While it's unmistakable that there's a shortage of pediatric audiologists in the United States, quantifying exactly how many pediatric audiologists are needed, and where they're needed most, has proved difficult.
“Everyone complains that, especially with the implementation of universal newborn hearing screening, it's very difficult to get an appointment with a good pediatric audiologist,” said Yvonne Sininger, PhD, professor emeritus and past director of the Auditory Research Laboratory at the University of California, Los Angeles.
“Although there is a lot of talk, there is not a lot of data, especially because each state manages its own data along that line.”
Getting to the root of the problem could help the field move closer to a solution. What does seem clear so far is that the shortage of pediatric audiologists is a regional issue.
Near specialty hospitals and major medical centers, like UCLA or Boys Town National Research Hospital in Omaha, NE, parents seeking an appointment for their child won't have to wait too long to see an audiologist.
“We can usually get patients in within a week,” said Ryan McCreery, PhD, who writes one of The Hearing Journal's pediatric audiology columns, “Building Blocks,” and is associate director of audiology and staff scientist at Boys Town.
But when he worked at Mary Bridge Children's Hospital in Tacoma, WA, the wait tended toward six weeks. And in more far-flung areas, the lag can be even longer.
“I've heard many colleagues report much more significant delays in getting patients in, on the order of two or three months,” Dr. McCreery said.
That's a major concern, he added.
“We could be delaying the identification and management of hearing loss in kids. Research has suggested that waiting time for an appointment is one of the most significant reasons that early diagnosis of hearing loss and fitting with hearing aids are delayed.
“At worst, this could put us in a situation where we finally have universal newborn hearing screening, but we are still not identifying kids because we don't have the capacity to do assessments and fit aids.”
FIXING THE SYSTEM
The search for factors behind the pediatric audiologist shortage creates a complex picture. Some of the backlog of patients in certain areas may be attributable to the way the screening system is organized.
In California, for example, a newborn who fails the in-hospital screening must have a second screening test before being scheduled for a diagnostic examination.
“An appointment for a quick screen is much easier to get than an appointment for a whole diagnostic test,” Dr. Sininger said.
The second screen eliminates a number of newborns who had fluid in the ear or some other temporary middle ear problem shortly after delivery that caused their failing result, cutting down on how many babies need a lengthy and more difficult-to-schedule diagnostic exam with a pediatric audiologist.
Then there's the matter of what screening tests are used. Otoacoustic emission (OAE) testing is easy and inexpensive, but it also has a significant false positive rate, reported to be anywhere between 5 percent and 21 percent.
“Many babies comes out of the hospital with false positives and need a follow-up exam, putting a lot of pressure on the system,” Dr. Sininger said.
Auditory brainstem response (ABR) testing, on the other hand, is much more precise, with about a four-percent false-positive rate.
“At a really good hospital, you should be seeing about a two- to three-percent failure on the newborn screen,” Dr. Sininger said.
“If a hospital has a 10-percent fail rate, they're either less experienced or they're using OAE and getting a lot of false positives.”
‘NOT A MONEYMAKER’
Simply cleaning up the screening system, with more thorough training and more consistent use of ABR instead of or along with OAE, could help reduce the workload for the existing workforce of pediatric audiologists, but such measures alone won't completely solve the problem.
Regional concentration is a particular challenge for pediatric audiology. Unlike general audiologists or geriatric audiologists, pediatric audiologists, especially those with the American Board of Audiology's Pediatric Audiology Specialty Certification, are almost exclusively found practicing within specialty centers and hospitals like Boys Town.
Because of the costs and time involved in the delivery of pediatric services, it's much harder to make a living in private practice as a pediatric audiologist than it is as an audiologist serving the adult population.
“It costs a lot to see children,” Dr. Sininger said. “You spend a lot of additional time on counseling and rescheduling appointments because the baby won't cooperate.
“It's not a moneymaker, either for medical centers or an audiologist in private practice, but the medical centers have the capacity to absorb it. An individual practitioner doesn't.”
SPECIAL EXPERTISE CRUCIAL
Audiologists who primarily see adults do not necessarily have the skills or experience to handle pediatric patients.
“Some of the things you do with adults can translate to children, but much of it cannot,” said Patricia Chute, EdD, dean of the School of Health Professions at New York Institute of Technology.
“Fitting a hearing aid on a 25-year-old is very different than fitting an aid on a one-year-old. One of them can tell you what he hears, while with the other one, you have to observe and get feedback from parents.
“If you're not accustomed to looking for some of these smaller responses, you can miss them and over-fit or under-fit as a result.”
Seeing a provider without specialty pediatric training could actually prove harmful, Dr. McCreery said.
“If a baby fails newborn screening and goes to a clinic without pediatric expertise for a rescreening, the infant could pass erroneously. If you don't see kids a lot, that's an easy mistake to make.”
In research soon to appear in the American Journal of Audiology, Dr. McCreery and his colleagues report that an inaccurate “normal” screen in the wake of a failed newborn test is one of the primary reasons hearing loss diagnosis and treatment are delayed in children.
“Even if the parents might have suspected hearing loss, a normal assessment could cause the parents to doubt,” he said. “Then they come back when the child is two years old and not talking.”
Unlike medicine and nursing, audiology does not have federally sponsored forgiveness grants and loans to entice providers to pursue a career in an underserved subspecialty or community.
“The cost of becoming an AuD has increased, so people really have to think twice,” Dr. Chute said.
One approach that may help draw more Doctor of Audiology students into pediatric audiology is LEND (Leadership Education in Neurodevelopmental and Related Disabilities), a federally funded program that, since the 1950s, has provided graduate-level education concurrent with clinical training in several disciplines.
In 2009, the Health Resources and Services Administration (HRSA), in conjunction with the Association for University Centers on Disabilities (AUCD), funded the first nine LEND training programs aimed at pediatric audiology; two more were added in 2011.
Although the LEND sites, like many pediatric audiology programs, are located within major medical centers such as the University of North Carolina at Chapel Hill and Vanderbilt University, the training and experience they offer may give audiology students the confidence to strike out on their own to expand pediatric audiology in more underserved regions.
“We should try to focus on getting more pediatric experiences such as these for AuD students,” Dr. McCreery said. “The specialty center of excellence model cannot serve every child.
“There are a lot of places where there's not a pediatric center available for miles. If you're out in the middle of Wyoming, where I grew up, it's not feasible for you to drive five hours to Denver on a regular basis to see a pediatric audiologist.
“Another possibility may be to create another tier of pediatric audiologists with a more limited amount of experience to support kids in these areas and then refer to the specialty centers for more complex things like ABRs.”
Audiology programs could also help AuD students understand the appeal of the pediatric side.
“We don't face the same threats that our profession faces in seeing adults,” Dr. McCreery said. “There are chiropractors and physical therapists vying for our patient base in vestibular; for adult and geriatric, there are hearing aid dispensers and Costco and the Internet.
“Pediatrics is one of those areas where no one else wants to fit hearing aids on kids, or do ABRs and hearing assessments.
“It's a paradox to me: it's something that we have the expertise and training to do that is incredibly unique. I'd think there would be more interest.”
HELP FROM AFAR
Until and unless the pool of specialty-trained pediatric providers can be expanded, teleaudiology is likely to play a key role in meeting the needs of many pediatric patients.
“It's already been shown that you can map these kids with a remote interface,” Dr. Chute said.
A number of remote cochlear implant programming efforts have proven successful, including projects sponsored by Utah's Intermountain Healthcare and Australia's Sydney Cochlear Implant Center.
“Of course, one of the most important aspects of audiology for any age group is the amount of counseling you have to do with patients,” Dr. Chute noted.
“With cochlear implants, each minute of testing equates to about five minutes with parents helping them understand. Can we do telerehabilitation? I think we can, but that hasn't been fully explored yet.”
Beyond teleaudiology, consulting relationships between specialty pediatric programs and more general audiology practices can help to fill the gaps.
“Although we are the center of excellence in our area, there certainly are other clinics that see children, and we have a collaborative approach with them,” Dr. McCreery said.
Boys Town offers an annual community workshop for general audiologists interested in learning more about pediatrics, which usually draws about 30 to 40 professionals.
Another more hands-on offering—which this year focused on infant diagnostic assessment and ABR, and in past years has covered pediatric amplification—usually gets about 10 to 20 participants annually.
“As pediatric audiologists, we have to make this topic more interesting for general audiologists,” Dr. McCreery said. “We can't just keep preaching to the choir. We don't own the pediatric patients, and we can't see all of them.”
THE AUSTRALIAN APPROACH: GOVERNMENT-FUNDED PEDIATRIC AUDIOLOGY
For an example of a truly comprehensive approach to meeting the needs of children with hearing loss, the United States might look to Australia.
There, all children and young adults with permanent hearing loss under age 26 receive services from a government-funded national provider, Australian Hearing, which sets protocols for the entire nationwide network of Australian Hearing centers.
“They also receive high-quality technology, including hearing aids, FM systems, upgrades to cochlear implant processors, and related technology, at no cost to the families,” said Teresa Ching, PhD, senior research scientist at National Acoustic Laboratories (NAL).
“The NAL is the research arm of Australian Hearing, so research findings directly feed into evidence-based practice.”
Australian Hearing is generally well supplied with pediatric audiologists, thanks to the specialty training provided.
Newborn hearing screening using automated auditory brainstem response (AABR) testing or a combination of otoacoustic emission and AABR testing was rolled out throughout the country about two years ago. Following confirmation of hearing loss, which is conducted mainly through hospital and community specialist audiology services, the national coverage from Australian Hearing permits every child diagnosed with a hearing loss to be seen by a pediatric audiologist.
“Because we have a dispersed population and because congenital hearing loss is a low-incidence condition, some families have to travel considerable distances to access services,” noted Alison King, Australian Hearing's pediatric manager.
Like the United States, Australia is looking to teleaudiology to improve support to families in more remote areas.
The country is also pursuing distance learning to expand the pool of pediatric audiologists who might be willing to practice in those areas, since most audiology training is currently based in the capital cities.
“We are beginning to see exciting changes in the educational field, with online learning through HEARnet established under the Australian Government's Cooperative Research Centers Program, HEARing CRC, and collaborations between agencies like the Royal Institute for Deaf and Blind Children and the Victorian Deaf Education Institute providing training that can be accessed in person or via video conference,” Ms. King said.