During spring 2020, higher education faced drastic changes to education delivery due to the coronavirus  pandemic. The rapid change challenged clinical education goals due to clinic closures and the cessation of student participation in patient care and hands-on laboratory experiences. 

The clinical coordination team at The University of Texas at Dallas focused on the clinical education of its AuD students and telehealth service delivery, embracing that this journey could improve student education and patient care beyond simply the bare minimum. 

We developed remote clinical education models to meet clinical hours and continue the growth of student competencies across the scope of practice, challenge audiologists’ adaptability, and reach patients in quarantine. The feedback from audiologists and students suggested they benefited and confirmed that these lessons will be incorporated moving forward. 

Given the rapid necessity of remote clinical experiences, the Council on Academic Accreditation (CAA) and the Council for Clinical Certification in Audiology and Speech-Language Pathology announced changes to the process of AuD education. While the councils maintained the number of required clinical hours (the equivalent of 12 months of full-time experience for externships) and the proportion of hours allowed via simulation (10 percent), the nature of the simulated hours was expanded to include case-based discussion models through August 1, 2020. Furthermore, students were credited for remote participation in telehealth experiences compared to previous shoulder-to-shoulder preceptor-student models (CAA, 2020).

With these guidelines, the clinical coordination team developed three modes of remote clinical education: simulated case sessions, telehealth clinic sessions, and virtual clinic sessions. 

Simulated case sessions were those in which clinicians collated case studies and used debriefing to guide students through the evidence-based diagnostic, rehabilitation, and counseling processes that occur in face-to-face encounters. Up to six students participated in these sessions, which were scheduled for one to two hours per week and included clinical assignments. 

Figure 1-Audio suite set up for virtual clinic education at the UT Dallas Callier Center in Richardson, Texas.
FIGURE 1. Audio suite set up for virtual clinic education at the UT Dallas Callier Center in Richardson, Texas. This figure illustrates how students can virtually participate in an in-person clinic session. The clinical computer  is enabled with a video camera and Microsoft Teams access to enable students to join a meeting. The clinical computer screen is duplicated to the TV monitor  so that student faces can be displayed on the TV monitor during patient interaction. An external microphone  is placed near the patient’s chair and connected to the microphone jack in the tower of the clinical computer . Similarly, a loudspeaker  is placed near the patient and connected to the headphone jack on the tower of the clinical computer  to serve as the audio output for the computer. The clinical computer  is networked to the immittance , audiometer , and verification  units, enabling students to operate them from the shared screen of the clinical computer . The loudspeaker  can be repurposed when the patient enters the booth for testing by plugging it into the audiometer  and serving as the audio output, which is loud enough for the students to hear the patient’s responses from within the booth.  

Telehealth clinic sessions became available as clinicians became confident with the technology, in compliance with HIPAA guidelines. Efforts were supported by manufacturer trainings, our information technology and HIPAA team, and our business associate agreement with Microsoft Teams (Microsoft, 2020). Clinicians securely videoconferenced with patients and students for remote hearing aid programming, aural rehabilitation sessions, and hearing aid checks with established patients.

Virtual clinic sessions converted our typical interactions into off-site student participation in clinic. Through virtual clinic sessions, patients, and clinicians were face to face and a secure videoconference was established with students, who could speak directly with the patient and operate the clinician’s computer remotely (FIGURE 1). 

Protocols established the standardized processes among all clinicians. Feedback from formalized surveys and informal conversations enhanced student and practitioner experiences. In each remote clinical education model, the lessons learned will influence the future of AuD education and patient service.

Simulated Case Sessions

In the initial wave of stay-at-home orders, our clinicians were faced with work-from-home time and new responsibilities of developing cases and guiding student learning through new media, in addition to their clinical projects that could be completed remotely. 

Audiologists often express that student interactions improve their own skills. This remained true in the remote environment. In preparing de-identified case studies, clinicians revisited cases with new, sometimes more experienced, eyes. Student questions prompted clinician self-reflection in ways that could not have been explored in depth during the pace of in-clinic appointments. 

Students appreciated how the simulated case reviews were slower than typical clinic encounters, allowing time for critical thinking. They asked questions that they otherwise wouldn’t have while maintaining an efficient in-person clinic encounter. Many clinicians used the simulated case time to introduce detailed use of hearing aid software, inventories, and other clinical tools.

Coincidentally, 2020 began with new ASHA requirements for continuing education in clinical precepting for supervising clinicians, mostly obtained through the eLearning modules developed by the Council of Academic Programs in Communication Sciences and Disorders (CAPCSD, 2020). Therefore, clinicians had a foundation in best practices of clinical education, including feedback, assessment of student learning, and fostering effective student-clinician relationships. 

The implementation of clinical educator competencies became particularly important in the online environment. Relationships between students and clinicians no longer hinged on shared—but primarily clinician-directed—tasks necessary to keep a schedule on track; rather, much of the discussion was student-led. Thus, clinicians spent more time addressing skills in which students felt less confident. 

Though repetition is a vital part of the learning process, student-clinician relationships are enhanced when students can ask their most pressing questions and have dedicated instructors answer with their real-world and evidence-based experiences. 

Simulated case sessions, particularly for the early cohorts, included use of clinical audiometry simulators, such as CounselEAR, and testing demonstrations on YouTube. These materials were screen-shared and clinicians prompted student thinking across numerous patient profiles. 

Other simulations were researched for use in small groups once a return to campus was allowed for coursework and for remote access. These include the AudSim audiometric testing and masking simulator, Otosim otoscopy demonstrators, simulated ABR (sABR) (Herdman, 2020), Baby Isao from Intelligent Hearing Systems (IHS, 2020), and Baby- and Base-CARL. This research suggested that our audiology colleagues have been developing high-quality simulators that can supplement clinical education of all kinds.  

Initial surveys obtained after the first weeks of simulated cases generated positive and constructive responses from the students and faculty. All parties reported the anticipated confusion regarding online platforms and concern about the potential impact to clinical proficiency and graduation requirements. However, by the end of the semester, most students and audiologists were impressed with how well the simulated cases kept their audiological critical-thinking skills sharp. 

Telehealth Clinic Sessions

Telehealth is undergoing substantial development and advocacy within the field, recognizing its potential to expand clinic operations to the cutting edge of patient accessibility. Although telehealth is a long-standing model, its uptake was somewhat limited in hearing-health care. The pandemic necessitated quick and large-scale operations, which could not have happened without collaboration among all parties. 

Challenges included identifying the sessions that could be moved onto a telehealth platform, such as hearing aid checks, aural rehabilitation sessions (often with family members in other locations), and remote programming with capable devices. Clinicians were adaptable to the remote-delivery model, prioritizing checking in on their patients with recent hearing aid deliveries, hearing tests, and those with known, needed follow-up. 

The limitations to traditional delivery challenged clinicians to come up with creative solutions to problems, such as teaching patients via videoconference to change wax guards. In addition, we recognized a need for common troubleshooting videos to which we could direct patients for self-help resources. By creatively solving such problems, clinicians exercised the very concept of self-advocacy we emphasize for patients, recognizing what  they needed and effectively   advocating for themselves and their patients in challenging situations.  

Similarly, students were challenged to learn in new ways. Remote interaction allowed automated live captioning, reinforcing lessons about clear communication with patients. They learned that captioning was more accurate and in sync with their voices when they slowed their speech—a skill we often cannot directly teach in clinic, but which is very important when speaking with our patients. The students also learned that they needed more specific verbal communication about hearing aid-related tasks (i.e., orientations and checks), when the easier, but less effective, option of doing the tasks for the patients was removed.

Though we recognized that a pivot to include telehealth services was in the future for the profession of audiology, we will be refining how best to continue to use telehealth in compliance with HIPAA and licensure laws. It was clear that patients appreciated the ability to include family members who could not otherwise attend an appointment. In addition, the opportunity to stay in touch with patients at risk for isolation was imperative to maintaining the rapport between patient and clinician. 

Virtual Clinic Sessions

After weeks of simulated cases and telehealth service delivery, the Callier Center began phased reopenings, with clinicians allowed back on campus while students were still restricted to remote education. Patients returned to the clinic for needed testing and reprogramming of devices. At first, students continued to participate remotely while patients and clinicians interacted in person in the clinic. 

The prior experience with the telehealth services and videoconferencing platform led to a smooth transition to virtual clinic sessions. By connecting an external microphone close to the patient and using our existing TV monitors and external loudspeaker as the duplicated computer screen and external sound source for the students’ voices, respectively, our clinic booths were established with this new capability, for approximately $30 each.

Changes to standard clinical process resulted from the simultaneous emergence of revisited infection-control policies and remote education. For example, in response to Centers for Disease Control (CDC) recommendations, audiologists across the country wear masks, inevitably reducing the audibility and visual cues available to patients. 

By enabling the remote-education model, the student can communicate to the patient via the TV screen without wearing a mask and, for enhanced communication, automated live captioning can be enabled for the patient, clinician, and student. Similarly, because the remote-screen-control features within Microsoft Teams allow students to operate the computer remotely, clinicians who are wearing gloves for tasks don’t need to take a glove off to operate some computer-based programs.

Students enjoyed being on the cutting edge of these experiences, albeit through a trial-and-error process. 

“It was rocky the first week, since this was a totally foreign concept for us, but by the end of the semester, it was a great experience overall,” Payton Brown, a second-year student, said. “I have learned new skills via online clinic and got to focus on the counseling piece more than I would in person. The best part of this whole process is that I now can utilize telehealth services in the future, if appropriate.” 

Remote education experiences are not without their limitations. For example, in this model, some diagnostic testing, such as evoked potentials, is accessible only by observation. Therefore, in-person modes remain the cornerstone of clinical education endeavors. 

However, with open minds, patience, and dedication, clinicians developed new skills and modeled a professional team approach in some of the most challenging situations we have yet faced as a profession.

Fortunately, while there was the initial stress associated with such a big change in our program, students adapted quickly and found ways to make this learning process even better than we could have expected. In fact, many of them were so grateful for these experiences that they enthusiastically suggested we incorporate the varying remote clinical education models into our standard clinical instruction.

Summary

Clinical education requires adapting to changing circumstances, where new students, new patients, and advancements in clinical best practices create an exciting laboratory for high-quality patient care and student learning. In the unexpected circumstances brought about by enhanced health and safety precautions, this experience is no different. All parties involved—students, clinicians, administrators, and patients—responded innovatively to the challenges presented. 

Students were able to overcome their initial hesitations to master new technologies, while simultaneously managing their changing home environments. Incidentally, we learned much about our students’ challenges. For example, many students’ internet access was unstable, as everyone in their neighborhoods moved to remote work, reducing internet bandwidth. Some students adjusted to shared office spaces and managing the remote education of their school-aged children. We even got to meet many students’ pets, an unexpected but delightful side effect of remote education! 

Equally important was the mentorship that each clinician provided during these times, by diving headfirst into supplementing the clinical education of students in an entirely novel way. By investing time, energy, and compassion in the process, clinicians shaped these experiences that will continue to be important in our clinical education, modeling how to be an adaptable and ever-learning audiologist. 

Finally, administrative support was necessary for this undertaking, including the business associate agreement that allowed for secure remote education and telehealth, the extensive technical support provided on-site and remotely by the information technology team to ensure security in sessions, and the willingness to believe that true student learning can happen with the right mixture of student-educator relationships, feedback, and assessment.