Share this article on:

Breaking News: Audiology's Struggle for Independence

Shames, Yonit; Simpson, Jennifer AuD

doi: 10.1097/01.HJ.0000414384.90116.b0

Ms. Shames is a fourth year audiology student at Purdue University in the department of speech, language and hearing sciences, and an extern at the Indiana University Medical Center in Indianapolis. Dr. Simpson is the director of clinical education in audiology, and a clinical associate professor in the department of speech, language and hearing sciences at Purdue University.

The healthcare reform debate has brought familiar issues to the table — high costs, the growing number of under- or uninsured, an expanding underserved population — but these are far from the only topics being pondered. The conventional doctor-centric model of healthcare is also being questioned in favor of collaborative, patient-centered care, creating an opportunity for auxiliary healthcare professionals to gain more responsibility.

Audiology, one of the newest additions to the nonmedical doctoring community, has made astonishing gains in autonomy since its inception after World War II and, more recently, the creation of the doctorate of audiology. That autonomy is still in its infancy, but it shares many obstacles with other doctoring professions, such as chiropracty, physical therapy, and optometry, that hold lessons for audiology. (Figures 1 and 2.)

Several nonmedical doctoring professions require a doctorate as a prerequisite for practice, and that brings with it increased responsibility. Obtaining a doctorate comes with its own challenges, most notably a demanding set of degree requirements unique to each profession, and establishing public legitimacy, defining scope of practice, addressing discrepancies in state laws, and uniting the constituency have met different levels of success.

Back to Top | Article Outline


Chiropractors specialize in the musculoskeletal system, using multiple diagnostic techniques and treatments. Most states allow chiropractors to conduct imaging procedures, including magnetic resonance imaging, computed tomography, thermography, and x-rays, and to order laboratory tests. (J Neuromusculoskeletal Syst 1999;7[3]:102.)

Chiropractic care is considered complementary and alternative medicine, and also includes massage therapy, acupuncture, and naturopathy. Some organizations within chiropracty, however, have tried to bring it into the mainstream, particularly for pain management. Others have endorsed maintaining chiropractors' traditional role as a provider of holistic and alternative medicine. (Chiropr Osteopat 2008;29[16]:10.) Advocates for mainstreaming chiropracty believe it will preserve and increase its market share because its scope of practice overlaps with other healthcare professions. (Chiropr Osteopat 2005;6[13]:9.)

Chiropracty has helped create and maintain mainstream acceptance of other nonmedical doctoring professions (Chiropr Osteopat 2008;29[16]:10), most notably in public health initiatives, which bring to mind audiology's push for universal newborn hearing screenings. Audiology could also continue to advocate for hospital-based residencies, more clinical exposure, and more research. The profession has already seen success in many areas, including the majority of audiology graduate schools being within universities, most of them research institutions, according to the American Speech-Language-Hearing Association's EdFind, a search engine for degree programs in audiology, speech-language pathology, and speech, language, and hearing science. (See FastLinks.) Implementation of the doctorate in audiology has brought about many improvements in the profession, including a prerequisite for more clinical hours and research projects.

Back to Top | Article Outline


A master's degree is required to become a physical therapist, but more and more physical therapists are earning doctorates. (Indiana Physical Therapy Committee, 2009. Laws and Regulations; see FastLinks.) Physical therapy's autonomy battle is unlike chiropracty's; access to its services is the primary concern, not consumer demand or scope of practice. State laws for access to physical therapy range from unlimited direct access to no direct access. (Figure 3.) Restricted access is physician-controlled, and based on a traditional model of healthcare. (Phys Ther 2007;87[1]:98.)

This contrasts with the move toward newer, interdisciplinary models of healthcare that advocate collaborative relationships among professionals. This type of healthcare has been promoted for its ability to curb rising healthcare costs, reduce healthcare duplication and inefficiencies, reduce overuse of emergency departments, increase access to healthcare services, and manage complex medical conditions better. (Health Sociol Rev 2006;15[5]:481; J Allied Health 2007;36[2]101.)

But physician-centered healthcare systems turn a disability into a medical problem rather than allowing physical therapy and audiology to address impairment. Many states require physician diagnosis or supervision to varying degrees, if not direct referral, for physical therapy, emphasizing medical diagnosis of underlying pathology. The effect is that no distinction is drawn between physical impairment and degree of functional impairment. (Phys Ther 2007;87[1]:98; Disability Studies Today. Cambridge, UK: Polity Press; 2002.) This is similar to marginalizing the consequences of hearing loss in favor of only treating the underlying medical cause.

Evidence shows that patient-centered care improves outcomes and addresses disparities in the healthcare system. The current medical system, however, may penalize patient-centered practices such as counseling in favor of physician-centered practices such as ordering a full spectrum of laboratory tests. (Arch Intern Med 2009;169[17]:1551; Acad Med 2001;76[6]:598; Health Aff 2010;29[8]:1489.)

Current trends point toward a more collaborative healthcare model, and like physical therapy, audiology has the opportunity to establish itself as an essential member of a fiscally efficient team. Access restrictions to audiology, however, remain a significant barrier.

Back to Top | Article Outline


Unlike chiropractors and physical therapists, optometrists enjoy a uniform, independent scope of practice across the United States. Optometry is arguably the most successful nonmedical doctoring profession to expand its scope of practice. Optometry has a function-oriented mission like physical therapy and audiology, rather than a disease-oriented one, but its autonomy is more developed despite its direct competition with ophthalmology. Optometry's success has been a function of four cornerstones: (Optometry 2004:75[6]:341.)

• Education must precede legislation. This helped optometry gain diagnostic and therapeutic drug prescription privileges, which were preceded by comprehensive pharmacologic education requirements. Audiology is well on its way in this; the requirements for the doctorate of audiology cover many topics, including aural rehabilitation, even though audiologists cannot bill for this.

• Change in scope of practice legislation is more likely to come from state associations than from national organizations. The American Optometry Association initially opposed expanding optometry's scope of practice, even threatening state-level organizations that sought to increase prescription privileges, but pressure from these organizations slowly shifted AOA's position. This suggests that audiology should not depend on its national organization to change its billable scope of practice.

• Improved access is the strongest argument for expanded authority. Optometrists established themselves as the go-to vision care providers with particular emphasis on rural and small communities without ophthalmology practices. Audiologists should establish themselves as the first-line hearing healthcare providers.

• Support from professional groups with no direct financial interests, such as the American Public Health Association, significantly bolstered public interest. APHA legitimized optometry's efforts and helped garner public support for expanding its scope of practice. Audiology should form similar partnerships with public interest groups.

Back to Top | Article Outline


The American Medical Association publicly devalued audiology's degree and training, stating that physicians should be the primary entry point of care for all hearing impaired patients. (American Academy of Audiology, 2009. Response to the AMA Scope of Practice Data Series: Audiologists; see FastLinks.) Most hearing loss is genetic, related to noise exposure, or a result of the aging process, all of which are not yet medically treatable. (Harvard Medical School Center for Hereditary Deafness, 2004. Common Causes of Hearing Loss; see FastLinks.) Hearing loss is considered a functional problem rather than a medical one, and audiologists are better trained on its effects than family physicians. Audiologists may also be more accessible and cost efficient than ENTs. (Table.)

Audiology has established itself as a legitimate, evidence-based profession. It curricula is science-based, and has taken the lead on several public health issues, particularly newborn hearing screenings. The profession also has defined its scope of practice through independent organizations. But audiology is left with challenges that threaten its development as an independent doctoring profession. Audiologists cannot bill for many of the services they are trained to provide, leading to poor education and a limited selection of patient services.

Medical doctors still dominate the scope of practice because of legislative and insurance conventions, and patients may still fail to recognize audiology's potential role in treating hearing loss. Trends point toward more patient-centered care, and audiology is in a prime position to overcome these challenges, particularly on the legislative front, but the profession will need to work aggressively to increase its public standing and legitimacy and be prepared to provide concrete evidence of enhanced holistic patient outcomes and better cost-to-care ratios and accessibility than doctors.

Back to Top | Article Outline


* Use ASHA's academic search engine at

* Read more about Indiana's Physical Therapy Committee at

* View AAA's response to the AMA at

* Harvard's common causes of hearing loss document is available at

* Click and Connect! Access the links in The Hearing Journal by reading this issue on

* Comments about this article? Write to HJ at

* Follow us on Twitter at

© 2012 Lippincott Williams & Wilkins, Inc.