Rehabilitation and Prosthetic Services
Audiology Pioneer Looks Back at His 42yr VA Career
A self-described maverick, Dr. Richard Wilson has always pushed boundaries.
When he joined VA in 1972 as chief of audiology in Long Beach, Calif., he was told "research was not part of the responsibility' of the audiology team there.
That policy didn't last long.
"Not having an understanding of the word 'no' and under the cover of a clinic, we started a research program,' says Wilson.
His group managed to find much of the hardware it needed in a nearby government warehouse that stored surplus equipment from the space industry: pure-tone and noise generators, attenuators, audiometers, an early-model computer, racks to hold it all. They found more instruments and two sound booths at other VA sites. "It was everything a person need to run an audiology lab,' recalls Wilson.
Fast-forward to 2014 and Wilson has now retired from VA after more than four decades leading groundbreaking work in hearing science. Hearing loss is the number-one service-connected disability in the VA system. Wilson's work, applied today in clinics throughout VA and much of the English-speaking world, has improved assessment and care for a multitude of Veterans and other patients. And the scores of audiologists he's taught and mentored over the years, many now in the VA system, are carrying the science forward.
A peer of his, Dr. Judy Dubno at the Medical University of South Carolina, had this to say when she, among others, nominated him in 2011 for the prestigious Jerger Career Award for Research in Audiology, given by the American Academy of Audiology:
"[Dr. Wilson] has worked to develop and refine clinical tests to assess speech recognition, focusing on aspects of these tests that had received little attention. …These tests have been recorded on CDs and made available to clinical and research audiologist throughout the VA system and around the country. Thus, Dr. Wilson's body of work represents the best example of experimental audiology research that has been translated to the clinical setting and has had a direct, widespread, and positive impact on the practice of audiology.'
High accolades, considering that many researchers toil for years without seeing much clinical impact from their work.
The translation from lab to clinic was never a "bonus' for Wilson: He saw it as essential. His work always straddled the two settings, and he is skeptical of researchers who lack grounding in everyday clinical practice.If integrating the two paths—clinician and researcher—has come naturally to Wilson, it may have something to do with his birth. He was born in a town—Bristol—that sits smack dab on the state line between Tennessee and Virginia. He was born on the Virginia side, but grew up on the Tennessee side. "So I'm technically a Virginia native, but basically I'm a Tennessean.' That sort of duality seems to have worked its way into his DNA.
Clinical investigators, in Wilson's eyes, are an exalted breed in the world of health research. "They have a firsthand view of what problems need to be solved,' he says.
By the same token, he asserts, they have ready access to a patient population and can try out innovative ideas more easily.
He recalls the first time he realized the direct impact that research could have on patient care. It was during his time at Long Beach in the 1980s, when his team took part in a multisite VA trial on cochlear implants. "Our patients would otherwise not have had access to cochlear implants at that time,' says Wilson.
Nowadays, especially, there are extensive protections for research participants. Internal review boards must review and approve protocols. Stringent federal and other quality standards must be met. Informed consent paperwork must be carefully explained to study volunteers and signed off on. Wilson wonders whether in some cases, this is "too much of a good thing'—whether barriers are put up between research and clinical practice that don't need to be there.
"There are a lot of things, like hearing tests, that don't need all the extensive protection,' he argues. "We used to be able to implement protocols. Now, there's so much involved, you can't just do it during a clinic visit. You have to have people come back.'
On a related note, he laments that sometimes the myriad forms and lengthy approval processes involved in securing federal research grants can stifle curiosity and creativity, passion and initiative. "By the time your project gets funded, you've lost interest in what it was you wanted to study to begin with,' he says, only half joking.
VA itself has taken steps to combat that problem, with innovative funding models that allow promising ideas to move forward while non-critical details get worked out.
Curious by Nature
Despite his qualms, Wilson succeeded in maintaining continuous VA and external funding—such as from the National Institutes of Health—for decades. He was lead investigator on some 17 federal grants, mostly from VA, and co-investigator on several others, totaling more than $12 million. Fortunately for his career and for those who have benefited from his work, no amount of red tape could suppress his natural drive to learn more about workings of the ear and the brain's auditory system.
"I'm curious by nature,' he reflects. "Good scientists have to be curious. You have to ask questions. And to ask questions, you have to think about things.'
Wilson spent roughly the last half of his career at the Mountain Home, Tenn., VA Medical Center, where since 2001 he ran the Auditory and Vestibular Research Enhancement Award Program, funded by VA Rehabilitation Research and Development. He started with one sound booth and built the program from there. It developed into an important hub for multidisciplinary research. Alongside VA's National Center for Rehabilitative Auditory Research in Portland, Ore., the REAP in Mountain Home is one of the nation's top sites for hearing science.
Balancing research and clinical work isn't easy, admits Wilson. He points out that clinical investigators must compete for funding with full-time investigators, and they get only limited chunks of time for their research. "It's tough to do research projects when you get only a day or a day and a half of 'release time' from your clinical responsibilities. So you end up working a lot of nights and weekends. I did that all my career, regardless of how I was funded. But it gets to be old hat after a while.'
Knowing firsthand the challenges involved, he points proudly to the fact that all the investigators in his program were also "in the clinic.' The REAP funding, he says, made that possible.
Hub for Training
Mountain Home has also become well-known among audiologists for its annual Appalachian Spring Conference. The training event draws some 200 participants and features nationally known speakers. Wilson praises the "three-legged stool' model that VA embarked on in the 1940s, through its partnership with the nation's medical schools: research, clinical care, and training of health professionals. In 2013 alone, outside of physicians and nurses, VA trained more than 31,000 "associated health professionals,' including 163 audiologists.
Wilson helped launched a doctoral program for audiologists at East Tennessee State University, leveraging the hands-on training opportunities at the nearby Mountain Home VA.
He talks about his classroom philosophy: "As a teacher, I don't lecture. I figure graduate students can read. I give them study guides. They can read through and then we talk about the readings in class. I ask questions but I try not to answer them. I try to get other students to answer. That way, you start to understand what your students really understand and don't understand. That's where your teaching comes in.'
Digging beneath the surface to see what people really understand—that can serve as a metaphor for Wilson's research. His main interest has been speech recognition. It's not enough to give people a hearing test in which they raise their hand when they can hear a tone. Wilson wants to know: Can they make out what their friend across the table is saying in a crowded restaurant? When they watch a movie, can they understand the dialogue over the music soundtrack?
"The most common complaint the typical older adult has with their hearing loss is not being able to understand speech, especially when there's background noise,' says Wilson. "Most audiologists understand that, but they don't test it.'
Wilson adds: "We know a lot about how the ear works, if we're talking about the peripheral sensory organ. What we don't understand very well is how the output of the organ is channeled and processed by the central nervous system into a mental concept. That's where the problems of understanding speech in noise, or any distorted speech signal come in.'
He admits the problem affects him personally. "When I go to a restaurant, I don't participate in conversation, because you can't understand it. You put on a hearing aid, it doesn't help very much in noise. It makes things worse, because it doesn't separate out the noise from the signal.'
These questions get at important quality-of-life issues—not only for older people, but also for many younger returning Veterans. Many Iraq and Afghanistan Veterans may pass a standard hearing test fine, but at the same time they suffer from auditory dysfunction, often the result of blast exposures. The sound signal passes through the ear fine but doesn't get interpreted correctly in the brain. In some ways, says Wilson, the problem appears identical to that experienced by many older adults, although scientists don't yet understand all the underlying brain mechanisms.
Testing Speech Recognition
One exam Wilson has developed to measure and diagnose such problems is the Words-in-Noise test. The audiologist plays a recording on a computer and the patient, wearing headphones, is asked to repeat the words he hears the announcer say. The background "babble'—many people talking at once—stays at a fixed level, but the announcer's voice grows softer, making it more difficult to make out the words. The test allows audiologists to fix an exact score to a person's problems with speech recognition in noise. This way, they can get a better handle on what types of counseling and rehabilitation are needed, and track the results.
As for treatment, hearing aids do help in some cases. Newer digital models, though a bit pricey, have directional microphones and do a fair job of filtering out background noise. But there are also other things to try.
Wilson recommends, for example, a "companion microphone' system. A hearing-impaired person who is going out to eat with friends gives a small microphone to each to attach to his or her collar. "This in effect moves the people closer in than they would be otherwise,' says Wilson. "It's basically improving the signal-to-noise ratio. It's good technology.' He acknowledges that the system is not used as widely as it could be, perhaps because of the social awkwardness some potential users might feel.
In a more hypothetical vein, Wilson wonders why TVs can't come with a feature that enables watchers to adjust the ratio of speech to noise, similar to how those with vision loss can adjust the size of the type on their computer screen.
"In TV and movies,' he points out, "the signal is the speech, the dialogue. The noise is the background music and special effects. The way they adjust those [in Hollywood studios] is that some young whippersnapper sits in the control room and makes the speech and the noise just like he likes them. In fact, older people like me need a substantially different ratio between the speech and the noise so we can understand the speech.'
That may be a whimsical vision, but the lack of such options is a real problem for much of the U.S. population, says Wilson. "TV and movies, where many older people spend a lot of their time, are very difficult and frustrating for them because they have trouble with speech in noise.'
Along with "speech in noise,' Wilson has also turned his attention to "interrupted speech.' Rather than introduce background babble, the idea here is to simulate the speech that people typically hear—but struggle to recognize—in real-world conversation. To produce the testing materials, Wilson uses a process similar to video editing. He takes a segment of recorded speech and plays with it digitally to make it less clear.
"We do anything we can to change, or distort, the wave form of the speech. Whatever we do to the speech signal—compressing, dicing, chopping, whatever—they all result in the same thing: poor understanding of speech.'
Though the Words-in-Noise test and a couple of other products from Wilson's lab are in fairly widespread use, most U.S. audiologists are still doing only basic assessments. "You go to most audiologists and they'll tell you they do pure-tone and speech testing and that's about it,' notes Wilson. "And oftentimes that speech testing is in quiet, with the tester saying the words themselves, not even using standardized materials.'
The concepts behind Wilson's tests may seem simple enough. But developing and validating such tests demand countless hours of painstaking work in the lab and clinic.
"They are very involved, very tedious, very time-consuming,' says Wilson. "I doubt many people in the field have any appreciation whatsoever for what goes into it.'
Tackling such research projects is critical, says Wilson, but they don't always catch the fancy of funding agencies.
"They tend to not get excited about it. But a lot of times, what needs to get funded is the more routine grunt work, more so than a 'sexy' project that attracts a lot of attention.'
Wilson was never deterred by such unglamorous undertakings. In his 2011 letter nominating Wilson for the Jerger Award, Dr. Donald Dirks of the UCLA School of Medicine, who mentored the Tennessean before he went on to pursue his doctorate at Northwestern University in the 1960s, recalled him as having a "vigorous work ethic' and being "steadfast' and working "laboriously until the task was finished.'
Those traits have stuck with Wilson—even after more than a half-century. He may have indeed built his career around "grunt work.' But what a distinguished and rewarding career it's been.