Interview with David Fabry Ph.D., President-Elect American Academy of Audiology
AO/Beck: Dave, thanks for your time this evening. We're very pleased to have you here and to have you share your thoughts and concerns with us.
AAA/Fabry: I'm delighted to be here.
AO/Beck: Dave, tell us about your professional and educational background please.
AAA/Fabry: I've been the head of the Audiology Section of the Department of Otorhinolaryngology at the Mayo Clinic in Rochester, Minnesota since 1994.
I have 'three degrees below zero', in that I received my Bachelor's Degree in Psychology in 1981, Master's Degree in Audiology 1984, and Ph.D. in 1988, all from the University of Minnesota in Minneapolis.
AO/Beck: Let's start with the Au.D. As you know, we have an article we're running from my colleague Delbert Ault. Del is the President of NAFDA and of course NAFDA is the National Association of Future Doctors of America. In his article, he points out that by September 2000 some thirteen-percent of all audiologists in the USA will be graduates of, or enrolled in Au.D. programs. What are your thoughts on that statistic?
AAA/Fabry: I think it's impressive that the Au.D. movement has taken such a firm hold on the profession so quickly and it is certainly impacting all aspects of the profession from education to daily practice. I think the growth of the Au.D. demonstrates that the profession and the training programs realize the doctoral level is the right entry level for us. There is also a political issue within the healthcare system which requires the doctoral level degree to help us obtain the limited license practitioner status which will allow us to bill independently for our services. This is an important foothold which we must achieve to survive and thrive as professionals in the healthcare system.
AO/Beck: Dave, who is it that issues the limited license practitioner (LLP) status? And what must we (as a profession) do to obtain LLP status? Who initiates the LLP status?
AAA/Fabry: The Health Care Finance Administration, which oversees both Medicare and Medicaid, regulates 'limited license practitioner' status. Limited license practitioner status is critical to audiologists' efforts to gain recognition as entry level providers of hearing health care. In order to achieve this objective, services provided by qualified audiologists within their legally defined scope of practice need to be considered as 'if provided by a physician'. Currently, audiologists need physician supervision (and their UPIN number) to receive payment for many services covered under Medicare and Medicaid. Those familiar with the 'any qualified provider' language found in insurance reimbursement laws will recognize the importance of that phrase for reimbursement directly to audiologists for the services they provide. In order to accomplish this, we need: 1) the entry-level doctoral degree, 2) Standard Occupational Classification (SOC) codes changed to classify audiologists into the appropriate diagnosing and treating category appropriate for our profession, 3) consistent Medicare and Medicaid statute definitions for the term 'qualified audiologist', and 4) better representation on HCFA committees and panels. These tasks are formidable, but not insurmountable.
AO/Beck: All right, what are the other immediate and short-term goals?
AAA/Fabry: HR 1068 is critically important to the profession right now and I think we have at least 14 co-sponsors for the bill. As you know, currently there is discrepent language between the Medicare and Medicaid legislation. ASHA was very wise a number of years ago to get excellent wording and support for the Medicare definition of what an audiologist is. ASHA recognized then that the basis for practice in audiology would go away from national certification and move towards state licensure, just as it is for dentists, physicians etc. HR1068 is an attempt to use a previously established and consistent definition of an audiologist across both Medicare and Medicaid legislation. This is critically important. If we're going to make headway across HCFA and become LLPs, we need to clearly and unambiguously define what audiologists are across federal legislation.
AO/Beck: Getting back to the Au.D. issues, how many Au.D. programs do we need across the USA?
AAA/Fabry: My personal feeling is that we would be well served by about one program per state. Obviously denser populations and demographic variables will impact the final number, but probably 50 programs would be quite enough. We don't want to reinvent the current situation where we have over a hundred programs, some with only two or three audiology graduate students. In my opinion, we don't really want tiny programs out there as they cannot afford to have the equipment and labs (to say nothing of patients) required to appropriately educate doctors of audiology. We are an equipment intensive profession and the equipment is very expensive. If you have only a handful of students (or less), you simply cannot afford ABR equipment, dedicated hearing aid equipment and computers for digitally programmable and digital hearing aids, OAE equipment, miscellaneous electrophysiologic devices - to say nothing of vestibular test equipment, cochlear implant computers and the appropriate tune-up systems, audiometers, immitance units, and on and on. Our students need access to audiologic state-of-the-art equipment. When you look at optometry and veterinary medicine they have some 20 to 25 programs across the country and those seem like reasonable models for us.
AO/Beck: It seems like so many of the up and running programs are already so far behind in equipment acquisition and integration that the students are at a big disadvantage. I understand many of the programs depend on the externship sites to fill these gaps, but exposure is still terrifically limited regarding modern diagnostic equipment. I think you and I both know that some programs still use their Bekesey Audiometry units and these are not only dusted off for demonstration purposes - but indeed used for diagnostic purposes. They may have been marvelous machines with marvelous ability, but I'd certainly rather have students exposed to ABR, OAE and immitance as the backbone of their differential diagnosis.
AAA/Fabry: Yes, many training programs are hurting regarding their ability to expose, teach and integrate modern equipment into their diagnostic protocols. Let's face it, for 50 years we've been trying to eliminate the behavioral puretone threshold as the be-all and end-all of diagnostic audiometric testing. Puretone testing is very important but we're at the point where OAE and immitance are becoming incorporated into the standard of care for diagnostics. Additionally, we currently have the ability to differentiate some outer hair cell abnormalities and soon we'll be able to differentiate inner hair cell abnormalities through psychoacoustic and electrophysiologic measures. In five to ten years I think it'll be common to describe separate inner and outer hair cell function through objective measures. I think we're actually that close.
AO/Beck: What do you think our options are regarding having enough licensed audiologists to fill the needs over the next 5 to 10 years?
AAA/Fabry: Admittedly, this gets us into a can of worms. We are so highly educated, and so few in number, that we need to think about how we can train 'techs' or 'support personnel' to do the basic tests, while we manage patients and do more sophisticated and diagnostic tests. We need to explore large scale support personnel to better meet the needs of escalating health care costs and to meet the needs of the population we serve. There are simply not enough audiologists to do all of the NICU and Universal Newborn Screenings that need to be done.
AO/Beck: Dr. Luterman at Emerson has long pointed out that we are certainly capable of identifying nearly 100 percent of the children with hearing loss. In fact he states that in some respects, the issue is no longer identification - it is indeed management. That is, we can certainly identify the kids, but the weightier issue is who is going to manage them regarding hearing aids, counseling, rehab and cochlear implants? We simply don't have enough audiologists trained in pediatric amplification, family and patient counseling and related areas to do an appropriate and excellent job in this important arena. What do you think about these issues?
AAA/Fabry: I couldn't agree more. Remember, I am married to a pediatric audiologist who specilizes in early identification of hearing loss! Identification is but the first step in a continuum of audiologic care. We certainly need to work with the parents, the family and the caregivers to help them through the grieving process relating to the loss of their perfect baby and we need to manage these people to the best of our ability. Additionally, one of the goals is (and should be) to have identified children fit with amplification through hearing aids , FM systems or cochlear implants - within six months of identification, and certainly before they reach their first birthday. We now have the research data to support these goals.
AO/Beck: Dave, one of the 'new' ideas I've heard and read a lot about is the 'match program' for fellowship experiences - rather than the current non-scripted program. Can you elaborate on this?
AAA/Fabry: The match programs which we're developing are somewhat analogous to the medical model for residency experiences. The idea is that institutions and candidates would in essence work through the AAA to market 1- the availability of the program and 2- the availability of the new graduate. Then, the candidate would apply to the institution, and if the institution and the candidate found each other to be worthy, they would negotiate a mutually binding contract. The primary idea here is to increase the competition and to better match the best institutions with the best candidates. It's in essence a 'win-win' scenario but it's only in the incubation stage now. The match program will help the student be ready and able to be ready to practice when they finish their programs. Additionally, the student and the institution would grade each other to help assure future generations that the outcomes of the training program are what they oughtta be regarding the depth and breadth of clinical experience.
AO/Beck: One issue for the current crop of students is the problem of earning a master's in an environment which clearly embraces the doctorate. What can you suggest to the folks who are entering their MA/MS programs this fall regarding their credentials?
What is our responsibility to these students?
AAA/Fabry: This really is a very significant issue. I think the primary issue may well be the lack of information these students have been provided through their educational programs regarding the existence, importance and reality of the Au.D. programs. There has almost been a conspiracy of silence among these programs and the students are the ones who will be impacted by this. I know of one masters' program wherby the program director has stated 'I'll match my masters' students against any Au.D. student' as if it's a physical fight or some other nonsense. Clearly this fellow has missed the point entirely. We're not looking for an individual Olympic event - we're looking to continue the transformation of the profession to a doctoring profession. The decision has been made, the fight is over. AAA and ASHA and ADA all endorse the Au.D. as the entry level of practice by 2007. There are many doctoral programs and there will soon be many more. The masters' programs are our history, the doctoral programs are our future. My advice is that the current crop of students and the current MA/MS practitioners should definetly get involved and learn about their educational opportunites and responsibilities to help transform themselves and their profession into a doctoring profession. The issue is not about losing your job if you don't get the doctorate. Rather the issue is, you'll need the Au.D. in the very near future to be competitive.
AO/Beck: Is the Au.D. the only doctorate which is acceptable?
AAA/Fabry: Not at this time and probably not in the future either. The Au.D. is the unifying degree. It is our ultimate clinical/professional designator. However, we certainly want and need to promote the research degree (the Ph.D.) and some universities and colleges will go to a Sc.D. or a 'clinical Ph.D.' for their clinical/professional designator. I have no problem with that in the short term. I think we need to allow them to transition to a doctoral program within their specific situations and then we need to encourage and foster the transition of all clinical professionals to the Au.D. designator.
AO/Beck: Dave as you know, I'll be finishing my Au.D. courses at the University of Florida in a week or two and I'm curious to know whether you'll personally consider getting an Au.D.?
AAA/Fabry: In reality, the work that I do on a daily basis is more reflective of an AuD than a PhD, but the AuD was not available when I was in school. That said, I feel that the experience that I gained as a doctoral student at the University of Minnesota prepared me in so many ways that extend beyond research. There were no real-ear measurements or otoacoustic emissions systems in clinical use when I was a masters' degree student, and yet I use them both routinely now. In my opinion, one of the best things about education is that it prepares us for lifelong learning. I can't see that I will enroll in an AuD program for the next couple years, but after that I certainly would consider it. Hopefully, an old dog can learn new tricks, and plus then I would get to be a 'paradox'.
AO/Beck: David, thanks for all of your time this evening. I think we covered a lot of ground here and I hope we can do this again once you've assumed the AAA presidency.
AAA/Fabry: Thanks for letting me voice these opinions and concerns and we'll certainly get together again.
