February 1, 2015

Dear Ms. Knachal and Virginia Board of Audiology and Speech Pathology Board Members,

I am contacting you today as a member of the Illinois Board of Speech Pathology and Audiology in the hopes that you will consider my comments regarding the Virginia Emergency Regulations as they pertain to Cerumen Management by audiologists. While I commend you and your Board on the creation of much needed cerumen removal language, I believe that the language is so restrictive that it will impede quality care.

While I believe that your intention, as a consumer protection board, is to create language that will provide unparalleled protection for the consumer, the proposed language is so specific and restrictive that, it will have the unintended consequence of substantially hindering patient access to trained, competent and affordable cerumen management services.  

This reduction in access could lead patients to obtain cerumen management services from individuals, including but not limited to, nurses and medical assistants who are less trained than audiologists. Virginia’s current Regulations Governing the Practice of Audiology and Speech Pathology indicate, in section 18VAC30-20-280 (Unprofessional conduct) the following sections that would make inappropriate removal of cerumen by an audiologist an infraction of your existing licensure laws and regulations.  Those sections include, but are not limited to:

“Section 5: Incompetence or negligence in the practice of the profession;

Section 7. Failure to refer a client to an appropriate health care practitioner when there is evidence of an impairment for which assessment, evaluation, care or treatment might be necessary; and

Section 12. Inability to practice with skill and safety”. 

As a result of these existing regulations, the extent of the language in the current Emergency Regulations as they pertain to Cerumen Management by Audiologists appears unnecessarily detailed. You already have protections in place for consumers.

It should also be noted that physicians, even otolaryngologists, are not immune to medical errors in the removal of cerumen.  An article, published in October of 2013 in the Journal of Otolaryngology, Head and Neck Surgery (http://www.ncbi.nlm.nih.gov/pubmed/23894144), reported that, in the cases reviewed, cerumen removal was the most common procedure leading to malpractice claims in otolaryngology. 

If permanently enacted, Virginia would become one of the 22 states to have laws, regulations or guidelines on cerumen management by audiologists.  The American Speech Language Hearing Association (ASHA) has an excellent summary of these regulations as they exist in each of these states.  This is available at http://www.asha.org/Advocacy/state/State-Cerumen-Management-Requirements/. As you will note, outside of the regulations in California, Maryland and New Jersey, the language pertaining to cerumen removal by audiologists is very broad. This type of broad language allows for definition of scope for the audiologist, while allowing the patient the ability to receive accessible, affordable care by appropriately trained and competent audiologists. 

There is not a single audiology licensure law in this country (nor any code of ethics from any professional audiology association) that does not prohibit licensees from performing a service for which they are not appropriately trained and competent, nor does any licensure law or code of ethics permit services which will be harmful to the patient. 

I might suggest modifications to your emergency regulation that included the following;

A. In order for an audiologist to perform cerumen management, he shall:

1. Be a graduate of a doctoral program in audiology and which included didactic education and supervised clinical experience in cerumen management as specified in subsection B of this section; or

2. Complete a course or workshop in cerumen management which provides training as specified in subsection B of this section and which is approved by the American Speech-Language Hearing Association, the American Academy of Audiology, or another medical society or association.

B. An audiologist shall maintain documentation evidencing satisfactory completion of training in cerumen management to include the following:

1. Recognizing the presence of pre-existing contraindications that necessitate referral to a physician;

2. Recognizing patient distress and appropriate action to take if complications are encountered;

3. Use of infection control precautions;

4. Procedures for removal of cerumen, including cerumen loop, gentle water irrigation, suction and the use of material for softening;

C. An audiologist performing cerumen management shall:

1. Obtain informed written consent of the patient or legally responsible adult and maintain documentation of such consent and the procedure performed in the patient record.

2. Refer patients to a physician if they exhibit contraindications or experience any complication, such as dizziness, drainage, bleeding or pain, during or following the procedure.

Thank you for your consideration of my comments and for the opportunity to share my thoughts.  Please feel free to contact me at kim.cavitt@audiologyresources.com or 773-960-6625 if you have additional questions or concerns.

Respectfully,

Kim Cavitt, AuD

Vice-Chair, Illinois Board of Speech Pathology and Audiology

Adjunct Lecturer, Northwestern University

President, Audiology Resources, Inc.