What a year 1999 was! With excitement and apprehension as to what would happen when the ball dropped and all four digits of the year rolled over to 2000. Some people were stockpiling batteries and canned foods, while others were busy prophesying on what was to come.
As for me, I was an undergraduate. My primary concern was how my friends and I were going to make a 24-hour road trip down to Florida to ring in the New Year at Phish’s Big Cypress Festival and make it back in time for the start of spring semester. Graduate school was a few years away, and I was blissfully ignorant of most of the professional turmoil.
Meanwhile, audiologists were wondering what was to become of the profession. The AuD was in its infancy and master’s level programs still dominated the academic arena. However, changes were on the way.
In October, a special edition of Audiology Today, edited by Jerry Northern, published predictive articles from leaders of the time. Twenty years have gone by and I thought it would be interesting if a few of those leaders could reflect on their original ideas. I am grateful that a brave few returned my email request. You will recognize the names, as they continue to be influential forces in audiology education, business, research, and practice. Enjoy!
JERRY NORTHERN, PhD | Looking Back and Looking Forward
I remember well the uncertainty that surrounded the coming of the new millennium. Unfounded theories abounded about what would happen at midnight on December 31, 1999. However, in the midst of the anxiety leading up to the year 2000, audiologists generally held positive views of the future. At that time, the Academy was a mere 10 years old and we were concerned about turf wars, the AuD, and the effectiveness and inefficiency of hearing aid fittings. Although some audiologists expressed concern for the future of the profession, the promise of the growing population of baby boomers and seniors who would need our services gave us an optimistic view of the coming years.
The past 20 years for me have been a blur of rapid changes that I never could have predicted. We now take for granted technologies that we couldn’t have imagined in the year 2000. Our clinical-practice behaviors have been driven by unexpected turns and disruptive upheavals: one-stop hearing aid fittings, cochlear implants on 12-month-old deaf babies, streaming all forms of content to hearing aids, incredible visual speech technologies, automated audiometry, computer-directed hearing aid adjustments performed thorough the telephone. Who would have predicted those things in 1999?
Looking back is easy; looking forward—not so much. We still have ample problems ahead of us. How do we standardize our clinical practices to ensure high standards of care? Is there a role for aural rehabilitation? What about the exorbitant cost of AuD study versus mediocre starting salary levels? Are we becoming more technicians than professionals? What happened to clinical auditory research?
Will the progressively invasive warehouse hearing aid sales and new over-the-counter (OTC) hearing aid rules dilute our customized contribution to hearing-aid dispensing? How can we expand our limited pool of audiologists to meet the growing demands for our services? And, will we ever, as independent free-standing professionals, totally divorce ourselves from the influence of the American Speech-Language-Hearing Association (ASHA) certification?
Nonetheless, the future is bright. We bring a unique set of skills and attitudes toward helping persons with hearing impairments. The public marketplace will, no doubt, shape and direct our future directions. Who knows what new technologies will bring to our practices?
Twenty years later, it is still our challenge to make the public aware that we are the professionals who can best service their hearing needs. I know we are making progress because when I tell someone I am an audiologist, instead of saying, “What’s that?”, they put their hand behind their ear and, with a smile say “...ya’ mean like, huh?”
JAMES W. HALL III, PhD | Looking Back to 1999
In my 1999 Audiology Today article “Y2K: Clear, Inevitable and Fundamental Changes,” I was careful to refrain from predicting pie in the sky improbable developments for the profession. The opening sentence in the article attests to this caution: “No one expects the profession of audiology to undergo a sudden metamorphosis on January 1, 2000. None of us need to stock our double-walled sound booths with a supply of food, many bottles of our favorite beverage, and a pile of audiology journals in preparation for the end of our profession as we know it.” However, I did make some predictions that, looking back with almost 2020 vision, were reasonably accurate.
Thinking of some of my young, bright, energetic, and highly motivated audiology colleagues (including a few of my students), I commented in the article that “I’m sleeping better these days because there is an ever-growing cadre of ‘future career audiologists’ ready to begin ‘caring for America’s hearing’ and actually the ‘world’s hearing’.”
These audiologists are now among the leaders in the profession. As the first AuD programs began to appear in 1999, I commented about how thousands of new doctoral-level and career-minded audiologists “can only strengthen the profession, while also providing incentive for another generation of promising prospective students to enter audiology.” This too has come to pass.
Finally, even as many technology experts warned of a worldwide computer-based apocalypse, I listed the various ways computer technology was rapidly and profoundly enhancing and expanding clinical audiology services, from identification and diagnosis of infant hearing loss to intra-operative monitoring and vestibular assessment. The impact of computer technology on audiology clearly exceeded all of our expectations. Now, 20 years later, I remain equally optimistic about the future of audiology.
LISA L. HUNTER, PhD | Wake-Up Call: Are We Succeeding at Evidence-Based Practice?
Twenty years ago, when I was young and wrinkle-free, looking forward to a bright future, I wrote a column titled: “Education: Even More Important in the 2000s.” I offered only one prediction: “technology will continue to make our lives ever more complex, not more simple.” And it has.
Most of us are now carrying around a smartphone all day long that tracks our every move and keeps us in contact with friends and family all over the world. It can do all manner of amazing things including sound-level meter measures, hearing tests, otoscopy, and can even serve as a personal amplification device with noise cancellation. Those smartphones have made our lives a lot more convenient, but also much more complex. Now that I am looking at our “progress,” this is a wake-up prediction for the next 20 years.
Twenty years ago, I predicted that our profession would slowly evolve into a doctoral profession. Boy, has it been slower than I expected in some ways. While the vast majority of audiologists now have first-degree AuDs or distance-learning AuDs, we are not, as a whole, practicing like doctors. Our culture has not evolved enough, to our own and our patients’ detriment. This likely affects our earning potential, public perception of audiology, and most important, patient outcomes.
As an educator, I regularly ask my students what they are doing in externships. And the shocking truth is that they do not get to see or do best practice as regularly as they need to. When I ask how many have been doing real-ear measures, few hands go up. What about speech-in-noise testing? Maybe a couple have done it once or twice. Okay, how about the new auditory steady state response (ASSR) tests? Nope. Only in their classes. Are they using best practice otoacoustic emission (OAE) measures? How about aural rehabilitation? Outcome measures? Only a few, and not routinely. Are they using audiology assistants? Not really. What? Really?
By and large, these students are witnessing audiology practices similar to what I saw 30 or more years ago. That means pure-tone thresholds only up to 8 kHz, speech-reception threshold (SRT) and speech-in-quiet (often monitored live voice), 226-Hz tympanometry, hearing aids fit using “first fit” without real ear or outcome measures. Even worse, deferring to physicians for follow-up decisions and audiologic treatment decisions. This is unacceptable for a profession that has made the transformation to a doctoral degree that costs well over $100,000 to obtain. We are not doing right by our students or our patients if we continue to practice as if it was 1999 or earlier. Educators all over the country report the same situation; it is not unique to Ohio.
Now to be fair, there are many successes in the realm of newborn screening, cochlear implants, vestibular practice, tinnitus management, and patient-centered care. More than 97 percent of babies are now screened at birth and referred for diagnostics. If they receive timely hearing aids, cochlear implants and/or sign language, their outcomes are extremely good. But when we carefully look at our screening follow-up numbers, less than half of those babies receive a timely diagnosis from an audiologist AND early intervention.
My hopes for the next 20 years? We are now at a pivotal moment in our field. Health-care providers and payers are starting to understand that untreated hearing loss is a public health concern. The Academy, ASHA, and ADA are working together on legislation. Let’s capitalize on this positive news. When we provide the best, evidence-based care, our patients and our professional colleagues will understand that hearing care is vital for our patients’ quality of life. What we do matters, and we should be proud to do it right.
DENNIS VAN VLIET, AuD | Back to the Future: Where Are We Now?
In 1999 I was mid-career with more than 20 years behind me as a clinician. I decided to address a potential 2026 class of new AuD graduates.
I smiled as I read over my article from that publication. I naively predicted that holographic imaging technology would be commonplace. I’m not sure what I had in mind, but it sounds pretty entertaining. Similarly, I predicted that we would be employing physicians by 2026 since they would be having a hard time with reimbursement. I should have had better future goggles!
It also turns out that I was stretching a bit when I described a national consolidation of educational programs that resulted with a mythical California School of Audiology and four other world-class programs in the United States. We are not there, and I should have foreseen the huge problem of the student loan crisis as well.
What I was right about was the fact that technology and other systemic changes in hearing assessment and remediation do not serve as a substitute for counseling. Yes, YouTube videos are helpful, but they aren’t a substitute for the face-to-face addressing of the multiple issues that our patient population faces. There is justified concern about changes in our profession brought about by technology, consolidation, and changes in the delivery system of products. However, I have no doubt that we will adapt and I am optimistic that we will be able to do so by developing new and better approaches to hearing care.
Quoting myself from the past for our future:
Maybe you will become famous, maybe you won’t. Maybe you will provide services to kings and movie stars, maybe to the poor. Respect them all and provide the gift of hearing in the best way that you can. Don’t forget the counseling.
BRENDA RYALS, PhD | The Next Chapter
In the 1999 special issue of Audiology Today, I was invited to write my thoughts about audiologists of the 21st century. The discovery of hair-cell regeneration was 11 years old, and my thoughts revolved around how that discovery would progress and how audiologists of the future might be involved. To that end, my predictions were that treatments involving hair-cell regeneration or restoration would become a reality and that we would have available to us sensitive and more specific diagnostic tests to guide candidacy selection for those treatments. Technically, I was wrong on both counts–but I’m not giving myself an “F.” We are only 20 years into the 21st century, and the advances toward these treatments since 1999 have been tremendous!
While biochemical or pharmaceutical treatments of sensorineural hearing loss have not come to pass, we’ve made tremendous strides in identifying the molecular and genetic triggers for hair-cell regeneration or replacement in mammals. In fact, there are at least three drugs under evaluation in either in Phase I or II (safety and efficacy) human clinical trials that target hair-cell regeneration or restoration. That doesn’t mean we will have a pharmaceutical “cure” for sensorineural hearing loss tomorrow (only approximately 10 percent of Phase I trials make it successfully to market), but I think it does mean that we are looking at “when” and not “if” this treatment will work.
As for more specific diagnostic tests, unfortunately, I don’t believe we’ve made remarkable strides in this area. We continue to have great objective tests for the loss of sensory or neural cells, but we lack more specific tests that relate, for example, to the endocochlear potential and/or synaptic junctions.
Recent discoveries in animals with inner hair-cell synaptic loss (synaptopathy or hidden hearing loss) are driving current research efforts to find new tests or combinations of current tests that can specify synapse loss in humans. Such efforts will certainly help in the future identification of appropriate candidates for pharmaceutical interventions involving hair-cell regeneration/restoration.
The title of my 1999 article included a reference to a Gary Larson cartoon about “Chapter Nine” of a medical textbook for students of veterinary medicine. The chapter listed a page full of medical ailments, with only one option for treatment: shoot. I suggested that audiologists were faced with a similar dilemma whenever they made the diagnosis of sensorineural hearing loss—our only treatment option was amplification.
I will go out on a limb now and say that I continue to believe we will have more options for treatment in the 21st century and that our diagnostic tests will improve. I stand by my statement from 20 years ago: The “Chapter Nine” for audiology students of the 21st century is bound to be much more interesting and a whole lot more challenging!”
DAVE FABRY, PhD | Predictions: Two Decades in Review
Upon further review of my “millennium” predictions from 1999, I realize now that I should have predicted that I would have significantly fewer “outer” hair cells, and those that remain would be very gray! Regarding my audiology predictions, my record is mixed. By my count, I achieved around a 70 percent to 80 percent “hit rate.”
- AARP is a much stronger lobby group due to the aging baby boomers and their Chief Medical Officer, Charlotte Yeh, is a strong advocate for the role of the audiologist in brain health as means to “disrupt aging.” Oh, and another difference is that now I am an AARP member (for the discounts).
- Neural networks and artificial intelligence (AI) are now used widely in hearing aids to improve performance and adjust hearing aid signal processing.
- Adaptive beamforming arrays and remote microphones are capable (to the degree that the hearing loss allows) of augmenting reality for hearing aid users so that they can outperform their normal-hearing counterparts in certain noisy listening environments. But people still don’t use them enough!
- Telemedicine is easier to use than ever and yet clinicians have not adopted it widely as a means to combat commoditization of their role in hearing health care. I did mention, however, that telehealth could serve as a mechanism for monetizing audiology services within an over-the-counter environment.
- Sadly, we have not yet moved beyond the audiogram as the basic building block of defining hearing loss, yet.
- Audiologists and ENTs are still working collaboratively (mostly), and while cochlear implants have increased in popularity, implantable middle-ear devices and hair-cell regeneration have not replaced conventional amplification.
- Chris Campbell represents Indiana House District 26 and serves as the ranking member of the Government and Regulatory Reform Committee. Although I got that right, patients do not (yet) have direct access to audiology services. But we have made progress.
- We have many more than 50 AuD programs, some of which reside in colleges of liberal arts, but many more are housed in the health sciences.
- Sadly, we lost David Cyr shortly after this article was published, and Bob Brey and Neil Shepard are now retired. Awareness for the importance of healthy hearing and balance has increased dramatically. Hearing aids are now capable of fall detection, and balance training provides an important opportunity for audiologists to serve the needs of the millions who struggle with balance disorders.
- The Academy, the American Speech-Language-Hearing Association (ASHA), and the Academy of Doctors of Audiology (ADA) have once again discovered that it is better to provide a unified front toward legislative agendas for audiologists and have signed on to support proposed legislation (HR 4056: Medicare Audiologist Access and Services Act of 2019). Unfortunately, world peace has not yet been achieved, and cold fusion (what’s that?) was never scientifically proven.
JERRY NORTHERN, PhD
JAMES W. HALL III, PhD
LISA L. HUNTER, PhD
DENNIS VAN VLIET, AuD
BRENDA RYALS, PhD
DAVE FABRY, PhD
I can’t wait to see what the next 20 years bring for audiology—perhaps hair-cell regeneration really will happen!
I want to thank all of the original contributors and especially thank those willing to revisit this idea. As for me, while I have no idea what the future will bring for audiology, I do believe that we are (at least partly) in control of our destiny. We are still headed in the right direction, but the journey is far from over.