Interview with Carol Flexer, Ph.D.

Carolyn Smaka: Today I'm speaking with Dr. Carol Flexer. Welcome Dr. Flexer, and thank you for your time today.

Dr. Carol Flexer: Thank you, Carolyn.

SMAKA: Dr. Flexer, can you tell me about your background?

FLEXER: My official title is Distinguished Professor Emeritus of Audiology at the University of Akron. I retired from the University in 2006, but not from the profession. I continue to be very active in audiology. Most of my time is spent working with infants and children with hearing loss. I have also been lecturing on what it takes to teach infants and children with hearing loss to listen and speak. With universal infant hearing screening, we're screening 95-98% of all babies born in this country, which has led to identifying hearing loss in children earlier than ever before. Since 95% of children with hearing loss are born to hearing parents, many parents are very interested in their child learning to listen and speak well. My goal has been to identify what it takes to achieve that outcome, and doing staff development in several facilities so other professionals - such as audiologists, speech pathologists, deaf educators, and early interventionists - know how to deliver services appropriately. I have also been involved with the Alexander Graham Bell Association for the Deaf and Hard of Hearing, assisting in developing their new Listening and Spoken Language certification. This is a voluntary certification for professionals who want to obtain additional skills to administer services related to the development of listening and speaking. I am teaching audiology courses as well, working with John Tracy Clinic and the University of San Diego. I have a new textbook out with Jane Madell called Pediatric Audiology: Diagnosis, Technology, and Management (Madell & Flexer, 2008), as well as one with Elizabeth Cole that came out in 2007 called Children with Hearing Loss: Developing Listening and Talking, Birth to Six (Cole & Flexer, 2007).

SMAKA: Dr. Madell did a live seminar on AudiologyOnline this year on behavioral testing with infants (/audiology-ceus/course/readers-picks-hearing-eval-screen-children-special-behavioral-evaluation-hearing-in-babies-12919) and she shared some of the information from your new textbook.
It seems that as audiologists we are relearning the value of behavioral testing after relying heavily on electrophysiological testing for many years.

FLEXER: Exactly. The bottom line is what is done with the results of the testing that we do. None of the electrophysiological tests truly test hearing. Behavioral testing does test hearing and that is why we absolutely have to do it;especially now with more and more children identified with neuropathy spectrum syndrome. The only way to effectively follow these kids is with behavioral testing. For many audiologists, that means brushing up on our skills in behavioral testing. We have to become knowledgeable again about how children develop their auditory skills, their communication skills, and how those skills are characterized. This knowledge comes from studying auditory behavior. Pediatric audiology is blossoming now more than ever;we've added a lot of tools to our skill set that can be used with these babies and children.

SMAKA: How did you come to be involved with the SOC changes?

FLEXER: The work on the changes to the SOC codes began back when I was president of the American Academy of Audiology (AAA) in 1995 - 1996. I believe it really took off when Barry Freeman, who was the president-elect of the Academy at the time, brought up the fact that audiology was not classified as a unique profession by the government. This captured my attention and we began looking into the issue. It became such a passion of mine that I even made it a feature of my presidential address that year in Salt Lake City.

SMAKA: Please give us a little insight as to what the SOC is, and why it was such a concern for the profession of audiology.

FLEXER: The big picture is that the US Department of Labor categorizes and classifies every profession. These categories and classifications are listed in a publication called the Occupation Handbook. Each profession in the Occupation Handbook has a corresponding SOC code. When we looked in the handbook for the US Department of Labor's characterization and the SOC code for audiology, there was nothing there. In other words, in the eyes of the Department of Labor, audiology was not a profession. This was problematic because insurance companies and the government use SOC codes as a starting point when identifying and collecting data on any profession. Not having a code was tantamount to being invisible!

SMAKA: Why was no code listed for audiology?

FLEXER: Before the American Academy of Audiology was established, audiology was solely represented by ASHA. Speech language pathology and audiology were treated as one profession, with speech pathology getting the bulk of the benefit. This is partly because there were (and still are) so many more speech pathologists than audiologists, and speech pathology was always mentioned first in our shared professional designation. Therefore, audiology was listed under "S" because the profession was known as "Speech Language Pathology and Audiology". If anyone wanted to look up audiology, the person had to know to look under speech language pathology rather than audiology. This not only affected how insurance companies and the government looked at audiology, but also created difficulty in cultivating interest in the profession among students who didn't know audiology existed.

In addition, since we were adjunct to speech language pathology at that time, we were listed in the Occupation Handbook under the category of "therapist" along with recreational therapists, occupational therapists, and physical therapists. None of those professions were independent professions. They all worked at the direction of others, such as physicians. Audiology wanted to be seen rightfully as an independent profession where we diagnose and treat independent of physicians. Of course audiologists do provide therapeutic treatment measures, but they are done in the purview of being a diagnosing and treating profession.

We realized that we as audiologists could never be an independent point of entry in the healthcare system as long as we were characterized as therapists and under the subheading of speech pathology.

SMAKA: Hence our "identity crisis" as a profession.

FLEXER: That's right. The identity of audiologists had been intertwined with speech pathology for so long, it was hard for anyone to see that the two professions are vastly different. When delivering my presidential address for the AAA convention in Salt Lake, I discussed the Occupation Handbook and the SOC, which showed that, in the eyes of the government, speech pathology and audiology were one and the same. Then I discussed the personality characteristics typical of those attracted to each profession, as those characteristics are critical to identifying the work performed by a particular profession. The personality characteristics for one who typically chooses to be a speech pathologist and one who chooses to be an audiologist are actually quite different. The personality characteristics that are associated with audiologists put us squarely into the diagnosing and treating category, rather than the therapist category with speech pathologists. Looking closely at who audiologists are in terms of personality and temperament, as well as the work performed by audiologists, indicated that the profession as a whole was grossly miscategorized.

The breaking away process from speech language pathology started long before I was president of AAA. When the need for recognition as an independent profession became apparent, there were many of us that took on that banner. We believed that for audiology to grow as an independent profession, we needed to be recognized first as a profession. Our whole odyssey began with Barry and me, as AAA representatives, meeting with ASHA to state the case for audiology's need to be recognized as a separate entity. Understandably, ASHA was resistant to the notion, as it was in ASHA's best interest to keep audiology under its jurisdiction. ASHA claimed it was in audiology's best interest as well. ASHA felt it could best represent audiology because it had numbers on its side with 80,000 speech pathologists, and therefore had a stronger voice with the government. While the meetings with ASHA were cordial, ASHA's stance that audiology fell under the speech language umbrella did not change.

This became more frustrating for us at AAA as we were working with lobbyists and trying to have an influence in Washington. We realized that a main reason it was difficult to get a foothold in Washington and be taken seriously by legislators was because we were not our own entity in the eyes of the government. We weren't called out anywhere uniquely, and there was no official extrinsic recognition of audiology anywhere. It was after this realization that the Academy started working with the Department of Labor and the Bureau of Statistics to take the necessary steps to get audiology the recognition that it needed and deserved.

SMAKA: You mentioned the effort to change the SOC for audiology began in 1995 - 1996. Was it a multi-stage process?

FLEXER: Yes, it definitely was a multi-stage process. We didn't entirely qualify to be in the Diagnosing and Treating Professions category until we had the Au.D. as our entry level degree, as the other professions in that category had graduate practitioner degrees, such as M.D. or D.O. Because our degree designators were M.A., M.S. or Ph.D. at that time, we didn't fit the government's criteria. The Au.D. is not a clinical degree, it is a degree that allows audiologists to be independent practitioners, rather than under the supervision of another professional. We had to characterize who we were as a profession and change our own intrinsic view of who we were before we could have a powerful impact on the extrinsic view of our profession.

SMAKA: It sounds like getting this done took a lot of persistence.

FLEXER: You can't imagine how many personal visits we made to legislators, how many letters we wrote and all the efforts undertaken throughout the years to make this happen. It's been a long process that has involved many great people. A key person through this process has been Ed Sullivan, who is one of the staff members at AAA. Ed stayed on top of this issue, kept in touch with the lobbyists, and made sure that everyone was always aware of what was going on. Having key people stay on top of an issue like this is very important, especially with a primarily volunteer organization like AAA. Having Cheryl Kreider Carey as executive director for many years has also ensured that this vision was kept alive.

Getting an appointment to discuss our concerns with the US Department of Labor is much more complicated than simply calling and making an appointment. There are only certain times in certain years that either the public or professional organizations are allowed to comment on the Occupation Handbook. We had to follow a procedure, and part of that procedure was getting onto the Department of Labor's agenda. That's where persistence came in. It was our volunteers and their persistence that ensured the lines of communication stayed open between the academy and the government agencies. Once we were recognized as an organization with a concern, and made it on to their agenda, when the government was available for us to give our input they contacted us and let us know. The Academy and its volunteers kept their eye on the ball. If they hadn't, we would still be listed under "S" for Speech Language Pathology and Audiology, and the bottom line is that we would have no power at all to serve the people we are meant to serve.

The Department of Labor has since reorganized the Occupation Handbook, so the Handbook isn't laid out exactly the same way today as it was in 1995 and 1996. And in January of this year, thanks to the efforts of many, it was announced that in the SOC of 2010, audiology will finally be listed as a separate entity. Audiology will now be listed under the heading of Healthcare Practitioners and Technical Occupations and under a distinct subheading, under "A" for audiology. We will be now listed alongside many other professions that employ practitioners, such as podiatrist, pharmacist, dentist, and chiropractor, to name a few. This acknowledgement of our independence has allowed us to collect data that shows audiology as a very dynamic and desirable profession. Audiology is now more visible to guidance counselors and career counselors as well as to insurance agencies and legislators. This has been a critical step to the autonomy of audiology.

SMAKA: What benefit does audiology's increased recognition have on our ability to serve consumers?

FLEXER: As audiology has become recognized as the expert profession in hearing care, we now have our own point of entry into the service care arena, rather than relying on referrals from others. This allows us to be more visible to the public. The public has to know who we are in order to make the choice to utilize our services;you can't serve people who don't know that you exist.

Another benefit of audiology's increased visibility is that it is now easier to recruit new people into the profession. As young people search for careers that speak to their unique personality characteristics, more students may decide to become an audiologist before they enter college. Until recently we were essentially hidden in the shadow of speech pathology, so many young people who might have been interested in audiology didn't know the profession existed. Now that we're visible, we're seen as a valid choice for young people to make. This way we can recruit people from the get go rather than recruiting people from their studies in speech language pathology. Our primary recruiting pool has typically been undergraduate students with a Communication Disorders or Speech Pathology major. They'd have a course in audiology that would capture their interest and they'd find audiology to be a better fit for them. Audiology will still recruit people from speech pathology, but now with increased recognition we have a wider potential applicant pool. So, the increased visibility has helped audiology as a profession in more ways than many people realize.

As I mentioned, my current focus is with pediatric audiology and listening and talking. There's just so much going on now with children that makes it unbelievably fun and exciting to be a pediatric audiologist. The amazing difference we can make with children and their families makes everything we do worthwhile. For pediatric audiologists, for example, our position of independent practitioner gives us a much stronger platform and much more credibility with parents and other professionals. When we present our management recommendations for children with hearing loss, our newfound recognition and more credible credentials get us taken more seriously than ever before. So again, the increased recognition of audiology helps our profession on so many levels in countless ways.

SMAKA: Dr. Flexer, what else is needed for us to get to where we really want to be as a profession;what do you see as the next steps?

FLEXER: I think that we have the necessary structure in place now, but going forward there is still much to be done. Having the government recognize audiology with an SOC code was only the beginning step to complete professional autonomy. We need to utilize the structure as a springboard to get audiology recognized by insurance companies in order to be able to bill and be reimbursed appropriately. The government is looking at medical management and reimbursement, and potential universal healthcare coverage, which complicates matters right now. With our Au.D. degree we have a stronger intrinsic identity and extrinsic structure. We have strength and can bargain more effectively in terms of reimbursement and coding issues. Quality patient care is always most important, however reimbursement is what allows us to provide that quality care. This is why audiology has to be recognized by managed care agencies, in reimbursement agencies, and in legislative agencies - so that we can provide quality services to people with hearing loss.

SMAKA: Dr. Flexer, thanks for all your time with me today, explaining the SOC change for audiology, and why it's so great for our profession.

Where can I direct professionals if they want more information about your work?

FLEXER: You can direct them to www.carolflexer.com. Thank you for your interest and thank you for the interview, I appreciate it.

References

Cole, E.B., Flexer, C. (2007). Children with hearing loss: Developing listening and talking birth to six. CA: Plural.

Madell, J., Flexer, C. (2008). Pediatric audiology: Diagnosis, technology, and management. NY: Thieme.