Today's speech-language pathology and audiology students have different concerns from those of their predecessors. At the top of the list is their rising student loan indebtedness with a growing imbalance between debt/income ratios upon graduation. There is a related loss of men entering the fields. To add to the distress of the educational cost/benefit analysis, a significant undergraduate curricular component of the current six-year (master's in speech-language pathology) and eight-year (AuD) education is considered "liberal arts" and may not be optimally focused toward the knowledge/skills necessary for the current and future practice of the professions.
On the positive side, there is a high demand for our graduates as we face the current and future reality of inadequate numbers of speech-language pathologists and audiologists to serve the growing populations with communication disorders. There is also the reality that the professional service needs of the populations we serve vary in complexity, from complex diagnoses and treatment to routine activities such as communication disorders screenings, rote computer-based client-controlled treatment procedures, and technical chores such as hearing aid and assistive device trouble-shooting. Not all clients' needs demand service by a master's- or doctorally-prepared SLP or audiologist.
We must also recognize the reality that our high schools are introducing critical thinking and decision making into their curricula and their graduates are Internet and Information and Communication Technology (ICT) savvy. As we adapt our audiology and speech-language pathology programs in the future, the challenge will be to appropriately assess these skills and efficiently build on them from the first year of each student's college experience.
Provider Continuum Models
The imperative for our professions and academic programs is to create new educational tracks that acknowledge that different levels of preparation must be matched with the demand for different levels of clinical service, for example, assistants/technicians (who efficiently manage evolving automated technologies such as speech/language/hearing screening systems, computer-based client-controlled treatment tools, etc.) to doctorally-prepared SLPs/audiologists.
There must be increased efficiency and relevancy of educational preparation for all providers and increased rigor and prescription of the undergraduate curriculum leading to clinical education. In other words, new basic science tools will be required for SLPs and audiologists and their professional education has to begin earlier in their college experience.
Our challenge as academic educators is to envision the future and the best model for the "communication disorders service personnel continuum," identify the most appropriate educational preparation for the "scope of practice" of each team member, the target provider ratios, and in so doing, maximize and coordinate our community college and four-year university resources. Audiology would have been well served to have followed this approach.
What will be the best models and how can they be implemented?
A possible provider continuum model for speech-language service delivery is the following:
- Doctorally-prepared SLP
- "SlpD" For advanced clinical education not required for entry-level clinical practice, or
- PhD (with clinical certification and the research training required for research faculty positions)
- Master's-prepared SLP:
- Entry-level clinical practice degree
Settle on one designation as all currently exist causing great confusion for the consumer with well-defined preparation and SLP supervision requirements.
A possible provider continuum model for non-medical hearing service delivery is the following:
- Doctorally-prepared audiologist:
- AuD: entry-level clinical practice degree or
- PhD (with clinical certification and the research training required for research faculty positions.)
- Audiometric or hearing technician: with well-defined preparation (associates degree) and audiologist supervision requirements
- Non-audiologist hearing aid dispenser: They currently are licensed with no educational requirements. An associate's degree with hearing aid dispensing focus might be an appropriate level of preparation.
An alternative model for speech-language pathology and audiology preparation would recognize the previously cited current clinical education realities, and in addition to the post-graduate master's degree SLP and post-graduate AuD degree in audiology, allow for an alternative "seamless" (12+) "first professional degree" educational model that addresses both the shortage of clinicians and researchers, similar to the pharmacy doctorate (PharmD) model. This model might include:
High school + 3-year pre-professional education + 4-year professional education = 7- year clinical doctoral degree + 2 years of focused research training for the PhD = 9 years. The same outcome currently takes 10 years' minimum in speech-language pathology and 10-11 years' minimum in audiology.
Enactment of this alternative model would require knowledge about and passion for the professions among high school graduates accompanied by focused and ongoing outreach by our universities and professional organizations to the middle and high schools. For this alternative 12+ model to be possible (similar to the PharmD), the current ASHA certification and state licensure language would have to be modified to include a "first professional degree" rather than only a post-graduate (graduate) degree. Currently the ASHA certification language for audiology stipulates 75 post-graduate semester credit hours and 75 total semester credit hours with at least 36 credit hours at the graduate level for speech-language pathology.
In the new educational models it will be important to provide our SLP and audiology graduates (now majority female) with new tools to create "paths to power" (Josefowitz, 1980) in the workplace. Such curricular content might include organizational leadership, policy development, and grantsmanship. Such new skills theoretically should translate to added value in the workplace and higher salaries. Higher salaries should in turn create an increased (renewed) interest in our professions among men.
As we look to the future of the practice of our professions, there will be imperatives for coordinated, multidisciplinary patient management, with the application of ICT and other forms of technology and the development of new knowledge/skills that address changes in patient populations.
One example of a new educational program partnership development is the inclusion of engineering. The Regenstrief Foundation in 2004 awarded Purdue University $3 million to develop a "Regenstrief Center" that would improve access to and service delivery by the U.S. health care system. The new center will apply process engineering, management, science, and information technology to improve the delivery of health care. The current partners include engineering, nursing, pharmacy, health sciences, communications, with the hope of adding speech, language, and hearing sciences in the future.
This center will apply "supply chain management" and "just-in-time manufacturing" to health care, following the flow of information, funds, and materials through the system to achieve better results and efficiency. The focus is to improve safety, efficiency, access to, and effectiveness of patient care, and efficiency of deployment of health care personnel and coordination of inpatient/outpatient care across settings such as hospitals and community- and school-based clinics. Departments of speech, language, and hearing science across universities must facilitate partnerships with such interdisciplinary innovative projects on their campuses.
How might we integrate students in speech-language pathology and audiology with engineers in their pre-service education programs? Again, one example at Purdue University is the Engineering Projects in Community Service (EPICS) Program. In the EPICS program, speech-language pathology and audiology students work together with engineering students to address the need for new adaptive technology to meet the needs of their community partners, that is, school special education programs, adult learning programs, or the speech-language-audiology clinic. EPICS provides speech-language pathology and audiology students with the experience of working with engineers in front-end product development. The goal: developing a comfort among speech-language pathology and audiology students and a desire to partner with engineers in the future. EPICS programs now exist in 14 universities across the country.
It helps to have incentives for faculty and students to develop these partnerships. Again, at Purdue, the EPICS program is required for all AuD students and optional for speech, language, and hearing science undergraduates. The university, through its Burton Morgan Entrepreneurship Programs, has created the "idea-to-product (I2P) competition" with cash awards of $15,000, $10,000, and $5,000 for first, second, and third prizes, respectively, and the automatic entry of the first two place award winners in the $100,000 Burton Morgan Entrepreneurship Business Plan Competition. A speech-language-audiology clinic EPICS project took the $5,000 prize in 2005, demonstrating the shorter term economic (and, hopefully, long-term professional) incentives for audiologists and SLPs to partner with engineers.
New Models for Clinical Externship Sites
Academic programs are experiencing reduced access to health care externship sites, particularly to managed care clinical sites, caused by concern among these organizations about their "bottom lines." Participation in our clinical education programs does not enhance their business balance sheets. Increasingly, universities will be expected to "pay to play," that is, provide cash and infrastructure in the way of facilities and personnel in those arenas to compensate them for "lost revenue."
How will this be managed? We are also increasingly seeing (particularly in audiology) the expectation by the clinical sites for "provisional licensure" of externs for the purpose of third-party billing. Third-party payers are in fact now a significant driving force in our educational program policy decisions. This runs counter to the current AuD model in which all supervised clinical experiences are "pre-graduation" and counter to the future challenge to create more "seamless" and "relevant" post-12th grade educational programs in both speech-language pathology and audiology potentially resulting in the preparation for both disciplines being pre-graduation. There are those who strongly argue that these students are not finished with their degree programs, and therefore not ready to have any form of state licensure.
As stated earlier, many poor, uninsured children in the United States will increasingly receive their only primary health care, including speech-language pathology and audiology services, in the schools and community-based "free clinics." Current state and federal mandates and advanced technologies are driving an ever-increasing need for access of school populations to school-based speech-language pathology and audiology services. These include: 1) newborn hearing screening, 2) early intervention (birth-to-3), 3) most appropriate education in the least restrictive environment (more "sick" children and children with complex multiple disabilities in the classroom), 4) No Child Left Behind legislation, and 5) pediatric cochlear implantation and the presence of children using advanced signal processing hearing aids and assistive or augmentative and alternative communication devices in the classroom.
Public schools have an inadequate supply of SLPs and a ballooning need for educational audiology services and adequately prepared audiologists. The mandate for expanded educational audiology services is, however, confounded by poor public school administrator awareness for the need for audiology services, poor adherence to special education laws pertaining to children with hearing loss, and tight public education budgets. To make matters worse, there is inadequate inclusion of the curricular areas of educational audiology and pediatric aural rehabilitation in many current AuD programs.
With the increasing lack of availability of managed-care health care externship sites contrasted with the desperate need for speech-language pathology and audiology services in the public schools, our speech-language pathology and audiology education programs must look to their neighboring public schools and free clinics to combine our professional education goals with their need for services. Schools in the future can be sources of both "educational" and "health care" externship experiences in the presence of our shrinking access to more traditional health care sites.
In addition to the school and free clinics, the imperative is for audiology and speech-language pathology programs to incorporate additional "new" multi-disciplinary clinical sites with win-win potential for accessing target populations, for example, those in corporate wellness programs and multi-level-of-care retirement communities. Related to the search for new clinical education partners is also the need to expand our definition of "qualified clinical instructors," and the use of ICT technology for clinical instruction and access to new programs and populations. For example, it does not seem unreasonable that a licensed otolaryngologist experienced in nasal endoscopy could supervise nasal endoscopy experiences for SLPs and have those hours count toward the SLPs' clinical certification and state licensure.
In the future we must also look at how we can expand the existing capacity of our speech-language and audiology faculty through the use of Wi-Fi technology for purposes of distance instruction and clinical supervision. Dudding and Novak (1999) were among the first to use distance two-way audio/video computer-assisted supervision in their Virginia Department of Education-funded bachelor's speech-language pathology-to-master's speech-language pathology degree program.
This technology allowed school-based bachelor's-prepared SLPs enrolled in the University of Virginia master's program to obtain clinical experiences in their home communities using Polycom/computer-supported two-way audio/video interactive supervision. This technology allowed supervision of students in distant locations from the clinic in Charlottesville. This dramatically expanded capacity to meet on-site program needs at the University of Virginia as well as the needs for clinical supervision by those students enrolled in the distance program.
Global Shifts and Our Professions
Covey (2004) describes a number of "global seismic shifts" that have relevance to the future of our professions: 1) There will be globalization of markets and technologies resulting in educational "markets" without borders; 2) There will be an emergence of "Universal Connectivity: the glue that has held our economic (and educational) activities together is rapidly melting in the heat of universal connectivity" (Evans and Wurster, 1999); 3) There will be democratization of information and expectations. (In other words, no one will manage the Internet with the realization that information drives expectations and social "will" on a global scale); 4) There will be an exponential increase in competition. Covey asserts that we will no longer be able to afford to benchmark against competitors or even so-called excellence; rather it must be "world-class"; 5) There also will be "free agency" with the educational market turning into a free-agent market with students and faculty having more and more awareness of global choices. 6) And, finally, Covey cautions that we must continuously reaffirm the guiding principles of our professions and educational programs as we will be in a state of "permanent white water…and can be lost in the roar, the immediacy and urgency of the dynamic challenges we will face."
There is great potential for globalization of our professions and educational programs. We look forward to digital communication with no language barriers (real-time text-to-text, voice-to-text, and voice-to-voice language translation); participation in international seminars, colloquia, and grand rounds without leaving our offices; and participation of international students in U.S. educational programs, minimizing effects of changing visa policies on the viability of our educational programs.
We also look forward to increased ability for collaborative international clinical trials and other research with the substitution of institutional "silos" (farming analogy of one grain silo serving one farm) of clinical best practice and research for international networks of collaboration. We also will see rapid advancements in the global knowledge base of our professions with delineation of previously unknown cross-cultural/racial "truisms" for human communication and its disorders.
All of this will result in a progressive blurring of cultural differences among our future students and faculty. The Internet and advanced ICT technology will expand capacity for international professional networks to serve as resources for work with multicultural students and clients in the United States. There also will be an increasingly greater potential for intercontinental portability of qualified SLPs and audiologists. The ASHA quadrilateral agreement between the United States, England, Canada, and Australia facilitating mutual certification of SLPs by participating countries' professional organizations, is a recent tangible step in this direction for speech-language pathology. This needs to be expanded to audiology and to other countries.
Our challenge, as we incorporate technology and new educational models to enhance global service delivery to our ever-changing student and patient populations is to achieve the imperatives for change without abandoning those countries that are technologically disconnected and their populations with communication disorders.
Meeting the Challenges
"When you are inspired by some great purpose, some extraordinary project, all your thoughts break their bounds. Your mind transcends limitations, your consciousness expands in every direction, and you find yourself in a new, great, and wonderful world!" (The Yoga Sutras of Patanjali, Covey, 2004).
Once we are "inspired," time is of the essence to use our networks and organizational infrastructures to plan and implement the models, policies, and programs necessary to achieve the future imperatives for changes in professional education and service delivery.