James W. Hall III, PhD, a professor at the University of Florida-Gainesville who also maintains a clinical practice there, might be described as the “clinician’s clinician” on subjects related to auditory neurophysiology. The author of over 120 journal articles, book chapters, and five books and textbooks, he has gained a reputation for being able to cut through data and present some of the most complex audiological concepts in a clear, sensible, objective manner.
Dr Hall also devotes a lot of time to educating audiologists, and has been presenting a series of GSI Training Workshops for clinicians in the United States and around the world. Some of his more recent GSI Workshops have been “Diagnostics,” “Ototoxicity,” and “Tinnitus,” which also offer attendees continuing education units (CEUs).
In early January, HR caught up with Dr Hall by phone at his “new” home—a 1907 Victorian house in St Augustine that he and his wife recently renovated.
HR: You’re one of the world’s leading experts on ABRs, OAEs, and electrophysiology. How did you get started in this area and in conducting the GSI workshops?
Hall: I was fortunate enough to drift into the area of electrophysiology, and I was extremely lucky to work with [James Jerger, PhD] both as a PhD student and as an audiologist at Baylor. He was way out in the forefront of this field during the 1960s.
When the ABR came along, the big emphasis at that time was diagnosing patients with acoustic tumors—a rather glamorous area for audiologists prior to the era of CTs or MRIs. A big turning point for me was when Dr Jerger asked me to write a book chapter on the auditory assessment of children using ABRs. Well, I really got into the subject, found it absolutely fascinating, and the resulting chapter was much longer than anyone anticipated, including Dr Jerger [smiling].
This ultimately led to Sadanand Singh at Singular Publishing asking if I’d write a textbook (Handbook of Auditory Evoked Responses) about the subject. When I did, I came to realize that electrophysiology was a very important area that audiologists didn’t know enough about. Around the same time—the mid-to-late 80s—the ABR became the primary test-of-choice for diagnosing hearing loss in infants and young children. My colleagues and I became involved in some of the early trials of automated hearing screening devices. At that time, a frequent comment from the field was “Well, it appears you can screen them, but can you diagnose the hearing loss accurately enough to fit a hearing aid?”
So, by then, it became apparent that this was a huge niche that needed to be filled. It also became apparent that we have literally thousands of audiologists in the field who’ve never taken a course in electrophysiology, let alone have had any practical experience with OAEs and ABRs. Meanwhile, we have universal newborn hearing screening being conducted routinely, and there are thousands of children who require diagnostic hearing assessment prior to behavioral audiometry.
So, I started offering courses sporadically, until I was informed that Karl White at Utah State University was putting together a CDC grant to upgrade and educate audiologists throughout the United States on both the diagnostics and intervention with hearing aids for young children. This led to four or five workshops each year—and I’m still doing these workshops for audiologists who are motivated to receive the information.
These also evolved into a series of international courses that, through the decades, have taken me to places like South Africa and South America. It’s extremely gratifying to return to some of these countries 10 years later and find out that the very people who attended my previous courses went on to establish hearing screening and intervention programs. So, people are actually using this information, millions of kids have undergone early screening, and hundreds—if not thousands—of hearing-impaired children have been identified early and benefited from the programs these people founded.
HR: What do you cover at the GSI Workshops?
Hall: I have a general template for the workshops, but I always vary the courses depending on the audiences and their interests. So, for example, at the workshop held recently in San Francisco, we also focused slightly more on auditory processing disorders and on tinnitus.
However, all workshops provide a systematic and thorough review and overview of topics. In general, the assumption is that most of the attendees have had at least an introductory course in electroacoustics, which includes OAEs, ABRs, and—importantly—acoustic immittance measurements.
I’m also finding many audiologists have a tendency, like all of us, to drop some of the older technologies for the new. A lot of our important older audiological tests have fallen by the wayside, even though many clinicians still have the equipment in their offices.
Acoustic reflexes are a perfect example of this, and that is another topic update that I like to provide at the workshops. For example, I’ll show how acoustic reflexes can be useful not just in identifying middle-ear disorders, but also in diagnosing auditory neuropathy and helping to evaluate infants and young children without sending them for sedated ABR. I think we need to resurrect some of these “old procedures”; they may be old, but they can still tell you a lot about the auditory function of patients.
The other thing that I stress to my audience is that I’m a clinical audiologist at heart, and still do clinical work. I practice what I preach. I’m applying those things I’m discussing, and I can tell you that it works, it’s efficient, and it helps you get the best diagnostic results on these people.
HR: Obviously, GSI is sponsoring the workshops. What do you cover relative to their products?
Hall: In terms of GSI products, I touch on most of them, but I want to make it clear that I’ve never been a consultant for any company. I will talk mainly about the technology, and the exciting things about the technology, and it’s true that I’ll usually highlight my comments with actual devices within the context of the presentation. But I’m careful not to exclusively promote any one company in lectures and workshops.
GSI, of course, was one of the very first companies to develop products for tympanometry and acoustic reflexes, so it’s always easy to relate their products to the history and technological development within our field. And when I’m demonstrating these concepts, using printouts or slides, I think people can quickly figure out that I use a lot of GSI products. So, while I’m careful not to promote or endorse the products, the fact is that I do use them extensively, and I think that shows I hold GSI in high regard.
HR: A recent offering from GSI is the CE-chirp, developed by long-time industry researcher Claus Elberling, PhD, and HR has published a couple articles related to it. What do you think about the CE-chirp?
Hall: Although I like to try new things, when it comes to audiological procedures, I generally will not jump onto a bandwagon unless I’m certain it will get me there better than the old bandwagon. There have been many ideas that have come along that sounded great but didn’t really work well in the long run. And, as a clinician, I think you need to be careful. There is nothing wrong with traditional tone bursts and traditional clicks; they work just fine.
I’m still at the stage of convincing myself that I should switch to the CE-chirp. But, even within the last week [early January], I’ve had some clinical experiences that made me realize they do have a role: the CE-chirp responses near threshold were huge compared to the traditional tone-burst chirp responses and, at the very least, it made identifying the wave much simpler. There were a couple of instances where I got thresholds 5 dB lower—in other words, 5 dB more accurate—in estimating hearing threshold with the chirp-version of the stimuli.
[Dr Elberling] and others have pointed out that most of the data we have on chirps—or nearly all the data we’re basing our decisions on—were collected from normal-hearing adults. So, I think an important area of future research will involve getting good clinical information on these chirps, their accuracy, and their feasibility in infants, including those with different types of hearing loss. I think there will be a great opportunity to compare [the CE-chirp] to what we’ve been using, and then see when and where its use is most valuable.
What I tell clinicians is, if you’re using tone bursts or regular clicks, keep doing it. However, for at least one frequency or when you get down near threshold where the CE-chirp will be most useful, it simply becomes a question of calling up the program on your computer. Run a CE-chirp and see for yourself.
I’m confident that the CE-chirp is providing a larger response and probably an enhanced threshold. The only thing I want answered—which entails a longer-term research project—is “Does it correlate any better with behavioral thresholds and actual hearing?” It’s also possible to make the mistake, if the chirp is too big, of overestimating good hearing. So, this type of research data will be forthcoming. But, all in all, I think it’s a step in the right direction.
HR: There are several people in our field who always seem to be in the forefront of technology, and you are certainly one of them. Do folks like you and Dr Jerger hang out in labs and R&D departments and steal equipment?
Hall: No, not quite [laughing]. But I often describe myself as a water boy: whenever there is a new technique or procedure that flows out of a laboratory or manufacturer, I grab a bucket of it and bring it into the clinic so we can analyze it. So, of course, as they develop new technologies, I generally get to be one of the first to try it.
As these new techniques come along, I also like to introduce and discuss them at my workshops, as well as with researchers and graduate students. So it’s a positive relationship both ways.
HR: When GSI was purchased 2 years ago by William Demant Holding, HR interviewed GSI, and they made it clear that their goal was to re-establish the company as “Setting the Clinical Standard.” What has been your experience with GSI products?
Hall: When I started out in audiology, GSI had already been around for many years. Back then, I used the old GSI E-800 audiometer and one of their old speech audiometers—and I still keep many of these in my back office as examples of early devices.
In a lot of ways, GSI did set the standard. [Rufus Grason] started out, in part, by building instrumentation with [Nobel laureate] Georg Von Bèkèsy, so they have a real history of innovation. Two previous owners ago [prior to their purchase by William Demant], I made the comment to one of the Viasys executives that “I don’t know if you really appreciate the heritage that you’ve purchased; the name Grason-Stadler means quality.” And, at that time, like many companies that become small components within huge corporations like Viasys, GSI was kind of left to languish for awhile.
But now I think they’ve got a good home with a company that appreciates their heritage. And, fortunately, they still have people like Jan Painter from the old days and many others who understand that it’s important to resurrect that cutting-edge reputation. The equipment is still—and has always been—very solid, and I have no problem saying that, because I’ve used it for about 37 years.
HR: Are there any particular “holes” in clinicians’ knowledge or understanding that you see the workshops as particularly valuable in filling?
Hall: It’s fairly well known in audiology that we have a systemic problem where there are wide inconsistencies in undergraduate programs. So, it’s possible to get an AuD at one university and never have to do an ABR, while at another university you’ll get terrific background and experience using them. I believe all students should take a course in neuroscience to understand the nervous system and basic physiologic principles. The best programs have courses like that. However, one of the problems in conducting my workshops is that some of the people know this type fundamental information and some don’t. Obviously, I can’t cover everything, but I do try to start my lectures by giving people the basic principles and fundamentals. Many get a lot out of just that part of the workshop.
I think it’s gratifying that, many times, I’ll see people who previously attended my workshop, and I’ll ask why they came back to attend essentially the same one. They generally say that the first time served as an introduction to the topic, and now that they’ve been doing it, they know the questions they really need to ask.
We need to recognize that you just can’t expect to learn everything in one fell swoop, and continuing education is essential. That’s what these workshops are all about. It’s great that these workshops are helping a large cross-section of clinicians better understand this important area and upgrade their skills.
Visit GSI’s Web site at www.grason-stadler.com for upcoming trainings in your area or call 800-700-2282.