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Universities and clinical sites puzzle out the details of fourth-year externships

Pallarito, Karen

doi: 10.1097/01.HJ.0000285744.31470.8d
Cover Story

The growing need for suitable clinical externship sites for AuD students is raising a host of issues about how and where to find them, what externs should do, and how they should be paid.

Karen Pallarito is a freelance health writer based in Westchester County, NY.



Put yourself in the shoes of a budding doctor of audiology (AuD) in a newly minted university AuD program. Amid the initial thrill of embarking upon a career in this nascent doctoring profession, you'd be hard pressed to recall exactly what you'd been promised for your fourth year of clinical practicum.

That's how it was for Allison Ivey when she entered Auburn University in the fall of 2003, one of eight students in the university's first AuD class. At the time, details of the university's fourth-year clinical experience were sketchy at best. “If I'm remembering correctly, it was more of a wait-and-see kind of thing,” Ivey recalls. “And it was technically a find-your-own-place sort of deal,” she adds. “But we got a lot of help from our faculty. I mean, they never said, ‘Good luck with that.’”

As part of her search, Ivey ran across an online ad that ultimately led to a plum placement rotating among up to four different audiology clinics throughout the Henry Ford Health System in Detroit. Today, she's acquiring a broad range of clinical experiences, working with infants to centenarians. She's lucky, too, because the externship came with a stipend, helping to offset some of the costs of her cross-country relocation. Had the university limited her choice of sites, she might not have been so satisfied with her placement. “It would be really hard for me to support my school saying, ‘You have to go here or there,’” Ivey says. “It closes a lot of doors.”

With 70 AuD programs across the nation vying to place students in quality clinical experiences, the audiology profession has begun to ask some tough questions about the design of fourth-year externships. Should universities guarantee placement? If so, what's the best way to do that? How much money, if any, should students receive to offset their relocation costs? Should provisional licensure be permitted to boost billings by clinical sites that train students? Is there a better way to align the needs of universities, students, and clinical sites?

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If the transition to a fourth-year externship model has been chaotic at times, it's because the profession has not fully discarded the old way of doing things, many audiologists agree. Before the AuD, most audiology students who intended to practice in the field went to graduate school for a master's degree. As part of their coursework, they may have been involved in numerous clinical experiences arranged by their university. But the bulk of their clinical training took place after graduation. Students arranged for that clinical fellowship year (CFY) on their own, and universities had no stake in the outcome. For all intents and purposes, master's degree students provided a source of cheap labor for many clinical sites.

All of that has changed. Now universities award doctoral degrees after students have completed their externship experience. So it's incumbent upon those institutions to be involved in finding sites that provide quality experiences for their students—or “externs.” And now that student performance counts toward the final evaluation, universities and preceptors—the audiologists who oversee externs' clinical education—must maintain excellent communication back and forth.

“If you realize the paradigm shift that we're going through and that we have a whole profession to move through that paradigm, it's not surprising that, at least in these initial years, it's not perfect,” says Dianne H. Meyer, PhD, chair of the Department of Communications Disorders and Sciences at Rush University Medical Center in Chicago.

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Robert C. Fifer, PhD, director of audiology and speech-language pathology at the Mailman Center for Child Development at the University of Miami School of Medicine, marvels at the explosive growth in the quantity of information that audiologists must absorb to exercise good clinical judgment. “The entire AuD concept is a response to marketplace demands,” he says. In the first 3 years of study, students are exposed to different settings, including adult, child, and hearing aid venues, he says. “That fourth year is intended to be very much a finishing school, to really polish and expand their perspective of the profession.”

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Figure. Ba

Yet a growing number of hearing professionals now question the wisdom of waiting until the fourth year to begin the hands-on process. Vic S. Gladstone, PhD, chief staff officer for audiology at the American Speech-Language-Hearing Association (ASHA), says most academic programs now favor integrating clinical training throughout the 4-year curriculum. “That is creating the opportunity for flexibility in the fourth year,” he says. In some programs, he explains, students go away for the full year. Others are splitting up the fourth year into two semesters or multiple externships.

Starting clinical experiences early in the doctoral student's career helps assure they are getting diverse experiences and are entering the profession ready to practice, agrees Barry A. Freeman, PhD, chairman and professor of the Audiology Department at Nova Southeast University in Fort Lauderdale, FL. “It's not just sending them out on the fourth year and saying goodbye and good luck.”

George S. Osborne, PhD, DDS, dean of the Pennsylvania College of Optometry School of Audiology in Elkins Park, suggests that the ideal fourth year would be a series of 3-month rotations that would allow students to learn what it is to practice audiology in a variety of different sites and specialties. PCO, in fact, has tried that model, but it hasn't worked well, he admits, because the audiologists who serve as preceptors can't handle a student for 3 months. “They're so wrapped up in the whole-year thing,” he says. Plus, the logistics of finding housing for a 3-month period makes it all the more difficult to pull off. “So now,” he reports, “it's boiled down to a fourth-year, pretty much a full-year or 9-, 10-, or 11-month placement in an off-campus site.”

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Exactly how much universities should be doing to ensure that students get placements remains a topic of fiery debate. Deborah R. Price, AuD, chair of the board of the Audiology Foundation of America and owner of Hearing Professional Center in Dallas, insists that it is the responsibility of universities to provide externships for their students—period. She says they should not be telling students, “Go find yourself an externship and let me know where it's going to be.” After all, universities are taking students' tuition, and the externship is part of the 4-year program, Price reasons. “They should have sites set up that are going to maximize that individual's clinical experience,” she maintains.

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Figure. Deb

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Figure. C



The Northeast Ohio AuD Consortium (NOAC) is, in her view, “a model of how it should be done.” The consortium, a merger of the audiology programs of the University of Akron and Kent State University, maintains an exclusive agreement with the Cleveland Clinic for student training and clinical education. The clinic takes seven fourth-year NOAC students per semester, an arrangement that has several advantages, according to the NOAC coordinator Sharon Lesner, PhD, a professor of audiology at the University of Akron.

Students stay close to home, for one, and they train with world-class clinicians in every discipline. “We have almost constant contact back and forth,” she adds, “so it makes it easier and better for them and, I think, better for us in the sense that we know what they provide.”

“We participate in curriculum development, program development, student admissions, so we have real input into who these students are,” adds Craig Newman, PhD, the Cleveland Clinic's audiology section head. “We truly feel integrated into the process,” he says, whereas many clinical sites may not. On the other hand, Newman admits that a number of academic programs are quite upset with him. “They'd love to send students to us, and we have to tell them, no, we have this arrangement.”

Other sites prefer a competitive model, culling the best students from a larger pool of AuD applicants. The Audiology Department at Boys Town National Research Hospital in Omaha, NE, for example, conducts an extensive review to fill two 12-month placements. The process begins with a resume, letter of interest, and letters of recommendation from clinical supervisors or professors and culminates in telephone or in-person interviews.

“We do have a very diverse placement,” says Betsy Runnion MS, a clinical audiologist and preceptor. “The students who come here do vestibular testing—really all components of audiology. It's not just hearing aid fitting or just diagnostic hearing evaluations. They do the whole gamut during their 12 months,” The program, now in its second year, generated roughly 17 applications last year, but she suspects demand will increase. “If you open it to everyone, it's fair, and we can select the best candidates,” she says.

David J. Coffin, AuD, director of the doctor of audiology program at Ball State University in Muncie, IN, is very involved in the externship search and mentoring process at his institution. But he still expects students to do a lot of the legwork themselves because he wants them to be good at it. “This is about feeling comfortable enough with your knowledge, with your ability, just general self confidence, to pick up the phone and call somebody and say, ‘Hey, I'm interested. What can you do for me? This is what I can do for you.’”

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Clinical sites often frame participation in the fourth-year externship as an economic issue. Here's why: While preceptors are generally responsible for 12 months out of the 4 years of a student's training, there's no reimbursement for the services they provide.

That's why some audiologists favor provisional licensure. Some states, including Florida, California, and Virginia, now have laws allowing students who have completed all the requirements of a master's degree or the equivalent number of hours, to practice audiology under supervision. Nova's Freeman initially rejected the idea, but finds that it has worked very well. He says it's a way clinical sites can make up for some of the revenue they lose on clinical education.

But Gladstone says sites need to frame the issue differently. “They need to think about their responsibility as a partner in the education of audiologists with the academic community and get away from this notion of, ‘I need to bill for the services that the student provides,’” says the ASHA official.

Certainly, says Newman of the Cleveland Clinic, there are direct and indirect costs, including office space and stipends, as well as time planning students' experiences and rotations, providing immediate feedback after patient interactions, and conducting evaluations. But, while he hasn't conducted a formal cost/benefit analysis, he believes the clinic actually ends up seeing more patients—or seeing patients more efficiently—by using students in activities they can conduct independently. Students can teach patients how to insert earmolds, for example, or how to use their hearing aids.

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Anecdotal evidence suggests that the market for fourth-year AuD students varies widely in terms of remuneration. Relatively few paid positions exist anymore, as payment is frowned upon by professional leaders because they say it puts pressure on students to perform as employees. Stipends, however, are often permitted and can range from several thousand dollars to tens of thousands of dollars.

Fifer has had third-year students from other universities brag about going for big money in their fourth year. One found a site in Arizona that would pay $65,000 a year. The program director says he and his colleagues rolled their eyes “because we knew … that was going to be a busy hearing aid practice where this kid would be cranking hearing aids all day long. It had to be for that kind of money for a fourth-year student.”

On the other hand, several quality programs are also known for their generous compensations. The Department of Veterans Affairs, for example, offers 40 year-long externship positions to fourth-year AuD students across 29 VA facilities. The funding total for fiscal year 2007, including the VA's share of FICA and health and life insurance benefits, is $1,647,262, or more than $41,000 per position.

A fourth-year student at the Arizona School of Health Sciences in Mesa, who asked not to be identified by name, is serving in an active duty military position in Bethesda. The audiology externship pays about $50,000, and when she graduates, she'll have earned officer status in the Navy.

In general, though, Ball State's Coffin predicts that market forces will tame fourth-year pay, bringing stipends to lower levels as more clinical sites begin to realize that the old rules have changed: Students are not CFYs looking for a living wage; they're externs looking to offset expenses. “The universities see that, but I don't think that most sites yet see that,” he says.



Gary D. Lawson, PhD, an associate professor in the Department of Speech Pathology and Audiology at Western Michigan University in Kalamazoo, tells students when they apply that “we cannot guarantee that they will have a paid experience.” And, although he has no trouble finding placements now, Lawson doesn't dismiss the possibility of economic upheaval down the road.

“It's quite possible the economy won't be as good as it is today, and that will have an effect on the availability of externships,” he concedes. “And if externships are not readily available, then that could impact the students' graduation in a timely manner given that the externship is now part of the degree program.”

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Is there a better way to ensure that students and sites are properly aligned? One proposed solution is a national matching program, much like that used to match medical school students with available residency positions. The systems would help weed out inappropriate sites and bring students and sites together. The idea, though, has not bowled over the audiology community, at least not yet.

None of the major associations has expressed interest in taking this on, admits Freeman, one of the architects of the proposed program, along with the University of Louisville's Ian Windmill, PhD, and Richard E. Gans, PhD, a past president of the American Academy of Audiology. “We feel there's a tremendous need for it so that we can begin to identify sites and start assessing and weeding out sites that may not offer the kinds of services we want for students,” he says.

The National Association of Future Doctors of Audiology (NAFDA), the organization of AuD students, has several concerns. If a student doesn't match, there's little recourse. If a school heavily relies on the match, there may be few placements cultivated for those students who don't match. “It is a Band-aid to try and take care of a much more serious problem,” worries Elizabeth Gray, president of NAFDA. “There are too many students for too few quality sites. Not every clinic/placement is equipped to provide a student a well-rounded experience for their fourth year.”

Gray, for one, still hears horror stories of student placements that offer little teaching and leave the student with very little recourse because they don't have another position lined up ready to go. It's one reason NAFDA launched its own fourth-year database.

Meanwhile, the American Academy of Audiology will launch an online database of fourth-year externship sites this month at AudiologyNow!2007 in Denver. Access to the web-based registry, which was developed to improve communication and access to sites and bolster the quality of fourth-year externship experiences, will be free to universities, students, and clinical sites.

As AuD programs mature, it's likely that many of the growing pains plaguing fourth-year externships will be soothed, while other wounds will surface. A bigger problem, some say, is the glut of doctoral programs competing against one another for students, faculty, and clinical placements. That's where joint programs like NOAC have an advantage. By combining Akron and Kent students, its classes hover between 15 and 20, on average, giving the consortium a critical mass that exceeds many smaller programs and helps it sew up collaborative relationships with a variety of clinical sites in the region.

“I know some schools actually require that students go away, but we can accommodate them within the region,” NOAC's Lesner notes.

For Melissa Mourek Raterman and her husband, Kyle Raterman, AuD students at Nova Southeast University, the whole fourth-year externship experience has reinforced the value of a quality placement. Initially she explored externship opportunities in Chicago, her hometown, to be near family. Freeman, the program chairman, even helped vet the options. Ultimately, though, the best offers came from sites in Florida.



Mourek Raterman, in fact, accepted a position at Florida Hearing and Balance in Hollywood, FL, Freeman's private practice, where she learns how to run an office and work with hearing aids. And, because the office is situated in an ENT/otology practice, she also participates in surgeries and performs diagnostics on some unique patients. Her advice to AuD students: “Even if it means that you may have to sacrifice some pay or not be near family, in the grand scheme of things, it is just one more year. Choosing a good placement is worth it to round out your education and prepare you for the real world.”

© 2007 Lippincott Williams & Wilkins, Inc.