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Where Do You Place Value?

Gifford, René H. PhD

doi: 10.1097/01.HJ.0000526528.99704.2d
Editorial

Dr. Gifford is the director of the Cochlear Implant Program, the associate director of Implantable Hearing Technologies, and an associate professor of Hearing and Speech Sciences at the Vanderbilt Bill Wilkerson Center in Nashville.

Digital and legislative disruptions are increasingly affecting audiology. In some instances, these disruptions have improved the quality of patient care, clinical efficiency, and documentation (e.g., digitally programmable hearing aids, computer-based audiometers, electronic audiograms, etc.). A recent legislative disruption—the passing of the Over-the-Counter (OTC) Hearing Aid Act of 2017 (HR 1652)—allows some adults with mild-to-moderate hearing loss to access hearing technology without audiologist oversight. Yet other aspects surrounding the digital hacking of audiology—most notably, automated assessments and OTC hearing aids—may leave us with an uneasy feeling about the future.

I'd like to draw an analogy between audiology and radiology. Both fields originated in the late 1800s, and are inextricably dependent on technology for professional operation. In radiology, the x-ray was discovered in 1895 by Wilhelm Röntgen. While the 2-D x-ray is still used diagnostically, its relevance has been slowly eroding in favor of multi-slice computerized tomography (CT), ultrasound, magnetic resonance imaging (MRI), and even 3-D. Radiologists are increasingly critical to the success of image-guided surgery, placing indispensable value on image processing and interpretation. Radiologists work closely with imaging scientists and are involved in all aspects of medicine, from family practice to neurosurgery. Thus, the value of radiologists is not in the tests or test administration, but in their knowledge, interpretation, and the interdisciplinary nature of their work. The ability of radiologists to compile comprehensive patient data to order the appropriate tests is critical to both patient care and health care economics.

Audiology diverges from radiology in its adoption of advanced measures, interdisciplinary practice, and the perceived source of professional value of audiologists. The audiogram was first described by Artur Hartmann in 1885 as the “auditory chart,” and still serves as the foundation of our diagnostic toolkit. In many cases, no specialized assessments beyond tympanometry may be completed, not even speech understanding in noise, despite that being the primary complaint of patients in an audiology clinic. While our field is closely tied with speech-language pathology and otolaryngology, it is rare that we engage in interdisciplinary practice with these colleagues. Furthermore, many audiologists and administrators have placed the source of our professional value on test administration and sale of hearing technology. However, like radiologists, our value is in our extensive knowledge of the auditory system and the effects of hearing loss on various aspects of communication and quality of life. Our value is in providing diagnostic accuracy, subsequent intervention, and verification and validation of recommended technology to ensure that patients reach their optimal auditory potential.

I hold an optimistic outlook for the future of this field if we can evolve professionally and recognize the source of our value. For example, only 50 percent of children who meet the CI criteria actually receive implants in the United States, compared with about 90 percent in Europe (Cochlear Implants Int. 2013;14 Suppl 1:S4). We need to increase our visibility and restructure our relationships with referring pediatricians, speech-language pathologists, otolaryngologists, and audiologists who may not work with CI recipients.

We are overdue for a reassessment of our role in hearing health care. If we place our value on pushing buttons or on the sale of a pair of high-end hearing aids, then we have reason for concern. In a world where there are striking differences between those who have embraced technology (e.g., Netflix, Apple) and those who have resisted change (e.g., Blockbuster, Tower Records), which side will we choose?

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