Autonomy of Speech-Language Pathology and Audiology

Definitions

In its exact definition, autonomy means self-government. It contrasts with the term hegemony, which means the domination of one state or group by another.

As it applies to professions, and particularly to the profession of speech-language pathology and audiology, autonomy acquires some special connotations, hence this definition:

An autonomous profession is one in which the practitioner has the qualifications, responsibility, and authority for the provision of services which fall within its scope of practice.

Autonomy does not mean complete freedom from all monitoring and regulation. Even the most entrenched professions are closely scrutinized and their practices repeatedly reviewed by bodies established by federal and state statutes, by accrediting agencies, by consumer groups, and by peers in the same profession. With the growing involvement of government agencies and corporations in underwriting the costs of human services, and with the growing trend for challenging professional competence through litigation, there is an ever-increasing abridgment of the independence of all professions.

In recognizing its autonomy, therefore, the profession of speech-language pathology and audiology does not assert its immunity from external review and regulation. Nevertheless, it does declare its responsibility for formulating standards for preparation for independent practice, for the definition of the appropriate scope of its professional practices, and for the development of individual and institutional standards for the delivery of services to children and adults with speech, language, and hearing disorders.

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Qualifications

ASHA has defined the qualifications for entry into the practice of speech-language pathology and audiology through its Certificates of Clinical Competence. Those certificates are available to all professionals who meet the specified qualifications. Although the ASHA certificates are sought voluntarily, they have acquired official recognition. Those certification standards form the basis for definitions of qualifications in the 36 state licensure laws. Furthermore, those certificates are used to define qualified providers of speech, language, and hearing services in most federal laws and regulations.

All the licensing laws are uniform in that none require that services be under the supervision or control of any other person; nor are referrals limited to particular sources. The licensing laws authorize qualified practitioners to evaluate and treat all persons with speech, language, and hearing disorders.

Even with licensure, problems arise which ultimately undermine consumer interests. These problems derive from the exemptions granted by most licensure laws. Typically, such exemptions accord members of other professions the right to provide services that fall within the scope of practice of speech-language pathology and audiology without any demonstration of qualifications to provide such services. Often they even grant such privileges to any and all individuals who presumably work under the “supervision” of such professionals.

Licensure laws also often grant blanket exemption to individuals holding credentials to work in specific work settings, typically to those working in the public schools. These exemptions are regrettable because they may award the right to practice this profession to individuals who do not meet the entry-level standards established by the profession. There is no evidence to support a contention that the delivery of services to children in the schools is less demanding of thorough professional preparation than is the delivery of services in any other setting or to any other group of individuals.

It is ultimately in the best interest of all consumers of speech-language pathology and audiology services and of the profession that provides those services if no exemptions are granted in licensure laws. Although authorization for employment in a particular work setting may require special qualifications, those qualifications should be accommodated within or added as a supplement to the requirements specified in the licensure laws.

It is also important to recognize that while the Certificates of Clinical Competence and state licenses qualify individual practitioners to deliver all services that may fall within the entire scope of speech-language pathology and audiology, nevertheless, providing specific diagnostic and treatment services for which the practitioner is inadequately prepared shows inadequate concern for clients' best interests and may result in malpractice liability exposure. Therefore, members of the profession are enjoined in ASHA's Code of Ethics that they “must neither provide services nor supervision of services for which they have not been properly prepared.” In other words, the provider of particular services, even though they clearly fall within the profession's scope of practice, may be well advised to seek preparation beyond what is entailed in completion of requirements for the Certificates of Clinical Competence.

Qualified professionals must remain current in those fields in which they provide services. It is not enough to have completed the entry-level qualifications signified by the Certificates; it is also essential that practitioners remain abreast of significant developments. Through its continuing education program, ASHA assists professionals in these efforts. The Award for Continuing Education is offered as a tangible recognition.

Another important aspect of professional qualifications relates to the quality of the education programs that are preparing students to enter the profession. Certification and licensure requirements can only enumerate areas to be covered in curricula, they cannot monitor the quality of the education provided in those areas. Although examination requirements offer some checks on the quality of education, they are, at best, a partial solution. Inevitably, the best approach to quality assurance in educational programs is accreditation. Thus far, only 60% of the graduate education programs in speech-language pathology and audiology are accredited by the Educational Standards Board (ESB) of ASHA. The Association must now move forward deliberately to ensure that in the foreseeable future all graduate education programs that prepare students to meet certification and licensure requirements are either accredited or have achieved formal recognition as being in process toward achieving such accreditation.

All qualifications for the delivery of acceptable services do not relate to the qualifications of individual providers. Some also relate to the resources, practices, and policies of the institution in which those services are provided. Institutional qualifications have been established in the standards for accreditation set by the Professional Service Board (PSB). Institutions which provide speech, language, and hearing services may also be accredited by other agencies, in particular by the Joint Commission for the Accreditation of Hospitals and the Commission for the Accreditation of Rehabilitation Facilities. Since these latter agencies do not require thorough peer scrutiny of speech-language pathology and audiology services, either in their standards or in their accreditation procedures, they fall considerably short of PSB accreditation as a means of establishing institutional qualifications. Nevertheless, it is the responsibility of the profession to ensure that all accreditation standards facilitate the delivery of acceptable speech-language pathology and audiology services.

Again, however, all accreditation programs fall short of the goal of quality assurance in the daily delivery of professional services. It is, therefore, the responsibility of the profession both collectively and individually to develop and apply other quality assurance measures. Such measures fall within the reasonable expectancies of consumers of speech, language, and hearing services and of the individuals and private and public agencies who underwrite the costs of providing those services.

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Authority

Authority to function autonomously within the scope of practice of a human services profession is signified when members of that profession:

1. are a point of entry for services that fall within its scope of practice;

2. select the appropriate candidates for those services;

3. determine appropriate diagnostic methodology and suitable approaches to and duration of treatment;

4. effect referrals for services to be provided by other speech-language pathologists and audiologists as well as by members of other professions.

These characteristics should be manifested in the delivery of services by speech-language pathologists and audiologists. When any are abridged, children and adults with speech, language, and hearing disorders may be deprived of needed services, or the quality of whatever services are provided may be impaired.

The position of the Association was clearly restated in Legislative Council Resolution 52-83 which declares,

RESOLVED, That the American Speech-Language-Hearing Association (ASHA) affirm its position that speech-language pathologists and audiologists, by virtue of their professional qualification, are an appropriate point of entry into speech, language, and hearing services; and further

RESOLVED, That individuals with communication disorders should have unrestricted access to speech-language pathology and audiology services; and further

RESOLVED, That ASHA reaffirm the responsibility and professional obligation of speech-language pathologists and audiologists to make referrals to other professionals when appropriate; and further

RESOLVED, That ASHA and its members actively promote the position that the appropriate professional to contact regarding services for people with speech, language, and hearing disorders is a certified and/or licensed speech-language pathologist and audiologist.

Federal laws generally do not require the supervision and direction of speech-language pathologists and audiologists by physicians or members of any other profession. For example, under the Hearing Conservation Amendment of the Occupational Health and Safety Administration, programs designed to determine hearing loss among American workers must be supervised by either a physician or an audiologist. (29 CFR 1910.95(g)(3))

Under the Longshoremen's and Harbor Worker's Compensation Act, PL 98-426, audiograms for the purpose of evaluating hearing loss among workers may be administered by a licensed or certified audiologist or by an otolaryngologist:

The Conference Report (No. 98-1027) states: In requiring audiograms to be administered by certified audiologists or otolaryngologists, the conferees wish to assure that audiogram results are certified by competent medical personnel.

Under the Medicare statute (PL 96-499), plans of treatment for persons receiving speech-language pathology services may be established by either the physician or the speech-language pathologist.

At the time Congress enacted this law, the Report of the Committee on Ways and Means (No. 96-588) stated,

Since speech pathology involves highly specialized knowledge and training, physicians generally do not specify in detail the services needed when referring a patient for such services.

The independence of the profession was affirmed by the Department of Health and Human Services in Health Resources Statistics-Health Manpower and Health Facilities, 1974 which stated,

Speech pathologists and audiologists are primarily concerned with disorders in the production, reception, and perception of speech and language. They help to identify persons who have such disorders and to determine the etiology, history, and severity of specific disorders through interviews and special tests. They facilitate optimal treatment through speech, hearing, and language remedial procedures, counseling, and guidance. They also make appropriate referrals for medical or other professional attention.

In the courts as well, the qualifications of the profession have been held to overcome the contrary opinions of those not meeting the qualifications, such as physicians. (See Raisor v. Schweicker, 540 F. Supp. 686 (1982).

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Responsibility

Recognition of a profession's authority must be immediately followed by recognition of that profession's responsibility. Responsibility may be generally defined in two respects: legal responsibility and ethical responsibility.

An essential characteristic of a profession's autonomy is that its members bear individual legal responsibility for all of their practices. When speech-language pathologists or audiologists are employed by institutions or other individuals or organizations, that legal responsibility may be shared, but the speech-language pathologist or audiologist is never absolved of individual responsibility. For example, the Court of Appeals of California decided that parents could sue an audiologist whose alleged misdiagnosis of the deafness of the first child results in the parents' conceiving another child who is also deaf (Turpin v. Sortini, 174 Cal. Rtpr. 128, 1981). Furthermore, in many instances, members of the profession may also share legal responsibility for services delivered by the students and by the professionals and paraprofessionals they supervise. Therefore, certified and licensed speech-language pathologists and audiologists are personally responsible for instances of malpractice or negligence before the courts and licensing bodies as well as under ASHA's Code of Ethics.

Ethical responsibilities extend well beyond legal responsibilities. They include assuring the quality of services, offering consumers freedom of choice and providing whatever information is needed for making informed choices, and maintaining salutary interand intraprofessional relationships insofar as is consonant with consumers' best interests.

Ethical responsibilities are always incumbent on individual professionals. They are never transferred to the employers, administrators, or supervisors to whom a professional is answerable.

Although licensure laws and laws relating to service delivery generally do not require physician supervision of speech-language pathology and audiology, such supervision is mandated in many laws and policies governing third-party reimbursement. The Association is actively engaged in efforts to bring these outmoded policies up-to-date in view of the following facts.

Under the ASHA Code of Ethics, “individuals shall use every resource available, including referral to other specialists, as needed, to provide the best service possible.” (Principle of Ethics I.A) In addition, under the Code, it is unethical for an individual to “provide clinical services by prescription of anyone who does not hold the Certificate of Clinical Competence.” (Principle of Ethics Ethical Proscription I)

Physician supervision is unnecessary because it is often duplicative. Most individuals who need speech-language pathology or audiology services already have an attending physician who understands the patient's medical condition and who probably made the referral in the first place. To impose another physician is redundant and unnecessary and extremely costly.

Many clients of speech-language pathologists and audiologists have chosen not to see a physician. Persons with various communication disorders frequently complain that advice from a physician was inaccurate or postponed obtaining necessary care. When these individuals choose to go directly to a qualified, licensed professional, that choice is worthy of respect and it is wrong to force the individual or a third-party payer to pay for a service which the individual does not want to receive. In fact, most clients of speech-language pathologists and audiologists do not wish to involve physicians when they seek care for their communication disorder. Many have learned from experience that physicians have little to contribute in the rehabilitative management of most communication disorders.

Speech-language pathologists and audiologists receive referrals from many sources, medical and nonmedical. When physician supervision is attempted, it becomes apparent that no one medical specialty is well equipped to supervise the service. Physiatrists, psychiatrists, pediatricians, neurologists, otolaryngologists, and family practitioners all refer to speech-language pathologists and audiologists. All of these medical specialties have completed only fragments of the preparation for the evaluation, treatment, and management of communication disorders required of speech-language pathologists and audiologists. In addition, each medical specialty has its own orientation and is behaving in increasingly competitive fashions. When speech-language pathology and audiology services are under the control of one physician, referrals from other physicians decrease, depriving the patients of the care and attention which they would otherwise receive. Therefore, although interrelationships through referral are both appropriate and desirable, mandates for supervision do not serve the best interests of children and adults with communication disorders.

The problem of physician training in this area was highlighted in a recent report from the Office of Technology Assessment, an arm of the Congress of the United States. Its report, Technology and Aging in America (June 1985), states, “Physician evaluation is important to identify impairments that are medically treatable, but physicians usually receive little training in the management of hearing impairments and alternative approaches to compensate for hearing loss.”

The footnote to this sentence states,

Otolaryngologists receive some training in hearing measurement techniques and amplification, but few otolaryngologists receive extensive training in sophisticated aspects of auditory processing and its relationship to communication ability. Their training focuses primarily on medical diagnosis for and medical/surgical treatment of conditions affecting the ear, nose, throat, head, and neck, and on facial, cosmetic and reconstructive plastic surgical techniques.

Finally, physician supervision is unnecessary because of the extremely low incidence of improper care or treatment of patients. Malpractice risks are, of course, present, but the very low premium for liability insurance attests to the few instances of poor patient care.

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Definition of Scope of Practice

One aspect of professional autonomy relates to scope of practice. The scope of practice of speech-language pathology and audiology has been variously defined. It has been defined legally in licensure laws enacted to date in 36 states. Somewhat more detailed definitions are found in the United States Department of Labor's Dictionary of Occupational Titles-1977.

AUDIOLOGIST (profess. & kin.) 076.101-010. Specializes in diagnostic evaluation of hearing, prevention, habilitative and rehabilitative services for auditory problems, and research related to hearing and attendant disorders: Determines range, nature, and degree of hearing function related to patient's auditory efficiency (communication needs), using electroacoustic instrumentation, such as pure-tone and speech audiometers, and acoustic impedance equipment. Coordinates audiometric results with other diagnostic data, such as educational, medical, social, and behavioral information.

Differentiates between organic and nonorganic hearing disabilities through evaluation of total response pattern and use of acoustic tests, such as Stenger and electrodermal audiometry. Plans, directs, conducts, or participates in conservation, habilitative and rehabilitative programs including hearing aid selection and orientation, counseling, guidance, auditory training, speech reading, language habilitation, and speech conservation.

May conduct research in physiology, pathology, biophysics, and psychophysics of auditory systems. May design and develop clinical and research procedures and apparatus. May act as consultant to educational, medical, and other professional groups. May teach art and science of audiology and direct scientific projects. May specialize in fields, such as industrial audiology, geriatric audiology, pediatric audiology, and research audiology.

SPEECH PATHOLOGIST (profess. & kin) 076.107-010. Specializes in diagnosis and treatment of speech and language problems, and engages in scientific study of human communication: Diagnoses and evaluates speech and language competencies of individuals, including assessment of speech and language competencies of individuals, including assessment of speech and language skills as related to educational, medical, social, and psychological factors. Plans, directs, or conducts habilitative and rehabilitative treatment programs to restore communication efficiency of individuals with communication problems of organic and nonorganic etiology.

Provides counseling and guidance to speech and language handicapped individuals. May act as consultant to educational, medical, and other professional groups. May teach scientific principles of human communication. May direct scientific projects investigating biophysical and biosocial phenomena associated with voice, speech, and language. May conduct research to develop diagnostic and remedial techniques or design apparatus.

Further definitions of the scope of practice of the profession are found in Federal compilations of health professions, educational rules and regulations (such as PL 94-142), other regulatory statutes, and, at least by implication, in the standards set by ASHA in its CCC.

All of these statements about scope of practice reflect the state of professional endeavors at the time they were written. Scope of practice evolves as the profession evolves due to the pressure of emerging technologies, advanced state of research, and new demands.

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Economic Factors

Economic factors may influence professional autonomy in three major ways. First is the basis on which the professional earns his or her income. Second is the source and manner of payment for the services that professional provides. Third is the level of responsibility assumed by the professional for economical service delivery.

The key to understanding the implications of the first factor—the source of the professional's income—lies in the fundamental definition of autonomy, i.e., self-government. When professionals are employees, self-government is inevitably compromised. Although the extent may vary widely, every employee yields autonomy in accepting whatever restrictions are imposed by his or her employer.

Throughout the history of the profession, most speech-language pathologists and audiologists have been employees of public and private institutions. Even though increasing numbers of members of the profession are employed in other settings, the public schools remain the single major employment setting. Public education has never afforded significant autonomy to most professionals engaged in the direct delivery of services. Outside the education system, the largest segment of speech-language pathology and audiology services are delivered within the health care system. Traditionally, most segments of that system have granted autonomy only to physicians. Thus, speech-language pathologists and audiologists have often been accorded even less autonomy than the education system.

The most important adverse consequences of these abridgments of autonomy do not lie in their impacts on the profession, but rather in their influences on the services available to those who need them, These abridgments inevitably lessen the authority of speech-language pathologists and audiologists to function effectively throughout the entire scope of professional practice.

The growth in autonomy of this profession is inextricably related to the growth of services provided through private practice. So long as speech-language pathologists and audiologists practice primarily as employees, inherent limitations in professional autonomy will remain.

The second impact of economics on autonomy lies in the basis of payment for professional services. When such services receive overall programmatic support from public or private sources—i.e., where an entire program is underwritten, rather than fees paid for individual services—professionals usually function as employees, hence the just-cited restrictions obtain. But even when services are supported by fees, several factors may impede professional autonomy.

The earlier-noted growth in the delivery of speech-language pathology and audiology services within the health care system is again significant. In achieving payment for those services, it has often been necessary to accept policies and procedures that were never designed for this application. Most especially, payment is often contingent on physician judgments of necessity for the services, and, even if judged to be necessary, physicians are frequently required to approve the frequency, duration, or intensity of services. These policies assign crucial decisions to professionals who are, in many instances, poorly equipped to make them.

Third-party payers themselves may make decisions with far-reaching implications on the kind and quality of services that may be delivered. Some of these decisions are clearly described in written policies; others are made—often quixotically—on a case-by-case basis. Once again, these abridgments of the profession's autonomy can seriously impair the nature, extent, and quality of services available to consumers.

In the final analysis, the profession of speech-language pathology and audiology must itself assume the responsibility of broadening the available support for services. Although it is essential that improvements be effected in the authorization of and review of claims for reimbursement from health services payers, it is also essential that the profession develop new avenues for payment outside of the health care system.

In addition, it must be recognized that the profession has failed to take crucial steps that might improve payment. It has never developed commonly accepted terminology, either in applying diagnoses to the conditions served or in designating the diagnostic and treatment services it provides. Furthermore, it has generated no database for determining the circumstances which lead to treatment recommendations or for determining the probable intensity, extent, and duration of treatment. It is unlikely that significant improvement in reimbursement for professional services can be achieved until such terminology and data are available.

It is also crucial to recognize the revolutionary changes that are occurring in approaches to payment for services. The profession must be alert to these changes and assume responsibilities for enabling their optimal application to payment for speech, language, and hearing services. Moreover, the profession must offer systematic approaches to assuring the quality of whatever services are provided.

The third cited consideration relates to the assertion that members of autonomous professions assume individual responsibility for economy in the delivery of services. This pertains regardless of whether services are supported on a broad programmatic basis or on the basis of fees, whether paid directly by the consumer or by another payer in the consumer's behalf. Among the important elements of economy is ensuring that only needed services are provided and only for as long as they yield benefit; that services are accomplished as efficiently as possible; and that only those overhead costs are assumed that can be reasonably attributed to whatever services are provided.

Members of autonomous professions must be accountable for the economic implications of whatever services they recommend, whether those services are provided by members of that profession or by members of other professions. Such implications may be manifested in factors beyond the direct cost of those services, e.g., factors such as transportation costs, time expenditures, and lost income by consumers. In the interest of economy, all alternatives must be interpreted when making recommendations. Consumers must be offered full information as a basis for making informed choices, considering, as well, the likely consequences of declining any and all recommendations.

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Implementation

For several years, the autonomy of the profession has been a growing concern within the profession. The Association has responded to this by increasing our attention to these problems and by creating ways in which they might be solved. Among the activities of the Association in this area are:

1. Creation of a standing Committee on Interprofessional Relationships.

2. Seeking the establishment of joint committees with other professional and transdisciplinary associations (e.g., American Occupational Therapy Association and the Association for the Severely Handicapped).

3. Expansion of the National Office's Governmental Affairs staff by three positions in the area of licensure and reimbursement.

4. Commissioning of studies to be performed on the prevalence and incidence of communication disorders in various settings, services received, and the outcomes of those services.

5. Commissioning of studies on the “market” for speech-language pathology and audiology; studying the strengths and weaknesses of the profession, its competitors, and searching out opportunities for growth for the profession.

6. The development of a classification/coding system for communication disorders and treatment.

7. The development of standards of practice for the profession.

8. The creation of a litigation assistance program to assist members or state association litigation on issues of importance to a large number of the members. This program is available to challenge restrictive policies of health care payers.

9. The creation of a program to provide additional funding to state associations for carrying out legislative and regulatory activities.

10. The creation of a political action committee to enable the Association to demonstrate its support of candidates for federal elective office who support communication disorders services.

11. The creation of a separate organization outside the Association to consult directly with members on their business development and third-party reimbursement problems.

12. Reassessment and redrafting of specific indicators of the standards for PSB accreditation (i.e., standards for professional practice) so that accreditation is more appropriate to specific settings, such as acute care hospitals, rehabilitation agencies, etc.

The work of achieving full professional autonomy touches every facet of the profession's activity. That work will continue. However, it is essential that the Association and the profession continue this struggle if we are to assure that persons with communication disorders will receive the services which they need.