess1.lib.cuhk.edu.hk. A new set of Standards has been approved and will go into effect in August 2017. The CAA Standards comprise six major components, with the first requiring information about administrative structure and governance. This area requires the program to document such important areas as mission statement, strategic plan, nondiscriminatory policies, program director qualifications, and others. The second section, focusing on faculty, specifies such important areas as faculty qualifications, student-faculty ratios, whether faculty members are remaining current, and whether there is a diverse faculty. All standard sections require supporting examples and documentation, such as copies of handbooks, policies, faculty curriculum vitae, curricula and others. The third section requires a program to outline its curriculum, ensuring that there is a depth and breadth of experiences that thoroughly cover the scope of practice. Required course content areas are specified, as are areas of skills and knowledge that the student must demonstrate, through integration of didactic coursework with clinical practicum experiences. There are requirements for the scientific underpinnings of clinical practice, as well as the research base such that graduates are skilled at critically analyzing the literature and applying concepts to daily practice. The fourth area targets the student body, ensuring that admissions processes are rigorous, that the recruited student body is diverse, that students with alternate learning styles receive proper accommodations, and that proper mechanisms are in place for student advising and mentoring. The fifth area requires a program to have assessment tools in place relative to all facets of education. For example, the program may describe formative and summative assessment methods related to such areas as course evaluations, practicum supervisor evaluations of student practicum performance, alumni and employer surveys, and faculty surveys related to major program areas. The sixth and final area relates to resources, ensuring financial support, that facilities are conducive to learning, that there is appropriate support staff, and that the program is positioned to flourish and develop further.

The CAA requires a program to submit an accreditation or reaccreditation report, according to a chosen cycle that is typically 5 to 8 years in length. A site visit team is formed that conducts an in-person site visit of the program, typically lasting 2 to 3 days. An annual report is submitted by the program during years when reaccreditation does not take place, with continual oversight by the accrediting body.

The Accreditation Commission for Audiology Education (ACAE) is a second accrediting body that is in existence, having developed approximately 12 years ago. It was developed of, by, and for the profession of audiology and may be accessed at http://www.acaeaccred.org. This organization is affiliated with AAA. There are currently five major areas of Standards, including a general category as the first, whereby programs must describe governance and policies that are in place. The second area involves administrative structure, whereby programs state goals and how they accomplish goals or outcomes in a measurable way. Programs describe finances and facilities, resources, and recruitment/retention of a high-quality and diverse student body. The third area relates to planning and evaluation, where programs must perform self-study and planning, along with assessment that serves to improve various aspects of the program. The fourth area specifies actual curricular standards, requiring that students learn via multiple modes of instruction. Specific knowledge and competency areas are divided into four subcategories that include foundational, diagnosis and management, communication, and professional responsibility/values. This section helps determine if programs are meeting standard requirements for optimal clinical environments, the externship experiences, and projects to foster development of the research foundation. The fifth section relates to faculty and ensuring quality, numbers, experiences, and expertise. ACAE Standards have also recently been revised via an expert panel and a peer-review process; they are currently undergoing the adoption process. In a fashion similar to the CAA protocols, ACAE-accredited programs enter data yearly into a web-based platform, undergoing initial accreditation and reaccreditation via self-study, virtual site visit, and face-to-face site visit.