Tinnitus Education for Audiologists Is a Ship at Sea: Is It Coming or Going?
Round 1
Reviewer 1 Report
This is an important and timely communication on the importance of tinnitus training in AUD programs. Timely because audiologists are looking to operate at their full scope of practice in an environment in which traditional hearing aid dispensing is being challenged by OTC hearing aids. The author makes excellent points regarding the training provided in USA audiology training programs, and the reasons for hesitancy in practice. These issues have resulted in continuing education programs, outside of the AUD programs. Although the focus of the manuscript is not continuing education the US certificate program graduating numbers are mentioned - the author states in a small informal sample “however the graduates also indicated that the certificate program did not extend in a substantive way the class and clinic experiences provided during their matriculation through the AuD program.” A quick check of google scholar with “tinnitus continuing education” identified a few papers discussing continuing education outcomes for tinnitus. A brief consideration of these maybe helpful for readers considering what can be done to address the gaps identified.
The statement in the conclusion “it is more likely that audiologists can gain experience with, and implement on their own, strategies from formal programs such as CBT and self-efficacy training” is ambiguous. I don’t disagree with self-efficacy in tinnitus management, or employing counselling methods based on CBT, however I do not agree that Audiologists should be performing CBT unless they are trained CBT therapists, it is unlikely this can be achieved within the most dedicated tinnitus programs, and not in 2 day workshops. I don’t think the author is intending Audiologists to be CBT’s, but could a more definitive statement be made? I believe the intent is captured in section 3.3 “elements of cognitive training that foster a patient’s managing tinnitus may be employed”. In the abstract “Audiologists in many cases lack the confidence to provide in-depth counselling while mental health providers lack basic understanding of tinnitus, its mechanisms, and the elements of audiologic management that could support patient coping.” …both groups need greater understanding of each other’s professions and tools that bridge gaps, but just as psychologists fitting hearing aids is undesirable, so is Audiologists performing CBT. The Counselling is common to both and is where major gains can be made in audiology.
Author Response
Thank you for the careful reading and suggestions regarding additional items for manuscript inclusion. Regarding the specific suggestions:
Reviewer comments:
This is an important and timely communication on the importance of tinnitus training in AUD programs. Timely because audiologists are looking to operate at their full scope of practice in an environment in which traditional hearing aid dispensing is being challenged by OTC hearing aids. The author makes excellent points regarding the training provided in USA audiology training programs, and the reasons for hesitancy in practice. These issues have resulted in continuing education programs, outside of the AUD programs. Although the focus of the manuscript is not continuing education the US certificate program graduating numbers are mentioned - the author states in a small informal sample “however the graduates also indicated that the certificate program did not extend in a substantive way the class and clinic experiences provided during their matriculation through the AuD program.” A quick check of google scholar with “tinnitus continuing education” identified a few papers discussing continuing education outcomes for tinnitus. A brief consideration of these maybe helpful for readers considering what can be done to address the gaps identified.
Response 1:
Thank you for this suggestion. I have included mention of additional online, asynchronous opportunities, including AudiologyOnline, ASHA, and the Salus program starting at line 100. The following text is now included in the MS:
Professional organizations serving audiologists, as well as academic programs and specialty continuing education outlets, offer additional certification or training opportunities for clinicians. These programs are in most cases offered online, using asynchronous delivery, and employ modules related to different aspects of tinnitus mechanisms and management. Therefore, the challenges of coordinating clinical opportunities with the classroom work might not be easily, nor reasonably addressed. Ultimately, learners must translate the educational components into routine clinical practice, and while the online programs endeavor to address gaps in training, their effectiveness may be tempered by an unavoidable disconnect if face-to-face clinical opportunities are not provided concurrently.
Several organizations offer continuing education opportunities or certifications intended to support development and sustainability of tinnitus-related services. The American Speech-Language Hearing Association (ASHA) offered 591 opportunities in the past, however only three continuing education “products” [ASHA, 2023] are currently available. According to ASHA, it is rare for members to access tinnitus-related opportunities; fewer than ten individuals have completed any tinnitus related work in the past year. The AudiogyOnline continuing education service offers 52 options, about half of which are linked directly to manufacturers of devices. Most of the course options on AudiologyOnline indicate reviews of the courses that number from 100-2170, hence some courses accommodate thousands of viewers across several years. Most of the courses are indicated as “intermediate” however presentation modalities are heterogenous, consisting of videos from academic meetings as well as question and answer text offerings. As with ASHA, the continuing education is offered online or as recordings; no opportunities for clinical practice are offered and numbers of consumers not easily determined [AudiologyOnline, 2023]. Salus University offers six 1.5-credit modules that cover tinnitus mechanisms, management, and sound tolerance disorders as part of an Advanced Studies Certificate Program. The modules are optional for students completing Salus’s program of study, and are offered entirely online (also offered via AudiologyOnline) and asynchronously in order to maximize availability for international participants.
One notorious barrier to provision of tinnitus services remains the professionals’ remuneration for the clinical endeavor. Fee schedules for tinnitus services provided in clinics whose population contains medicare recipients may reimburse for basic, albeit often uninformative measures such as pitch and loudness matching. Many professionals conduct tinnitus-related activity as an ancillary service to, and separate corporate entity from their routine practice. In such cases, patients are required to pay for services out of pocket, therefore the service will be available to a subset patients who seek help. Tinnitus and sound tolerance issues, for both patients and providers, highlight many of the US healthcare system’s shortcomings; the reimbursement difficulties may represent both a cause and effect of the shortfall of providers and lack of adequate service. It should be noted that, for years, all of the continuing education and certification training opportunities indicated above were intended to address the shortfall of providers, yet the need remains acute. One additional, and widely-recognized designator, the Certificate Holder-Tinnitus Management (CH-TM), may support potential providers in a more durable manner, and is summarized below.
#2: The statement in the conclusion “it is more likely that audiologists can gain experience with, and implement on their own, strategies from formal programs such as CBT and self-efficacy training” is ambiguous. I don’t disagree with self-efficacy in tinnitus management, or employing counselling methods based on CBT, however I do not agree that Audiologists should be performing CBT unless they are trained CBT therapists, it is unlikely this can be achieved within the most dedicated tinnitus programs, and not in 2 day workshops. I don’t think the author is intending Audiologists to be CBT’s, but could a more definitive statement be made? I believe the intent is captured in section 3.3 “elements of cognitive training that foster a patient’s managing tinnitus may be employed”. In the abstract “Audiologists in many cases lack the confidence to provide in-depth counselling while mental health providers lack basic understanding of tinnitus, its mechanisms, and the elements of audiologic management that could support patient coping.” …both groups need greater understanding of each other’s professions and tools that bridge gaps, but just as psychologists fitting hearing aids is undesirable, so is Audiologists performing CBT. The Counselling is common to both and is where major gains can be made in audiology.
Response 2:
Thank you for this thoughtful comment. I agree that this “border region” between (or across) clinical psych and audiology is fraught. The conclusion is changed, moreso in the direction of the reviewer’s quote from section 3.3. Starting on line 332:
Clearly, some audiologists currently generalize elements of CBT or self-efficacy training, during hearing aid fitting for a patient who denies hearing loss, or who has rejected amplification in the past. The audiologist’s success would rely upon their ability, at least in part, to support the patient’s reconsidering the fitting, their expectations, the stigma of a device, or any number of other negative beliefs held by the patient. The argument here is that audiologists already employ strategies that rely upon tenets of CBT, or the patient’s self-efficacy, when managing such clinical encounters. Barriers for employing such techniques during tinnitus management, therefore, may arise not from a lack of management/counseling options, but rather from a lack of confidence or familiarity with the counseling elements that would be of most value to the patient. Learning about tinnitus mechanisms, as would be possible during an asynchronous continuing education opportunity, might provide a reasonable inventory of talking points for the clinician, but without concurrent clinical practice, such information’s value may not be maximized.
The conclusion’s final paragraph picks up w/ the content from line 334.
Reviewer 2 Report
This is a communication letter of Tinnitus education for audiologists.
The article is written appropriately, but it can be uncomplicated if there is a table
to show the results.
Author Response
Reviewer #2: This is a communication letter of Tinnitus education for audiologists.
The article is written appropriately, but it can be uncomplicated if there is a table
to show the results.
Response to reviewer 2:
Thank you for this suggestion. It is not clear how such a table would be crafted, given the state of continuing education opportunities and the dearth of standardization across AuD programs in the US. I reached out to organizations offering continuing education opportunities, as a way to develop a table that would depict attendees at offerings, however those numbers could not be provided. It is likely that the references made to the Henry et al study would provide for readers the most comprehensive accounting of program offerings. Other options for continuing education and online modules now appear starting on line 171. It is my hope that these additional items will support the reader’s appreciation of currently available educational sources.
Reviewer 3 Report
The present manuscript summarizes the current status of clinical education and practices for tinnitus. The author provided a brief introductory summary of tinnitus care and highlighted the necessity and barriers to educating clinicians to provide high-quality clinical care. The manuscript is written well, and all issues discussed are valid and relevant. The "Perspectives on translational and interprofessional practices" section summarized clinical challenges while providing sufficient details to help clinicians direct toward valuable resources. In summary, this is a well-timed and well-written article that addresses an important clinical issue.
Adding a section on billing and insurance-related issues for tinnitus evaluation and management could further improve the manuscript.
Author Response
Reviewer #3:
The present manuscript summarizes the current status of clinical education and practices for tinnitus. The author provided a brief introductory summary of tinnitus care and highlighted the necessity and barriers to educating clinicians to provide high-quality clinical care. The manuscript is written well, and all issues discussed are valid and relevant. The "Perspectives on translational and interprofessional practices" section summarized clinical challenges while providing sufficient details to help clinicians direct toward valuable resources. In summary, this is a well-timed and well-written article that addresses an important clinical issue.
Adding a section on billing and insurance-related issues for tinnitus evaluation and management could further improve the manuscript.
Response to 3:
Thank you for this comment and suggestion. I agree that such information would be of value, although a detailed explication merits its own manuscript. Mention is now made of options to acquire such information (at about line 133):
