State Licensure Checklist
by David Zapala, PhD and Terri Pratt, AuD
(on behalf of the Academy State Licensure Subcommittee)
The purpose of this checklist is to serve as a guide in your review of your state licensure law. The checklist is structured as a series of questions that address specific aspects of licensure. Your answer to those questions can be used to guide your evaluation of the effectiveness of your licensure act, particularly in identifying and prioritizing potential weaknesses that need to be changed. The list is by no means complete. Each state is likely to have different, unique licensure issues, as each state has its own unique history of legislative activities that address the practice of audiology. Nevertheless, answering these questions will serve as a starting point in the process of evaluating your current law.
Licensure serves many purposes. Its primary function is consumer protection. Implicit in the recognition of professional status is the notion that the professional has unique knowledge and ability that is unavailable to the consumer. Consequently, the consumer must be able to trust that: (1) the professional has the necessary knowledge and ability that the consumer seeks, and (2) the professional will use that knowledge and ability to act in the consumer's best interest. Each profession and each professional is expected to protect the public trust. However, because of the vulnerability of the consumer, the state has an interest in protecting the interests of its constituents. Licensure is one method by which the state can protect the consumer from unscrupulous or poorly tutored professionals. With licensure, the state imposes the following: (1) The minimum qualifying standards for the practice of the profession; (2) A legal description of the activities a licensed professional can perform (scope of practice or SOP); and (3) A vehicle for disciplining professionals who deviate from the above standards. Because even the state does not have the necessary knowledge and ability to regulate the profession, most licensure laws provide for the establishment of a licensure board. The board will typically have members of the profession being regulated, along with a representation of other interested parties. In the case of audiology, there are often nonprofessional board members who look after the consumers' interests. There also may be a physician, presumably to protect the community health. The board serves to establish and implement regulations under the charter of the licensure act and adjudicate complaints against licensees.
Philosophically, our goal must be to develop licensure laws that reflect the capabilities and services (scope of practice) provided by audiologists as owners of an autonomous profession. It also must provide for meaningful of self-regulation, including such issues as minimum entrance standards, continuing education requirements, and disciplinary activities. Keep these matters in mind as you review your current licensure law to answer the checklist questions.
Also, it is important to know that license laws are passed by the legislature and difficult to change. However, boards have the authority to write rules that interpret the statutes. Most professions keep the language in their statutes broad so that the board can make interpretations based on current practice standards. As you review the checklist, note if changes need to be made in the actual statutes/laws or in the rules written by the board.
One final thought: The purpose of this checklist is not to advocate for specific changes in your licensure law. That is the responsibility of each state association. The idea behind this checklist is to help you focus on issues that may need to be addressed locally.
Definition of Audiology & Scope of Practice
- What is the definition of an audiologist? Is there protection against other practitioners defining or promoting themselves in a way that would be confusing to the lay public? (i.e. hearing aid audiologists, audiometrists, audioprosthesiologists and the like).
- What is the definition of audiology? Is an audiologist able to use the following audiologic principles, methods or procedures for the purpose of designing or implementing audiological management and treatment or other programs for the elaboration of such disorders or conditions?
- Instruction or research related to hearing, vestibular function, balance and fall prevention, and associated neural systems, or any abnormal condition related to tinnitus, auditory sensitivity, acuity, function or processing, speech language or other aberrant behavior resulting from hearing loss
- Is hearing aid dispensing clearly defined as part of the scope of practice of audiology? If so, does the audiology board oversee the activities of all hearing aid dispensers in the state? Should there be this oversight? What about mail order and Internet hearing aid purchases?
- Is an audiological evaluation by an audiologist required prior to purchasing hearing aids?
- Is an audiologist able to perform...
- Otoscopic examinations, remove cerumen, place electrodes or other devices in the external ear canal?
- Surgical monitoring of sensory and motor nerve function?
- Hearing aid selection, fitting, dispensing, and related services?
- Hearing conservation and hearing loss prevention services?
- Infant screening and early intervention services?
- Therapeutic services such as auditory habilitation and rehabilitation services; vestibular rehabilitation services and canalith repositioning for BPPV? (Should they be called therapeutic services or should we remain using rehabilitation related terms? Rehabilitation related terms are generally used by non-diagnosing professions.)
- Tinnitus assessment and management services?
- Educational Audiology services?
- Is an audiologist required to be a member of a private organization in order to meet minimum requirements for licensure? (i.e. is proprietary ASHA certification required?)
- Are audiology assistants allowed? Who can supervise an audiology assistant and how? (i.e. are they supervised by an audiologist, physician, physician's assistant, nurse practitioners, etc.) Are there limitations to what an audiology assistant can do? For example, the American Academy of Otolaryngology recently proposed a broad scope of practice for audiology assistants to work under the general supervision of a physician. Is this allowed in your state?
- Is there an exclusive right to practice, or can employees of physicians' offices or other service providers assess hearing, fit hearing aids, and otherwise treat hearing problems? Do audiologists employed by physicians need to be licensed, or can audiologists work under the physician's licensure? Is hearing screening considered part of the scope of practice of audiology and if so, can non-audiologists screen hearing or perform pure tone audiograms for hearing conservation programs?
- Are students and employees of school districts exempted from licensure? Should they be?
- Are other professions or service providers legally able to provide oversight of an audiologist's clinical decision-making? For example, can a patient rescind the transaction for purchasing a hearing aid by obtaining a letter from a physician stating that a hearing aid will not be of benefit for them, or is otherwise contraindicated?
Entrance into the Legal Practice of the Profession
- Is the proprietary ASHA certificate of clinical competence required to obtain licensure? Does the board have the ability to use ABA Board Certification in Audiology as an alternative? Is there language allowing for equivalency—that is, having the experience equal to ASHA certification without actually paying ASHA for the certificate? Does the board recognize the Au.D. degree as meeting the academic requirements necessary to be licensed?
- Are practical hearing aid fitting examinations required to demonstrate competency for the purpose of licensure? Are other examinations required for licensure, and are they reliable and valid tools? Are entrance tests left to the discretion of the board, or are they written into the letter of the licensure act?
- Is there a specific reference in the practice act to the type of education required as a perquisite to practice in the state, or are the specifics left up to the board? For example, some states require graduation from a program accredited by the ASHA Council on Academic Accreditation (CAA) or an agency that recognizes its Accreditation. Other states require graduation from a regionally accredited university. Currently, the American Academy of Audiology suggests that the following text might be helpful to have in the actual licensure law: "graduation from an academic program accredited by an agency or organization that is recognized by the US Department of Education to accredit Audiology programs." If the language is too narrow, then it does not permit room for other accreditation agencies beyond CAA to accredit Au.D. Programs. If the language is too broad, then any school (or sham school) may set up a training program and graduate students who call themselves "audiologists", including mail order diploma mills. Currently, the only nationally accredited body is the CAA of ASHA, which credentials master's level programs.
- Are students completing their fourth-year Au.D. externship (student) able to practice in the state under the direction and oversight of a licensed audiologist (provisional licensure)? Is there a requirement for a postgraduate fellowship experience or just supervised experience? What are the limits of their scope, and what kind of direction and oversight is required? Remember, if they are licensed, they can bill. Is it a good thing for a student to be licensed? Also remember that any reference in the statute to a clinical fellowship year necessarily requires a postgraduate experience and implicitly, ASHA certification.
- Do you have a board of Audiology, or do you have a combined board including speech language pathologists, or possibly speech language pathologists and hearing aid dispensers? Are hearing aid dispensers and speech language pathologists able to vote on issues pertaining to the practice of Audiology? For example, can a hearing aid dispenser vote on a case adjudicating the results of an infant screening or surgical monitoring case?
Is it possible for the board of audiology to oversee the behavior of hearing aid dispensers without allowing hearing aid dispensers on the board of Audiology? For example, in some states, there is a Council of Hearing Aid Dispensers that can act autonomously, and is financially self-supporting. The council is organized under the audiology board and the board approves its rules and regulations. The important feature is that consumers may appeal to the audiology board if they experience unsatisfactory responses to complaints made to the hearing aid Council. The audiology board would have the ability to adjudicate and discipline hearing aid dispensers (as they have the ability to discipline audiologists) when considering such appeals. (In the author's opinion, this organizational structure is the logical outcome of acknowledging hearing aid dispensing as part of the practice of audiology.)
- Most health-care boards are required to be financially self-sufficient. Costs to the board are incurred whenever a complaint is investigated. If the investigation indicates that the complaint is justified, additional costs are incurred when the board hears the case and adjudicates. In combined boards (where audiologists and hearing aid dispensers are treated as one group), audiologists pay for the expense of fielding complaints against hearing aid dispensers (and vice versa). If the number of complaints against hearing aid dispensers greatly outnumbers complaints against dispensing audiologists, this represents an unfair financial burden to audiologists, who support the board by paying for licensure fees.
In the author's opinion, it is important that the number of complaints and actual cases adjudicated against audiologists and hearing aid dispensers be a matter of public record, and these counts should be separated by professional group. In your state, is the licensure board required to publish disciplinary actions against licensees in a public record? Is it required to keep count of the number of investigations performed by different professional groups (i.e. audiologists, speech-language pathologists, hearing aid dispensers)? Does the board publish the number of complaints in a public record? Does the board track and publish trends in the number of complaints against hearing aid dispensers relative to audiologist? Does the board track expenses related to investigating complaints against hearing aid dispensers versus audiologists? Bottom line: are audiologists and speech language pathologists unfairly paying the burden of policing hearing aid dispensers?
- How many consumers are required to be on the board? Are any of them required to be hearing impaired? Senior citizens? Parents of hearing impaired children?
- Is a physician required to be on the board? Is more than one required? Why?
- Is there a lemon law for hearing aids in your state? If so, does it allow an independent audiologist to determine whether a hearing aid fitting is appropriate? Does it allow for a physician to determine whether a hearing aid fitting is appropriate?
- Are their clear guidelines for infection control in the rules and regulations for your state?
- Is continuing education required and in what form? What types of activities can constitute continuing education?