When I began my career in 1996, I cannot say that I ever imagined audiology would become a doctorate-level profession, or that the fourth-year externship would evolve into its current level. 

Now that I celebrate 20-plus years as a practicing and supervising audiologist, I look back and try to assess the value of that advanced degree and what our new, bright fourth-year candidates bring to the profession. I can remember with excitement, all of the discussions and hopes for what the doctorate-level degree would bring to our practice of audiology. I know I date myself to say that. I was genuinely excited at the prospect of pushing what we were and who we are to the next level. I expected to have a much more advanced focus on tinnitus, pharmacology, rehabilitation, and amplification, and create a more medical or provider based approach to what we do every day. 

As a director of a large, private ENT medical group, I am fortunate enough to be exposed to many different facets of audiology—both clinically and in practice management. In accepting this role, I made the decision that we would develop externs rather than hire audio-techs or audiology assistants. I believed then and now that we needed to invest in our professional future rather than use staff who did not have extensive training in our field. We have grown our fourth-year externship program to a very competitive site in a few years’ time, and have helped to train and support some of the most phenomenal preceptors. 

Three-Track System 

We divide our externs into three tracks. The first is a rotational track with focus on cochlear implants, vestibular testing, pediatrics, and tinnitus/amplification. The second track is focused on diagnostic assessment, hearing aid fittings, and management, as well as some videonystagmography or auditory brainstem response (VNG/ABR) training. The difference in the second track is that we also spend a significant portion of time on practice management and learning how to run a business. 

Our newest track is a pediatric/cochlear implant (PED/CI) track. This is our first specialty track. This track is designed for the extern who is looking for the opportunity to focus on cochlear implant evaluation, initial stimulation, mapping and follow-up, pediatric diagnostics, amplification, and follow-up. The externs in this track will also have at least one day per week for clinic diagnostics and routine hearing aid patients.

With this growth, it is time to step back and take a look at what we provide and what students really seem to need. In addition, it is great to get feedback from our externs on their perception of their academic training, their externship time, and what they feel needs improvement. Many of our externs have joined our staff, with some recently celebrating their fifth-year of employment with us. Their historical perspective and input is invaluable, and it is quite wonderful to see them grow as preceptors in their own right.

The basic question my extern clinical coordinator and I discuss each year with a new group of externs is, “What is our job/role/goal here with externs?” That seems like a very simple question, yet it has so many layers to it. 

I have always believed that the goal of the externship that we provide is to make the externs independent, capable, and able to provide excellent patient care in any setting, with most any clinical service need. My own externship, or clinical fellowship year, as it was called 20 years ago, left me to be mostly independent with a routine check-in with my supervisor. It was expected that I would be capable of patient care, for the most part, on my own. 

That was the expectation after six years completing an academic master’s degree. Today, I have to ask, “What exactly changed when we moved to a doctorate-level profession? Are today’s externs more capable now compared to clinical fellows of the past? Do they receive more clinical training prior to embarking on their fourth year?” In my experience as a hiring director of a facility that attracts and educates numerous externs each year, the answer appears to be variable, but in some cases, very little appears to have changed in these areas.

Trends in Preparedness

Over the last six years growing our extern program, we notice some trends in preparedness and experience level coming to us from good academic institutions. Clinically, it is noted that experience with providing direct patient care in pediatric testing and hearing aid fitting is often considerably absent or limited. Very few externs came with any exposure or direct patient care in tinnitus management, performing VNG and ABR testing. The fourth-year extern experience became much more about teaching students basic skills, rather than taking the year to polish their skills and make them independent. Observation or lab experiences for various audiology services are noted by the externs, but not as much hands on practical experience. 

Additionally, externs come with very little understanding of billing, coding, reimbursement, or insurance benefits. Their previous off-site experiences did not typically allow for independence in billing of services or training to understand the details of the administrative and business knowledge the independent health-care provider needs. Academic training at their universities typically included business plan creation, but little or no practical day-to-day benchmarking and tracking. We are training these students to expect the pay and respect that comes with the title doctor of audiology, but they have no clue how to justify the salary they want to receive or how to cost effectively run a clinic. 

The combination of these facts makes the job of being a preceptor much more challenging. Preceptors have to be capable of assessing clinical skill level as well as teach what is necessary for audiological services. They have to monitor, sign off on the work, take the responsibility for services and billing, and be available to provide constant feedback. It is a burden. Our preceptors are willing to assume extraordinary stress to give back to their profession. Their role, at this point, should be as a mentor, a guide, and a polisher. Precepting should be a sharing of experience and helping in teaching the greater perspective on patient care.

As we transition new 2017–2018 externs in May and June, we decide to implement a confidence assessment questionnaire from the externs’ point-of-view. The results confirm what we have seen clinically in our previous years. Only about 20 percent of the respondents indicate reasonable experience in providing VNG, ABR, and CI testing and service provision. They note that the ability to adequately interpret results is an area that needed focal improvement. Results further confirms that 100 percent of the respondents have no billing, coding, insurance, or practice management experience, and list it as an area with no confidence and required training.

With the amount of time, dedication, and work required to take on an extern, it is no surprise that busy medical offices look to adding audiology technicians or hearing instrument dispensers. From the American Academy of Audiology:

It is the position of the American Academy of Audiology that audiologist’s assistants are vital to the future of this profession and they can provide valuable support to audiologists in the delivery of quality services to patients. The duties and responsibilities of audiologist’s assistants should be assigned only by supervising audiologists. The supervising audiologist maintains the legal and ethical responsibilities for all assigned activities that the audiologist’s assistant provides. The needs of the consumer of audiology services and protection of the patient will always be paramount. Audiologists, by virtue of their education and training, are the appropriate and only qualified professionals to hire, supervise and train audiologist’s assistants.

Reading this definition, it strikes me to be remarkably similar to the definition of a preceptor to an audiology extern. I have sat in on many practice management seminars, symposiums, and conferences that include chief operating officers, directors, and audiologists. What is concerning is that I hear more frequently the reduction of audiologists in a clinic, and the addition of audiology technicians and hearing instrument specialists for cost reasons. Is that route easier for a practice than investing in externs? As a profession, we should support providing externship experiences, instead of adding assistants, and investing in the future of our field. In order to do that, we have to better prepare students to learn and help a practice thrive as a result, not challenge the preceptors with a heavy responsibility to teach and train more so than mentor.​


Prior to its dissolution, and acting on a recommendation from the Conference on Professional Education II held in fall 2008, the American Foundation of Audiology (AFA) surveyed more than 6,500 audiologists regarding their views of the AuD program (Ulinski, 2010). 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. 

Survey questions about preceptoring produced some interesting findings. Most respondents (58 percent) had not been preceptors for an AuD student in the past two years, and when asked if they would be interested in doing so, only 38 percent said yes and 62 percent said no. When those who said no were asked what it would take for them to become a preceptor, the most common responses were a change in job, supervisor, or setting (about 20 percent); more time (about 12 percent); and more information and guidance about expectations (about 10 percent).

Current Academy President Ian Windmill (Windmill and Freeman, 2013) proposed that “a concerted and coordinated effort needs to be undertaken to increase the number of persons interested in audiology as a career.” The demand for hearing care services will be rising over the next 30 years due to increases in the population. Windmill’s numbers project the number of graduating AuDs will need to increase from approximately 600 per year to 900 per year.

Additional quality externship sites will be required to support the education and preparation of our AuD students. Clinical audiology must be prepared to focus on meeting the challenge of establishing and maintaining quality externship site programs. The importance of tight coordination between clinical audiology and academia has never been greater. Emphasis must shift from how to train assistants to how to maintain and support our profession’s viability.