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Compound variables continue to cloud AuD extern landscape

Bloom, Sara

doi: 10.1097/01.HJ.0000396584.52118.22
Cover Story

In 1994, Tabitha Parent was one of three master's degree students to enroll in the AuD program at Baylor University, the first institution in the nation to offer the clinical doctorate in audiology. Much has changed in the interim 17 years: Tabitha Parent is now Tabitha Parent-Buck, AuD; her student days behind her, she is associate professor and chair of audiology at the Arizona School of Health Sciences; Baylor's AuD program is now one of some 70 such programs throughout the country; the two-year master's program in audiology has been abolished; and students entering the field must be prepared to study for four years, not two, now that the clinical doctorate is the entry-level degree in audiology.

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What has not changed in this span of time, though, is debate over the academic and clinical requirements to earn the AuD, particularly the handling of the externship that is built into every candidate's final year of study. For insight into this thorny issue, the Hearing Journal consulted university professors, the major professional organizations representing the discipline, and preceptors — audiologists who volunteer to absorb into their practices or other hearing service settings, one or more fourth-year students for the entire academic year, supervising this intensive clinical experience.

What HJ learned is that opinions on the efficacy of the externship program vary widely. For example, Parent-Buck says externships are, “A unique opportunity to support up-and-coming practitioners,” while Vic S. Gladstone, PhD, chief staff officer for audiology at the American Speech-Language Hearing Association (ASHA), says they are “Not necessarily a good thing.” And still, a dissident Ian Windmill, PhD, professor and chief of the Division of Communicative Sciences at the University of Mississippi Medical Center, wonders “Should we just scrap it and start over?”

This article will look at the issues that make the externship requirement so controversial, and explore what is being done to resolve them.

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INCONSISTENCIES PRODUCE WIDE-RANGING RESULTS

Parent-Buck admits to concerns she harbors as a result of inconsistencies in the AuD program in general, and the externship year in particular. True, not every AuD program is organized in the same way, but that's to be expected in any academic discipline, she points out. In the end, as long as universities graduate “solid, well-rounded audiologists,” she says, their methods can and should be their own. Her major problem with inconsistency concerns the externship year and how the sites are identified and monitored.

Some universities, like the Arizona School of Health Sciences, are totally involved in the process, she says, explaining that a clinical coordinator is responsible for approving, supervising, and sometimes identifying externship sites for the approximately 12 fourth-year students in her school's 50-student AuD program. Students may have a particular geographical preference, or a certain specialty within the scope of practice that they want to focus on, but the clinical coordinator is the last word on each student's placement, Parent-Buck says.

Anne Marie Tharpe, PhD, agrees that fourth-year students are just that — students — and as such, need the university's guidance in identifying quality and worthwhile placements. From a list of partnerships provided by the Department of Hearing and Speech Sciences at Vanderbilt, where she is professor and chair and also associate director of the Vanderbilt Bill Wilkerson Center, the school's eight or 10 fourth-year students in the 40-student program can prioritize their top choices. But it is the university that will make the initial contact and confirm that a position is available, she says. Externship sites in Vanderbilt's program vary from children's and VA hospitals, to private practices, and even other university programs, where students may be exposed to “a different cultural mix or a clinical or research experience in keeping with individual interests,” Tharpe says.

Other universities may leave much of the externship site legwork to their students, raising concerns that a site selected by a student may provide a quality teaching-learning environment, but it may not be an ideal site for that particular student— meaning it may not capitalize on that student's strengths, or fulfill that student's needs, both Parent-Buck and Tharpe say.

For instance, Parent-Buck says she's heard that some practitioners may get a cold call from a student, who says he or she is looking “for a job” to fulfill the externship requirement, explaining further that the audiologist's name was found in the phone book. In the first place, Parent-Buck says, the externship is not a job; it is clinical training for which the student cannot expect to be paid. Some sites do pay a small stipend to help with expenses, but in no way is the externship year to be considered as employment for pay.

Secondly, the student has no way to know whether or not the site will provide an acceptable learning environment, one that will augment the student's knowledge and skills. Windmill agrees. “It's more important for students to find the best opportunities for clinical experience,” he says, “but left to their own investigations, this may not be the end result.”

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NOAC'S SPECIAL ARRANGEMENT

A different experience is in store for students enrolled in the Northeast Ohio AuD Consortium (NOAC) program, a merger of the audiology programs at the University of Akron and Kent State University. In addition to the combined programs, where students are taught by professors from both universities, NOAC has an arrangement with the Cleveland Clinic, which accepts seven externs each year. The advantage, says Sharon Lesner, PhD, professor of audiology at Akron and coordinator of NOAC, is that students “stay close to home and train with world-class clinicians in every discipline.”

Lesner acknowledges that because academics are not always the best clinicians, the externship allows students to apply their theoretical, classroom learning in a professional, clinical environment. “And because we work so closely with the Cleveland Clinic, we are familiar with their high expectations, just as the clinic is familiar with our teaching methods and strengths,” Lesner says.

“We can make suggestions to the clinic regarding practical experiences for our students, just as the clinic can recommend adjustments in the academic program to correspond to the proficiency they require.”

NOAC is one of the largest AuD programs nationally, with 82 students currently enrolled, typically about 20 in each class. As part of the NOAC arrangement, all 20 fourth-year students interview at the clinic; those not chosen for that rotation are helped by the two universities to find other approved sites in the region, including hospitals, private practices, and VA hospitals. While some universities allow their students to select sites based on geography, the NOAC program frowns on that, preferring that students complete their externship at nearby sites, known to the universities for the quality of their supervision.

Craig Newman, PhD, is head of the audiology section at the Cleveland Clinic. He, too, praises the NOAC arrangement for its close monitoring of the clinical progress of its students by an involved faculty, and a familiarity with the academic program by preceptors trained to work with students and move them to the next level of their training. “Other preceptors may not have this insight,” he says, distinguishing the NOAC arrangement from other clinical sites around the nation. “We take only seven students so that no one gets shortchanged,” Newman says, pointing out that each student is always with one of the seven audiologists on staff.

Newman calls the fourth year of study “a year of polishing.” Students may start out only observing, he says, but by the time the rotation is complete, they will have been exposed to more advanced teaching, such as intraoperative monitoring, tinnitus management, and cochlear implants. There is also an academic component to the clinical year, calling for PowerPoint presentations and reports. “It puts a lot of stress on the students, but it is good preparation for their careers,” Newman says.

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THE ISSUES WITH EXTERNSHIPS

Academic freedom

Windmill points out that the clinical experience for the two-year master's degree in audiology varied according to the school the student attended. One of the goals of the AuD was to make the program more uniform as well as more rigorous. The externship intended to bring together a student's academic and clinical training as part of the formal program of study, unlike the master's program, which called for a clinical fellowship year (CFY) following the awarding of the degree. Designers of the AuD felt that the change was more in line with other professional degrees, like optometry and dentistry.

Nevertheless, Windmill, who is chair of the recently formed Accreditation Committee for Audiology Education, an independent agency governed by the U.S. Department of Education that reviews only audiology programs, not audiology as well as speech pathology as does ASHA's Council for Academic Accreditation, sees serious problems with the externship program as it currently exists. Specifically, he wonders whether or not a year away from a student's academic institution is beneficial.

Windmill explains that his committee looks at outcome—“the results of problem-based learning,” he says, and he questions whether externship sites can be expected to provide better skills than would be acquired in the university setting. “Universities are hamstrung by these externships,” he declares, explaining that because licensing laws required the CFY for master's degree holders, AuD programs built an externship into the curriculum. Affirming Parent-Buck's thoughts on the subject, Windmill says that academic programs “should have the freedom to train students in ways that allow them to learn, and the flexibility to choose from the many avenues available to accomplish that.”

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The C's

Another major hurdle centers on ASHA's Certificate of Clinical Competence in Audiology (CCC-A), known as “the C's.” In order to qualify for that certification, students must train for 1,820 hours under the supervision of an audiologist who holds the C's. Tharpe insists that her faculty audiologists at Vanderbilt, as well as the university's preceptors “have that metric to indicate a level of competence,” she says. But in fact, many practitioners and university faculty have allowed that certification to lapse, or maybe they never bothered to apply for it. For instance, neither Parent-Buck nor Windmill currently has C's. Nevertheless, about half of the nation's AuD programs require that preceptors have them—a situation that severely limits the number of eligible extern preceptors in some regions.

“Do C's make a student more marketable?” Parent-Buck asks. “It's hard to say, but we want to give our students every opportunity, which makes practitioners without C's virtually ineligible as preceptors, even though they may demonstrate excellent teaching skills in desirable settings.”

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Length of rotation

Another problem for Parent-Buck is the year-long rotation. When she was at Baylor, she took part in 10-week rotations for both years of her training. She says she enjoyed the variety of settings and experiences, but admitted to a lack of continuity, often not being able to complete patient follow-up to a treatment or hearing aid fitting. Longer rotations allow continuity, but sacrifice variety, she says.

Although Tom Goyne, AuD, owner of Aberdeen Audiology in Wayne, PA, sees value in the year-long externship experience for AuD candidates, the full-year commitment makes it impossible for him to participate. Goyne is an adjunct professor at Salus University in Elkins Park, PA, which means he is out of the office and unable to supervise an extern full time as required by the university. He does take second-year and third-year students for shorter rotations, working them in around his teaching schedule.

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Work for hire

Another problem for modest-size hearing care offices is finding enough for an extern to do, Goyne says. A one- or two-person practice may keep the principals busy and provide them with a comfortable working schedule and a profitable business. Add another full-time person, and there's likely to be a lot of down time, with not much to do, little to learn, and insufficient income to pay a worthwhile stipend. Bottom line, the length of the commitment and the size of many hearing care practices likely rule out participation by some audiologists, he says, further reducing the available pool of preceptors.

On the subject of money, depending on the site, some students may receive stipends or tuition credit or housing for the work they perform during the externship year, and some preceptors would like to be compensated as well for the time they contribute to the student's education. Windmill is not averse to the idea and suggests not money per se, but perhaps benefits in the form of continuing education or other incentive. Currently, with no standard “payment” for preceptors or students—some receiving compensation or value-added benefit and others nothing at all—the system seems unfair, he says.

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Medicare reimbursement

Another complication involves Medicare reimbursement. Hospitals cannot bill Medicare for services performed by an unlicensed employee or student, unless the student is within the line of sight of the supervisor. This cuts down on the duties an extern can perform and, as a result, the practical experience he or she will receive.

If an externship is supposed to be a learn-by-doing experience, externs have to be able to perform services beyond hearing screenings and aural rehabilitation, Windmill says, although in some settings, those duties are extremely helpful to busy practitioners and may fit into what the student envisions in his or her career. Some states issue temporary student licenses so that externs can participate in activities within the full scope of practice. On the other hand, if a licensed student makes an error or if a procedure or treatment goes terribly wrong, who is responsible? Should a preceptor be held responsible once the state licenses an individual? Should a student be held liable in a learning situation?

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MATCHING PRECEPTORS AND STUDENTS

With so many AuD programs nationwide, the competition for preceptor sites seems like a never-ending battle. So far, universities maintain that sooner or later students find sites for their fourth-year externships, although admittedly some of the placements may not be ideal matches for the student's needs or the preceptor's expectations.

Other factors that might make or break a relationship are the personality, initiative, and attentiveness of the extern, and the attitude and willingness of the preceptor. Students don't want to feel as though preceptors are taking advantage of free services or, worse, that they are doing students a favor by allowing them to participate in their practices. Similarly, preceptors don't want to feel unappreciated for their efforts, or worse, that students are just putting in the time until they graduate.

Identifying preceptor sites and, hopefully, circumventing some of the mismatches that can occur, represent some of the thinking behind the creation of the Web-based listings initiated by some of audiology's professional organizations. Just launched in August 2010, for instance, is the Academy of Doctors of Audiology (ADA) Extern Exchange (www.jobs.audiologist.org), an online resource where students can post resumes, and preceptors can post openings, says Stephanie Czuhejewski, executive director of the ADA.

“We're still getting the word out, notifying our members and university professors, and building the database,” she says. “We're hoping the site will serve as a modified career board, providing opportunities for students doing their own legwork.”

Goyne, chairman of the ADA's web committee, helped to develop the site. “I would see third-year students blindly sending out letters and combing the Internet for openings, and I thought there had to be a better way,” he says, conveying the impetus for the exchange. Goals for the project were ease of use, broad geography, and variety of experience. One of the distinguishing features of the site is the exchange concept, where preceptors can review student resumes, and students can see where openings actually exist, rather than squandering time trying to establish contacts with audiologists not eligible or not interested in mentoring a student.

About five years ago, the American Academy of Audiology established an online Externship Registry (www.audiology.org) that lists sites only, not students searching for sites.

The database is extensive and includes the names of hundreds of audiologists and the focus of each practice so that students can narrow their investigations to opportunities in the specialties they find interesting.

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VIEW FROM THE PRECEPTORS

To look at the externship from a preceptor's point of view, HJ chose a name at random from the ADA Extern Exchange and reached Mindy Brudereck, AuD, from Berks Hearing Professionals, LLC, in Elverson, PA. Brudereck has accepted students for short rotations in their second and third years, and once accepted a fourth-year student.

The ability of any student to “step in” depends largely on the student's comfort level in dealing with patients and in taking on the tasks necessary to run a practice, she says, noting that preceptors, in turn, must be willing to interview every student who applies in order to weed out those not appropriate.

“In my practice, I don't want to teach the basics; I have higher expectations,” she says, pointing out that if you take the time to “find the student who is right for you,” the role of preceptor is a good experience that does not take up more time than you are willing to give.

Deborah Price, AuD, owner of the Hearing Professional Center in Dallas, has twice been a preceptor for students from different universities. She finds it a “rewarding experience,” she says, to work with young people, to “fine tune” their education, and to see the “higher caliber” of students coming out of the AuD program than from the old CFY program. “I don't feel as though I'm babysitting for a year,” she says.

On the other hand, she found vast differences in how each of her students was prepared—one extremely capable, and one hardly beyond the basics. Price attributes the discrepancy to a lack of standardization in the university programs. Moreover, a poor experience as a preceptor discourages practitioners from continuing to volunteer, a situation that may account for the diminishing pool of preceptors, she says.

Price was president of the Audiology Foundation of America (AFA) when, after 21 years of existence, its board of directors voted to disband. “Our mission was to transform the profession from a master's program to the AuD, and we fulfilled that undertaking,” Price says. She acknowledges that preparation in the four-year AuD program far surpasses that of the two-year master's program, yet she feels the AuD program needs refining, an opinion shared by others within the discipline, according to a 2009 AFA survey.

Prior to its dissolution, and acting on a recommendation from the Conference on Professional Education II, held in fall 2008, the AFA surveyed more than 6,500 audiologists regarding their views of the AuD program (HJ 2/10). Based on a 15% percent response rate, the survey provided “a snapshot of current trends and a good platform for future discussions and opinions,” says Susan Paarlberg, who was then executive director of the AFA.

Of the externship program, comments often were critical: pay less attention to research and more to clinical skills; refine skills in university clinics, not off-site placements; establish standards among the various programs; apply greater rigor, commensurate with other doctoral professions; add more business skills.

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MUDDIED WATERS

Windmill stands ready to reconfigure the practicum aspects of the AuD, perhaps taking greater advantage of university clinics, where professors can be more watchful of their students. On the other hand, Gladstone insists that labs and simulations are “not the same kind of experience as real live patient-clinician exposure.”

Still, Gladstone is not convinced that the externship program, a fourth-year intensive experience, where a student is “shipped to some facility for a full year,” he says, fulfills that mission. Clinical experiences should be “infused throughout the four years,” he says. Moreover, “academic programs abdicate their responsibility if they leave the finding of a clinical site to the student.”

Despite recognition of the issues muddying the externship waters, the field is far from a consensus regarding the appropriate steps to revamp such programs. Just how this issue will sort itself out, no one can be sure.

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MATCHING MOTIVATED STUDENTS WITH INFORMED PRECEPTORS

Craig Newman, PhD, audiology section head at the Cleveland Clinic, holds a unique position in connection with the fourth-year AuD externship program. On one hand, he interviews about 20 students who apply for one of seven openings at the clinic each year. On the other hand, before he assigns any student to a supervisor—a preceptor— he requires his staff of audiologists, no matter how experienced or skilled, to take the how-to workshop he leads with Sharon Sandridge, PhD, “Becoming a Better Clinical Preceptor.”

Dr. Newman is, in a sense, a one-man matching program, selecting the most appropriate students for the clinic's program and staff, and assuring that those students will receive the best instructive experience the clinic can provide.

In the face of increasing demand for suitable externship sites, HJ asked Dr. Newman what qualities he looks for when interviewing students, and what expectations he has for preceptors. Perhaps these observations will encourage practitioners to volunteer their services and settings in order to increase the volume and potential variety of educational choices for students' externship year.

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STUDENT QUALITIES

The following list of qualities could serve as a guide for prospective preceptors as they interview students for their particular settings:

* Motivated to build clinical skills;

* Eager to build academic background;

* Strong work ethic to be a team player in a rigorous program;

* Skillful interaction with patients;

* Intelligent clinical decision-making;

* Personally professional and articulate;

* Prepared to move beyond basic skills.

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PRECEPTOR BENEFITS

“Many of the benefits of being a preceptor are intangible,” Dr. Newman says, pointing out that, for him, the benefits and rewards far outweigh the challenges. A few benefits are the ability to:

* Give back to the profession, sharing knowledge and expertise;

* Validate your professionalism and your practice;

* Network with the audiology community;

* Provide feedback to the university, to shape and improve academic curriculum;

* Learn new theoretical information from students

* Enhance clinical productivity;

* Provide value-added services for patients (e.g. hearing aid walk-in clinic);

* Reduce workload as students progress;

* Recruit new staff.

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PRECEPTOR CHALLENGES

“The decision to become a preceptor should not be taken lightly,” Newman says. “Anticipate that you may face some challenges inherent in the clinical education process.” To ensure a positive experience, preceptors should:

* Make time to plan experiences, provide feedback, and evaluate students;

* Allow time for student to understand site's policies and procedures

* Balance clinic, administrative, and/or research responsibilities with potential loss of productivity;

* Offer insufficient patient volumes and clinical diversity for depth of experience;

* Manage inconvenient start date;

* Incur costs for office space or stipend (optional) with no tangible rewards, remuneration or recognition;

* Experience burnout related to the yearlong length of the rotation.

Dr. Newman describes the AuD student's education as a “collaborative effort among the student, university faculty, and preceptor,” where students learn by doing. The importance of the externship and of the preceptor's role cannot be understated, he says. “Preceptors are the bridge between academic theory and knowledge, and the reality of a professional clinical practice.”

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WHAT DO YOU THINK?

Does the AuD Externship program need to be revised? Let us know by filling out the quick poll on our website at www.thehearingjournal.com.

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