Dear Ms. Knachel and Members of the Virginia Board of Audiology and Speech Language Pathology,

As a practicing audiologist since 1976, the last twenty in private practice, I read the proposed "limited cerumen management" regulations with concern.  Having served two terms on the Board (five as Chair), I applaud the Board's willingness to address the cerumen management issue and the audiologist's role.

The regulations, as proposed, would have a very restrictive effect on the actual practice of audiology and the care of our patients.  As you know, both AAA and ASHA include cerumen management within the scope of practice of audiology and do not define limitations. After reviewing neighboring states' regulations, including West Virginia, Maryland and North Carolina, all of whom include cerumen management within the scope of practice, none are as restrictive as the currently proposed regulations. Most of the contraindications listed in Section C of 18VAC30-20-241 are addressed  in the Maryland regulation (Chapter 07, 04 Training, Knowledge, and Skills) with one critical difference. Maryland stipulates that the pre-existing conditions be addressed through training and does not bar the audiologist from performing cerumen management as does the Virginia proposal.

Audiologists are categorically one of the best trained disciplines to perform cerumen management. Through my practice, I have encountered many patients who have just seen their primary care physician who has referred them on for audiological assessment. Most of the time, some amount of cerumen is present which was not removed by the physician prior to the appointment.  As you are aware, patients who wear hearing aids are at risk for developing blocked canals due to the daily insertion of a device. By restricting the audiologist's role, these patients will not be able to receive this essential service to obtain accurate test results or maintain comfortable use of their aids. Patients will have to wait weeks, and in some cases months, to be seen by an otolaryngologist for ear cleansing, which will also add extra costs to their care. For example, Section C, item 8 bars an audiologist from removing an "actual or suspected foreign body in the ear." As read, this would prevent me from removing a hearing aid eartip which has dislodged in the canal. Most tips are very easy to remove. Rather than quickly taking care of the problem in my office, I would have to refer out and the patient would incur an unnecessary medical charge.

Currently, in my locale, there are providers of cerumen removal who do not require any guidelines. One of these treatments is known as candling, which involves placing the smaller end of a tapered cone near the opening of the ear canal. The cone is made of cloth soaked in beeswax or paraffin. The larger end is lit and the heat is said to create suctioning which "draws" the cerumen from the canal. To date, I have not encountered anyone burned or injured by the procedure but do not advocate its use. The point of this example is to further stress the need for our profession to be able to provide cerumen management without the proposed restrictions so that our patients have reasonable accessibility and choice as to where to obtain service.

As I have watched our profession evolve through the years, developing greater  autonomy by becoming a doctoral level profession, I would think that we would trust the judgment of the professionals trained through our universities.  Currently, those of us dispensing hearing aids are taking ear impressions that extend deep into the ear canal. Practitioners who assess the vestibular system are introducing either water or air when irrigating the canal for calorics. All of these skills involve risks which our training has addressed.

Instead of developing a restrictive approach to cerumen management, which will have unintended consequences for the patient, the practitioner and the profession, I recommend that training be stressed as the defining point for performing cerumen management and let the audiologist use his or her professional expertise and judgment to determine where the service should be done. I am asking the Board to take into consideration the burden these regulations will place on the patient and the practitioner. Rather than moving forward with the current draft, I suggest that further study be undertaken to ensure that the regulatory change is appropriate and does not damage our patient's access to service. 

If we are now a doctoral level profession, shouldn't we act as such?

Respectfully,

Julie Farrar-Hersch, Ph.D.

Augusta Audiology Associates, P.C.