Audiological medicine
BMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7075.2 (Published 18 January 1997) Cite this as: BMJ 1997;314:S2-7075
- Cliodna O Mahoney, Consultant,
- Dr Valerie Newton
- Department of Audiological Medicine,Great Ormond St. Hospital for Children,London, WC1N 3JH
- School of Audiology, University of Manchester, Manchester, M13 9PL (0161 275 3370).
- Useful contacts: Professor Linda Luxon, Royal National Throat Nose and Ear Hospital, Gray's Inn Road, London WC1 (0171 915 1590).
Though small, audiological medicine is expanding rapidly. Cliodna O Mahoney, a consultant in the specialty, outlines its attractions
Audiological medicine deals with the identification, assessment, management and rehabilitation of adults and children with hearing loss, tinnitus, dizziness and other disorders of balance. First recognised in 1975, the specialty's expansion has been driven by a decline in chronic infections which reduced the role of surgical intervention in disorders of the ear. The emergence of the specialty has also reduced the fragmentation of care of patients with symptoms of dizziness, imbalance, and vertigo. Because these may be caused by pathology in many different systems, their management was often divided between different specialties. The resulting multiple referrals resulted in no one physician taking overall responsibility.
There are now 33 consultant audiological physicians working in Britain, 13 in Calman specialist registrar posts, and one senior house officer. The specialty has steadily expanded, with the rate of expansion increasing in recent years. For example, during 1995-6, six newly approved consultant posts were filled in addition to replacement posts. Two consultant posts are currently advertised and three Calman specialist posts are about to be advertised for the rotation in the Thames regions.
Until the introduction of the Calman specialist registrar system most trainees entered the specialty at senior registrar level, having worked for many years in other specialties. About half the current consultants came to audiological medicine from ear, nose, and throat surgery. The balance is drawn from a wide range of specialties including from paediatrics, neurology, auditory research, general medicine, general practice, and rehabilitative medicine. This diversity of backgrounds has meant that audiological medicine has developed as a specialty in its own right while retaining its relevance to, and liaison with, many other areas.
There are three main aspects of work within the specialty: paediatric audiology, adult rehabilitation, and neurotology. The vast majority of the patients' problems are dealt with on an out patient basis: there are few hospital admissions.
Paediatric audiology includes the confirmation or exclusion of hearing loss and tinnitus in children, identification of its aetiology and associated pathology, appropriate interventions-for example, amplification. This is followed by rehabilitation of the child designed to minimise deleterious social, emotional, educational, and vocational effects of the pathology.
Hearing loss has profound impacts on the lives of the children affected and their families; an audiological physician must address the family's many concerns. These include questions about the child's speech development and overall intelligence, as well as wishing to understand the underlying reasons for it. Parents often feel guilty that some aspect of their care has been responsible, and worry that their other children may be affected. Supporting the parents and providing information about the child's education and social development is very important. Hearing impaired children may need extra help at school and can be socially isolated. Addressing these complex questions requires skill from many professionals, and the audiological physician's role, in addition to specific audiovestibular investigations and interventions, is to anticipate and identify problems, the nature of which will change over the years, and ensure that patients are put in touch with the professionals and agencies.
Adult rehabilitation applies the same principles to the management of hearing loss in adults. Neurotology includes the investigation and management of dizziness and imbalance, with or without concomitant hearing problems, in both adults and children.
As well as their diagnostic hospital based work, most audiological physicians are involved with community based screening and surveillance programmes, such as neonatal screening for congenital hearing impairment, and screening for age related or noise induced hearing loss.
Depending on the particular interest and background of the individual consultant, and the kind of hospital in which he or she works, some audiological physicians specialise entirely in one area, while others span all three fields. Whichever areas trainees ultimately choose, as consultants they will be working as part of a multidisciplinary team which includes audiological scientists, technicians, psychologists, teachers of the deaf, speech therapists, and hearing therapists. As much of the management of the patients is long term and rehabilitative, liaison with other specialties and the community services is an important aspect of the audiological physician's work. As is probably true of most of the smaller specialties which overlap with other more established disciplines, audiological medicine offers a flexibility that enables doctors to carve out their own niche, and to pursue their own clinical interests. The pressures to spend all one's time providing a standard service, which is possibly less stimulating for the physician, is less than those in the main specialties. This is presumably because there are relatively few departments of audiological medicine, so the concept of a standard service is not rigidily delineated. Because of the unfamiliarity of the service for many managerial, and indeed medical, colleagues, the downside is that time must be spent on marketing: explaining the nature of an audiological physician's work, demonstrating the effectiveness of the service, and justifying, on the basis of the improved quality of service, the costs incurred by this specialised service. Good communication and interpersonal skills are not just a great asset for dealing with patients.
Research in audiological medicine is in its infancy and the scope for basic scientific, technical, clinical, and epidemiological studies is vast. Interest and skill in many types of research is applicable to the various aspects of audiological medicine and is warmly welcomed. Those who feel daunted by the prospect of being obliged to embark on research, which is now a compulsory part of training in all specialties, the well structured and supervised MSc course ensures a supportive and painless introduction, even for the totally uninitiated.
Entry criteria
Audiological medicine was Calmanised in October 1996. From that date entry into specialist training commenced at specialist registrar level, and membership of the Royal College of Physicians, fellowship of the Royal College of Surgeons, or equivalent is a prerequisite for entry. Clinical experience in paediatrics, neurology, ENT surgery, geriatrics, psychiatry, general medicine, or community medicine are looked upon favourably. An MD or PhD in a relevant topic may be an acceptable alternative to a membership or fellowship examination provided that the candidate has sufficient general clinical experience as well. Personal attributes, such as good communication skills and a common sense approach to problems are also very important qualities.
Until now, doctors would have needed a lot of luck to even have heard about the specialty, because, though all students and doctors have had undergraduate teaching on topics now encompassed by audiological medicine, only a small minority will have been taught by audiological physician; many may even be unaware of the existence of the specialty. This is hardly surprising: a recent study showed that more than half of the undergraduate deans are not aware of its existence.
Training structure
Because doctors' previous experience on entering audiological medicine has been so varied, the skills and attributes which it is necessary to acquire during subsequent specialist training have long since been defined.
Training lasts for up five years from the time of entry into the specialist registrar grade, depending on previous experience. During this time the trainee will become experienced in each of the three areas mentioned above with a view to being awarded the certificate of completion of specialist training. Flexible training is welcomed.
Training is currently organised into two rotations, one between hospitals in Manchester, Sheffield, Nottingham, and Cardiff and the other in the Thames regions. There are two intake dates each year-in March and September. Training includes experience in both specialist and general hospitals, for three years in one hospital and a further two years in one other of the hospitals on the rotation. During this time trainees study for an MSc in Audiological Medicine (Manchester or London) on two days each week over two years.
Experience in neurology, ENT, paediatrics (in particular developmental paediatrics) geriatrics, genetics, and ophthalmology is arranged during the five year training period, in accordance with the training needs of the individual. Regular formal appraisal is incorporated throughout training.