The views and opinions expressed in this article are those of the author and do not represent the official policy, position, or opinion of the American Academy of Audiology.

This two-part article presents factual information and mounting evidence to explain and demonstrate why there is growing concern about the intentions of hearing aid dealers. They should come under greater scrutiny and oversight by government officials and agencies to ensure that they conform to and comply with state and federal laws. Their efforts to enter health care have been increasing both at the state and national levels. Based on how their limited occupational education, training, and licensure requirements are defined and viewed in health care, their identity could be legitimately reconstituted and branded as “hearing aid technicians.”

Currently in the United States, distribution of hearing aids is facilitated primarily through audiologists, physicians, and hearing aid dealers. However, there is confusion in the marketplace over the “branding” of each group. Proper branding of the truth addresses inaccurate statements, positions, and perceptions, while differentiating between the profession of an audiologist and the occupation of a hearing aid dealer. The passage of the Over-the-Counter (OTC) Hearing Aid Act (2017) will create additional confusion through the development of a new channel for hearing aid distribution. Therefore, it is essential that audiologists properly “brand” and differentiate our role in hearing health. 

Part 2 of this series continues with discussion regarding identification of health-care language; and description of “professional” language for professions vs. “occupational” language for vocations.

Health-Care Language

There is an ever-increasing demand for health-care information. The public expects us to brand the truth as they depend on receiving understandable, reliable, and truthful information about their health care. They also deserve ethical behavior from their providers, regardless of position in the health-care hierarchy. In addition, it is a common rationale that the greater amount of education required to enter an occupation or profession, the greater the work-roles (job duties and responsibilities) or broader scope of practice, respectively. 

There are certain well-established work-roles and scopes of practice in the health-care hierarchy providing for a distinct, accepted, and understood “division of labor.” For example, in nursing, there are nurse’s aides (NA), licensed practical nurses (LPN), registered nurses (RN), nurse practitioners (NP), and doctors of nursing practice (DNP). Each has a well-defined position and specific level of education and training that prepares them for either occupational/vocational/technical work-roles for some; and for others, a professional scope of practice. It is recognized and easily understood that a nurse’s aide is intentionally and purposely not prepared to perform the duties of a RN, NP, or a DNP. 

Statutorily, the hierarchy, or division of labor, differentiates between occupations and professions and specifically defines and restricts what services are allowed to be provided, how they are provided, and by whom they are provided to meet the varying needs of and to protect the consumer. For example, otologic technicians and opticians are not allowed to incorporate ENT’s and optometrist’s scopes of practice into their respective work-roles. Similarly, neither are hearing aid dealers allowed to incorporate audiologist’s scope of practice into the hearing aid dealer’s work-roles. It is harmful to the public’s best interest to expand any ancillary or support personnel’s work-roles to include that of a healing arts doctoring profession’s scope of practice. In 2016, the United States Code, Title 38, was amended to include hearing aid dealers – listed as hearing aid specialists (Veterans Health Administration, 2016). It reads in part:

(b) Requirements—With respect to appointing hearing aid specialists under sections 7401 and 7402 of title 38, United States Code, as amended by subsection (a), and providing services furnished by such specialists, the Secretary [of Veterans Affairs] shall ensure that—

  1. a hearing aid specialist may only perform hearing services consistent with the hearing aid specialist's state license related to the practice of fitting and dispensing hearing aids without excluding other qualified professionals, including audiologists, from rendering services in overlapping practice areas;
  2. services provided to Veterans by hearing aid specialists shall be provided as part of the non-medical treatment plan developed by an audiologist; and
  3. the medical facilities of the Department of Veterans Affairs provide to Veteran’s access to the full range of professional services provided by an audiologist.

The Office of Management and Budget’s (2010) Standard Occupational Classification (SOC) Code lists audiologists under the group category of Health Diagnosing and Treating Practitioners. Hearing aid dealers (or, hearing aid specialists) are listed under the group classification titled Miscellaneous health technologists and technicians. 

According to the Bureau of Labor Statistics (2016) and Allied Health Schools (2016), technicians commonly are required to complete a two-year associate’s degree program that stresses practical skills or a one-year certificate program. Health-care technologists, on the other hand, complete a four-year bachelor’s degree in medical technology or life sciences.

The Association of VA Audiologists (2013) note that “…hearing instrument specialists can, currently be hired under Health Aide and Technician Series 0640 of Title 5. The level of education and training specified for hearing aid specialists in this bill is consistent with the knowledge, skills, and abilities of health technicians hired under job series 0640 and employed in VA audiology clinics.”

The U.S. Office of Personnel Management (USOPM) (2016) explains the general schedule (GS) for health aides and technician qualifications as follows: 

  • GS-3: Successful completion of one year of study that included study in medical, health, or related fields. 
  • GS-4: Successful completion of two years of study that included at least 12 semester hours* in subjects related to the position.
  • GS-5: Successful completion of a full four-year course of study leading to a bachelor's degree, with major study or at least 24 semester hours in subjects directly related to the position.

* Apprenticeships are not structured to award “semester hour” credit. This is reserved for college and university degree programs.

The U.S. Office of Personnel Management (September 1988), classifies health aides and technicians as follows: 

  • Health aide is the suggested title for GS-1, GS-2, and GS-3 positions and health technician is the suggested title for positions at grades GS-4 and above. (Audiologists are GS-12 grade level or higher.) 
  • Specific titles indicating separate specializations are not suggested because in such a broad series the range of possibilities is too great. The general principles governing position titles apply. Titles may be descriptive of the specialized area of the work of the position, e.g., technician work supportive to the work of the optometrist, ophthalmologist, audiologist, or speech pathologist, etc., or of the “mixed” nature of the position, e.g., a position involving work in both medical radiology technician functions and medical technician functions.

According to the USOPM’s classifications, hearing aid dealers who have entry-level licensure requirements of a high school diploma, a one-year apprenticeship, or a one-year certificate program are considered “health aides.” Those who have entry-level licensure requirements of a two-year course of study, such as an associate’s degree, are considered “technicians.” Some hearing aid dealers might argue, while again branding the lie, that they have earned degrees in other areas of study beyond the associate’s degree; and, consequently, deserve greater recognition. This point is moot, because it is the education requirements for licensure that determine whether a group is identified as an occupation or a profession and, consequently, technicians or professionals.

The National Center for Educational Statistics (NCES) (2016b) uses “hearing instrument specialist”; as an illustrative example it refers to “hearing aid technician.” In the health-care arena, based on their limited educational requirements and job skills for licensure, hearing aid dealers are considered a ‘nonprofessional health-care occupation’; and they qualify to be labeled with the designation “technician,” not “specialist.” 

Professional vs. Occupational Language

Just as there are delineations in the health-care hierarchy, there are delineations between what constitutes a profession versus an occupation. Education at the bachelor’s, master’s, or doctorate level is compulsory for a profession, but not for an occupation. Once we understand the structure of education, the hierarchy becomes more apparent in health care, work-roles, identities, licensing laws and their restrictions. 

 

TABLE 1. Statutory Requirement in Hearing Aid Dealer’s Laws for the Minimum Education Needed to Obtain a Hearing Aid Dealer’s License.

MINIMUM EDUCATION REQUIRED

TOTAL

STATE/DISTRICT

High School Diploma or Equivalent

41

AL, AK, AZ, CA, CO, CT, DE, DC, FL, GA, HI, ID, IN, IA, KS, KY, ME, MA, MI, MN, MS, MT, NE, NV, NJ, NM, NY, NC, ND, OK, OR, RI, SC, SD, TX, UT, VT, VA, WV, WI, WY

Associate Degree

8

AR, IL, LA, MD, MO, NH, 

TN, WA

None

2

OH, PA

 

The health-care industry requires systematic, sequential, and more rigorous training along with a higher educational standard in order to achieve recognition and advancement to positions having greater responsibilities and authority. Vernacular should be used that is statutorily correct, representative of, and commensurate with academic and technical/vocational understanding and recognition. 

Jax (2016), in discussing “occupational versus professional education” notes, among other things, that

  1. …the field of postsecondary education generally sees an occupation as unskilled work, or a skilled trade, while a profession is a job requiring advanced and broad education.
  2. Career and technical colleges provide training for occupations, as do community colleges.
  3. Occupational education is specific training for a particular job.
  4. Training for a profession generally involves attaining a bachelor’s degree and sometimes requires a graduate degree, as is the case with doctors and lawyers.

Entry requirements for skilled-worker occupations, such as a hearing aid dealer, typically are limited. Table 1 shows the minimum educational requirement for licensure as a hearing aid dealer statutorily is a high school diploma or equivalent in 41 of the states/District of Columbia (DC); an associate degree in eight states; and none required in two states.

Apprenticeships are a viable way to learn a trade or an occupation [Office of Disability Employment Policy (ODEP) (2016); Employment and Training Administration (ETA) (2016)]. The ODEP and ETA recognize and identify groups who have apprenticeship programs as occupations, not professions. There are more than 1,000 occupations with registered apprenticeship programs, e.g., laboratory technicians, optical technicians, and dental assistants. They note that, “once an apprenticeship training program is complete and necessary job-skills attained, the trainee/apprentice receives a Certificate of Completion of Apprenticeship.”

The U.S. Department of Education (2016) and the National Center for Educational Statistics (2016a) report that the 1990 Perkins Act defines vocational education as organized educational programs offering a sequence of courses which are directly related to the preparation of individuals in paid or unpaid employment in current or emerging occupations requiring other than a baccalaureate or advanced degree.” 

TABLE 2. U.S. College Programs for Hearing Aid Dealers

COLLEGE**

DEGREE/CERTIFICATE

PROGRAM

CAREER PREPARATION AS EMPHASIS

Bates Technical College

AAS*

Hearing Instrument Technology

Hearing Instrument Fitter/Dispenser

Rowan College at Burlington County

AAS*

Hearing Instrument Sciences

Hearing Instrument Specialist 

Hearing Instrument Dispenser

Hearing Aid Dispenser

Ozarks Technical Community College

AAS*/Certificate

Hearing Instrument Sciences

Hearing Instrument Specialist 

Hearing Instrument Dispenser

Hearing Aid Dispenser

Spokane Falls Community College

AAS*/Certificate

Hearing Instrument Specialist Program

Hearing Instrument Specialist 

Hearing Instrument Dispenser

College of DuPage

Certificate Only

Hearing Dispensary Certificate Program

Hearing Healthcare Provider

Hearing Instrument Specialist

*AAS = Associate of Applied Science  |  **College contact information in “References” below.

According to the International Hearing Society (IHS) (2016), there are five U.S. College Programs for Hearing Instrument Sciences. Two programs are degreed; two are degreed and certificate programs (fewer requirements for those not seeking a degree or needing a degree for licensure); and one certificate-only program. IHS states that “… an academic degree in hearing instrument fitting and dispensing” can be earned; however, this claim is at best misleading and, at worse, false. There is no existing degree awarded that is called a “hearing instrument fitting and dispensing” degree.

Associate and baccalaureate degrees are recognized as undergraduate academic degrees. The College Atlas (2016) explains that associate degrees “… are primarily offered by junior or community colleges and vocational schools.” It goes on to distinguish and clarify the differences between the two categories of associate degrees, i.e., transfer and occupational: For those students wanting to eventually earn a baccalaureate degree, the “associate of arts (AA) and associate of science (AS) are two-year degrees that are designed primarily as transfer degrees.” 

In contrast, “occupational associate degrees are designed to help students acquire specific knowledge and skills in preparation for a particular career path.” The occupational “associate of applied science (AAS) degree is a two-year degree designed for people who intend to enter the workforce immediately following graduation from their program.” Also, “… some AAS courses are not granted transfer equivalency credit nor will they fulfill the general education requirements of a bachelor’s degree program.” 

Table 2 shows the degree granted by colleges for hearing aid dealer preparation is an associate of applied science (AAS) degree. The AAS degree is considered a two year “technical/vocational degree.” This is further distinguished from degrees that prepare students for professional careers requiring a baccalaureate, graduate, professional doctorate, or research doctorate degree. 

The wide variety of terminology used in the above colleges prevents a common vernacular as a basis in which to communicate between programs, define programs to students, convey accurate information to the public, and to be recognized for purposes of uniformity and reciprocity between state licensure boards. This is unlike the audiology profession, where there is no vernacular confusion between the 70+ doctor of audiology programs. 

U.S. colleges offering AAS degrees and certificate programs for hearing aid dealers would assist in branding the truth if they revised their program terminology to conform to statutory and occupational/technical/vocational vernacular. Examples are 

  1. Program emphasis would best be identified as “hearing aid technology.” 
  2. Career preparation should be for the occupation of “hearing aid dealer” or “hearing aid technician” rather than for a profession or field. 
  3. Those in occupations have “work-roles (i.e., job duties and responsibilities)” rather than “scopes of practice.” 
  4. Hearing aid dealers/technicians provide “hearing aid services” rather than “hearing health-care services.” 
  5. Use “on-the-job training” or “supervised work experiences” rather than “clinical practicum.” 
  6. Use “laboratory skills” rather than “clinical skills” since hearing aid dealers are not trained or licensed to enter clinical practice.

Engelmann (2008a) notes that the International Institute for Hearing Instruments Studies (IIHIS) accredits educational programs for IHS. The IIHIS established the American Conference of Audioprosthology (ACA) in 1976. Engelmann (2008b) emphasizes that “… the IIHIS and the ACA are NOT academic institutions, are NOT accredited by any accrediting agency recognized by the U.S. Department of Education, and CANNOT award academic credit for any of their educational material.” Also, “… it is very confusing and misleading when IHS, IIHIS, and ACA weave the vernacular of universities, colleges, and the academic community into their literature, leaving consumers with the false impression that ACA is some type of accredited academic institution.” 

For example, IHS’s literature notes that “ACA is a baccalaureate-level course specifically designed for hearing instrument dispensers with two or more years of experience.” “The ACA program contains five courses structured to conform to a semester-hour format common to universities.” “Students that successfully complete the ACA program earn 15 semester hours or credit toward baccalaureate degree category that can be applied to a variety of undergraduate programs.” The use of terms such as “baccalaureate level,” “semester-hour format,” and “earn credit toward baccalaureate degree” creates the impression that the ACA is a university-based program, when this is not the case. 

ACA also number their courses in the 300s and 400s as if to appear synonymous with upper division undergraduate courses at a college or university intended for juniors and seniors working on a bachelor’s degree. Coursework during the first two years at a college or university is commonly numbered at the 100 and 200 levels to denote freshman and sophomore courses. Upper division courses are typically not available for freshmen and sophomores let alone for individuals who have only a high school diploma and have never been enrolled in a college or university. Again, this numbering system, common in colleges and universities, appears to indicate that the ACA is a university-based program.

One of ACA’s course offerings is “Practicum (403).” ACA’s use of professional and university-based terminology like “practicum” is associated with a graduate school-level course that provides students “supervised practical application of a previously or concurrently studied theory.” Practicum is neither a term associated with continuing education courses nor correct vernacular to use for preparing someone for a vocational/technical job. An appropriate example of the correct and proper use of “practicum” is when referring to clinical teaching with master’s degree students in speech-language pathology. The experiential aspect to dealer’s training would be better expressed by using the designation “supervised work experience” or “on-the-job training.” 

Conclusion

Professions and occupations have every right to take the necessary and appropriate steps to advance themselves and improve their qualifications. However, the efforts to do so should not be accomplished by branding through merely inflating titles and promoting false identities or by using misleading terminology.

For some time, hearing aid dealers have worked on shedding their image as retail salespeople and establishing themselves as hearing health-care professionals and members of the hearing health-care profession when they are neither. If their goal is to be recognized in health care, they must be held accountable and required to use the proper language of statutes, academia, and health care. They should also recognize their place in health care’s hierarchy that is based largely on education and training requirements for licensure. For that, they are identified as belonging to a skilled-worker’s occupation and are recognized as technicians. 

Hearing aid dealers should rise to no higher level than other health-care employees who have jobs requiring a minimum of a high school diploma, on-the-job training, an apprenticeship, or a vocational/technical two-year associate of applied science degree. They are legislatively and statutorily mandated to be restricted deliberately and confined to narrowly defined work-roles. 

If hearing aid dealers change their educational directives for the entire occupation/trade/vocation along with all licensing laws to mandate an associate of applied science technical/vocational degree as the entry-level degree, then they should be able to advance in health care to the level of other health-care employees who have jobs that require a minimum level of an AAS degree; the same would apply for bachelor’s, master’s, and doctorate degreed professions. Allowing hearing aid dealers and their membership organizations to deceive the public by using false and deceptive language, by developing programs that foster and promote hearing aid dealers to expand their occupational work-roles and activities into the scopes of practice of audiologists and physicians, and by exceeding their qualifications, is not in the best interest of the public health and safety. They have not earned the requisite academic degree nor do they possess the advanced training that goes along with the expanded scopes of practice responsibilities of allied health-care professionals or doctors. 

Branding the lie serves no one other than those doing the branding. Audiologists, and others, should resist the temptation of falling into the trap of branding the lie by rejecting bogus, improper, and illegal terminology; and demand that branding the truth becomes the gold standard of care and best practices for those of us in health care that are bound by and adhere to state and federal laws and ethics. Branding the truth is our obligation and responsibility to society. Consequently, we can ask our organizations to petition federal and state agencies and colleges to use vernacular that is statutorily correct, commensurate with academic understanding and recognition, and is representative of technical/vocational occupations. For example, petition the Office of Management and Budget Standard Occupational Classification (SOC) Code, the Veteran’s Health Administration, the USDOL’s Office of Apprenticeship, and the National Center for Educational Statistics and others to change the descriptors from “hearing aid specialist” or “hearing instrument specialist” to the more appropriate descriptor “hearing aid technician.” 

Attempts to popularize hearing health-care profession, hearing health-care provider, hearing health-care professional, or hearing health-care practitioner (HHCP), or any similar titles, should be avoided and discouraged. They serve only to ignore the important differences between physicians, hearing aid dealers, and audiologists. The truth is that the audiology and medical professions should not surrender their identities and be forced into one collective group. Conveying this false impression is branding the lie and is especially dire for consumers when they are trying to make important choices and informed decisions about health care and determining which providers are best suited for their needs. 

Branding the truth requires avoiding occupational fraud, academic misrepresentation, and vernacular confusion and by not using terms like HHCP in written correspondence such as journals and patient literature or in oral communications like meeting presentations. Identification and recognition of separate occupations and professions are essential for consumer understanding and transparency. Organizations representing audiologists should be role-models and pursue branding the truth by notifying all stakeholders to stop branding the lie and increase our directed efforts at branding “audiologist” and “audiology” as household names.