Filling the Void of Neuromonitoring Knowledge Base

At the ASNM 2015 Winter Symposium there was a block of talks examining the future of IONM and the emergence of Expert Systems. The ensuing panel discussion acknowledged the demand for high-level and mid-level practitioners in light of the increasing lack of expertise in the OR.

I just returned from the ASNM Winter Symposium in Scottsdale, Arizona, and I thought I’d share some of the highlights with my readers. I’m going to divide the content into several posts to keep it short. In today’s post, I’d like to tell you about the panel discussion on the Morning of February 21st. The morning started with the following presentations:

  • The State of EEG Monitoring in the ICU
    • Sabrina Galloway
  • The Future of Technology and Expert Systems in Neuromonitoring
    • Brett Netherton
  • The Future of Teleneuromonitoring
    • David Morledge
  • The Future of Neuroanesthesia
    • Tod Sloan

At the end of the morning session, the presenters formed a panel and took questions from the audience. While all of the morning talks were very interesting, the content of the ensuing panel discussion, including audience participation, really related to presentations by Netherton and Morledge. So, I’ll give you a short overview:

Brett Netherton noted that there are not enough people in the field of IONM to monitor all surgeries. So, we either need more of us, or the assistance of Expert Systems (computer systems, with a Decision Engine and a Knowledge Base, that act in a way to emulate the decision-making ability of a human expert). Netherton poses the question, who will populate the Knowledge Base of the Expert Systems? Expert systems are coming no matter what. Present examples are automated and surgeon-directed systems. 

David Morledge noted that changes are happening in all sectors of healthcare, and how these changes will manifest for IONM will depend on how its value is perceived by decision makers [value=(quality*access)/cost]. We presently have 2 types of staffing models in IONM:

  1. one-person provider model (performs technical and professional duties)
  2. two-person provider model (1 technologist and 1 professional).

There is an increasing push for direct involvement of the Professional in surgery, even with constant 2-way audio and video communication become more frequently the norm. Meanwhile, demand for physicians will outpace supply by 130,000 by 2025. Morledge poses the question, which service delivery model(s) result in the most value?

I don’t have a perfect memory, but I’ll do my best to reconstruct the ensuing discussion. Each paragraph (line break) represents me paraphrasing individual questions or comments from the room, roughly in the order in which they occurred:

Question: How do we fill the void in expertise?

There are extraordinarily bright people out there who choose not to pursue a PhD or MD, but they can have expertise. What if folks with bachelor’s or master’s degrees could achieve something commensurate with a CRNA? If the field were defined in such a way, these very bright people would probably flock to our field in droves.

Question: There is an increasing lack of expertise in the OR, particularly with the automated or surgeon-directed systems (collectively referred to as the “black box”). Does anyone actually know what’s going on with the patient anymore?

This is a serious problem. In the situation with the black boxes, sales reps are now coming to the OR, rather than neurophysiologists, and they are not allowed to touch the patient. Instead, the have to tell OR nurses where to place electrodes, and no one is interpreting the data. In this situation, there is no education, no training and no quality…but black boxes have the advantage of cost.

This returns us to question of how we fill the void of neurophysiology “knowledge”. Is the surgeon going to fill that void? Is the surgeon knowledgeable enough? I would argue no. Large companies have so much money pushing their sales model to get their products used. Meanwhile, the managed care model is pushing to get costs lower, and this looks good for the black box.

From the perspective of the Joint Commission (JCAHO), the best way to push back against the knowledge void is to have established quality standards in the OR, such that the hospital requires the presence of the neurophysiologist (knowledge base), as opposed to just a sales rep.

Question: The Society for Neuroscience has tens of thousands of neuroscience PhDs scrambling for dozens of positions, taking on their third or fourth postdoc working for $30-40k/year. These are people with an amazing knowledge base…level of education…level of professionalism…that with a little clinical training could be excellent candidates to move into this middle-level professional job in IONM – why are they not flocking?

From my experience, there is a personality type amenable to being that person in the OR. A huge portion of basic neuroscientists are extremely introverted. This probably explains why, percentage-wise, extremely bright people don’t transition into the field.

But, if even 5% of PhDs looking for jobs in the Society for Neuroscience transitioned into IONM it would quadruple the number of D.ABNMs virtually overnight.

The biggest names in our field, and some examples include Leo Happel, Jay Shils, Chuck Yingling, Tony Sestokas, etc, etc…as far as pure definition, are all considered techs. These people built a place for themselves in a different time, before there was this idea of a “tech”. It is different today because people who come from SFN would be taking a big step down the career ladder. They are too smart. They won’t be techs.

I am a PhD neuroscientist transplanted into this field, and I’m here to tell you that we will never attract a PhD to a mid-level position…they have already reached the highest level of education that one could possibly attain. Why would they take a step down to the position of a tech? Sure, they’d get a big pay increase, but they’d sacrifice their career, and that’s interpreted by the community, to their family, to themselves as failure, as giving up. I came into this field in a Professional Practice Model of IONM. Everything was interpreted in the room, and by extremely well-educated, well-trained, knowledgeable people, many of whom had PhDs, DCs, AuDs. We never used the word “tech”. If anyone had told me prior to entering this field, that I’d eventually be considered a tech, I would have said forget that! We must create a space for PhDs to operate at a higher level, not a mid-level, or you will never get PhDs flocking to this field. Furthermore, the PhDs and other non-physician doctors that are presently in the field will simply leave, and that further contributes to the problem of a knowledge void.

I trained as a researcher, ran a research lab, wrote grants and chased money, too. Then one day, I was asked to work with a neurosurgeon and suddenly didn’t have to write grants anymore. I got paid more, and could record from electrodes inside the human brain, instead of an animal or the scalp of a sophomore volunteer. So, I thought I had the best of both worlds.

We need to incorporate these high-level thinkers to high level positions, and not just from neuroscience. What about audiology, chiropractors, engineers, etc.? We need people that have the ability to comprehend surgery, anesthesia, neurophysiology, etc.

Question: Are there even any Master’s program in neuromonitoring in the United States?

Aage R. Møller has one in texas, but it’s just classroom.

Well, we need to find a way to reach these students out there in universities and tell them about our field.

Ok, well, that’s the summary of the morning panel session. I thought it was very interesting and that’s why I chose to share it with you. Stay tuned, as I hope to share more highlights from the meeting in my next post.

Dr. Rich Vogel is board-certified intraoperative neurophysiologist working for Safe Passage Neuromonitoring. He started the Neurologiclabs website and blog to connect with others in the field of neuromonitoring.


12 thoughts on “Filling the Void of Neuromonitoring Knowledge Base

  • Reply Stephen messana February 23, 2015 at 17:19

    Fantastic post! Bravo. I whole heartedly agree. I don’t have an advanced degree but the amount of knowledge required for our job is definitely not too be looked upon as a “tech” level. It’s a shame that so many brilliant neuroscientists would stray away from a profession because of the stigma of being labeled a technologist. I wanted to attain an advanced degree for my own personal endeavors but knowing that unless I persue a phD my title will still remain as a Neuromonitoring tech, even with a cnim board certification. I hope the day of automated machines never replaces the surgical neurophysiologist. Thank for taking the time to write this one.

    • Reply Richard Vogel February 26, 2015 at 16:42

      You’re welcome. Thanks for reading, and thanks for writing!

  • Reply Thelmond Cooper February 23, 2015 at 18:22

    Very informative. Keep those coming! i had no idea about these “expert systems”!

    • Reply Richard Vogel February 26, 2015 at 16:42

      Thanks for the comment. I’ll keep writing if you keep reading!

  • Reply Eric L Hargreaves February 24, 2015 at 19:59

    I am one of those Ph.D. Neuroscientists, who after 5, postdocs in three different countries, with over 30 publications including 2 Science article, each with well over 200 citations, who still could not breakthrough and was finally drafted by a neurosurgeon.

    I Participate in DBS surgeries, and in the long term management and programming of the implanted IPGs. On occasion look at requirements of IOM exam to become certified, and find the requirements daunting in terms of number of hours and cases required. Do not have much desire to put the effort in to fulfill the requirements after having gone through all my other training, and continuing to work full time in my current clinical/research position. If you wish us to join in droves maybe another route to certification needs to be developed that might recognize the several thousand hours of animal electrophys in addition to my meager 600hours of human IOM.

    • Reply Richard Vogel February 26, 2015 at 16:41

      I agree with you. Sadly, the way it stands now, a PhD with 30 years of experience (even clinical IONM experience and professional board certification) is considered a “tech” and must be supervised by someone with absolutely no experience. Indeed, even a recent med school graduate will qualify as a “neuromonitoring professional” in the eyes of the 1) federal and state government, 2) hospital credentialing committee, 3) insurance company/payor, etc, etc. The whole system has become a joke, and the only people not laughing are the patients who don’t know any better.

    • Reply Rob Arias February 28, 2015 at 16:59

      Eric, you deserve enormous credit for your dedication to neuroscience. In a former existence, I spent almost a decade writing a novel I thought would prove my breakthrough in to a different, but equally crowded marketplace. Fortunately, I’d also been simultaneously working on my Plan B in neuroscience drug discovery. Despite personal noble intent and herculean effort, the reality of the job market obeys the economic law of supply and demand. I think many of us operate, erroneously, by the unquestioned assumption that the work we are most suited to do, which most elevates our human faculties and which most benefits our fellow beings, we assume such is the work which must necessarily also provide us the greater tangible reward, be that money, fame or influence. It would be nice if the world worked that way, but my experience has taught me it doesn’t.

  • Reply Rob Arias February 28, 2015 at 16:37

    Rich, thank you for yet another informative post. From this and other fragments of discussion (e.g., How many cases do we cover in a year?), it seems we don’t have a clear understanding of IONM’s “addressable market,” so to speak, never mind the more challenging task of formulating a logistics for addressing it. I love the idea of a CRNA-like certification, a recognized professional designation of deep expertise in clinical neurophysiology, as well as the effective implementation of that knowledge in the OR. Someone with a PhD in neuroscience and exemplary technical skills won’t necessarily be an effective IONM practitioner. This reminds me of the distinction Jerry Garcia made between recording an album and performing a concert. One is like building a ship in a bottle, the other like sailing on a rough open sea.

  • Reply Brain Molecule Marketing March 1, 2015 at 19:36

    lol…this sales stuff is always funny. We are a loong way until we understand animal behavior, let alone human, let alone transfers to clinical work and even longer to business applications. Probably decades.

    “Knowledge is (very) expensive.” and takes decades of massive funding and work. The idea that bolting on a few grad school folks is going to mean anything is a lie.

    There is simply no way any commercial enterprise will ever have enough time or money to make any discoveries.

    Neuromarketing, neuroecnomics, behavioral economics and cognitive neuroscience aren’t even evidence based theories yet – if ever.

    • Reply Richard Vogel March 1, 2015 at 19:55

      That comment makes absolutely no sense, and has no clear connection to the topics presented in this discussion.

  • Reply diane bouchard April 2, 2015 at 19:50

    so are you advocating for a two person provider model?

    • Reply Richard Vogel April 4, 2015 at 16:08

      I think a 2 person model works well in an in-house group when both a professional and a technologist are onsite. In the contract model of IONM, it doesn’t work very well. See related discussion here.

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