Striking the Right Balance – Looking to the Future of Vestibular Practice in Canada
In this edition of “Striking the Right Balance,” Carolyn Falls, MClSc writes an opinion piece about the future of vestibular audiology practice in Canada. This is part one of a two-part series; stay tuned for a future article by Emma Leblanc who will look at education and practice differences between the United States and Canada.
Michael Vekasi, AuD, R.Aud, Aud(C), FAAA and Erica Zaia, MSc, RAUD are coordinating the “Striking the Right Balance,” feature which will cover the latest information on ‘all things vestibular.’
If you would like to be more involved in all things vestibular, please sign-up for the Vestibular Special Interest Group. Sign-up by simply emailing firstname.lastname@example.org to let us know you want to be a part. Also, check out our Facebook page for a free list of online vestibular resources at the CAA National Vestibular Special Interest Group page.
Lately, I have been doing a bit of dreaming about the future of vestibular audiological practice in Canada. As a profession, I think we have made a lot of progress in the last 10 years towards better recognition of this area of practice. Still, I think there is a lot of work to do for audiology as a profession, but specifically vestibular audiology as an area of practice, that would go a long way in establishing ourselves as an autonomous profession that boldly takes ownership of our expertise and scope of practice.
In my mind, there are six key pillars that I believe will need to be addressed to accomplish this goal. Thankfully, some of these initiatives are in progress nationally or have already been achieved in some provinces.
I would like to lay out this groundwork for you as I see it, in hopes that it will generate some discussion, debate, and hopefully movement forward. None of the individual concepts I’m writing about are particularly novel, but I believe there is great value in establishing a clear direction in moving together towards a common goal.
1. Direct Referrals to ENT
All audiologists are familiar with the frustrating game of ping-pong that results when a patient needs timely intervention from an ENT physician. As a profession, we are more than capable of making this determination when indicated, including those of us in vestibular practice.
As a hospital-based audiologist with ENT colleagues who trust my opinion and are willing to facilitate a solution when there is a legitimate concern, I have seen how a streamlined process results in better patient care. I immediately think of a time we were able to expedite imaging for a child who presented with concerning central signs on VNG and was diagnosed with a brain tumour soon thereafter.
More common are the numerous communication breakdowns and missed opportunities for patient care that result when we are at the mercy of primary care physicians to interpret our results and heed our recommendation for an ENT consult.
Thankfully, the potential for this to improve patient outcomes has been recognized and the Canadian Academy of Audiology is working with the Canadian Society of Otolaryngology and Head and Neck Surgery to implement direct referral of patients to ENTs in all provinces, which will benefit vestibular and non-vestibular practitioners alike.
2. Diagnostic Privileges
Why does diagnosis matter in vestibular practice? At its core, diagnostic privileges give us the freedom to identify the exact pattern of dysfunction in order to make clear recommendations for our patients. Nothing lost in translation.
In my experience, with the exception of neurotologists (uniquely trained ENT vestibular subspecialists), many ENTs do not feel confident managing dizzy patients who are not surgical candidates. I receive enough “what should I do next?” and “what does this mean?” phone calls from ENTs and other physicians to believe that many would benefit from the diagnostic information we could provide. There are gaps when it comes to the care of dizzy patients and too few neurotologists to handle the overwhelming demand from an aging population. Audiologists are well-placed to take on some of that load, by managing the cases that do not require physician intervention and appropriately triaging the cases that do. We just need to have the language to be able to do so effectively.
The ability to communicate a diagnosis is something that varies significantly from province-to-province, according to provincial laws and therefore college regulations. In British Columbia, for example, an audiologist may “make a diagnosis identifying, as the anatomical cause of behavioural, psychological or language-related signs or symptoms of an individual, an auditory or related communication disorder.1” Similar privileges are not in place yet in Ontario, where we are prohibited from even communicating when a patient has noise-induced hearing loss. For provinces like Ontario, this needs to change for the well-being of our patients, who miss out on appropriate counselling and follow-up when we have to dance around critical information we are more than capable of conveying. Even in regions where diagnostic privileges are already in place, there may be a need to clarify exactly what is allowed within the realm of vestibular practice.
As a starting point, I believe all vestibular audiologists with sufficient competency should be able to diagnose vestibular hypofunction (unilateral/bilateral), as well as all variants of BPPV. These are patterns of dysfunction that we irrefutably have the skill set to diagnose and are generally responsive to vestibular rehabilitation. One caveat: there is a need to exercise caution around medical diagnoses, particularly those that rely on imaging. No doubt, we will still need to work with our ENT colleagues to further investigate our clinical suspicions when a specific diagnosis falls outside of our expertise.
3. Open Communication with ENTs
There are many areas of audiology within which we are capable of practicing autonomously, but there are also limitations, as previously mentioned. We need our ENT and other physician partners to provide the medical care that some of our patients need. We also need to develop relationships that allow physicians to see the value that we bring to the table for our patients. Too often, ENTs dismiss the utility of vestibular function tests based on information that is incorrect or antiquated.
At Toronto General Hospital, we have the luxury of working in parallel with a number of ENTs, neurotologists, and residents/fellows, which results in valuable exchanges of ideas and knowledge. I am forever grateful for the many teaching and learning opportunities that have resulted from these cross-disciplinary discussions. However, these conversations cannot be confined to the hospital if we want to advance vestibular practice in Canada.
If we want to ensure that our patients receive appropriate follow-up based on our results, it is up to us to help the physicians who refer to us make valuable connections between our test results and an eventual medical determination. ENT residents often receive only limited training when it comes to vestibular test interpretation and our tests are always evolving. Those knowledge gaps need to be filled.
Building trust across professional lines can take time, but I am certain that it will benefit both our patients and our profession at large if physicians develop a better understanding of our results, expertise and scope of practice. If a referring ENT insists that they only want VNG because they believe it is the “gold standard”, make sure you take the time to explain the value of adding vHIT, for example. Pick up the telephone, write that letter, and make sure that you are a trusted source for vestibular knowledge in your community.
4. Education & Training
None of these recommendations have any value if we do not have the skill set as vestibular audiologists to provide excellent care to our patients.
The path toward becoming a competent vestibular audiologist in Canada is not always straightforward. Even those who realize that they have an interest in vestibular practice whilst still in school face the challenge of finding an appropriate placement, as only select sites across the country (overwhelmingly hospital-based sites) have a strong focus on vestibular audiology.
Perhaps the greatest challenge is faced by private-practice audiologists who discover an interest in vestibular practice after graduation. Though Canadian audiology programs have come a long way when it comes to providing dedicated coursework in this area, critical hands-on instruction is often limited.
I regularly receive emails from private-practice audiologists looking to develop vestibular assessment services for their patients. While I agree that these services are needed in the community, vestibular assessment is an entire area of audiological practice that simply cannot be picked up competently without hands-on practice and supervision.
I realized the extent to which this was true during an international teaching rotation, where vHIT was being performed at the in-house clinic based on technique learned from training DVDs. The resultant tracings were of such poor quality that it was impossible, even to the trained eye, to decipher between normal and abnormal pathology. The audiologists and ENTs in the clinic could not understand why they were struggling so much with interpretation, but it was actually basic technique that was lacking. These were conscientious health care providers who were trying to improve patient care by offering vestibular services. Unfortunately, their results were essentially useless due to lack of skill.
Similarly, I worry that audiologists without sufficient practical vestibular testing experience will rely solely on manufacturer guides and protocols when it comes to interpretation. Unfortunately, we have learned through experience that manufacturer software is rarely capable of making a correct interpretation on its own. Knowing the many nuances of interpretation requires experience and expertise that does not develop overnight. While advanced skills can develop over time and gaps in knowledge can be filled by courses and textbooks, there is no easy substitution for the essential skills built through practical hands-on experience.
So, what is the solution? How do we develop as a profession in this area of practice when there are such barriers to getting started? Above all else, it is critical that audiologists who regularly see dizzy patients agree to be preceptors for audiology students whenever possible. The more placement sites that offer vestibular services, the greater the likelihood is that our audiology trainees will get at least some hands-on exposure during one of their placements. To me, this is the most concrete way to firmly establish appropriate education in this complex area of assessment.
It may also be practical for provincial colleges to require advanced certification to perform vestibular testing and rehabilitation, similar to what they have in place in British Columbia, if it is determined that a high proportion of those practicing do not meet a baseline level of skill.2 It is essential that the care we provide reliably meets an acceptable standard.
Lastly, I would like to see more hands-on training opportunities for those who develop an interest in this area after graduation. Post-graduate placements for those with an appropriate level of motivation and introductory education might indeed be an option, but there is a need to develop specific opportunities at appropriate training sites.
5. Expanding Vestibular Services
As audiologists, our scope of practice gives us so much freedom to provide valuable services to our patients, including vestibular assessment and rehabilitation. Unfortunately, in my opinion, other allied health professions have done a better job of taking ownership of the various areas of vestibular practice. In particular, physiotherapists are increasingly participating in vestibular assessment, while some key stakeholders, especially in the United States, have tried to establish that vestibular rehabilitation therapy (VRT) should only be performed by physiotherapists and not audiologists. In my view, audiologists absolutely have the skill set to provide VRT, though there are select instances when a referral to physiotherapy would be indicated.
To truly solidify our role as vestibular practitioners, I believe that vestibular audiologists need to collectively develop a skill set within vestibular rehabilitation. Vestibular rehabilitation is a critical link between vestibular assessment and management that we have within our skill set to provide and can truly improve the quality of life of our patients.
A simple way to provide some basic rehabilitation is to learn how to identify the different BPPV variants and treat with the appropriate repositioning maneuver when indicated. There are some excellent courses that teach these skills. I highly recommend one with a significant hands-on component.
For those with the motivation to develop skills beyond that, there are many other services within VRT that audiologists are capable of providing. Falls prevention is another worthwhile area that deserves more attention.
6. Funding and Advocacy
The biggest impediment to audiologists providing any sort of vestibular services in the community (assessment or rehabilitation) is funding. Audiologists do not have the ability to bill provincial healthcare plans directly for testing, nor will private insurance plans cover the cost. Even for audiologists who are able to bill for vestibular services under an ENT, reimbursement is exceptionally low, especially when you consider the high cost of purchasing and maintaining vestibular equipment.
Conversely, patients with extended health insurance benefits can often receive reimbursement for vestibular rehabilitation therapy. Unfortunately, patients can generally only submit for reimbursement when the service is provided by a physiotherapist.
As vestibular audiologists, one of our biggest challenges moving forward will be to advocate for appropriate funding for our services. It is my hope that vestibular audiologists across Canada can tackle some of these funding challenges together while also advocating for the valuable services we provided.
- Government of British Columbia. Speech and Hearing Health Professionals Regulation, BC Reg 413/2008, section 5(1). Queen's Printer, Victoria, British Columbia, Canada. Available at: https://www.bclaws.ca/civix/document/id/complete/statreg/413_2008
- College of Speech and Hearing Health Professionals of British Columbia. Advanced Competency in Vestibular Assessment and Management - CSHHPBC. Available at: http://cshbc.ca/wp-content/uploads/2019/05/CSHBC-CP-A-Vestibular-Assessment-Management.pdf