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:
- one-person provider model (performs technical and professional duties)
- 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.
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.