Philip Mark Brown, MD’s audiologist coworkers keep him apprised of the current state of the art regarding the available battery of audiologic tests. “If we are considering purchasing or instituting [a product or service],” he said, “we meet as a group practice and our audiologists make an argument for or against it. They are key in keeping us abreast of what is going on in audiology. Everything is done in conjunction with the practice’s audiologists.”
Dr. Brown, who is a principal with Central Park ENT in Arlington, TX, speaks frequently to his audiologist colleagues, who work in the same suite of offices. “Most of the time audiologists are contractors and not part of the practice,” he said. “We felt very strongly that we wanted a totally integrated system where we work together on every single patient. Just today we have already got together four times to discuss patients.”
This is an example of the best kind of audiologist-otolaryngologist partnership, said Maurice H. Miller, PhD, Professor of Audiology in the Department of Speech-Language Pathology and Audiology at the Steinhardt School of Education of New York University. Idiopathic sudden sensorineural hearing loss, Meniere’s disease, tinnitus management, and cochlear implants are among the many disorders where collaborations between the audiologist and the otologist lead to superior and essential patient management.1–3
“I don’t understand [when people get caught up in politics] and this market share thing,” Dr. Miller said, “because sensorineural hearing loss at the present time is not surgically or medically correctable in the overwhelming number of cases. That clearly falls within the province of the audiologist. The audiologist is the specialist in amplification, fitting, dispensing, programming and reprogramming, whereas when we come to disorders of the middle ear or the outer ear, that is clearly within the realm of the surgical otologist. We work together; I see no conflict.”
Dr. Miller, who was the recipient of the 1996 American Academy of Audiology (AAA) career award for outstanding contributions to research, clinical practice, and teaching, routinely refers to surgical otologists those patients with otosclerosis who see him first and have surgically correctable conditions. “My strong preference is for surgical correction when indicated and my referrals through more than a half century of clinical practice confirm this,” Dr. Miller said. “Surgery would be my choice if I had otosclerosis with a large air-bone gap.”
The bottom line is that any political and financial concerns can interfere with patient care, said John K. Niparko, MD, the George T. Nager Professor in the Department of Otolaryngology–Head and Neck Surgery and Director of the Division of Otology, Audiology, Neurotology, and Skull Base Surgery at Johns Hopkins School of Medicine in Baltimore. “Viewing audiology–otology issues from a political perspective is the wrong approach and it only builds barriers between the specialties,” said Dr. Niparko.4 The political issues should be subjugated for the larger issues of patient care. “The issue is not taking patients from one another; literally 80 to 90 percent of the population who could benefit from our interventions don’t access it because of the lack of awareness,” he said. “The key thing is to focus on the patient. …Both specialties need to target ignorance and lack of awareness of [diagnostic and treatment] options, and it is my firm belief that everything else will flow from that.”
But what about smaller practices that can’t justify adding an audiologist to their in-house team? Can otolaryngologists learn to perform audiometry themselves?
“That would be worst direction in which we could go,” said Dr. Miller. It’s really not within their purview and it is counterproductive to quality patient care. “When it comes to audiosurgery, the surgeon who did the procedure should not do the postop audiologic workup,” he said. Pre- and postoperative audiologic evaluation should be performed by an audiologist. “It’s not within the otologist’s scope of practice. But it is within the scope of practice for the audiologist.” A competent audiologist’s objectivity ensures a means of quality assurance, Dr. Miller said. “The independence of the audiologist contributes to objective audiological evaluation and consultation.”
Dr. Miller would advise otolaryngologists in smaller practice settings to refer their patients to a certified licensed audiologist in their own locale or region. Audiologists who are members of the American Academy of Audiology are distributed geographically in most parts of the country. (See Resources at the end of this article.)
Given the new technologies available in the modern era, there has been an evolution of the hearing care specialties. Some hearing devices are now so technical both from the medical/surgical perspective and the audiologic fitting perspective, said Dr. Niparko, that audiology and otology specialists will have to upgrade their collaborations in order to adequately fit these devices.
There are a number of areas in particular that will require this. Early detection of childhood hearing loss is one. “If childhood hearing loss, even in 2007, isn’t aggressively addressed, there are devastating consequences,” said Dr. Niparko. “And that still happens routinely in our society.” There are some very troubling statistics being published now with respect to this issue, he said. It may be that a substantial percentage of kids in their middle school years are already manifesting high-frequency hearing loss. This, again, is an area of really crucial collaboration for otologists and audiologists.
“New semi-implantable hearing devices for patients with moderate to severe hearing loss require that computer-savvy audiologists effectively program and interpret the various sound environments that an individual experiences,” said Dr. Niparko. “This really comes to bear in a situation where you’ve got a challenging environment corrupted by noise.”
Testing is another area in which the field has evolved, said Dr. Niparko, who is also Director of The Listening Center at Johns Hopkins and the past president of the American Otological Society. It starts with an early identification program. Universal newborn screening protocols now mean that clinicians are assessing hearing loss in children who are 24 hours old. “Being able to intelligently tell a family what the risk of their child’s hearing loss might be at that stage requires that we understand these tests and interpret them carefully. Good communication is essential… and is more critical now that the technology of diagnosis and intervention are more complicated, more technical,” said Dr. Niparko.
Qualifications for Audiologists as Partners
Dr. Miller and a number of his colleagues have taught courses at AAO–HNS meetings, which are a good place for otolaryngologists to learn more about interpreting, ordering, and judging the quality of their audiologic resources. As for what to look for in an audiologist, Dr. Miller recommends that otolaryngologists select someone who holds an earned (as opposed to an honorary) doctorate degree from a university accredited by the American Speech-Language–Hearing Association (ASHA) or someone who is a member of the American Academy of Audiology (AAA) and holds certification from the American Board of Audiology (ABA), or both.
The emerging audiology clinical practitioner’s degree is the AuD and differs from the classic PhD degree, awarded to those who plan to become researchers and teachers. Another criterion to look for in an audiologist is a broad scope of experience. And when the audiologist is managing the patient with sensorineural hearing loss (SHL), meticulous and competent device fitting increasingly depends on computer expertise.
Dr. Miller suggests giving a prospective candidate a trial of several days in the practice to see how he or she relates to patients, manages the equipment, and interprets the results. It is also wise to request letters of recommendation from professors with whom the candidate has studied. Someone right out of school could work with sufficient in-practice training as long as a supervising audiologist is easily accessible.
The key to providing successful audiologic rehabilitation for the patient with SHL involves a good and long-term relationship with an audiologist, said Dr. Miller. “The new era is one in which the audiologist and patient establish a long-term relationship so that issues such as changes in hearing and difficulty with hearing aids can be addressed and include hearing aid reprogramming to allow the patient to function efficiently in different listening conditions that are important in the everyday life of the patient,” he said. “The audiologist must be available. It’s no longer just about evaluation. You want someone who is humane and patient and knowledgeable, and establishes great long-term relationships with patients.”
As technologies drive and evolve the otolaryngology and audiology specialties, the greatest collaboration in the future will involve training. “Some of these new interventions call for very novel strategies,” said Dr. Niparko, “again, related to both medical/surgical and audiologic intervention. This will guide our continuing education in the future.”
American Academy of Audiology (AAA): www.audiology.org
The AAA’s Web seminar home page is: http://eo2.commpartners.com/users/audio/index.php
American Speech-Language-Hearing Association (ASHA): www.asha.org/default.htm
- Miller MH, Schein JD. Selected complex auditory disorders. J Rehabil Res Dev 2005;42:1–8.
- Miller MH, Schein JD. Sudden deafness, part I: Diagnosis and treatment. Geriatrics Aging 2005;8:46–49.
- Schein JD, Miller MH. Sudden deafness, part II: Rehabilitation. Geriatrics Aging 2005;8:67–69.
- Niparko JK. Audiology & otolaryngology. Otol Neurotol 2006;27:909.
©2007 The Triological Society