Counterpoint To Recent Objections To The SLP Revised Scope Of Practice

Over the past few weeks I have read a number of opinions regarding ASHA's recent call for peer review of the Revised Scope of Practice in Speech-Language Pathology.

After reading statements and opinions and from organizations representing our profession (Glaser & McDonald, Oct 9, 2000) and from individuals (Simon, October 4, 2000) I am more concerned about the projected image of our profession, than I am by anything in ASHA's scope of practice revision.

One of the first things that struck me (after obtaining a copy of the ASHA revision statement myself) was that the Glaser & McDonald article was written only within days of the end of the peer review period (October 10). Thus, we the readers, had little time to respond. This causes some concern as to how well the organizations that represent us are keeping in touch with current issues.

That point aside, however, I feel the need to offer counterpoints to the issues raised, in order to provide readers with another viewpoint on the matter and perhaps allow a more fair, or at least an alternative analysis of what is going on in our chosen profession.

The issues that have been raised have been within the section of ASHA's draft proposal explicitly labeled Scope Of Practice, and numbers 2, 3, and 4 under that section. I will reiterate the exact wording here - but you should review the statements previously mentioned in the News and Viewpoint sections of Audiology Online, or perhaps even obtain a copy of the draft from ASHA, before finishing this article.

Number 2, under "Scope Of Practice" states that speech-language pathology involves "Developing and establishing augmentative and alternative communication techniques and strategies including selecting, prescribing, and dispensing of systems and devices." The first time I read this statement, it appeared to me to fairly well summarize the current function of SLPs.

I am quite sure that the words "prescribing" and "dispensing" caused the panic with this statement. Statements by Dr. Simon and Drs. Glaser and McDonald said that this section may be interpreted as including hearing instruments ("devices") - perhaps it will. They also recognized that a later paragraph (number 6) contains a footnote stating that hearing instruments should not be included in the "Selecting, fitting, and establishing effective use of prosthetic/adaptive devices for communication..."

Frankly, why not? I believe that most people in this country (including SLPs) do not believe speech-language pathologists should be fitting hearing instruments. However, if one should wish to obtain education, pass their state hearing instrument dispensing exam, and undergo the necessary apprenticeship in order to obtain a license/certificate, why shouldn't they be allowed to dispense hearing instruments just as any hearing instrument dispenser?

A "Scope Of Practice" statement by ASHA isn't going to automatically give SLPs the privilege of dispensing hearing instruments. Nor is it going to cause state licensure boards to rewrite their licensure requirements to allow speech pathologists to dispense.

The next section states that the practice of speech-language pathology involves "Providing services to individuals with hearing loss and their families (e.q., communication counseling, auditory training, speech reading, speech and language intervention secondary to sensory aid placement, manual inspection of amplification devices including verification of appropriate battery voltage)."

There are two issues in this statement that have caused concern. The first is, SLPs should inspect amplification devices. Some people feel strongly that speech-language pathologists should not be doing this. I have long been an advocate of SLPs doing routine checks of hearing instruments. If a child in a rural school has an earmold that is occluded with wax, or a hearing instrument with dirt in the microphone port, wouldn't we prefer the SLP deal with it rather than have the child wait until the audiologist makes their next visit? The SLP in this case can surely remedy the problem by removing the blockage, in no poorer fashion than the repair tech at a manufacturing facility (who, by the way, is not an audiologist).

The same issues exist with patients at speech-only practices. Do we want to deny patients timely services for lack of a little training, just because the battery is dead or they didn't realize the instrument was on telecoil? I believe it is within the scope of practice of SLPs to have them perform the same tasks many professionals teach their front office staff to perform when the audiologist or dispenser is out of the office.

Additionally, many have raised the issue as to whether or not speech-language pathologists should not be providing aural rehabilitation (AR). In my opinion, most auditory rehabilitation (aka - aural rehabilitation) being offered is already performed by speech pathologists.

If audiologists performed adequate AR on a large scale, there would probably be no need for other professions to provide AR services. Most audiologists provide counseling and minimal AR, limited to the fitting of hearing instruments. By and large, audiologists do not have the resources or time necessary to truly provide long-term AR services.

I think SLPs can, and probably should, provide AR. Of course, I would prefer to see more audiologists appropriately trained in AR, and offering and providing AR services to the patients we serve. Until that happens, SLPs are contributing considerably to national AR efforts, and should continue to do so. SLPs are very well equipped to provide AR services such as speech reading, teaching communication strategies, helping patients manipulate their environment to assist in hearing, and helping patients learn to listen to and self-monitor a voice that sounds different.

The final section of interest really has me scratching my head. Number 4 states the SLP scope of practice involves "Screening hearing across the life span through the use of conventional age-appropriate pure-tone screening methods, as well as screening for auditory system dysfunction through the use of dedicated physiologic and acoustic screening technologies (e.g., ABR, OAE, aural acoustic immittance) for the purpose of initial detection and referral of individuals with possible hearing loss."

In my former life as a special equipment distributor, I trained OB nurses, family practice nurses, ENT nurses, general practice nurses, technicians, community volunteers, hearing instrument dispensers, and even speech pathologists to do all of these screening tests. Every manufacturer's representative has done so.

Nowhere in the entire ASHA document could I find a reference to SLPs performing diagnostic audiological tests. Screening tests are designed to use criteria set by audiologists (most notably, Boys Town National Research Hospital, University of Miami, Vanderbilt University, and independent studies) to provide a pass/refer score for a test.

It has always been under the scope of practice of speech pathologists to perform hearing screenings. Why shouldn't they be allowed to use the most current tools to do so?

Do I believe that we should work with ASHA to recommend changes to this document to clarify statements? Absolutely. Anyone who knows me knows there is no love lost between myself and ASHA (it started with them losing my CFY paperwork twice and went downhill from there). However, they are still the most powerful lobbying force in our profession and they still set the educational standards for our profession.

The ASHA draft explicitly states that "It is recognized that levels of experience, skill, and proficiency with respect to the activities identified within this scope of practice vary among individual providers. It may not be possible for a speech-language pathologist to practice in all areas of the field. As the ASHA Code of Ethics specifies, individuals may only practice in areas where they are competent based on their education, training, and experience. However, speech-language pathologists are not limited from expanding their current level of expertise. Certain situations may necessitate that speech-language pathologists pursue additional education or training to expand their scope of practice."

Rather than complaining that speech-language pathologists do not have the education necessary to act as complements to audiologists, let's help them get it.

The ASHA document also states (in the opening section) that one of the purposes of the proposal is "Establishing a reference for curriculum review of education programs in speech-language pathology." Let's support the draft, then demand that ASHA enforce the educational requirements needed to meet the scope of practice. This only makes both professions stronger. ASHA needs reform to better serve us all, no doubt. Many audiologists and speech pathologists agree on this. Let's work with ASHA to recommend some wording changes and/or the inclusion of the footnote that Drs. Glaser and McDonald recommend.

My summary is: I am increasingly noting that I am "represented" by organizations whose primary mission often appears to me to be to fight with ASHA. I prefer that a collaborative and mutually beneficial relationship be established and fostered. However, just as your patients will not be helped by you continually pointing out everything that is wrong with their hearing, our profession will not be helped by constant negative, condescending, and alarmist statements. I urge restraint, collaboration, cooperation and thoughtful and respectful critical thinking.