Seventh Survey of Audiometric Practices in the United States

Transcription

1 J Am Acad Audiol 9 : (1998) Seventh Survey of Audiometric Practices in the United States Frederick N. Martin* Craig A. Champlin* Janet A. Chamberst Abstract A 5-page questionnaire was sent to 500 audiologists who were randomly selected from the directory of members of the American Academy of Audiology to assess the clinical practices most commonly used by certified audiologists in the United States. Survey content was limited to only those practices and procedures routinely used by audiologists across the nation. The current results were then compared to those obtained in similar studies conducted in 1971, 1972, 1978, 1985, 1989, and 1994 to determine which clinical procedures are being retained, modified, or replaced. Key Words : Audiologic practice, audiologic survey, auditory tests, questionnaire s an autonomous profession, audiology lacks the mandates and regulations that A are necessary for the standardization of clinical procedures. While regulations may not sound appealing to most professionals, there remains a need for some sense of standardization so that both interclinical and intraclinical results can be understood. The American Speech- Language-Hearing Association (ASHA) responded to this concern with their position statements and guidelines. The most recent statement regarding the scope of practice in audiology was published in Martin et al (1994) and, while it provides audiologists with accurate and updated information, these statements are merely guidelines and therefore lack the strength of regulations or mandates. Despite the availability of these guidelines, previous surveys revealed some disturbing results regarding the practice of some essential audiologic procedures. One has only to glance through the literature to get a sense of the technological growth that has manifested itself in the field of audiology. Along with this growth, there *Department of Communication Sciences and Disorders, The University of Texas at Austin, Austin, Texas, tstarkeytaboratories, Austin, Texas Reprint requests : Frederick N. Martin, Department of Communication Sciences and Disorders, The University of Texas at Austin, Austin, TX is an jncreasing need for communication among professionals. A series of surveys has been carried out in the past to determine which procedures are in common use (Martin and Pennington, 1971, 1972 ; Pennington and Martin, 1972 ; Martin and Forbis, 1978 ; Martin and Sides, 1985 ; Martin and Morris, 1989 ; Martin et al, 1994). It is hoped that the current survey can provide an important update for the practicing professional. In assessing current audiometric practices, the following questions were asked : 1. Which are the most commonly used procedures by certified audiologists in this country? 2. What changes have occurred in these procedures since the 1994 study of audiometric practices? METHOD 10-page, 98-item questionnaire was used. A The questions were predominantly objective in nature and required multiple-choice answers. The questionnaire was a modified and expanded version of the survey used by Martin et al in Additional questions on the new version inquired about the use of insert receivers, measuring otoacoustic emissions (OAEs), management of central auditory processing disorders, and multilingual test administration. Several

2 Journal of the American Academy of Audiology/Volume 9, Number 2, April 1998 questions were modified to a subjective format to more appropriately investigate issues such as masking formulas and procedures for cerumen removal. The survey also used a subjective format to investigate the types of intraoperative monitoring being performed and reasons for not dispensing hearing aids. A section of the questionnaire regarding demographic information was used to aid in identifying respondents. For example, only those respondents who were actively engaged in clinical work at least 15 hours per week, or only occasionally clinically active but functioning primarily as teachers or administrators, were included. In contrast to the 1994 study, all practicing clinicians meeting the above requirements were considered regardless of whether they held the ASHA Certificate of Clinical Competence (CCC) or state licensure. The survey was mailed to 500 audiologists who were randomly selected from the directory of members of the American Academy of Audiology (AAA). Although previous surveys sampled different associations, such as the American Speech-Language-Hearing Association (ASHA) and the American Auditory Society (AAS), it is believed that these organizations are essentially comprised of the same members and that AAA, with its large membership, is an adequate representation of practicing audiologists in the United States. A cover letter detailing the purpose of the research accompanied each questionnaire, and a postage prepaid envelope was included to facilitate the return. Despite attempts to preserve anonymity, many respondents voluntarily included identifiable information such as names and addresses. RESULTS response rate of 44 percent (218 usable surveys of the original 500) was obtained for the A present study. Although 239 surveys were actually returned, 21 respondents did not meet the qualifications to be included in the research. The following sections detail the results obtained. Demographic Information Of the 218 respondents, 85 percent hold both the ASHA certificate and state licensure. Seven percent are certified by ASHA but are not licensed by the states in which they reside, 4 percent are state licensed, and 4 percent are neither ASHA certified nor state licensed. In order to qualify for inclusion in the present study, a respondent must have been clinically active at least 15 hours a week or occasionally performing clinical duties but functioning primarily as a teacher or administrator. Twenty-one incomplete surveys were returned by individuals who did not meet these qualifications and their data were not included in the findings. Eighty-two percent of the sample are actively engaged in clinical audiology at least 15 hours a week as either clinicians or supervisors. Only 3 percent of respondents identified themselves as administrators, while 1 percent were categorized as teachers. Results indicated a predominance of respondents with 0 to 5 years (23%) and 16 to 20 years (23%) of experience. Twenty percent of sampled audiologists have been practicing for 6 to 10 years and the remaining 34 percent reported a variety of years of experience. By chance, 42 states were represented, excluding Alaska, Arkansas, Delaware, Idaho, Louisiana, Montana, Wisconsin, and Wyoming. There appears to be an increase in the percentage of respondents who work in physicians' offices (22% in 1989, 25% in 1992, and 33% in 1997). Twenty-six percent of the respondents are working in hospital settings. Although the 1994 survey revealed an increase in the number of responding audiologists who are in private practice (almost 19% in 1989 to approximately 25% in 1992), the present results indicate that only 17 percent are currently in private practice. See Figure 1 for an illustration of the most common work sites among the responding clinicians and Figure 2 for a comparison of these sites through the past 8 years. Pure-Tone Audiometry Seventy-five percent of respondents reported that they monitor their audiometric equipment through electroacoustic calibration checks. Other Public/l'&. School private Practice Private Sp.&Hrg. Clinic Univ. Sp.&Hrg. Clinic Hospital Physician's Oloe Percent of Respondents Figure l Primary work setting of respondents in

3 U.S. Audiometric Practices/Martin et al Physician's Office Hospital Univ. Sp.&Hrg. Clinic Private Sp.&Hrg. Clinic Private Practice Public/Priv. School other Percent of Respondents Figure 2 Primary work setting of audiologists : comparison of 1989, 1992, and Psychoacoustic calibration checks are performed by 21 percent of the sampled audiologists ; 4 percent specified that they assume that their equipment is correctly calibrated. The use of insert receivers was of particular interest in this study, in part because it has not been previously addressed. The percentage of time that audiologists are using insert receivers for particular purposes cannot be accurately determined from this study. However, results do indicate that 24 percent of responding audiologists are using insert receivers in some clinical capacity. In their 1978 guidelines regarding puretone audiometry, ASHA recommended that, at a minimum, air-conduction thresholds should be obtained at octave frequencies from 250 to 8000 Hz, with additional testing at interoctave frequencies when a threshold difference of 20 db or greater exists between adjacent octaves. Similarly, bone-conduction thresholds are to be routinely found at octave intervals from 250 through Table 1 Frequencies Routinely Tested during Pure-Tone Air-Conduction (n = 218) and Bone-Conduction Testing (n = 217) Frequency (Hz) Air Conduction Bone Conduction Other 1 1 Figure 3 Respondents' routine use of air-conduction testing at 3000 and 6000 Hz Hz. However, the guidelines do allow that testing frequencies by bone conduction below 500 Hz requires strict environmental considerations. Table 1 illustrates that a preponderance of the respondents are following these guidelines with respect to the frequencies they use for testing. Figure 3 shows the trend toward increased testing of the interoctave frequencies of 3000 and 6000 Hz. It was assumed that the vast majority of practicing audiologists are routinely performing air-conduction pure-tone audiometry, so this question was not asked directly. Seventy-three percent of respondents routinely perform boneconduction audiometry, unless air conduction reveals normal hearing sensitivity. Of the sample, 6 percent believe that bone-conduction audiometry is warranted only in situations where immittance measures indicate a possible conductive component to the patient's loss, while 17 percent obtain bone-conduction thresholds on all patients. Despite findings regarding the placement site for the bone-conduction oscillator, which support the forehead as the preferential site (e.g., Martin and Fagelson, 1995), 92 percent of respondents continue to place the bone-conduction transducer on the patient's mastoid process (97% of the 1992 sampling population responded similarly). Speech Audiometry Although ordinarily of minimal clinical value, the speech detection threshold (SDT) does, at times, provide useful information. Sixtynine percent of respondents assert that they routinely determine the SDT when the speech recognition threshold (SRT) is not obtainable,

4 Journal of the American Academy of Audiology/Volume 9, Number 2, April Year Figure 4 Step size used for SRT determination from 1972 to Year Figure 5 Comparison of NU-6 and W-22 word lists for word recognition testing: 1972 to while 14 percent always obtain an SDT and 15 percent never obtain it. Almost all of the responding clinicians (99.5%) obtain an SRT using spondaic words, primarily through the use of monitored live voice presentations (94%). Despite ASHA's strong recommendation not to eliminate the familiarization component of SRT determination, only 58 percent of respondents comply with this suggestion. While the majority (57%) do not present spondees with a carrier phrase, 36 percent use "Say the word..." before each word. ASHA suggests that both 5-dB and 2-dB steps may be used in establishing the SRT since the 5-dB step does not appear to compromise the measure and offers a substantial time savings (ASHA, 1988). This survey reveals a continuing trend toward using a 5-dB step size in determining SRT (Fig. 4). Sixty percent of respondents do not appear to comply with ASHA's method of determining the SRT and instead rely on a "2 out of 3 correct" criterion for obtaining the SRT. Table 2 details the testing materials preferred by the 91 percent of respondents who are routinely administering word-recognition tests. Figure 5 compares the use of the CID auditory test W-22 to the NU-6 word lists. Note the declin- Table 2 Test Materials Used Most Often for Word-Recognition Tests (n = 212) Response CID auditory test W NU-6 word lists 44 Synthetic sentences <1 CID sentences <1 Rhyme tests 0 Other 7 ing popularity of the W-22 lists and concomitant increase in the use of NU-6 lists. The majority (91%) of these clinicians do not familiarize patients with the test material. The manner of material presentation remains virtually unchanged since the last survey, in that 82 percent are still using monitored live voice, only 12 percent are turning to compact discs, 4 percent are using tape recordings, and 1 percent digitized speech. Sixty-seven percent of responding audiologists administer wordrecognition tests at a level that is referenced to the SRT. Numbers of other references, such as to the pure-tone average, are used. Of the population using phonetically balanced (PB) word lists, over half (56%) continue to administer 25 word lists (in each ear) to their patients. Only 4 percent pay heed to the caveat that the likelihood for measurement error increases with decreased sample size (Thornton and Raffin, 1978). Thirty percent discontinue the test if, following 25 words, the patient responds to all of them correctly. Behavioral Tests for Site of Lesion The current survey clearly shows that the movement away from behavioral site-of-lesion testing is, indeed, continuing. This is illustrated in Table 3. Of the people routinely performing the tone decay test (TDT; 61% of respondents), the Olsen-Noffsinger (Olsen and Noffsinger, 1974) TDT remains the most popular version, with over half (56%) beginning test administration at 20 db above threshold and discontinuing the test when one level has been heard for 60 seconds, or the limits of the equipment have been reached (51%). Other tone decay versions are apparently still in existence : 20 percent 98

5 U.S. Audiometric Practices/Martin et al Table 3 Changes in the Percentages of Audiologists Who Perform Behavioral Over a Period of More Than 25 Years Site-of-Lesion Tests Bekesy audiometry SISI ABLB Tone decay perform tone decay starting at 5 db SL, 9 percent begin the administration at 0 db SL (Carhart, 1957), and 7 percent perform the Suprathreshold Adaptation Test (STAT) (Jerger and Jerger, 1975), which begins at 100 db HL and concludes upon the completion of 60 seconds or when the patient signals that the tone is no longer audible. Forty-five percent of respondents reported that, typically, tone decay testing is completed within 60 seconds (Rosenberg, 1958, 1969). Masking in Pure-Tone and Speech Audiometry The issue of masking in pure-tone and speech audiometry was of particular interest in this study because previous surveys revealed that some clinical audiologists appeared to use improper amounts of masking. The present survey was modified to facilitate the investigation of this issue. Questions that required multiplechoice answers assessed situations in which masking was commonly used. Other questions, which were subjective in nature, were designed to determine initial masking amounts used in situations where masking is warranted. Approximately one half (53%) of the respondents reported that masking is needed in pure-tone airconduction testing when a specified difference exists between the air-conduction thresholds between the ears for a particular frequency. The most common "specified difference," as reported by respondents, is 40 db. For the most part, when the "specified difference" was greater than 40 db, respondents included comments explaining that these values were used when testing was accomplished using insert receivers. The majority (46%) of the remaining respondents determine the need to mask by comparing the difference between the air-conduction threshold of the test ear and the bone-conduction threshold of the opposite ear. Differences around 40 db were the most prevalent criteria used in determining the need to mask. Almost all of the respondents (98%) are using narrow-band noise when masking is indicated in pure-tone audiometry. Almost one half (49%) of responding clinicians consider an air-bone gap of a specified amount when determining the need to mask in bone-conduction audiometry. A gap of approximately 10 to 15 db was reported by most respondents as warranting the need to mask. The subjective questions assessing the amount of initial masking used in pure-tone audiometry yielded a variety of responses. They ranged from using a level equal to the air-conduction threshold of the nontest ear, adding a specified amount (anywhere from 5 db to 50 db) to the nontest ear air-conduction threshold, and using a specified amount such as 50 db (no reference stated). Responses also took the form of generalizations including "just the right amount," "varies," and "crank in 65 to 80 db no matter what the threshold is." Some respondents reported using inappropriate procedures, such as considering an occlusion effect for airconduction masking. Most (57%) of the responding clinicians routinely mask for the SRT when a specified difference (usually 40 db) exists between the SRTs obtained at each ear. The majority (37%) of the remaining respondents look for a difference of approximately 40 db between the SRT of the test ear and the best bone-conduction threshold of the opposite ear. Similar to the results regarding initial masking amounts in pure-tone audiometry, the reported initial SRT masking amounts varied widely. For the most part, respondents reported using the SRT of the nontest ear as a baseline for initial masking amounts and adding correction factors (ranging from 5-50 db) to that amount. However, some individuals reported using set amounts, such as 50 or 70 db, for masking, while still others gave more general answers such as "whatever is necessary." Fifty-one percent of respondents believe masking for word-recognition testing is indicated when a difference of approximately 40 db exists between the SRT of the test ear and the best bone-conduction threshold of the opposite

6 Journal of the American Academy of Audiology/Volume 9, Number 2, April 1998 ear. A smaller percentage (32%) mask when there is a specified difference between the speech thresholds of the two ears. This difference, as reported by the respondents using this method, ranges from 5 to 70 db. It appeared more common to use a set amount of masking when needed for word-recognition testing. Standard amounts were reported as 50 to 75 db HL. Many respondents also base their masking level for word-recognition testing on the stimulus level presented to the test ear and subtract a set amount, such as 20 db. The fact that so many respondents do not consider the actual level that speech is presented when considering masking is somewhat unsettling. Immittance Measures The vast majority (93%) of respondents are still performing immittance testing (Table 4). These results indicate slight decreases in use when compared to the previous study; however, the prevalence in tympanometric measures remains constant at 96 percent from 1992 to the present. Of the 96 percent routinely performing tympanometry, 52 percent are using automatic equipment and 41 percent use both automatic and manual tympanometric devices. Tests for Central Auditory Processing, Disorders Figure 6 clearly illustrates the preferred tests for evaluating central auditory processing disorders (CAPDs). The SCAN (a CAPD screening tool that was not previously queried) and various speech-in-noise tests are currently the most popular. What is not evident from Figure 6, Table 4 Immittance Measures Routinely Obtained (n = 203) Response Static compliance Absolute impedance - 16 Otoadmittance Tympanometry Contralateral acoustic reflex Ipsilateral acoustic reflex Acoustic reflex decay SPAR 8 5 Multifrequency tympanometry 10 8 Other < 1 Mon. Filtered S=:~FR: 1-1 Bin. Filtered Speech SSW Speech in Noise SSI-1cM r_ SSI-CCM PIPB Competing Sentences wibeford i d Percent of Respondents Figure 6 Routine use of central auditory tests by audiologists from 1989 to however, is that only one half of the respondents are assessing CAPDs. The data obtained in 1992 indicated that 64 percent of respondents evaluated CAPD. Although knowing the prevalence of particular CAPD tools is helpful, what may be of more interest is the overall audiologic management of patients exhibiting these symptoms. The questionnaire item assessing this area was subjective in nature and, unfortunately, many audiologists did not respond to this question. Those clinicians who did reply are primarily referring their CAPD patients to other specialists, such as ear, nose, and throat (ENT) physicians, speech-language pathologists, or other audiologists who specialize in CAPD testing and rehabilitation. Electrophysiologic Tests As mentioned earlier, due to technologic advances in audiology, the number of respondents performing electrophysiologic testing was expected to increase ; thus, this area of the survey was greatly expanded from the 1992 questionnaire. Only 25 percent of respondents are not performing any variety of electrophysiologic testing (Table 5). The inclusion of OAEs in the survey was of particular interest, considering the significant clinical value offered by this measure, as well as its ease of administration. Of the 33 percent of respondents who are measuring emissions, 67 percent are using the test in a screening capacity, primarily evaluating infants and newborns (46%). Distortion product OAEs are being used by approximately 42 percent of clinicians who are engaging in OAE testing, while transient evoked OAEs are routinely used by 30 percent. Only 33 percent reported using these measures in a diagnostic capacity. OAEs are useful for assessing a 100

7 U.S. Audiometric Practices/Martin et al Table 5 Administration Tests (n of Electrophysiologic = 212) Test % Evoked otoacoustic emissions 33 Electrocochleography 25 Auditory brainstem response 65 Middle latency responses 9 Late evoked responses 2 40-Hz potential 1 Mismatch negativity (MMN) 1 Cognitive (P-300) response 5 Electronystagmography 47 Other 7 Do not test 25 variety of impairments, such as monitoring the detrimental effects of ototoxic drugs (claimed by 7% of respondents), determining pseudohypacusis (16% of respondents routinely use OAEs in this fashion), assessing fluctuating hearing loss (5%), and separating cochlear and neural components of sensorineural hearing losses (common among 18% of responding audiologists). Table 6 details those procedures used in conjunction with OAE testing. The auditory brainstem response (ABR) is the most popular electrophysiologic test among survey participants who are engaging in these measures (performed by 65%), mostly for site of lesion (54%) or pediatric (31%) testing (Table 7). Although 94 percent of survey participants who engage in auditory evoked potential (AEP) testing are responsible for interpreting the test results, only 55 percent deliver that information to the patient, and 43 percent of respondents claim that this task is accomplished by a physician (Table 8). Regarding the use of sedation with AEP testing, one half of respondents who administer AEP tests claim to use sedation "sometimes" with uncooperative patients. Of the remainder, 18 percent reported using sedation "always" with uncooperative patients and 24 percent "never" use sedation. Table 7 Most Common Population Tested Using AEP Audiometry (n = 178) Response Pediatric patients 31 Pseudohypacusic patients 5 Site-of-lesion testing 54 Difficult-to-test patients 7 Other 2 Approximately one half (47%) of responding clinicians are conducting electronystagmography (ENG). Only 34 percent of respondents surveyed in 1985 were performing ENG testing, which increased to 51 percent in Sixty-eight percent believed that an audiologist should perform ENG testing and 18 percent chose a technician as the proper choice for ENG administration. However, 80 percent of respondents believed that an audiologist's role in ENG should be both as administrator and interpreter. Only 5 percent claimed that audiologists should have no role in ENG. Although ASHA declared in 1992 that intraoperative monitoring is within the scope of practice of audiology, not many audiologists appear to participate in this activity. Only 10 percent of respondents are currently performing this procedure, which has only increased by 3 percent in the past 5 years. Of those performing this procedure, the majority claim that removal of an acoustic neuroma is the most common surgical procedure for which intraoperative monitoring is warranted. Many also perform intraoperative monitoring during cochlear implant and spinal cord surgery. Hearing Aids Consistent with the survey published in 1994, 83 percent of the respondents are dispensing hearing aids and 70 percent of these dispensers manage the fitting of hearing aids with Table 8 Personnel Responsible for Table 6 Procedures Commonly Performed in Interpreting AEP Results (n = 145) and Conjunction with Evoked Otoacoustic Informing the Patient of the Results (n = 173) Emissions Testing (n = 95) Interprets Results Informs Patient Response Response Pure-tone audiometry 30 Physician 6 43 Immittarfce 42 Audiologist ABR 24 Technician 0 0 Other 4 Other 1 2

8 Journal of the American Academy of Audiology/Volume 9, Number 2, April 1998 Table 9 Prescriptive Hearing Aid Fitting Procedures Most Often Used (n = 237) Response Berger 4 POGO 7 CID procedure 1 NAL-R 56 DSL 12 Other 10 Do not use prescriptive fittings 11 two to five sessions with their patients, during which hearing aid orientation and aural rehabilitation are addressed. Seventy-three percent of these dispensers claim to use probe microphone measures at least some of the time (41% sometimes perform these measures and 32 percent always obtain probe microphone measures). Almost one half (44%) of the sample who fit hearing aids use ABR results for fitting difficultto-test patients. With the advent of prescriptive hearing aid fitting methods and programmable aids, there have been modifications in dispensing practices (Table 9). Fewer and fewer audiologists are fitting aids by testing the functional gain and comparing word-recognition scores of different instruments. The majority (62%) of dispensers responding to this survey keep five or fewer aids on hand, while a smaller percentage (26%) has from 6 to 15 aids in supply. Of the remainder, only 3 percent maintain more than 26 aids. A large percentage (77%) of respondents who dispense hearing aids take earmold impressions in a speech and hearing clinic or physician's office. Those respondents who do not dispense hearing aids generally refer their hearing aid candidates to dispensing audiologists (81%). Very few (6%) refer their patients to hearing aid dispensers. Table 10 illustrates the respondents' preference for measuring uncomfortable loudness Table 10 Patients for Whom the Uncomfortable Listening Level (n = 208), Most Comfortable Listening Level (n = 209), and Dynamic Range are Determined (n = 219) Response UCL MCL DR For every patient For hearing aid candidates only Yes, other No levels (UCL), most comfortable levels (MCL), and the dynamic range (DR) for hearing aid candidates. A questionnaire item was included to determine the most commonly recommended hearing aid style among the respondents. The question asked audiologists to rank order the hearing aids listed according to their preference. Included in the list were styles such as behind the ear, in the ear, in the canal, and completely in the canal ; body and eyeglass hearing aids were also included. The data indicate that the most popular hearing aid styles appear to be in-the-ear, in-the-canal, and behind-the-ear aids. Programmable aids, regardless of style, also appear to be relatively popular. A subjective item was included to determine why some respondents are not dispensing hearing aids. The majority who responded to this question explained that they work in a school setting. Of these individuals, many mentioned that it is common for them to dispense personal FM systems. A number of clinicians wrote that they are too busy or do not have the necessary administrative support for dispensing. Some respondents report that the setting in which they work does not allow for dispensing, while others believe that dispensing would be a conflict of interest. Two respondents claimed disinterest in dispensing. Counseling It goes without saying that counseling is an. integral part of audiology. However, having clinical audiologists perform this task, particularly in a physician's office setting, may be controversial. Fortunately, results of this survey reveal that for the majority of respondents, the audiologists are the primary counselors of their patients (Table 11). These results are consistent with previous surveys dating back to 1985, when the issue of hearing aid dispensation was first addressed. Miscellaneous The first miscellaneous question in the survey assesses the routine use of the audiometric Weber test and, consistent with the 1994 survey, shows that only a small portion of respondents (18%) are performing this measure on a regular basis. Similarly, only 22 percent of respondents use hearing handicap assessment scales, such as the Abbreviated Profile of Hearing Aid Benefit (APHAB) or the Communication Profile for 102

9 U.S. Audiometric Practices/Martin et al Table 11 Persons Who Inform the Patient of the Type and Extent of Hearing Loss (n = 236), Course of Management (n = 253), Recommend a Hearing Aid Evaluation (n = 256), and Conduct the Follow-Up Counseling (n = 225) Response Type and Extent of HL Course of Management Recommends HAE Follow-Up Counseling Physician Audiologist Technician <1 <1 <1 1 Other 1 <1 1 3 Do not conduct <1 the Hearing Impaired (CPHI). An overwhelming majority (93%) of respondents are not routinely calculating the AMA percentage of hearing impairment. A comments section devoted to this question revealed that many respondents believe that this measure can be an inaccurate reflection of an individual's hearing loss, as well as being potentially misleading. Many responded that, considering the questionable value of a percentage of hearing impairment, they compute it only when necessary, such as for insurance purposes or for legal matters. Pseudohypacusic patients can often provide the practicing clinician with a substantial challenge. To help circumvent the problems caused by these individuals, a battery of tests designed for evaluating difficult-to-test populations has been established over the decades. Table 12 outlines the popularity of various tests used by audiologists in assessing functional hearing losses, and these results are essentially consistent with results obtained in 1992, with the exception of OAEs, which were not investigated in previous studies. Test Table 12 Tests Used for Pseudohypacusis (n = 218) Electrodermal audiometry 0 Lombard 6 Stenger 79 Doerfler-Stewart 2 Late evoked response audiometry <1 Auditory brainstem response 54 Middle latency response audiometry 2 Acoustic Immitance measures 73 Standard Bekesy 1 LOT Bekesy 3 Otoacoustic emissions 32 Other 13 Do not test 6 As mentioned previously, cerumen management now falls within the scope of practice of audiology. However, only 28 percent of the responding audiologists are routinely performing this task. Of those who are actively practicing cerumen removal, the most preferred methods involve the use of a curette, irrigation, and suction. Many respondents, in compliance with ASHA's (1992) suggestions for cerumen management, reported that they proceed with cerumen removal only when it can be done safely. In contrast to previous surveys, the present questionnaire included a section related to audiologic testing in the face of language barriers. Results indicate that only 31 percent of respondents are proficient in one or more languages, other than English, that are used in a clinical setting. Of the population who responded that they are proficient in other languages, almost one half perform audiometric testing in the other language. The most frequent languages used by these audiologists are sign language (in various forms) and Spanish. For the remainder who are monolingual, a question was designed to investigate how testing is conducted when the patient speaks another language. A variety of procedures were noted in this section, with the most prevalent being the use of an interpreter or family member who speaks English. CONCLUSIONS peculation regarding causative factors and generalization of the findings of this study to the entire field of audiology must be limited, due to the nature of the questionnaire and its results. Audiologists were simply asked what they are doing clinically and how they are doing it. The only question designed to ascertain why a particular procedure is not being practiced pertains to why hearing aids are not being dispensed. In order to assess the reasoning behind

10 Journal of the American Academy of Audiology/Volume 9, Number 2, April 1998 certain results, future surveys would need to more explicitly assess individual clinical areas. To incorporate additional subjective information into a survey based upon the present one would create a document so lengthy as to reduce the response rate. As audiologists continue to choose electrophysiologic tests for site-of-lesion diagnosis, the prevalence of behavioral site-of-lesion testing declines further. The present survey reveals a decrease in the use of Bekesy audiometry, the Short Increment Sensitivity Index (SISI), the Alternate Binaural Loudness Balance (ABLB) test, and TDT. The only behavioral site-of-lesion test still used by at least one half of respondents is tone decay, with the Olsen-Noffsinger version remaining the most popular. There are indications that some audiologists may be more interested in the more technologically advanced procedures than in the mundane ones, such as bone conduction and masking. Since the "basic" audiometric procedures constitute the heart of much of what follows in the way of patient management, this conclusion is somewhat disquieting. In some cases, adherence to some of the recommended audiologic guidelines may help to solve this problem. RECOMMENDATIONS urrent recommendations, some of which are C based on those stated by Martin and Morris in 1989 and Martin et al in 1994, are as follows : 1. Results from this survey can provide a baseline for audiologists to compare to their own practices and procedures, as well as to educate themselves on common emerging procedures. 2. The results and trends revealed by the survey can aid educators in their attempts to teach students those procedures that are most widely used by practicing audiologists. Along the same vein, the results from this survey can give educators an idea of those procedures performed "incorrectly" so that they may modify their teaching, if necessary. 3. Topic areas too broad to be thoroughly investigated in the present study, such as mask- ing and electrophysiologic testing, may need additional evaluation in the form of more specific questionnaires. - Acknowledgment. This study was funded, in part, by a grant from the Shell Foundation. REFERENCES American Speech-Language-Hearing Association. (1992). External auditory canal examination and cerumen management. ASHA 34(Suppl): American Speech-Language-Hearing Association. (1988). Guidelines for determining threshold level for speech. ASHA 30: Carhart R. (1957). Clinical determination of abnormal auditory adaptation. Arch Otolaryngol 65 : Jerger J, Jerger S. (1975). A simplified tone decay test. Arch Otolaryngol101 : Martin FN, Armstrong TW, Champlin CA. (1994). A survey of audiological practices in the United States. Am JAudiol 3: Martin FN, Fagelson M. (1995). Bone conduction reconsidered. Tejas 20: Martin FN, Forbis NK. (1978). The present status of audiometric practice : a follow-up study. ASHA 20: Martin FN, Morris LJ. (1989). Current audiologic practices in the United States. Hear J 42 : Martin FN, Pennington CD. (1971). Current trends in audiometric practice. ASHA 13 : Martin FN, Pennington CD. (1972). ASHA audiologists : professional background information. ASHA 14 : Martin FN, Sides DG. (1985). Survey of current audiometric practices. ASHA 27 : Olsen WO, Noffsinger D. (1974). Comparison of one new and three old tests of auditory adaptation. Arch Otolaryngol 99 : Pennington CD, Martin FN. (1972). Current trends in audiometric practices : Part 11-Auditory tests for site of lesion. ASHA 14: Rosenberg PE. (1958). Rapid Clinical Measurement of Tone Decay. Paper presented at the American Speech and Hearing Association Convention, New York. Rosenberg PE. (1969). Tone decay. Maico Audiological Library Series. Report 6. Thornton AR, Raffm MJ. (1978). Speech-discrimination scores modeled as a binomial variable. J Speech Hear Res 21 :