20Q: Predicting the Future of Audiology

From the Desk of Gus Mueller

Predicting the future of audiology?  There are many clever quotes about predictions, but my favorite is from Danish physicist Niels Bohr, who said: “Prediction is very difficult, especially about the future.”

Prognostication is one way to improve predictions, but we also can study the past.  In the profession of audiology, if we look back 40 years, one event that had a huge effect on the future was the late-1970s ruling by ASHA that made the sale of hearing aids “ethical.”  This immediately had an impact on private practice audiology, and within a relatively short period of time, changed the business model within clinics, hospitals and university settings too.

Of course, if ASHA had not changed the ethics ruling, the sale of hearing aids by audiologists eventually would have happened anyway, by way of mass exodus from that organization.  This leads to another event of the audiologic past worth studying—when there indeed was a mass exodus from ASHA—the founding of the American Academy of Audiology in 1988.  A related change in the profession occurred shortly thereafter, the transition to the doctoral-level entry degree, with the first AuD program starting in 1994.

What would audiology be like today if we were still sitting in the ASHA professional house rather than the AAA?  What would audiology be like today if the clinical entry degree were still the Master’s, rather than the AuD?  Even when armed with over 20 years of data, predictions about the profession of audiology are still somewhat difficult to make.  So you might ask, who would be willing to stick his or her neck out, and predict the future of audiology?  We did find someone, and not just a man on the street, but rather, the President Elect of the Academy of Audiology, Ian Windmill, PhD.

Dr. Windmill is the Clinical Director of Audiology at Cincinnati Children’s Hospital Medical Center and is adjunct Professor in the Department of Otolaryngology at the University of Cincinnati. As already mentioned, he is President-elect of the Academy of Audiology, past board member of this organization, and past Chair of the Board of Directors of the Accreditation Commission for Audiology Education. 

Dr. Windmill is no stranger to addressing the tough topics facing audiology.  You may be familiar with his publications addressing issues such as the demand for audiology services, AuD entrance and graduation requirements, obstacles for growth in audiology, and audiologist attrition.  He also has been directly involved in the future of audiology.  In the 1990s, as Chair of the program at the University of Louisville School of Medicine, he began one of the first AuD programs, and also was responsible for the formation of NAFDA, the precursor to the current Student Academy of Audiology. 

It was Abe Lincoln who said:  “The best way to predict the future is to create it.”  We wish Ian the best in his upcoming tenure as president of the Academy, and will heartily support him in creating a promising future for audiology.

Gus Mueller, PhD
Contributing Editor
April 2016

 

To browse the complete collection of 20Q with Gus Mueller CEU articles, please visit www.audiologyonline.com/20Q

20Q: Predicting the Future of Audiology
 

   Ian Windmill

1. Can you really predict the future?

Absolutely!  It has been a gift since early childhood, although it doesn’t seem to work on the stock market, horse races or the lottery.  And I struggle with predicting how my wife reacts to some of my shenanigans.

Actually, predicting is the wrong word to use. Prediction is an estimate of future outcomes based on past data.  It is simply extending the past and current trends forward, and assumes the external environment in which the past data was measured will not change in the future.  A better word is “forecast”, which takes predictions and subjects them to manipulations based on known or possible changes to the external environment.

2. So can we forecast the future of audiology?

We certainly can try.  In this case, we take what we know or understand about the past and current state of the profession, and then consider what will happen given changes in the environment external to audiology. It is an attempt to identify the range of possible outcomes that might happen given any set of assumptions about the environment in the future.

3. You mention changes to the environment?

In this case we are referring to the general healthcare and service delivery environment in which audiology operates.  These would be factors such as consumer demands, government rules and regulations, developments in industry, new technologies, or telehealth initiatives.  These are all extrinsic factors that are generally beyond our control, but which can impact audiologic practice to varying degrees.

4.  So could you give me an example of forecasting the future in audiology?

Sure.  Several years ago, Barry Freeman and I published an article in the Journal of the American Academy of Audiology (JAAA) that looked at the number of graduates we need in audiology given the population growth (Windmill & Freeman, 2013).  We looked at past and current graduation rates, and at past and current population figures.  We “predicted” that audiology would need to double the number of graduates over the next 30 years in order to meet the demands imposed by changes to the population.  We then “forecasted” what would happen given changes to the external environment.  In one case, the change was the influence of improvements in practice efficiencies due to technological advancements such as electronic medical records.  Using this assumption, the number of graduates needed would only need to increase by about 50% rather than double.  In another manipulation, we considered the speed at which academic programs could add additional students.  By changing the assumptions, the prediction of the number of students needed changes.  Hence we can “forecast” how many students we will need if we agree on a set of assumptions about the future of academic programs and consumer demands.  I might mention, that when developing our forecast I was quite surprised (and disappointed) when we looked at the attrition of audiologists.  Our data revealed that the number of audiologists who voluntarily leave the profession after graduation is about 40%. We did not attempt to examine the reasons so many leave the profession, but the numbers are for pre-AuD training, so this might be lower today.  To give some perspective, physician attrition is around 9%, including those retiring (Robert Wood Johnson Foundation, 2013)!

5. What are some of the specific environmental factors that need to be considered as we look to forecasting the future?

A good example of an environmental factor that would need to be considered for the future would be if the Food and Drug Administration (FDA) were to eliminate the need for a medical evaluation prior to getting a hearing aid.  Anyone who fits hearing aids understands that adult patients either have to have a pre-purchase medical evaluation to rule out active ear disease, or they can sign a waiver of the right to have the evaluation.  Suppose the FDA came to the determination that the evaluation was no longer a requirement.  What would the impact be on audiology practices?

6. I agree, that is probably something we could forecast.  Anything more dramatic?

There are numerous factors that we could consider when trying to forecast the future, but perhaps the one that serves as an obvious example of an environmental factor is the potential for hearing care technology to be available to the public without the need to see an audiologist.   This technology could be over-the-counter hearing aids, personal sound amplification products (PSAPs) used to treat hearing loss, or some technological combination of hearing aids and “hearables.”   As many audiology practices have hearing aid dispensing as an integral part of their services, there is the potential for great disruption to this service delivery in the future.  One might argue that the number of patients seeking professional services will decrease due to the more easily accessible technologies, which has the obvious impact of changing the economics of an audiologic practice.  On the other hand, some believe that these technologies will make consumers more aware of the benefits of amplification, and will drive more patients to audiologists.  And of course, there is no reason audiologists couldn’t integrate these new technologies in their practices.  Clearly, this environmental factor needs to be considered.

7.  That sounds like a factor that could have a potentially significant effect on the future of hearing care.  Do you have any ideas regarding how it might shake out?

Right now, there is only speculation about the potential impact.  Weather reporters often talk about their long-range forecast in terms of a range of possibilities, and then narrow down the specifics over time.  Same here.  At this point, we cannot even “forecast” the impact of such a change in the availability of hearing technologies, much less predict the impact.

8. You specifically mentioned PSAPs as a possible issue that could impact audiology in the future?

This is an interesting issue as PSAPs have been around for a long time.  In a broad sense, PSAPs are probably no different than assistive listening devices.  Audiologists have always used and recommended assistive devices for patients, including those that had limited financial means, dexterity problems, needed a device for a specific listening situation, or had some complicating factor that prevented use of traditional amplification.  Many PSAPs have the same characteristics as assistive listening devices, but over the past few years they have begun looking more and more like hearing aids.  Because of the increasing similarity with hearing aids, the FDA issued a guidance document that specifically stated that PSAPs could not be used to treat hearing loss, nor could they be marketed as such (FDA, 2013).  In addition, as PSAPs were consumer electronic devices and not medical devices, the regulation of PSAPs was outside the purview of the FDA, and there was not need for the FDA to evaluate their capabilities. 

The paradox of this guidance document is: 1.) It does not prevent a consumer from using a PSAP for hearing loss; and, 2.) the document is only guidance, it is not a rule.  In fact, the document explicitly states that this is not a rule of the FDA.  So in essence, an audiologist could provide a PSAP to a patient to treat hearing loss, much like assistive listening devices have been provided for years, even though these devices have not been regulated by the FDA.

The President's Council of Advisors on Science and Technology (PCAST) has recommended that the FDA withdraw its guidance document on PSAPs (PCAST, 2015).  If this were to happen, it opens up the market to manufacturers of PSAPs to allow them to market the devices for hearing loss.  The FDA has already indicated a willingness to examine this course of action.

9. Interesting take on the PSAP issue.  Why should we worry that a few consumers might find their way to PSAPs?

A few obvious concerns include that the amplification provided by the devices might not match the hearing loss, that the amplification might cause even more damage to someone's hearing, and that poor outcomes with PSAPs might discourage patients from seeking professional help.  In addition, one significant issue is the companies and associations that are getting involved in the PSAP market.  For example, the Consumer Electronics Association (CEA), now called the Consumer Technology Association (CTA), has a working committee to develop standards for PSAPs.  Most people know the CTA as the annual host for the world’s largest technology showcase in Las Vegas, the Consumer Electronics Show.  The mere fact that this association is engaged should convey the sense that there is a market for PSAPs – particularly if they could be used by consumers to help with their hearing loss.

We know that PSAPs are much less expensive than hearing aids; at least consumers appear to have this perspective.  We could also speculate that over-the-counter hearing aids would be less expensive than those available in the traditional service delivery model.  As such, retail outlets such as Walgreens or CVS drug stores would have an interest in such products.  Considering that the number of Walgreens and CVS stores outnumbers the combined total of audiology, hearing instrument specialist, and otolaryngology practices, there is every reason to believe that the access to these devices will result in more than a few consumers choosing that option.

10. Surely consumer organizations must be worried about the quality of PSAPs, and the more commercial availability of hearing care?

I'm really hearing two questions here.  First is the quality of the products.  Perhaps initially many PSAPs were of low quality, but on a regular basis we see new products emerge that have higher and higher quality.  Some of our audiology colleagues are intimately involved in the development of these products.   Given the potential to have performance standards through the CTA, we could expect the quality to improve to an even greater extent over time.  And consistent with other consumer electronics, the cost of the devices might decline over time.

The second part of this question is whether consumer groups would support the availability of PSAPs or OTC hearing aids in a direct-to-consumer model.  The answer is yes.  The Hearing Loss Association of America issued a position statement in April of last year supporting consumer access to all these devices, and to be able to access them through retail outlets, online or through professional practices.

11.  You keep using the term “consumer” rather than “patient.”  Explain?

Consider that all patients are consumers, but not all consumers are patients.  Patients are consumers of healthcare, or in our case, audiology care.  They have engaged with professionals and are paying for and receiving services or products.  Those persons who have not yet engaged our services are not patients, but they can be consumers, especially in terms of using OTC hearing aids or PSAPs.   All of us can be consumers of health care, rather than patients, if we choose to self-direct our care.

12. Are you talking about “patient-centered” care when you say self-directed care?

Patient-centered care is a concept that assures patients are fully engaged in any decisions regarding their own health care.  This concept is more typically directed to the professional providing the care, and thus patient-centered care occurs after the patient has engaged with the professional.  Self-directed care occurs before the patient engages with the professional.  Think about the person playing a game of touch football who suddenly plants their foot wrong and goes down with pain in their ankle.  Initially, that person might self-diagnose a sprain and thus choose to use ice or heat to treat the pain, and keep off the foot for a few days.  In addition, they might initially choose to use an over-the-counter medication to reduce the inflammation.  After a few days, if the problem is resolving, the person might use an ankle brace to improve stability while walking.  Finally, when the problem resolves, the person resumes normal activity.  All the care this patient received was self-directed.  But let's change this scenario slightly.  Let’s say the ankle doesn’t improve, even after ice, heat, anti-inflammatories, and wraps, and the decision is made to seek the advice of a physician.  Even in this case, all the treatments tried before engaging the professional are self-directed.

In hearing care today, there are few options for self-directed care.  One either copes with the loss or engages a professional. Our colleague Brian Taylor talks about consumers and “arms-length” transactions. An arms-length transaction is a one-time, anonymous transaction that the consumer engages in when there are a number of options for a given product.  This contrasts with the relationship-based transaction that occurs in audiology.  In audiology, the relationship between the consumer and provider is an integral part of the process, the transaction is not anonymous, and the transaction occurs over multiple visits.  The arms-length transaction is part of self-directed care while the relationship-based transaction is typical within audiology practices.  Hence the perspectives of groups like the HLAA, which seek to open up options for self-directed care for hearing loss, prior to engaging the professional.

13. Why did the concepts of self-directed care, consumers versus patients, PSAPs, and OTC hearing aids become an important extrinsic environmental factor?

Remember earlier when I mentioned the President's Council of Advisors on Science and Technology?  Well in October of last year, PCAST released a series of recommendations regarding the technology associated with hearing aids.  I’ve already alluded to the recommendation to withdraw guidance for PSAPs.  The other recommendations include having the FDA approve a class of hearing aids that can be used over-the-counter, and for which no pre-approval process is needed, and to allow the use of online diagnostic hearing tests.   The PCAST also recommended that patents be given copies of their audiologic test results and programmable audio profile.  We assume the “programmable audio profile” means the prescription for the hearing aids.  This would allow patients to shop around for devices, including purchasing them online or via the retail market.

On top of this development, the Institute of Medicine, now the National Academy of Medicine (NAM), convened a committee to examine the accessibility and affordability of hearing health care in the adult.  This committee had numerous public hearings over the past year and the American Academy of Audiology (AAA), the American Speech, Language and Hearing Association (ASHA), and Academy of Doctors of Audiology (ADA) worked together to provide input to the committee.  The final report and recommendations of the committee are to be released in June.   There are expectations that this report will provide both similar recommendations regarding the technology, but also additional recommendations about the service delivery model.

14. You noted that the PCAST recommendations included online diagnostic hearing tests?  Can you really diagnose hearing loss online?

I think we all understand that the diagnosis of hearing loss is not a simple process, particularly given that diagnosis includes the need to understand auditory system function, the underlying cause(s), the impact on communication, and the clinical decision-making associated with deriving a treatment plan.  In this regard, all the professional organizations in audiology have opposed the idea that diagnostic hearing testing can be conducted online.  Perhaps hearing screening, or estimates of degree of loss, or some superficial assessment of speech-in-noise capability, can be conducted online, but not a diagnostic hearing assessment.

15.  The PCAST recommendations are just recommendations, right?

Correct.  The PCAST simply makes recommendations to the President in the science and technology areas.  The President must then task the appropriate branch of the government to act upon the recommendations.  At present, there is no statutory or regulatory weight behind the recommendations.  Similarly, the NAM only makes recommendations.  However, the NAM is viewed as an independent advisory body whose recommendations can become the basis for statutory or regulatory initiatives.  In this regard, we have to be prepared to consider the impact of these recommendations on audiology – and then consider the future if or when the recommendations are acted upon.

16. There certainly is a lot to consider in terms of the impact of these reports.  Are there any other developments we have to consider when trying to predict the future of audiology?

Two things come to mind.  The first is another technological factor – the merger of hearing aids and “hearables.”   Many people are familiar with wearable technology these days.  Perhaps one of the most common wearables these days is the wristband that provides feedback on parameters of fitness such as the number of steps taken or heart rate.  Hearables can perform the same function, only in the ear.  Hearables can also provide direct audio input to the wearer, including navigation directions, feedback on heart rate, or phone communication.   Persons with hearing loss cannot benefit from these devices if the audio output is not shaped to the loss.  Conversely, hearing aids could incorporate the benefits of hearables.   So we have to assure that this marriage of technologies will be part of the future. 

17.  What is the second development you are thinking about?

This one is probably a little farther off but I am thinking about the significant effort being expended globally to find a pharmaceutical treatment for hearing loss.  One only need search the Internet and discover the impressive number of companies and researchers engaged in this effort.   And some of these companies are the top pharmaceutical industries.  So there must be an expectation that a pharmaceutical treatment is possible in the future. 

The other area that pharmaceuticals could come into play is in the area of prevention of hearing loss.  We know that colleagues such as Kathy Campbell have been investigating ways to prevent hearing loss through pharmaceutical means.  Some of the so-called “otoprotectants” are currently in clinical trials.  The potential to prevent hearing loss in a relatively simply way could change the scope of hearing care, both in terms of the number of persons seeking preventative methods, and the long-term impact on reducing the number of persons needing hearing care after the fact.  Circling back to forecasting the number of audiologists needed in the future, this is an environmental factor that could alter the equation in some way.  Perhaps we need more audiologists, perhaps less.

18. What will the development of pharmaceuticals mean for audiologists and audiologic practice in the future?  

This is where assumptions about the future come into play.  We can assume that there is some miracle breakthrough that quickly restores all hearing loss, for every person, to normal.  In this case, the entire hearing care industry will be turned on its ear (ear- get it!)  Or we can assume that medications will have varying degrees of success – a much more likely scenario.  In this case, there will still be a need to assess the hearing to start, to identify which patient could benefit from pharmaceutical treatment, to determine which medication to prescribe, to measure the effects of the treatment, to determine subsequent courses of action, and to dispense devices for those persons whose hearing is not restored.  In a broad sense, the development of pharmaceuticals to treat hearing loss will be just another arrow in the quiver of treatments available.  In some ways, this might drive more persons into our practices to seek treatment for the loss. 

The second part of my answer to this question might be somewhat controversial.  The audiologist is the primary provider of hearing care.  There is no one who is better trained or has more answers for patients with hearing loss than audiologists.  I work at Cincinnati Children’s Hospital Medical Center and am always fascinated at the complete deference to the audiologist by all other providers for children with hearing loss.  I’m not talking about otitis media, but rather those children identified with sensory loss.  Think about it: audiologists manage the newborn screening programs; an audiologist assesses and identifies the hearing loss; the audiologist counsels the parents and sets the treatment course; the audiologist determines which devices to use and when; the audiologist refers to the ENT for cochlear implant (CI) surgery, but the patient immediately comes back to audiology for the long-term care.  Parents of children with hearing loss rely on the audiologist for advice, counsel, recommendations, and care.  And, as I noted earlier, all other providers, from primary care through ENT, defer to the audiologist's expertise and role in regards to a child with hearing loss and their parents.  The observation is the primacy of the role of the audiology in hearing care.

So if this is the case, why should audiologists not be involved in the determination, prescribing and monitoring of pharmaceuticals for hearing loss?  If audiologists are the experts in hearing loss, this seems to be a logical extension of our roles.  I know there are those who might not agree with this observation or direction, but in my mind it is worth having the discussion.   But wow, wouldn’t this be an interesting environmental factor to impact the future of audiology?

19. Are you suggesting audiologists get prescribing authority?  This seems like a massive undertaking.

I am not suggesting that audiologists get blanket prescribing authority.  But I am being very specific with regards to the use of pharmaceuticals to treat sensory hearing loss or to prevent sensory hearing loss.  If we are the experts, then we should discuss whether we should be engaged in this process as well.

In terms of an undertaking, you are quite correct – this would require a massive change across the board.   It would take the academic programs ramping up to include training in pharmaceuticals.  Practicing audiologists would have to learn the same material.  Licensure laws and government regulations would have to be addressed, and both state and national professional organizations would have to commit significant resources.  But I remember 30 years ago, and the proposal to change our degree structure from the masters to the doctorate, and it seemed a similar massive undertaking.  Look what we accomplished in working together to a common end. 

20. So bottom line, what are your predictions about the future of audiology?

Well, I certainly do not embrace the perspective that we are all doomed, or that we need to explore opportunities to quit audiology and open a bakery any time soon.  But we do have to be realistic when we look into the future and try to anticipate these environmental factors that might/maybe/potentially/possibly have an impact on audiology.  We need to consider the opportunities these potential developments have, both on our profession and on individual practices.  For example, at Cincinnati Children’s Hospital we have already begun investigating how and when a PSAP might be the treatment of choice for a child.   There might be circumstances where these devices are better options than what we have available today.  A child with a persistent unilateral conductive loss where there is the expectation of surgical repair in six months might benefit from a low-cost, short-term product for use in the classroom.  We extend our reach through examining the possibilities.  I think the same thing about audiology or audiologic practice – we can either extend our reach, or we can attempt to remain in place. This reminds me of a Chinese proverb:  When the winds of change blow, some people build walls, while others build windmills! 

References

Food and Drug Administration. (2013, November 7). Regulatory requirements for hearing aid devices and personal sound amplification products - Draft guidance for industry and Food and Drug Administration staff. Retrieved from https://www.fda.gov/medicaldevices/deviceregulationandguidance/guidancedocuments/ucm373461.htm

President’s Council of Advisors on Science and Technology. (2015, October 26). PCAST recommends changes to promote innovation in hearing technologies. Retrieved from: https://www.whitehouse.gov/blog/2015/10/26/â pcast-recommends-changes-promote-innovation-hearing-technologies

Robert Wood Johnson Foundation. (2013, March 21). Physician turnover rate at highest since 2005. Retrieved from https://www.rwjf.org/en/culture-of-health/2013/03/physician_turnovera.html

Windmill, I.M., & Freeman, B.A. (2013). Demand for audiology services: 30-year projections and impact on academic programs. Journal of the American Academy of Audiology, 24, 407-426.