Interview with Barry Freeman Ph.D., 1996-97 President, American Academy of Audiology (AAA)

AO/ Beck: Hi Dr. Freeman, thanks for spending a little time with me this evening. I'd like to get your thoughts on the state of the profession and a few other issues as well. Let's start with ... What year was your AAA presidency?

Freeman: I was AAA president from July, 1996 through July, 1997. Back then we presided for a full year in accordance with the fiscal year. At this time, AAA uses the calendar year so it's a little easier to track. Dr. Glaser is actually working a few extra months as president to help ease the transition. His presidency started October 1999 and will conclude December 31, 2000.

AO/Beck: How long have you been the Dean at Nova Southeastern?

Freeman: It's been three years.

AO/Beck: Tell me about your responsibilities at NSU. Are you primarily addressing administrative functions as the Dean, or do you teach classes in audiology too?

Freeman: NSU is a unique university. We have approximately 17,000 students of which 14,000 are in graduate and professional degree programs including medicine, dentistry, optometry, pharmacy, and law. As you know, we had the first distance-education Au.D. program and we now also have the post-baccalaureate, 4 year Au.D. program. I also am responsible for other clinically based programs. We have the master's program in speech-language pathology, which is the largest master's program in the USA with approximately 400 students. We also offer a new doctorate in speech-language pathology, the SLP.D. It too, is a professional degree, modeled somewhat after the Au.D. There are also graduate programs in substance abuse counseling and a master's program in gerontology and so, I am the Dean of these clinically based graduate degree programs. I primarily teach a doctoral level practice and business management course and this upcoming semester I'll be co-teaching one of the differential diagnostic courses.

AO/Beck: I'm familiar with NSU's history and they certainly have been extremely innovative and progressive. Certainly Nova will continue to grow and prosper and I am certain their faculty and students are proud of the excellent education and practicum available to them. Additionally, I think the doctorate in SLP will attract an enormous quantity of students. Let me switch gears here and let's focus on your general impressions as to where we are as a profession and where should we be going?

Freeman: I think the vision of the AAA, and the vision for the future can be summarized in two words -- professional autonomy. I'd like to expand on that a bit. We need to incorporate professionalism into every audiology-based activity. By the way, some of the ideas which I'll discuss here came while working with Michael Marion, when he became the Chair of the Marketing Committee for the Academy in1996.

Nonetheless, when I think of professionalism, I like to break it into intrinsic and extrinsic factors which impact audiology as a profession. The intrinsic factor analysis revealed that we have not always presented ourselves as professionals. Importantly, the intrinsic issues impact the extrinsic issues.

For example, one of the basic flaws we discovered was when an audiologic evaluation was ordered in a physician's office, the audiologist often failed to introduce themselves as 'Hi, my name is Joe Smith, I'm an audiologist'. Without the proper introduction, patients thought the audiologist was a technician, or a nurse of some sort. In essence, the patient had no idea they were being evaluated by an audiologist.

Additionally we found that the front office personnel had very little knowledge of who or what an audiologist was. In response to that problem, the AAA developed a Front Line Training Kit and it included tapes and workbooks. We believe this training kit has impacted the offices of approximately 3000 audiologists who have used this product to teach their staff about how to interact with patients. So when I talk about professionalism, we have to recognize and acknowledge that we are indeed professionals and we need to transfer this image and reality to our colleagues and our patients.

In fact, in the new Audiology Today (July/August 2000, page 34) Pamela Fuhrman, one of our Washington lobbyists, discusses the status of the Academy's request to have an SOC code for audiology and to be classified as a 'health diagnosing' profession. She points out that audiology now has their own code. We are no longer under Speech-Language Pathology, we are now recognized as 'Audiology'. The next step in this venue will be to remove us from the 'therapist' codes (which is where occupational therapists, physical therapists, radiation therapists, recreational therapists and SLPs are) and have us placed in the category called 'Health Diagnosing and Treatment Practitioners', which is the category for optometrists and others who have the rights, privileges and responsibilities of physicians, within their scope of practice, and they have direct access to patients and direct reimbursement.

Interestingly, the OMB commented that for audiologists to move from the 'therapist' codes to the 'diagnosing' codes, we are certainly moving in the right direction by moving the profession to the doctoral level.

However, they also pointed out that we do not use the word 'diagnose' in our licensure laws or across our websites to represent what we do. Frankly, we need to get the word 'diagnose' into our laws and scope of practice so as to better reflect the work we do and to better align us for future professional growth. So here is an example of how the intrinsic issues really do impact the extrinsic issues. We need to present ourselves as a 'diagnosing' profession before we can be defined in law that way. Of course the extrinsic issues here are how the Department of Labor, the patients, and the insurers all view and regard us.

AO/Beck: That brings me to the issue of limited license practitioner (LLP) status. Can you address this for me?

Freeman: The LLP status is very important. The LLP status provides licensed, non-physician health care practitioners the rights and privileges of physicians. That is, direct access to patients and the ability to bill for services without a physician referral. HCFA (Health Care Finance Administration which administrates Medicare and Medicaid) first used the term 'LLP' in the Federal Register and although the term may not be universally used, the description of LLP status practitioners is common and we need to obtain the LLP status, just like optometrists, chiropractors, podiatrists and dentists. Again, to obtain LLP status, we need to define ourselves as diagnosticians within our scope of practice and within our state laws and have a unified professional doctoral degree designator like other health care professions.

AO/Beck: Dr. Freeman, can you tell me about the recent meeting of the Au.D. Program Directors?

Freeman: Yes, I'd be happy to. Our most recent meeting of the Program Directors was held during the NAFDA meeting in Washington DC last week. The Academy has been instrumental in trying to promote the residential and distance-education based Au.D. programs. The AAA asked Ian Windmill and I to co-chair a task force that would bring the program directors together. In January 2000, the AAA provided the resources to bring all of the Au.D. program directors to get together in Florida. We met at Nova Southeastern and then we had a follow-up meeting at the AAA meeting in Chicago. The two primary issues we discussed were the fourth year of training in the Au.D. residential programs and accreditation issues.

Regarding the fourth year of training, we are developing a matching program. Fourth year students will have the opportunity to visit and rank order clinical sites where they would like to complete their fourth year of training. Clinical training sites that participate in the matching program also will rank order students. Using a national service, all students will be matched and notified on the same day. This is quite different from the traditional approach we have used in the profession. Students will still be enrolled in their degree program and will pay tuition to the university for this fourth year. It is anticipated that the training experience will be twelve months. The universities will expect the student to have diverse clinical experiences and the Program Directors are currently working with several representatives from clinical sites (including Jim McDonald, president of ADA, Dave Fabry of Mayo Clinic, and Lucille Beck of the VA) to develop a strategy to qualify clinical sites. The training sites need to represent global, across-the-board, well-rounded competencies and it is expected that all will pay a stipend to the student while they are working. We'll develop this further, but the idea is to provide an excellent overview of clinical practice in a fourth year 'externship' site.

AO/Beck: When do you anticipate the match program will start?

Freeman: Probably during the summer of 2001. The match would be exclusively for the four year post-baccalaureate Au.D. programs.

AO/Beck: Please tell me about accreditation issues.

Freeman: There are two types of accreditation. The first is regional which accredits the college or university. In audiology we traditionally also have maintained accreditation from ASHA Council on Academic Accreditation (CAA). The CAA accredits entry level degree programs in audiology and speech-language pathology which traditionally have been master's degree programs. The CAA has traditionally not accredited doctoral programs because doctoral students generally have already earned the entry-level master's degree. With the doctoral level entry for audiology, however, the CAA now is accrediting doctoral programs. The AuD program directors met with representatives from the ASHA CAA recently in Washington. At this time the CAA is accrediting programs still using criteria developed for master's degree programs. While apparently working on some changes to the accreditation process, the CAA has not asked for input from any of the AuD programs. They explained that they cannot develop new standards until the guidelines for certification (CCC-A) are complete. The accreditation process is designed to support the ASHA certification program and to assure that future graduates meet the standards that will permit them to acquire the CCC-A.

The accreditation has some definite benefits to the programs, including quality control, site visits, adequate faculty, and generally making sure the house is in order. However, the CAA also functions to assure the student can graduate and be eligible for ASHA certification.

Among the issues the program directors discussed with the ASHA CAA was the requirement that the supervising faculty must have their CCC-A for their supervisory time. As ASHA knows from their recent Work Study (published in March, 2000), only 66% of currently practicing licensed audiology practitioners maintain their C's. Thus, it is becoming more difficult to find 'certified' practitioners to supervise students. Also, as we know, many of these 'non-certified' practitioners are certainly qualified to supervise students. These and other issues were discussed with the ASHA CAA representatives. The program directors expressed concern that the CAA is not responding to the needs of the training programs and, more importantly, the profession. Therefore, the program directors have begun investigating other models of accreditation, including Optometry, Dentistry, Podiatry, and Medicine. This is a complex and critical issue for the future and one that should be addressed immediately.

AO/Beck: Dr. Freeman, how many of the audiologists across the USA have their CCC-A?

Freeman: According to the ASHA Work Study that was released in March, 2000, only 59 percent of newly graduating audiologists are joining ASHA and are getting the CCC-A. Additionally, only 66 percent of the licensed audiologists in the USA have their CCC-A currently. Contrast that with Speech Language Pathologists, where 97 percent of the practitioners have their CCC.

AO/Beck: Then the question may become ... Suppose AAA or ASHA have certification programs, and suppose that the majority of audiologists want to see the profession recognized and defined based on their license and degree, is there truly any need for any certification program?

Freeman: First, let me say there are no states in the USA that require certification for licensure. However, there is no question that having the C's makes it easier to get a license because at this time most states recognize the C's as proof that a practitioner has met the requirements for the license. It now is time for audiologists to make changes in their licensure laws.

We started this conversation talking about the intrinsic and extrinsic issues impacting the profession. Laws must begin to reflect our scope of practice, including the right to diagnose. Similarly, licensure boards should recognize the AuD degree as proof of completion of the requirements for the state license. In Florida, for example, the university program directors and state associations petitioned the License Board to recognize the AuD as the entry to the profession and proof of requirements for the license. This is the model followed by other health care professions. I agree, Doug, that we must be recognized by a unifying doctoral degree designator with our legal right to practice provided by licensure boards.

AO/Beck: Before I let you run, I'd like to revisit a study you did about four years ago. The study dealt with access to audiologists, and I think it was by Freeman, Windmill, Bratt and Hall?

Freeman: Yes, that was an interesting and revealing paper. When President Clinton became president and when Mrs. Clinton was looking at health care issues, we recognized the need to have a well defined position statement for audiology. At about the same time, a study was published by a group of ENTs at Henry Ford Hospital. They were looking for cost effective and efficient care for their otolaryngology patients. They discovered that 80 to 90 percent of their patients presenting with ear/hearing complaints could be seen and managed by the audiologist. Additionally, by having the audiologist manage and somewhat triage those patients, the ENTs were free to better address the critical care needs of their patients and they were able to more efficiently use their time for surgical and medical demands. Additionally, just after that article came out, there were hearings in the Senate's Committee on Aging, and the discussion turned to hearing loss and hearing aids. Dr. Jerry Goldstein (former executive vice-president of the American Academy of Otolaryngology - Head and Neck Surgery) testified before the committee. Dr. Goldstein was asked something like...'What percentage of the patients do you really need to see?' Dr. Goldstein replied that audiologists could see some 90 percent of the ear/hearing patients to make the diagnosis and the appropriate referral. We did a retrospective study at several practice sites and discovered that, when using conservative referral guidelines, 80% of patients presenting ear/hearing complaints did not need medical/surgical intervention and could be properly managed by the audiologist. Of the 20% who did need intervention, the audiologist had the knowledge and skill to make the appropriate referral. Therefore, we concluded in our publication that patients given direct access to audiologists would receive cost-effective care without compromising the quality of patient services.

AO/Beck: Dr. Freeman, thank you very much for the time you've given us tonight. I appreciate your efforts on the behalf of the profession, and I am appreciative of your time here this evening.

Freeman: Doug, thanks for your help too. Please remind the readers to vote in the AAA election and thanks for your time too.

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Interview with Barry Freeman Ph.D.
Former President of AAA
Dean of the Programs of Communication Sciences and Disorders,
Nova Southeastern University, Fort Lauderdale, FL