When we anticipate the next 10 years of the development of speech-language pathology and audiology, it is helpful to gain perspective from a quick look to the past. Ten years ago e-mail was viewed with great expectations for shortening work days and creating paperless offices! We were in the early years of cell phone use and dot-com mania, and had minimal use of PDA devices and wireless technology. The term "nanotechnology" had not been invented. There was no evidence of hair cell regeneration in mammals. Baby boomers were truly middle aged.
Today, some of these technologies are already old hat. Others are on the brink of discovery and will have the greatest consequences for our future.
Manuel Castells, a noted social scientist and professor at the University of California, Berkeley, and professor at the Information Society of the Open Catalan University in Barcelona, Spain, has contributed significant research on the effects of technology and the Internet on societies. His description of the current social environment is directly applicable to the current stage of evolution of the audiology and speech-language pathology professions and our university programs; "…on the one hand, networks of instrumentality, powered by new information technologies…on the other hand, the power of identity, anchoring people's minds in their history, geography, and cultures…in between lies the crisis of institutions and the painful process of their reconstruction." (Castells and Ince, 2003).
Josefowitz (1980) succinctly suggests what strengths people will need to successfully negotiate this institutional reconstruction: "Pioneers needed: terrain uncharted, environment frequently hostile, sustenance meager or nonexistent, climate adverse, results uncertain and end of journey not in sight."
The challenges to our professions will be to incorporate new members (e.g., engineers and bio-scientists) and redefine our relationships with existing members of our professional culture (patients and their families, physicians, nurses, and teachers). We must also maximize the connectedness among the members of our cultural group, build new professional paradigms with the help of rapidly evolving Information and Communication Technology (ICT) and incorporate new technology to effect desired changes in educational programs, legislative policy, and professional practice patterns.
Audiology has suffered from "cultural" insularity over the past decade. The profession has experienced exclusion (PhD students not allowed equal membership in the National Association of Future Doctors of Audiology, NAFDA), insulation (alienation from the otolaryngology community), demands for conformity (call for the AuD as the sole designator of the practice doctoral degree) and "nationalism" (turf battles between ASHA-AAA-AFA-ADA). The result has been a reduced ability of the profession to develop a culture that is inclusive, innovative, outcomes-focused, and proactive in preparing for the future. Audiology must change its culture if it is to survive and flourish as a profession.
Universities and the Future
Our universities have been and will continue to be a source of great potential power in support of the development of programs needed to retool our professions. Castells concludes that the source of U.S. structural superiority is the American university system (more than 4,000 universities). It draws talent from all over the world, with many of the students and faculty ultimately electing to stay in the United States.
This has created what has become "the most important imbalance between the U.S. and the rest of the world." Castells and Ince (2003) report that 50% of the PhDs in science and engineering in the U.S. are foreigners who come to the U.S. and stay. In contrast, less than 5% of the PhD students in Japanese universities are from countries other than Japan. The result of the U.S. university system's global inclusiveness has been the evolution of "superpower status" for the U.S. derived largely from the superiority of its universities and absolute technological leadership (Castells & Ince, 2003). This is the engine that stands ready to power our professional evolution.
Although our collective U.S. university community is strong, it is also true that not all universities are equal. In fact, those that have become innovative and entrepreneurial are gaining the edge in areas of discovery, learning, and engagement. Specifically, as we examine our universities and the diminishing resources supplied by state and federal dollars, it appears that those with the greatest creative and technological edge are those with rapidly developing "research parks." These parks enable and create synergistic relationships between universities, businesses, and their states.
The synergies are win-win for both their faculty and students, and they result in significant financial resources coming to the universities. Concurrently, outflow of technological infrastructure in the way of new products, personnel, and overall economic development boost state and national economies.
As we look toward the evolution of our professions, with the explosion of cross-disciplinary communication and collaboration in the use and development of new technology, we also see a progressive blurring of the identity of professional disciplines. In the new frontier of microelectronics, work is now being done on genetic material with electric current being replaced by chemical reactions. In addition, DNA-based chips and the rapid evolution of the cross-disciplinary field of nanotechnology are now with us, with a merging of microelectronics and biotechnology into new materials. The result is the application of information processing to living matter.
There is also a merging of physics, biology, chemistry, and engineering, with tremendous potential for application to the disciplines of speech, language, and hearing science. We can now envision nano-bio-electric sensors being injected into the body to migrate to various target locations and, via wireless computer interfaces, provide information that will form the basis of medical decisions, or replace the function of cells and systems such as auditory hair cell sensory transducers.
Soon our concepts of "chip technology" in the context of the semi-conductor industry will be ancient history. Intel has recently announced that they have broken the 100 nanometers (nanometer = billionth of a meter) barrier forcing top-down circuit structure to pattern below 100 nanometers. There is now a confluence of top-down and bottom-up nano-scale organization that will result in the end of the "scaling era" in micro-circuit technology.
Timothy Sands, Materials Science and Engineering at Purdue University, predicts significant and potentially negative economic ramifications on the chip industry as it currently exists. He also reports the way is being paved for guided bottom-up self-assembly of cellular networks as occurs in nature, for example, crystal formation. The challenges in the development of this technology will be to control the self-assembly process, the accuracy of the process, and the containment of costs related to the implementation of this new technology (Timothy Sands, personal communication).
Our professions will also face a future of advanced regenerative biology and medicine, likely a dominating biomedical revolution of the 21st century. This technology will reproduce organs and appendages with bio-artificial alternatives made possible by the ability to guide the repair process along a regenerative pathway, rather than a pathway leading to scar tissue formation. The result: an ability to turn on mammals' hidden regenerative capacity that is now suppressed.
The current success in using this technology to treat some conditions using cell therapy, bio-artificial tissues, and molecular agents suggests that within a decade or two, "regeneration" will be a viable alternative in medical treatment.
We have recently witnessed the application of this technology to mammalian hair cell regeneration. Izumikawa and colleagues (Pobojewski, 2005) have reported the phenotypic transdifferentiation of nonsensory cells that remain in the deafened adult guinea pig cochlea using the Atoh1 or Math1 gene carried by an adenovirus and injected into the guinea pig cochlea. This resulted in the regeneration of hair cells and substantially improved hearing thresholds in a mature deafened inner ear. This is the first report of the demonstration of cellular and functional repair in the Organ of Corti of a mature deafened mammal, paving the way for a new therapeutic approach for cellular and functional restoration in the damaged auditory epithelium and other sensory systems.
In other arenas, we are also now seeing the application of robotic technology to surgery. The Center for Computer Integrated Surgical systems and Technology at Johns Hopkins has developed surgeon-guided robots, which have the potential to do precise procedures with greater accuracy and reliability than the human surgeon alone. The implication is that robots will change surgical practice as profoundly as they have changed manufacturing.
What will robotics assist or replace in our professions? Automated interactive hearing test protocols with diagnostic summary and written reports, automated interactive swallowing/voice/ speech/language evaluation immediately come to mind.
Implications and Imperatives
What are the imperatives of this brief technology overview? Our professions and our university programs must maintain and enhance the flexibility that will be necessary to adopt rapidly changing technology in support of our missions of discovery, learning, and engagement. We must prepare to continuously modify our practices and refine our professional cultural identities based on technological advances affecting and determining the characteristics of the people we serve.
There are of course negatives associated with our technology dependence. These include: 1) difficulty protecting intellectual property in the thoroughfares of cyberspace, 2) the cyber-proliferation of non-peer-reviewed "truths," 3) the contamination of the knowledge base of our professions, 4) problems protecting the integrity of databases from advanced hacking and cyber-terrorism, and 5) lack of reward for faculty when they pursue collaborative research facilitated by ICT technology for purposes of promotion and tenure, if indeed these concepts exist in 10 years.
There will also be constantly evolving incompatibilities between ever-changing computer hardware/software and the functions we require as end-users. Examples are changes in input ports and the resultant incompatibilities of our peripheral devices, such as those used for programming hearing aids or analyzing acoustic characteristics of speech.
What will be the cost to university programs to maintain the technology "cutting edge"? Will it result in the survival of the financially "fittest" among our university programs? For example, Duke University in 2004 provided a free $300 iPod to each of that year's entering freshmen. Was this the best use of their funds? Did it give them a competitive advantage in the short and long terms?
Castells and Ince (2003) reflect that technology per se does not do bad or good to societies, but it is not indifferent. It enhances existing or potential trends and possesses great freedom for communication and global interaction, which makes it ideal for building networks. In other words, "the more intelligent an organization, the better it uses the Internet, which in turn, makes it more intelligent in a productive spiral."
What will be the context for the evolution of our professions? We will see shortages of most health care professionals with the mandate to do increasingly more with less. There will be increased inadequacy of third-party payer resources. There will be the well-documented shortage of doctorally prepared clinicians and researchers in our professions to maintain the professoriate. We will see logarithmic increases in people over the age of 65 years. It will be commonplace for infants of less than 23 weeks gestation to survive with increasingly inadequate long-term follow-up resources. And despite advancements in technology, it is predicted that more than 70 million Americans (children and adults) will have significant hearing loss by the year 2030 (Noonan, 2005).
As we look to the future of our clinical education and clinical services, what will be the status of our pediatric clinical populations? In contrast to the advances in technology associated with the Information Age, hundreds of millions of children will continue to live in poverty around the world. In the U.S., although 13% of all Americans live in poverty, 17% of U.S. children live in poverty lacking appropriate child care or health care.
We say children are our future, but we do not take care of them. There is a 10–20 year lag between demographic realities; for example, 70% of mothers in the workforce and their lack of access to safe, good-quality child care programs (Novak, 2005). Forty-three million Americans have no health insurance. The Child Health Insurance Plan (CHIP) was signed into law but there are significant barriers to enrollment that limit its effectiveness.
What about our older adults? In 10 years, 30% of the U.S. population will be over 65 years of age with an average life span well in excess of 70 years. In contrast to our children, most will expect a good quality of life. What are the implications of this shift in demographics for our fields? There will be increasingly heated ethical debates in the U.S. entrepreneurial health care system related to distribution of limited resources (children vs. older adults). In addition, we will see mounting and heated religious and moral debates regarding the application of cellular and genetic engineering with striking parallels to the eugenics movement (science dealing with the improvement, as by control of human mating, of hereditary qualities of a race or breed) of the early 20th century.
Will the past be prologue regarding clinical education in audiology and speech-language pathology and the evolution of our scopes of practice? The history of our professions shows that external pressures have resulted in the expansion/reduction of our scopes of practice, for example, swallowing (dysphagia), use of endoscopy, cerumen removal, intra-operative monitoring, vestibular assessment /rehabilitation, cochlear implantation, and tongue thrust treatment. What will be the scientific and health care system pressures in the next 10 years?
Based on the availability of rapidly advancing technology, it is possible to predict areas of expansion and retrenchment. Areas of expansion may include: the assessment/treatment of genetically engineered reconstructed tissue (laryngeal re-growth, reconstructed neural networks for stroke, auditory/vestibular hair cell re-growth, and speech prosthetics) all with a geriatric emphasis. We will also be increasingly participating in "tailored portals" (unique combinations of assessment/treatment/referral resources automatically assembled via the Internet upon the entry of a particular patient's unique combination of symptoms and diagnoses) for cross-disciplinary patient education and treatment with increased emphasis on early intervention with difficult cost-related decisions regarding distribution and extent of services to our various clinical population cohorts (Novak, 2005).
Areas of retrenchment may include the reduction of clinical populations through cellular engineering and nano-neurological rehabilitation including patients with Parkinson's disease, Alzheimer's disease, dementia, Down syndrome, birth defects, laryngectomy, and stroke. There will be an increased imperative for interdisciplinary team management and linkages of services through ICT.