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Ethics in Audiology

Ethics in Audiology
Barry A. Freeman, PhD
November 19, 2012

Editor's Note: This text course is an edited transcript of an AudiologyOnline live seminar. Please download supplemental course materials.

Dr. Freeman: I was asked by AudiologyOnline to give this talk about eight to ten months ago. At the time, I thought I would give a traditional talk on ethics and go over the American Academy of Audiology (AAA), American Speech-Language-Hearing Association (ASHA) or the Academy of Doctors of Audiology's (ADA) guidelines for ethics. As things have evolved this year, I decided to make the focus about ethics and "hot topics in audiology". Thank you all for joining me.

I thought we should open up by at least agreeing to some standard of "ethics." There are many definitions that you can find. The field of ethics can be said to involve systematizing, defending, and recommending concepts of right and wrong behavior. I am going to talk a lot today about professional ethics as well, which are standards of behavior that we must present, not just with our patients and our colleagues, but also as we represent ourselves in the audiology profession and as we make decisions about how we want to move forward with our careers.

There are three R's of ethics: respect, responsibility and results. Respect is an attitude that should be applied to people and to organizational resources. We have a responsibility to the people that we serve - our customers, our patients, our colleagues, our referral sources, as well as to the entire profession of audiology. What we do reflects back on the profession. Results are the means by which results are achieved. This is equally as important as maintaining respect and being responsible for the decisions that we make.

If you consider the three R's, you can avoid some of the rationalizations we sometimes hear such as, "Nobody's going to care if I do it this way. I see the director of our clinic doing this all the time, so why can't I do it?" Or, "I do not have time to verify all my fittings or to follow best practices." Or, "It is not my job to do that."

I am sure none of you make these kinds of rationalizations. I can certainly say I have said some of these things over the years. At least if you follow ethical guidelines, you can avoid some of these types of rationalizations.

Some of what fits under the general ethical framework is going to arise out of what is called societal ethics and values. This means that you want to be operating within the law. Sometimes there is a fine line between what is considered to be legal and what is considered to be ethical. We want to operate in concert with the community. I am not saying that ethics should change, but the values of certain communities vary. When I move from a major city like Boston to practice in Clarksville, Tennessee, trust me, the community expectations were slightly different. So, consider the values within your own community.

We also want to operate under the rules of public safety. We want to be aware of best practices to make sure that we are in keeping within the laws and ensuring the safety of our patients. If you develop an ethical framework, you can stay within the law and be safety conscious, as well as run a good practice.

Why Ethics?

Every practice needs to operate in some legally, fiscally and commercially responsible way. It needs to be done with all of the stakeholders in a consistent manner. What do I mean by that? Stakeholders might be your patients. They could be the family of your patients. They could be your suppliers, technology partners or manufacturers. They could be your employees. Define them all and deal with them in a consistent manner.

If you are the manager or owner of a practice, you want to set the model and standard for the practice. If you are an employee in a particular clinic or practice, you want to make sure that the way you manage and treat your patients is consistent with the model set by the director or by standards developed by the profession. You need to be thinking about developing policies and procedures for your organization and make sure that there is transparency in your interactions with your stakeholders.

Ethical considerations refer to the standards of behavior, principles and moral values. I want to tell a story I heard several years ago. A father wanted to teach his children about ethics, so he had them read books on ethics. The children were 8 to 12 years old. He read them Bible stories and did lectures about ethics. Finally he was convinced that they really understood what ethics were about. As a reward, he took them to the movies, but he leaned over and whispered to them, "Please, do not tell them what your real age is so that we can get a discount on the tickets." Talk about undermining the entire lesson of ethics that he tried to teach his children. We always want to be setting a best ethical practice model for the people we work with by our actions as well as our words.

Many organizations develop policies, but really, you are left alone when you are providing services to your patients, and you have to make judgments and decisions on your own. The key is to develop a set of principles, follow them and make sure that everyone in your organization is following them as well.

What is a Profession?

For many years, the audiology profession has been talking about the concept of professionalism and professional autonomy. This goes back to Dr. James Jerger, when he talked about creating an organization of, for, and by audiologists, which, of course, culminated in the creation of the American Academy of Audiology. We have tended to focus on creating a profession and the concept of professional autonomy. A profession is defined in a lot of ways. Exclusivity is a term that captures what we were trying to do in audiology. Entrance into the profession requires an academic doctoral degree, and the legal right to practice is defined by a license. This was something that we tried to achieve when the Academy was first founded, and we have been successful in the United States to have moved in the same direction as other health care professions, where the entry-level educational requirement is now the Doctor of Audiology degree. We also have a requirement for licensure in every single state in the United States.

Other aspects and components of our profession include a code of conduct, high ethical standards and autonomy by virtue of our specialized knowledge (Loh, 2000). No one has more knowledge about hearing and balance than the audiologist, and that is, in part, what helps us be defined as a profession. Yet sometimes, we still find people saying, "But how can we receive better recognition for who we are and what we do?" To answer this question, we must start identifying the intrinsic and extrinsic factors that impact our recognition.

Intrinsic means how we present ourselves and how we view ourselves as health care providers and in the health care system. Extrinsic means how others see us and how we are viewed by other health care providers and third-parties like the insurance industry. As you think about what we are doing, whether it is ethically or professionally, think about the intrinsic and extrinsic factors.

Intrinsically, if we live and present ourselves as professionals, then we are going to be viewed that way by others. How do we interact with our stakeholders? Are we viewed as hearing health care professionals or are we viewed as retail salespeople? Do we treat our patients fairly and honestly? How do we introduce ourselves? Do you go in and say, "I am Barry, and I am going to test your ears today," or do you go in and say, "I am Doctor Freeman, and I am going to evaluate your hearing today." What is your appearance and the appearance of your clinical facilities? What is your status in the community, your promotional materials, your marketing materials? Are you using a lot of price-type advertising and coupons as compared to branding yourself and your practice as the top in the community from a professional standpoint? These are all intrinsic factors that can sometimes impact the extrinsic view of what we are doing. Intrinsically, if we do not view ourselves as professionals and present ourselves in that manner, then neither will other people.

There is an interesting story that happened about eight to ten years ago, when a group from AAA went to, at that time, the Health Care Finance Administration (HCFA) in Baltimore. It is now the Centers for Medicare & Medicaid Services (CMS). The group at that time was led by Angela Loavenbruck, and they went to HCFA and asked them to recognize us in the Medicare and Medicaid system as limited licensed practitioners (LLPs). In other words, they wanted us to be considered independent providers of hearing care that can diagnose, manage, and treat patients.

HCFA responded back to us that they went to our literature, to our state license laws, to our web sites, and they found that we did not describe ourselves in this way. ASHA and AAA literature did not say that we could do these things. State laws did not say that we could diagnose. So they came back and said, "Why should we legislate change when you did not even present yourselves in that manner?"

Here was an intrinsic view impacting how we were being perceived extrinsically in the health care system. That taught us a lesson of how we present ourselves intrinsically. You will notice a lot of changes in our presentation and materials as professionals over the last several years from that experience.

Ethics of Weakness versus Ethics of Power

As I was building this talk, I happened to be watching Fareed Zakaria on a Sunday morning talk show, and he was interviewing Peter Beinart. Peter Beinart (2012) was writing a book that nothing to do with audiology or health care even. It was on Middle East relationships, rather, but I loved how he described what is called the ethics of weakness versus the ethics of power. Beinart asserts that people who deal from the ethics of weakness perspective see themselves as weak, as besieged by the world, and consider themselves victims. You do not think that you can respond to changes in health care. You do not feel that you can control suppliers like manufacturers. You do not think that you can be an independent practitioner in your own practice. Therefore, when you are presented sometimes with an ethical conflict, for example, attending certain trainings or going to dinners, participating in trips and programs, you feel that you have to agree or you are going to miss out on the opportunity, and you obsess on victimhood. Beinart talks about dealing from this position as ethics of weakness. Therefore, when you are presented with an ethical conflict, like attending certain trainings or trips where you feel you have to agree, you might end up embracing policies that lead to what we call a perceived survival. That is, you feel you have to participate in these things, regardless of the impact on your practice, yourself, the profession, or even on your patients.

When dealing from a position in the ethics of weakness, you are compromising your ethics for this survivals perception. If we deal from a position of the ethics of power, there is a perception of strength and ability to responsibly promote our own interests. This is the attitude that the profession of audiology was started on when Dr. Jerger proposed starting the American Academy of Audiology in 1988. It would be of, for, and by the profession of audiology. If you consider yourself as being in control, you can dictate your own existence. By not obsessing on victimhood, you can take advantage of opportunities in an ethical manner. You might be able to negotiate better product prices rather than taking a free trip somewhere. You do not need to go to a meeting sponsored by a manufacturer when you can attend a professional meeting where the profession dictates the presentations and the quality of the education provided.

Dealing from a position of ethics of power allows us to dictate the terms of the relationship. This is something that I would like to stress. Have you ever seen the picture of the small kitten looking into a mirror and seeing himself as a lion? I often use this picture when I am talking to students. How do we see ourselves? Do we see ourselves as the pussycat or the lion?

And there is a story that was mentioned in the book Selling the Invisible by Harry Beckwith (2012), about a woman walking on the left bank of Paris back in the 1950s. It was her first trip from the United States to France. While walking, she happened to notice Picasso painting a picture on the left bank in Paris. She was overwhelmed and went up and explained her emotional feeling to him. He took a scrap piece of paper and a pencil and he drew a little something for her. It took about 30 seconds, and as handed it to her, he said, "That will be 10,000 francs." She looked at him and said, "But that only took you 30 seconds." And he said, "Madam, it took me a lifetime to learn to do that."

From the standpoint of audiology and dealing from a position of power, let's not undervalue ourselves. Let's not compromise our profession, our knowledge or our skills. Again, how do we see ourselves? We need to see ourselves as the lion and deal from a position of an ethics of power.

Strong Ethical Leadership

There are four components of strong ethical leadership: purpose, choice, responsibility and trust and growth. These concepts are useful for practice managers to test whether a general ethical perspective has been communicated to the staff and those working within the practice. It also sets the stage for good customer service to our patients and their families by providing a direction and by permitting staff to make independent decisions for the patient and the practice within the guidelines that you established.

As a leader, you establish the purpose of having particular guidelines in your practice. You let people make decisions independently, but they need to work within certain guidelines because they are responsible for those decisions. You build a relationship of trust with the individuals and the stakeholders that you are working with.

We have a professional code of ethics, several in fact. ASHA has a code of ethics, AAA has a code of ethics, ADA has a code of ethics. You probably have ethical guidelines in your state license laws. If you have not reviewed those recently, you ought to take a look at what the states are saying about some of these issues as well. These ethical guidelines tend to be based on these four concepts, and we will talk about two of them specifically.

In the United States, the four main principles of ethical leadership in health care are based on the principle of nonmaleficence. It is a Latin term meaning, "Do no harm to the people you are serving." Beneficence, on the other hand, is the quality of being kind or being charitable, or providing services that are beneficial. Autonomy means to honor the patient's right to make their own decision. Lastly, justice is to be fair and treat like people alike, so that you are consistent in the care and services that you are providing.

Nonmalefiecence and beneficence ensure that the public is protected from incompetent, unethical practitioners. This is why many state license boards have guidelines. It offers some assurances that licensed individuals are competent to provide the services. AAA has ethical guidelines, assuring that their members are acting in a manner that is appropriate for the people that we serve. It also provides a disciplinary mechanism if you fall out of those ethical guidelines. In other words, it is all about preventing harm and advancing the good of the individuals that we serve.

I use what I call the 60-Minute rule. Years ago, Mike Wallace would show up on the doorstep of a practice and ask them about something that they were doing. If you passed the test, they would not show you on Sunday night television. In other words, would you pass the test of ethics you are when confronted with an ethical dilemma? "Is this in line with the objectives of my practice owner or my hospital or my clinic?" We do have a responsibility to the profession, as well as to the patients that we serve.

What is the ethical culture where you are practicing? The key is to build a relationship of trust with your stakeholders, which, as we defined before, can be your patients, referral sources, manufacturers, et cetera. If you focus on building trust with your stakeholders, you will practice in an ethical manner, and you will not have to worry as much about the perception that people may have, and 60 Minutes will not show up on your doorstep.

We must be doing a good job with this, because a survey was completed by the Hearing Industries Association (HIA) and showed some interesting results (Rogin, 2009). HIA is the organization that represents all of the hearing aid manufacturers, component manufacturers, battery companies, et cetera. They completed a large-scale survey of individuals who were successfully fit with amplification devices using a psychometric scale of "delight." They asked the hearing aid users, "What delighted you about your hearing aid experience?"

It is like a top-ten list. At number 10, the patients reported that they were delighted that the hearing aids really worked (Rogin, 2009). But we also saw things like the professionalism they saw in the practice, the counseling they received and the verification. But the number-one factor that delighted them about their experience was their relationship and trust they had with the audiologist. We must be doing something right, because patients are reporting that we are still relevant in this system.

Hot Topics in Audiology

Our goal when we approached CMS was to achieve the status as LLPs. This is a term that, in truth, was coined by the insurance industry. LLPs are health care providers that have all of the rights and privileges of physicians. We would have direct access to patients; we would not need a physician referral. We would be able to bill directly for those services, and we would have recognition as independent or autonomous professionals in the health care system.

We have done a pretty good job of this over the last two decades. We have achieved LLP status in most areas of heath care. Yes, Medicare remains a work in progress, as we still try to achieve direct access there, but we really have it in most other areas. So what has been integral to our success is the adoption of ethical standards? This is where I tend to get in trouble when I talk about these things.

I do not mean to offend anybody. But you know what? Audiology has done a great job developing and adhering to good ethical standards over the last number of years. That is somewhat unlike the history of the hearing care profession. I will talk some about this in a little bit. We have been able to control own destiny through influences of AAA, through working in our own practices at state levels, et cetera. We have license laws, and we have received better recognition and acceptance as independent providers. But we have to be careful. This is not a time to compromise our ethical attitudes and behaviors. Others are starting to watch us. We do not want to fall back to the way that things were done in the hearing care industry. Prior to the last decade-and-a-half, the education of professionals was delivered by the manufacturers. They controlled the message. They were the ones that ran the cruises and the trips that controlled the message that went to dispensers and anybody in the hearing care industry.

This still continues with the hearing instrument specialists. Some of my demographics show that there are about 8,500 licensed hearing instrument specialists in the United States. However, there are only about 800 or 900 members of the International Hearing Society (IHS), their national organization. There are about 2,500 board certified hearing instrument specialists, but only about 300 to 500 attend the IHS meeting every year. That means that those individuals are getting their message and their education through manufactured sponsored activities and speakers. Even at state and the national meetings, the majority of speakers are sponsored by the manufacturers.

As audiologists, we have moved away from that. The shift has been made primarily to the AAA meeting, where there are approximately 7,000 people attending. You have a pretty comprehensive education program that may include some speakers from industry; however, I am seeing a trend now where industry and manufacturing are trying to regain control of this message and run their own meetings, trying to get audiologists to shift back. We have to deal with this from a position of power. We have to maintain the ethics of power by asking, "Is this in the best interest of my practice, myself, the people I serve and the profession of audiology?"

Many people are watching and we have to be very careful of this. The United States Department of Health and Human Services (HHS) has released a document that you can pull up at any point in time, and it was tied in with the Affordable Care Act. Health and Human Services (2012) has said that, "Most [health care providers] strive to work ethically, render high-quality medical care to their patients. Society places enormous trust in [providers], and rightly so. Trust is at the core of the physician-patient relationship...Medicare, Medicaid, and other Federal health care programs rely on [provider] judgment to treat beneficiaries with appropriate services (p.2)."

With that in mind, they go on to say that, "Although some [providers] believe that free lunches, subsidized trips and gifts do not affect their judgment, research shows that these types of perquisites can influence [clinical] practices (p 24)." HHS says that the government now will be mandating that the public know about any gifts or payments that providers receive from industry. They are requiring all drug, device - that would be hearing aids - and biologic companies to publically report nearly all gifts or payments that are made to providers beginning in 2013. So we have to be extremely careful about what we are doing, because the government is starting to watch us.

You may sit there and say, "But Medicare does not cover hearing aids, so therefore, it is not an issue for us." Well, some supplemental Medicare insurance programs do cover amplification. If you are accepting vocational rehab patients, Medicaid programs, Tri-Care, Veteran's Affairs (VA) contracts, or if you see any Federal employees that are part of the Federal Employees Health Benefits Program (FEHBP) and accept their hearing aid benefit programs, you may violate not only the anti-kickback statues, but you may also fall under this new requirement for manufacturers to report any gifts that they are providing to you.

It is still unclear exactly which gifts will be included. HHS (2012) says, "nearly all gifts (p. 24)" so I am guessing that coffee mugs, pens and pencils may not be included. Certainly high-dollar items such as trips will be mandated to be reported to the Federal Government. We have to be very careful not just individually, but as a profession.

AAA anticipated some of this and updated their guidelines (AAA, 2011) this past year. They say basically the same thing as the HHS, revealing the influence of gifts on human behavior. They mention that pricing, features and customer relations from manufacturers can also drive decision makings. AAA says that general use business items like laptops, otoscopes and continuing education courses would be considered a gift and should not be accepted. However, unique items needed to dispense the hearing aid such as proprietary programming software, demonstration units, and cables are not considered gifts. They go on to say that meals and travel that are considered rewards are also considered gifts, but there is an exception where they realize that you need to learn about certain products and technologies, so you are permitted to accept what they refer to as modest meals and travel. These things are permissible, but you should not accept anything that is beyond modest travel expenses, meals, and lodging. You are encouraged to pay for as much of your own educational-related expenses as is reasonable. You have to make your own decisions in talking with your colleagues and in your practices to determine how far you can go in terms of following these guidelines.

The Academy (2011) finishes this section up by saying that, "Acceptance of gifts of any value by a member of the American Academy of Audiology from any company that manufactures or supplies products that he or she uses or recommends, may compromise, or give the appearance of compromising, the audiologist's ability to make ethical decisions and should be avoided (p. 3)."

Intrinsically, let's make decisions that are in the best interest of the profession and people we serve. Sometimes, we have to make tough business decisions that are in the best interest of our patients, the profession and our practices. Try not to be driven by emotion; proceed from a position of power. There is a lot going on right now in our industry. There are efforts to develop manufacturing-owned retail businesses, efforts by manufacturers to purchase clinics to guarantee their distribution system. There are efforts to commoditize hearing aid products by selling direct to consumers and bypassing us. There are efforts to require audiologists to sign exclusive product agreements. These are just a few of the things that we all know are going on.

Let's not be driven by emotion and fear. Let's focus on our strengths. We have the ability to make our own decisions, and we can do anything we make up our minds to do. We can retain our autonomy by leveraging our unified power as audiologists and not being led down a path that may not be in the best interest of our patients, our practices, or ourselves.

Our patients are also watching. We have to be aware of that, because they are also learning more and more about what we do and how we do it.

Following Best Practices: Hot Topics

Terry Chisholm and Harvey Abrams are, to me, the gurus of what we refer to as Implementation Science for Audiology. They often give the example of ship owners in the 1800s who knew that you could control scurvy onboard ships if you carried fruits and vegetables. Yet, why did it take 50 years for carrying fruits and vegetables to be a routine process? So we look at this and we look at our own science, and sometimes it takes a little longer for us to implement what we know is appropriate from the research literature. We tend to have this feeling that we know a little bit better because we have been doing this a long time.

I found a funny cartoon that I love. It shows a man on an operating table sitting up with his laptop bedside. Before the doctors begin the incision he tells them they should be making the incision in a different place, according to We tend to have patients like this who are starting to ask us about why we are doing things because they have read about things on the Internet.

David Hawkins (2010) published a great article in Audiology Today about a well-informed hearing aid patient. An audiologist evaluated a patient's hearing and recommended binaural hearing aids, then set up an appointment for the fitting. Before the fitting, the patient went to the AAA web site, and he went to the ASHA web site, and he went to web sites in other countries and found out about probe microphone measures and verification of fittings. So now he goes back to the practice for his fitting and he discovers that the audiologist uses a manufacturers' first fit. The audiologist says, "That is it."

Mr. Careful Consumer says, "Do you know whether speech is audible across the frequency range? Why do not you follow the recommended guidelines of your professional associations? Do you know it takes less than five to ten minutes to verify this fitting? How do you know what these hearing aids are actually doing in my ears?" What Dr. Audiologist say? "Trust me. I've been doing this a long time." Mr. Careful Consumer responds, "Let me understand. You want me to pay you $5,000 for hearing aids that I am going to wear 14 hours a day for the next five years, and you cannot spend five to ten minutes to adjust them and verify that they are properly amplifying in my ears? You do not deserve to be my audiologist, and I'll be leaving now."

Yes. Our patients are watching us. And we all know that they are becoming better educated than we have ever seen before in our history. We need to bridge this gap between clinical practice and adopt best practices which will lead to more effective and efficient hearing care.

Patient Counseling

There are other hot topics out there as well. An article in the about ten years ago documented a deaf lesbian couple that wanted children deaf children (Levy, 2002). They did not consider deafness to be a disability, but rather a culture. They wanted to choose deafness and they wanted to have the fetus deafened, basically. The author of this article said that the technologies that were being used to keep babies healthy could now be used to promote disability, or at least what we perceive as disability.

Peter Singer is a geneticist and an ethicist at Princeton University. He does a lot of writing in the New York Times. A wonderful article is Shopping at the Genetic Supermarket (Singer, 2003). He talks about the fact that genocide is the destruction of an ethnic group. He asserts that ethnic groups are identified as such because of common cultural conditions and values. Deaf people have an individualized identity that is distinctive because of their heritage and culture. He also states that cochlear implants are an attempt to eliminate the given trait of deafness. Eliminating this unique trait destroys a group of individuals whose identity is distinctive in terms of cultural traditions. By his reasoning, cochlear implants are genocide.

I imagine that no one in this forum believes that cochlear implants are genocide; yet, some of our patients may feel that way. They may feel that we are making improper recommendations for their children, for example. They feel that implants will cut them off from the Deaf culture and the Deaf community. I am sure you are all aware of this. As one Deaf parent said, "If someone gave me a pill to make me hear, would I take it? No way. I want to be deaf."

This may be difficult for us to understand. But we are dealing more and more with different cultures, and we have to be sensitive to the demands of each cultural background. I was recently involved in a humanitarian mission trip to Ethiopia. There is a school for the deaf in Addis Ababa, the capital city, and they wanted to know if we could come there. The next thing I know, we were caught in the middle of a Deaf culture debate in Ethiopia because the Deaf community did not want us coming and providing hearing aids to the children in that school. This issue is happening on a global basis, and we have to be aware of this so we can be prepared to interact with more cultures and people from diverse backgrounds. Sometimes we may need to separate our personal beliefs from those of our patients.

Audiology Students

Sometimes we think that all the ethical guidelines are written to address issues for us as clinical practitioners and our relationships with industry. But there is a larger scope to this that also affects the profession: audiology students. They are impressionable and very vulnerable to conflicts. They do not yet understand all the issues going on in the profession. They are unlicensed, and they cannot hold decision-making authority or roles within academia. If you are serving as a preceptor or you are a member of a faculty at a university, we have the responsibility to provide the appropriate model for these students and to discuss ethical guidelines with them.

You know, I did a little studying myself. I was trying to get a pulse on what was going on in the university work, as I have been doing a lot of work on demographics with Ian Windmill. I did a survey of university clinics a few months ago, and I discovered that 80% of university clinics have a relationship with a single manufacturer, some with two. Therefore, students are getting limited exposure to different technologies and to different manufacturers. There seems to be this struggle between student training and a for-profit model within the university clinics. Do we really want to be running a clinic to train the students or do we really want to be doing this because the university wants us to make a profit?

Ian Windmill, James Jerger, Jack Scott and I published an article in last year on Relationships and Guidelines for Relationships between Universities and Industry (Windmill, Freeman, Jerger, & Scott, 2011). In that publication, we stated that the clinical and academic decisions must be made by the university faculty based on student education and clinical decision-making, and not on the relationship with the commercial enterprise.

Some of this might be because of where a lot of our Au.D. programs are located within a university. If they are in a medical school, the medical school environment tends to understand that health care clinics for student training, such as dental clinics and optometry clinics, break even at best, because the real purpose is student training. If the program is housed in a communications school or a school of education or a graduate school, they may not understand that, so the pressure may be on to make more profit. That is probably where the majority of our Au.D. programs are housed. These are issues that we have to deal with ethically.

What about externship and clinical placement? We have an interesting issue there. I was reluctant to include this, but I think it is important, because it raises a very interesting ethical, and maybe even legal, situation occurring in our profession right now. I highlight Mayo Clinic and Duke University, because they are taking forth-year externs. When you visit their web sites and examine the requirements of their university program, they are mandating that any student applying for a fourth-year externship must have a master's degree in Audiology.

As a profession, we decided that the master's degree was no longer appropriate to properly train our students and prepare them to work with patients. In fact, the states where these universities and clinics are based, Arizona, Minnesota, Florida and North Carolina, require a doctoral degree in Audiology to be licensed and to be qualified providers of audiology services. So why then are these university programs requiring a master's degree for placement?

There are still some programs that are awarding master's degrees so that their students can qualify for a placement at Mayo or Duke. What is going on here? What are the ethical and even legal requirements? Is it because they feel that if a student has a master's degree, they will not have to directly supervise the student who may be seeing a Medicare patient? Is it because a student with a master's degree can get a National Provider Identifier (NPI) number and bill directly for services? How does this model good ethical behavior for students in the profession?

These are questions we must be asking ourselves and challenging our colleagues with. We should be asking why they are doing something that is in violation of the ethics of our profession. We have certain values, and our challenge is not to have a disconnect between what we profess and what we demonstrate. As my mother always said, "Practice what you preach."

We have a newly revised and published document on the standards of practice that just came out on the American Academy of Audiology web site (AAA, 2012). We should adhere to a standard or practice, because it is what is expected of us. We have to be sure to provide quality and defensible care to our patients. It is going to support our ethical and our clinical decisions and even protect us from legal recourse if we should ever be placed in that type of a situation.

The focus should be on the standard of care because it will protect you. It is what the profession owes our patients. It is what the reasonable, prudent professional delivers. We need to deliver this quality standard of care. To the extent that you have delivered the standard of care and you live in a perfectly just world, you are legally invincible. Patients will hear about your practice and come to your practice.

Ethical Considerations

As we finish up here, I recommend that you define the foundation of your ethical decisions. Is it in line with your objectives? If you are the practice owner or director of a clinic, set these policies. Ask yourself if they in line with the objectives of how you want your clinic to operate and be recognized in the community. Will the decision result in the right thing being done for your patients and all other stakeholders? Ethical principles are not concerned with how things do operate, but how they operate. Keep that in mind as you are developing your principles.

Understand that the most difficult decisions to make are those in which there is a conflict between two or more principles. Try to determine in advance your priorities and the culture, and realize that a lot is going to depend on various situations. Document and justify everything that you do. Develop standards and benchmarks of expectations for your team that you are working with in your practice.

It is really not just about the perception of the 60 Minute test or what patients are thinking; it is a culture that you instill in everyone and in the practice. Ethics, standards of care, your branding and your behaviors lead to trust, and trust leads to practice success.

So with that, thank you all for the opportunity to talk today.

Question & Answer

I have a graduate student working for me for the summer, and I had to fight the university to allow me to pay her for her 40 hours per week for two months. How come the universities allow students working long-term to not expect pay, minimal as it may be?

So you are not part of the university; you are probably a preceptor. This is a really hot topic in universities. Other professions are starting to demand that the universities start paying preceptors to take students in the clinic. Universities do not have it in the budget. University student costs are very high, so to put it in the budget would just mean an increase in tuition to the student. So a lot of practices have been absorbing those costs.

Right or wrong, the trend seems to be moving in the direction of more universities starting to budget. I was talking to someone in a physician assistant program yesterday, and they just put a quarter-of-a-million dollars in their university budget to pay for preceptors. But that meant that tuition for those students had to go up an equal amount to offset those costs.

It is a difficult issue, I hear what you are saying, and you are not alone in asking this question. Other professions are starting to deal with this as well. There is no simple answer. It is a negation that you have to have, or you just do not take the students in. But what many clinics are doing is taking the students in and having them be licensed or certified as audiology assistants, whatever your state requires, and let them function that way.

I just hired two audiologists finishing externships and met with people who employed externs that did not get paid.

That seems to be an increasing trend. More and more externships are not paying for the fourth-year student to come into their practice. If anything, they are paying a small stipend to offset the living expenses that the student has in order to travel or move to that location.

What is the ethical responsibility behind paying externs? Well, you cannot really bill for those students in there. I think that there are issues that have to be discussed as a profession, and you are raising great points and great questions here.

I am starting to see various professional and regulatory bodies putting together codes of conduct documents and ethical guidelines. However, it appears to me that following rule-based ethics is probably making us less ethical, rather, just at-minimum, rule following. So how can we as a profession grow ethical behavior?

You know, it has to be a culture instilled in your practice. There are guidelines that are established by the professional associations, but you need to establish it for your clinic. What do you expect from the people working for you? What do you personally expect? And, what do you think your patients would expect?

Carolyn Smaka: We get a lot of people writing in to AudiologyOnline with ethical dilemmas.

For example, just yesterday, an audiologist wrote to us and said that she worked at an ENT office, and her docs were telling her to offer free hearing testing because the competitors were advertising free hearing testing. She thought this was unethical as the practice was a Medicare provider, but she wasn't quite sure. She wanted to know if we could assist. I guess my question is, where can an individual audiologist go with an ethical dilemma? We know that every situation that is going to come up is not going to be spelled out in black and white in the Code of Ethics.

Dr. Freeman: Well, both AAA and ASHA have ethical practice committees. I think ADA does also. You certainly can go and pose the question to them and get an opinion. That is all it is- an opinion- and that is why they're a committee. It used to be a board within AAA, and the board had decision-making authority. That was changed many years ago, and it became a committee that can provide guidance for you without any decision-making. That is what I would recommend. You can pull up who is on those committees on any of the professional web sites and e-mail them.

Smaka: Thank you, Dr. Freeman. We appreciate all your time and expertise in presenting this course today.


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Hawkins, D. B. (2010). Best practice and the well-informed hearing aid patient. Are you ready? Audiology Today, 21(5), 64-65.

Levy, N. (2002). Deafness, culture, and choice. Journal of Medical Ethics, 28, 284-285.

Loh, K. (2000). Professionalism, where are you? (4), 242-243, 247-248.

Rogin, C. (13 October 2009). Top ten reasons for hearing aid delight. AudiologyOnline, Course 14615. Direct URL:
/audiology-ceus/course/va-selections-hearing-aids-adults-top-ten-reasons-for-hearing-14615. Retrieved from the Articles Archive on

Singer, P. (2003). Shopping at the genetic supermarket. In S. Y. Song, Y. M. Koo & D. R. J. Macer (eds.), Asian Bioethics in the 21st Century, (pp. 143-156). Tsukuba, JP: Eubios Ethics Institute.

U.S. Department of Health and Human Services. (2012). A roadmap for new physicians: avoiding Medicare and Medicaid fraud and abuse. Retrieved from

Windmill, I., Freeman, B., Jerger, J., & Scott, J. (2010). Guiding principle for the interaction between academic program in audiology and industry. Audiology Today, 22(2), 47-57.

Industry Innovations Summit Live CE Feb. 1-29

barry a freeman

Barry A. Freeman, PhD

President, Audiology Consultants, Ft. Lauderdale, FL

Barry A. Freeman is President and CEO of Audiology Consultants, Ft. Lauderdale, FL.  Most recently, he was Senior Director of Audiology and Education for Starkey, Inc.  Prior to joining Starkey, he was Chair and Professor in the Audiology Department in the Health Professions Division at Nova Southeastern University, Ft. Lauderdale, Florida. Dr. Freeman earned his Bachelor’s degree in business and economics from Boston University, a Master’s in audiology, and his Ph.D. in Auditory Science from Michigan State University.  Dr. Freeman has taught audiology at several universities including Syracuse, Vanderbilt, Gallaudet, University of South Florida, and Nova Southeastern. Prior to joining NSU, Dr. Freeman was in private practice for twenty years at the Center for Audiology in Clarksville, Tennessee. Dr. Freeman has more than 50 published journal articles, several book chapters, one book plus more than 300 professional presentations at national and international meetings.  He was president of the American Academy of Audiology in 1996-97 and served on the Academy’s Board of Directors for six years.  He continues to serve on professional committees including the Advisory Board of the Accreditation Commission for Audiology Education.  He received the Distinguished Achievement Award from the American Academy in 2006.

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