Larry E. Humes, Ph.D.
In 1997, the American Speech-Language-Hearing Association (ASHA) formally adopted new standards for the Certificate of Clinical Competence in Audiology (CCC-A) following several years of development and evaluation. A key feature of the new standards was that they were competency based and specified a comprehensive set of academic and clinical competencies that should be mastered by each prospective CCC-A recipient. A large-scale skills-validation study conducted for ASHA by the Educational Testing Service served as the primary basis for identifying the initial competencies. The initial competencies were subsequently fine-tuned in response to feedback received from the publication of various drafts of the proposed standards prior to their final adoption by ASHAís Standards Council in 1997.
The competency-based standards represent a welcome and significant change to the standards. According to the background information in the preamble of the standards, unlike prior versions of the standards, ďthe standards do not stipulate the specific courses or practicum experiences that are required. The applicant will be required to demonstrate that the acquisition of knowledge and skills was assessed by the educational program...Ē (ASHA, 1997). Yet, there are two key sections of the standard that seem to run counter to the competency-based spirit that permeates the 1997 standards for the CCC-A. In Standard I, for instance, it is indicated that the applicants for CCC-A ďmust have a minimum of 75 credit hours of post-baccalaureate education culminating in a doctoral or other recognized graduate degreeĒ (ASHA, 1997). It should be noted that this 75-credit-hour requirement is in effect for CCC-A applications received from January 1, 2007 through December 31, 2011. Afterwards, only a doctoral degree will be acceptable. Also, in Standard III, it is again reinforced that ďthe applicant for certification must complete a program of graduate study (a minimum of 75 semester credit hours)...Ē (ASHA, 1997). If an applicant can demonstrate the competencies that are the heart of the 1997 standards for CCC-A and can do so with fewer than 75 semester credit hours at the graduate or post-baccalaureate level, then why should such an applicant be denied the CCC-A? It appears to be contradictory to claim that the 1997 standards are competency-based standards, yet simultaneously be prescriptive and restrictive regarding the ways in which that competency can be achieved. Specifically, why must the 75 semester credit hours required to achieve these competencies be exclusively and entirely at the graduate level?
At Indiana University (IU), we have taken a competency-based approach to the development and evaluation of our audiology curriculum for at least the past decade. On almost an annual basis for most of the past decade, the eight core members of the IU audiology faculty on both campuses (four Ph.D. faculty members and two M.A. faculty members in Bloomington and two Ph.D. faculty members in Indianapolis) have met to compile and review an exhaustive listing of topics and content areas that the audiology faculty thought should be included in a program of the highest caliber. Next, a matrix was developed in which all the courses offered in the area of audiology were mapped against all of the critical topic areas identified. The faculty then examined this mapping of courses to critical topics and discussed topics that required redundant coverage versus those that required coverage only once in the curriculum. Course offerings and course content were then adjusted on the basis of this evaluation and in light of the constantly evolving scope of practice in audiology.
Regarding clinical practicum, a competency-based approach has also been used at IU over most of the past decade. Specifically, a series of benchmark skills were identified by the faculty for each semester and the student clinicianís progress was evaluated against those benchmarks. About four years ago, the audiology faculty at IU added a formative evaluation of clinical skills at the end of the first year in the Masterís program in which students were required to demonstrate proficiency in clinical techniques and clinical problem solving in a day-long series of individual, oral exams referred to as the ďGateway Exam.Ē This exam served as a ďgatewayĒ to externship opportunities for the students entering their second year of study. Masterís students must pass the Gateway Exam before they are permitted to receive clinical practicum outside of the IU Hearing Clinic in the form of externships. The exam also has proven to be a valuable source of feedback to both the students and the faculty. For the students, it identifies areas in need of additional attention and effort while there is still ample time in the clinical training program to work on remedies. For the faculty, consistent failure of several students in a particular area served to identify weaknesses in the program that needed to be addressed through curricular revisions.
The current version of the traditional Masterís program that has evolved from this decade-long process is illustrated in Table 1. The course titles are sufficiently informative as to the content of the courses and the sequence of the courses is also apparent. Practicum experiences within this model, however, are not obvious and will be described briefly. Generally speaking, within the first twelve months of the program, the typical student has progressed from an observer of experienced clinicians to a competent novice and has amassed 150-200 hours of clinical practicum at one site, the IU Hearing Clinic in Bloomington. During the second year, upon successful completion of courses and the Gateway Exam, the student acquires a wider diversity of clinical experiences through a series of externships that result in another 250-500 hours of clinical practicum. These external practicum experiences are mainly part-time (2 or 3 days per week) in the Greater Indianapolis area in the fall semester and full-time at sites around the U.S. in the spring semester.
When one totals up the credit hours and time commitment required to complete the traditional Masterís program at IU from Table 1, it is clear that the program is definitely a ďsaturatedĒ Masterís degree. That is, most graduate schools, including IUís, require approximately 30-36 semester credit hours for a Masterís degree, depending on options for a thesis, minor, etc. The curriculum outlined in Table 1 for the Masterís degree in audiology at IU requires 53 semester credit hours of the typical student for completion. In addition, students in the program are required to devote 21 consecutive months to the program, including both summer sessions between the first and second years. Yet, from a competency standpoint, the audiology faculty at IU felt this amount of coursework and time were required to produce top-quality audiologists as graduates.
The saturated traditional Masterís degree, although adequate to meet the educational and clinical training needs of todayís audiology graduates, clearly has some problems. First, it requires 50% more tuition and nearly twice the time commitment from students than does a 36-credit-hour Masterís degree common to other fields. Second, to minimize further ďtuition penaltiesĒ for students in these saturated programs, credit hours for practicum experiences, an extremely valuable component of the studentís education, are often kept to a minimum. This, in turn, makes the clinical-education component of the program more expensive to the university. Third, there is little room for electives, including Masterís theses or outside minors, in the saturated Masterís program. Fourth, there is no additional room for expansion to allow the program to grow with the continually expanding scope of practice for audiology without compounding an already unfavorable situation.
There are at least two general approaches to solving these problems and both have been examined several times by the audiology faculty at IU over the past decade. First, one could lengthen the program of study by one or two years and have it culminate in the awarding of a doctoral degree (Au.D. or clinical Ph.D.). Alternatively, one could move some of the courses in the Masterís program into an undergraduate curriculum. The latter was the course of action decided upon by the IU audiology faculty and an article describing our preliminary plans and rationale was published in 1993 (Humes, Diefendorf, Stelmachowicz, Fowler & Gordon-Salant, 1993). Other programs at other universities around the country have decided to pursue the other route and either have implemented or are planning to implement clinical Ph.D. or Au.D. programs at their institutions.
Before offering a comparison of the competencies achieved by students through these two options, the IU Bachelorís/Masterís model will be described in more detail here. Basically, to implement the Bachelorís degree with a concentration in audiology and hearing science, most of the courses taught in the Fall and Spring semesters of the first year of the Masterís program (see Table 1) were offered to juniors and seniors in the undergraduate program who had expressed an interest in audiology at that time. At IU, 400-level courses can be taken for either undergraduate or graduate credit and no new courses were required to permit undergraduates to gain access to the various 400-level audiology courses taught during the first year of the traditional Masterís program. On the other hand, 500- and 600-level courses at IU are offered for graduate credit only. Here, however, we followed several precedents on campus and simply developed descriptions for corresponding 300-level undergraduate courses that were identical to those of their 500-level counterparts. For example, an SPHS S376 undergraduate course was developed that paralleled the SPHS S576 Masterís level course on amplification. Both S376 and S576 are taught concurrently by the same instructor and cover the same material with only slight differences in course requirements to reflect the awarding of graduate credit in one case and undergraduate credit in the other. Thus, the faculty member may be teaching amplification concepts to 8-10 first-year Masterís students in our traditional Masterís program and a comparable number of seniors in the enhanced Bachelorís/Materís program at the same time. As a consequence, additional teaching resources have not been required to date to be able to offer both our traditional two-year Masterís program (Table 1) alongside an undergraduate major with a concentration in audiology and hearing science.
Table 2 illustrates the resulting distribution of audiology courses across the undergraduate and Masterís programs for the enhanced Bachelorís/Masterís model. Several comments on the contents in this table are noteworthy. First, note that only the audiology courses required for each year of undergraduate study are shown. It is readily apparent that there is ample room in this curriculum for additional courses that both complement audiology and hearing science and are fundamental to a well-rounded liberal arts education. Second, note that the corresponding Masterís program is now more typical or representative of Masterís programs in other fields in that 30-36 credit hours are included at the Masterís level. In fact, when our first two undergraduates received their Bachelorís degrees in audiology and hearing science in May of 1998 and immediately entered the Masterís program at IU, one of the challenges we faced as a faculty was providing them with enough credit hours to reach the Graduate Schoolís required credit-hour minimum for a Masterís degree. In other words, in addition to having the same courses in audiology that our traditional Masterís students have had, these students took some electives that prior Masterís students were unable to take and still had difficulty meeting the Graduate Schoolís minimum credit-hour requirements for a Masterís degree. In some cases, we were able to meet their needs for electives through courses available from our research-based Ph.D. program in audiology. Clearly, though, there is room for growth within this model to meet tomorrowís academic and clinical training needs. Third, the entire Masterís program in this model, including practicum requirements, can be completed in 12-15 months. The reduced length of graduate study, both in overall program duration and in credit hours, represents a considerable financial savings to the student. These financial savings are enhanced further when one recalls that graduate tuition is typically much more expensive than undergraduate tuition at most institutions.
To examine whether graduates of the enhanced IU Bachelorís/Masterís program would meet the knowledge and clinical competencies required in the new CCC-A standards, the prerequisite knowledge and skills section and the 64 individually specified knowledge or clinical competencies identified in Standard IV, Knowledge and Skills Outcomes, were presented in a series of tables. Courses and practicum experiences in the IU program that fulfilled each item in Standard IV were then identified and listed in these tables. The results can be found in Table 3. Clearly, the enhanced IU Bachelorís/Masterís model complies fully with Standard IV and allows each student who successfully completes these courses and practicum experiences the opportunity to become a highly competent audiologist. Yet, after December 31, 2006, students completing this rigorous and comprehensive program and applying for certification would not be eligible for the CCC-A from ASHA because they will not have completed 75 semester credit hours at the post-baccalaureate level (or after December 31, 2011 because they will not have received a doctoral degree in the process).
How does the enhanced IU Bachelorís/Masterís model compare to established professional doctorate (Au.D.) models? To answer this question, the author examined program bulletins available, either on the World Wide Web or from the institution, from four established Au.D. programs (Central Michigan University, Ball State University, the University of Florida, and the University of Louisville). From these materials, comparisons were made in the number of semester credit hours for audiology courses, the distribution of audiology courses across various topic areas, and the number of credit hours for clinical practicum. Table 4 provides a summary of these comparisons. First, the median number of credit hours in audiology for these four four-year Au.D. programs, not counting credit hours for practicum or theses, is 65 credit hours with a range of 54-78 credit hours. IUís enhanced Bachelorís/Masterís model provides a total of 64-67 credit hours in audiology (not counting closely related courses, such as acoustics of speech and hearing, mathematical foundations of speech and hearing sciences, etc.), with about half at the undergraduate level and half at the Masterís level. Clearly, the differences between these two models in academic content in the area of audiology are small. This does not mean, however, that the nature of the content is identical in all of these programs. Based on reviews of ďtypicalĒ curricula for the enhanced IU Bachelorís/Masterís model and three of the four Au.D. models (all but the University of Florida, which didnít provide such an illustration in sufficient detail in their materials), there are differences in all of these programs regarding the emphasis placed on various specialty areas within audiology. The last column in Table 4 highlights those differences based on the authorís review of these typical curricula and as judged relative to the IU model. In general, reflecting the biases of the IU audiology faculty, the IU model offers more coursework in instrumentation, signal analysis, hearing science and counselling than most of the other Au.D. programs listed, but offers less advanced clinical coursework in vestibular assessment and rehabilitation, advanced diagnostics (either advanced clinical electrophysiology or speech audiometry), or practice management.
There are, however, very large differences in the credit hours earned for practicum within the IU Bachelorís/Masterís model and the four Au.D. models (Table 4). Generally, the Au.D. programs require three to six times the number of credit hours for clinical practicum than the enhanced IU model. For the most part, this results from the fact that the Au.D. programs have essentially built the Clinical Fellowship Year (CFY) into the final year of the Au.D. program whereas that is not the case in the current version of the enhanced IU Bachelorís/Masterís model. Because the CFY is still a requirement for the CCC-A under the current standards, the IU audiology faculty have not confronted this issue in moving from the traditional two-year Masterís model to the enhanced Bachelorís/Masterís model with a one-year Masterís program. Clearly, there is room within the latter to add a second year of full-time clinical work and make it a two-year Masterís program. In comparison to four-year Au.D. models, this would still represent considerable financial and time savings to our students while continuing to graduate highly competent audiologists. The IU audiology faculty have avoided this issue for the time being because, from our perspective, it is a very ďthornyĒ problem. The ďCFY-likeĒ experience that would be built into the final year of the clinical education program, whether within IUís Bachelorís/Masterís model or someone elseís Au.D. model, is seldom on the premises of the degree-granting institution and often receives minimal, if any, supervision from the faculty of the degree-granting institution. Yet, the degree-granting institution often charges a significant amount of tuition for this full-year, full-time clinical experience. Moreover, we believe that students completing this final full-year ďCFY-likeĒ clinical experience will likely be paid even less than current CFYs are paid at present for similar kinds of experiences. If true, then the student in this ďnon-CFYĒ model not only makes less money, but also is paying out much more in the form of tuition to the degree-granting institution. This will greatly increase the debtload carried by students graduating from audiology training programs, regardless of the model. Nonetheless, if faced with no other alternative in order to comply with the new ASHA standards for the CCC-A, the IU audiology faculty are prepared to build the CFY into the second year of the enhanced Bachelorís/Masterís model, but will attempt to assess the minimum possible tuition that will maintain full-time status for the students (to enable them to remain eligible for student loans). At present, full-time status is defined as a minimum of eight credit hours per semester by the IU Graduate School, although exceptions can be defined for those Masterís students who have already completed the required 30-credit-hour minimum for a Masterís degree. Even if the IU students were required to enroll for an additional 8-12 credit hours in the second year ďCFY-likeĒ experience, this would still be fewer credit hours for practicum than assessed by the four Au.D. programs in Table 4. It is important to note, however, that this does not necessarily imply that the students completing the IU model would have less clinical practicum, only fewer credit hours that would appear on their academic transcript for that experience.
Still, even with an additional 8-12 credit hours for a second year of full-time practicum experience, graduates of the enhanced Bachelorís/Masterís program would fall far short of the 75 post-baccalaureate credit hours required for the transitional standard from January 1, 2007 through December 31, 2011 and would also not meet the requirement for a doctoral degree that is to be in effect after that transitional period. Yet, the IU enhanced Bachelorís/Masterís model will generate highly competent audiologists who will have achieved all of the knowledge and clinical skills competencies described in the new CCC-A standards. From the authorís perspective, as well as that of his colleagues on the audiology faculty at IU, this model should remain as one of several viable educational models through which students can become competent audiology practitioners. Perhaps in a decade or two, after graduates who have achieved the competencies defined in Standard IV of the new CCC-A standard with either Ph.D., Au.D. or Masterís degrees, including those completing enhanced Bachelorís/Masterís programs similar to the IU model, have co-existed, the profession will be in a better position to determine whether the door to such an alternative, but equivalent, path to competency should be closed. As noted previously (Humes and Diefendorf, 1993) and reinforced recently (Oyler, 1999), there is considerable uncertainty as to whether the additional time and money spent by the student in pursuit of a four-year doctoral degree will result in either enhanced professional autonomy or additional income for the audiologist. In the face of this uncertainty, it seems that all educational models (enhanced Bachelorís/Masterís, Au.D. or Ph.D.) that can demonstrate that their graduates have achieved the necessary knowledge and clinical competencies specified in Standard IV of the new CCC-A standards should have the opportunity to do so and should not be excluded due to an arbitrary and non-competency-based requirement for a specific distribution of credit hours between undergraduate and graduate levels. It is hoped that the new CCC-A standards, specifically Standards I and III, can be revised to indicate that applicants for certification must complete a minimum of 75 semester credit hours, at the undergraduate or graduate level, culminating in a doctoral or other recognized graduate degree. It is further recommended that this standard should become effective for CCC-A applications received after December 31, 2006 with no further transitions to a doctoral degree as the minimum entry-level degree specified at this time. Perhaps, in 10-20 years, the scope of practice for audiology will have continued to expand and the competencies listed in Standard IV of the new CCC-A standards will no longer be possible to achieve with an enhanced Bachelorís/Masterís model and a doctoral degree will be the only reasonable model with which to achieve these competencies. Then again, perhaps that wonít be the case and an enhanced Bachelorís/Masterís model will remain a viable path to competency for audiologists well into the future. In the face of such uncertainty as to the entry level degree requirements far into the future, why should that decision be made now?
Finally, it is important to emphasize that the IU enhanced Bachelorís/Masterís model described here is not just an alternative that maintains the status quo. The Bachelorís degree referred to here is not the typical undergraduate degree in speech and hearing sciences with a strong emphasis on speech-language pathology throughout the curriculum, especially in regard to clinical courses. Rather, what has been described here is a parallel track or area of concentration within the speech and hearing sciences major in which advanced clinical courses in audiology replace all or most of those in speech-language pathology during the senior year. Both concentrations within the major, speech-language pathology and audiology, share common foundation courses in the major, such as acoustics, anatomy and physiology, speech and language development, speech science, hearing science and the history and philosophy of science in speech and hearing. After completing this foundation material, however, the upper level undergraduate has two clear and parallel options for concentrations of the clinical courses taken as a junior and senior: audiology or speech-language pathology. It is only when paired with such a concentration of undergraduate coursework in audiology and hearing science that the Masterís degree can remain as a cost-effective and time-efficient vehicle to achieve the competencies identified in Standard IV of the new CCC-A standards. Otherwise, there is no room in an already saturated Masterís degree program for additional courses or a full-year ďCFY-likeĒ clinical experience. It should also be noted that, even if the doctoral degree emerges in the future as the only valid path to competency in audiology, a major or concentration in audiology and hearing science at the undergraduate level would still be a cost-effective, time-efficient option that could save the student both time and money in route to his or her doctoral degree.
American Speech-Language-Hearing Association (1997). Standards and Implementation for the Certificate of Clinical Competence in Audiology.
Humes, L.E., Diefendorf, A.O., Stelmachowicz, P.G., Fowler, C.G. & Gordon-Salant, S.M. (1993). Graduate education in audiology: We agree with the diagnosis, but not the treatment. American Journal of Audiology 2(1), 48-50.
Humes, L.E. & Diefendorf, A.O. (1993). Chaos or order? Some thoughts on the transition to a professional doctorate in audiology. American Journal of Audiology 2(2), 7-16.
Oyler, R.F. (1999). Survey examines employability of Masterís
vs. Au.D. audiologists. The Hearing Journal 52(3), 39-46.