Job Titles in Neuromonitoring

There are so many different “job titles” that are used to describe clinical personnel in the field of neuromonitoring (IONM), and it can be confusing to decipher their meaning, particularly because people often use them interchangeably. This post will clarify roles and review the history behind job titles on the professional and technical side of neuromonitoring.

When it comes to job titles in neuromonitoring, there has never been a consensus regarding who can use which title. To make matters worse, there is no consistency. What’s the difference between a neurophysiologist and an electrophysiologist? What about the difference between a technician and a technologist? This post has 2 main goals. First, I hope to illustrate the urgent need for standardization of nomenclature in the field of IONM. Second, in the absence of standardization, I hope to provide useful information to the lay-reader who may be looking for some clarity as they wade through the vernacular of the field. While I don’t expect to just clear things up, I hope this information will be informative to the masses while the various professional societies diligently work to publish guidelines on job titles as they relate to the qualifications of neurodiagnostic personnel.

Note: This is a re-write of a previous post which has been updated for the sake of clarity. For more information about the rewrite, see comments at the bottom of the page.

The Neuromonitoring Professional

The neuromonitoring professional is responsible for the supervision of neuromonitoring technologists and the interpretation of neuromonitoring data. The supervision can be done remotely via the internet, or onsite (in the same hospital complex as the surgery). Responsibilities include preoperative and postoperative patient examination, prescribing the monitoring plan, overseeing interactions with the surgical team, ensuring quality data acquisition, detection of injury to the nervous system, recommending interventions and generation of a monitoring report. Many of these responsibilities are often delegated to the technologist. Qualification for being a professional include having a doctoral degree (AuD, DC, DO, MD, PhD, or foreign medical). Appropriate board certification is essential for non-physicians, and recommended for physicians. I have previously written about what qualifies one to be a neuromonitoring professional, so I won’t repeat that topic here.

Difference Between Physician and Non-Physician Doctors

Physician

A person with MD or DO degree and licensed to practice medicine within a given state (USA). While recommended, the physician is not required to have any experience or training in neuromonitoring, and is not required to pass any nationally-recognized or accredited board examination. There are several specialties that now offer physician certifications in neuromonitoring, including the American Board of Clinical Neurophysiology (ABCN), the American Board of Neurophysiologic Monitoring (ABNM), and the American Board of Psychiatry and Neurology (ABPN). While there’s no specific board certification that is required for physicians to supervise and interpret neuromonitoring, it is with increasing frequency that physicians in the field of neuromonitoring are pursuing these certifications.

Non-physician Doctor:

Person with a doctoral degree, such as AuD, DC, PhD or foreign medical doctors, who is not licensed to practice medicine. The individual may have a license to practice their specialty (e.g, audiology, chiropractic, clinical psychology, etc.), and neuromonitoring may fall within the scope of practice for some of these specialties. Given that non-physician doctors come from a wide variety of backgrounds, demonstration of clinical competency as evidenced by professional board certification is absolutely essential. The American Board of Neurophysiologic Monitoring (ABNM) is the only nationally-recognized professional credentialing body specific to the supervision and interpretation of neuromonitoring. The ABNM examination is open to both physician and non-physician doctors. Prerequisites include a doctoral degree in the life sciences, formal education in neuroanatomy and neurophysiology, documented supervision of several hundred monitored cases in a variety of surgical procedures, and successful completion of written and oral examinations. Once certified by the ABNM, the Diplomate may use “DABNM” after their credentials to signify the highest level of competency in neuromonitoring.

Job Titles Used by Neuromonitoring Professionals

Neurophysiologist

This term is used by physician and non-physician doctors alike. It is most commonly used by non-physicians, particularly neuroscience PhDs.

Surgical Neurophysiologist

This term is used most commonly by non-physician doctors.

Intraoperative Neurophysiologist

This term is used most commonly by non-physician doctors.

Clinical Neurophysiologist

This term is used by physician and non-physician doctors alike. It is most commonly used by physicians, particularly by graduates of clinical neurophysiology fellowships who are BC/BE for certification by the American Board of Clinical Neurophysiology.

Neurologist

This term is used exclusively by physicians who are certified by one of several national boards that certify neurologists, such as the American Board of Neurology and Psychiatry.

Electrophysiologist

This is not a common term, but it is used by some physician and non-physician doctors. Outside of the clinic, this term is most commonly used by bench neuroscientists. In the clinical setting, electrophysiology is usually discussed in the context of cardiac monitoring. As it relates to the nervous system, I suspect that this title has more common clinical use in the international community.

IONM Professional (IONM-P)

Because there are so many different “titles” floating around the field of neuromonitoring, the American Society of Neurophysiological Monitoring (ASNM) has provided professional practice guidelines on the roles and responsibilities of neuromonitoring professionals in the execution of their supervisory duties (Skinner et al., 2014).  The ASNM defines the neuromonitoring professional as someone who holds a doctoral degree (MD, DO, PhD, AuD, for example), and is credentialed by one of the nationally-recognized Boards listed above.  This definition was abridged significantly for this post, and I encourage the reader to seek clarification directly from the ASNM.

The Neuromonitoring Tech

The neuromonitoring technician or technologist prepares the patient for surgery, collects neuromonitoring data and communicates data interpretations to the surgical team. Frequently the Professional’s responsibilities are delegated to the technologist due to the inability of the professional to be present in the OR. There are no specific qualification for being a neuromonitoring tech. Certification in Neurophysiological Intraoperative Monitoring (CNIM) is the recommended credential administered by the American Board of Registration of Electroencephalographic and Evoked Potential Technologists.

Difference Between Technician and Technologist

Technician

According to the US Bureau of Labor and Statistics, a technician in the arenas of science, medicine and engineering, is defined as someone whose highest level of education is high school through Associates Degree, who earns a certificate to perform certain functions within their chosen field, and is skilled in the technical aspects of their work. As it relates to neuromonitoring, one might define the technician as someone who has not achieved a bachelor’s degree and has not achieved the CNIM certification. Commonly, the technician will obtain a certificate of basic competency in EEG or similar (e.g., R. EEG. T).

Technologist

A technologist, by contrast, is someone whose highest level of education is a baccalaureate through master’s degree (often with additional certification), who is skilled in both the technical and conceptual aspects of their work. As it relates to neuromonitoring, one might define the technologist as someone with a college or master’s degree cin the life sciences (preferred) who has achieved, or is preparing to achieve, CNIM certification in neuromonitoring.

 

The inappropriate use of these terms in the field of neuromonitoring has caused some very serious problems, and it remains a major point of contention. You will meet college-educated people with the title “technician” and high school educated people with the title “technologist”, and that’s just a consequence of lack of standardization. To make matters worse, some people use the terms technician or technologist to describe someone in the field of neuromonitoring with a doctoral degree, but this is incorrect because having a doctoral degree is, by definition, fundamentally incongruous with being a Technologist or Technician. This problem alone has caused great confusion for patients, hospital administrators, insurance companies, and government regulators – all of whom make decisions based solely on what they hear from sources that they consider to be authoritative. Additionally, the “nomenclature” problem has caused tension between professional practitioners – many non-physician doctors find the title “Tech” insulting because it undermines their level of education.

Job Titles Used by Neuromonitoring Techs

Neuromonitoring Tech

The most common term used to describe technical personnel in the field. As noted above, many people use the terms Technician and Technologist interchangeably, but they are quite different, and this is why it is advisable to refrain from using the word “Tech” as an abbreviation.

IONM Technical (IONM-T)

For similar reasons listed above, the ASNM defines the IONM-T as someone who works in neuromonitoring, but does not possess a doctoral degree and professional board certification.

Synonyms for “Neuromonitoring Tech

  • CNIM (Certified Neurophysiologic Intraoperative Monitoring Technician/Technologist)
  • IntraOperative Neuromonitorist
  • IOM or IONM Technologist/Technician
  • NeuroDiagnostic Technologist/Technician
  • NeuroLogical Technologist/Technician
  • NeuroMonitoring Specialist
  • NeuroMonitorist
  • Neurophysiologist (also used by Clinical Neurophysiologists – see above)
  • NeuroTechnologist or NeuroTechnician
  • Surgical Neurophysiologist  (also used by Clinical Neurophysiologists – see above)
  • Also, hospital-specific titles such as Tech I, Tech II, etc.

Summary

The titles that are used to describe technical and professional practitioners of IONM lack standardization and cause confusion. As we move toward standardization, I support the development and implementation of nomenclature that reflects an individual’s level of experience, level of education, and level of practice.

References

  1. Skinner SA, Cohen BA, Morledge DE, McAuliffe JJ, Hastings JD, Yingling CD, McCaffrey M. Practice guidelines for the supervising professional: intraoperative neurophysiological monitoring. J Clin Monit Comput. 2014 Apr;28(2):103-11.
  2. United States Bureau of Labor Statistics
  3. United States Department of Labor

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.

NeuroLogicLabs

6 thoughts on “Job Titles in Neuromonitoring

  • Reply Neuro-what...?NeurologicLabs August 12, 2015 at 10:37

    […] blog, this website, is for anyone who is curious about neuromonitoring (aka: IONM). If you want to learn about neuromonitoring, or better understand monitoring personnel, types of certifications and the vast range of […]

  • Reply James A Armstrong October 3, 2016 at 18:11

    Dr. Vogel,

    This seems a very confounding post. It is becoming clear to me that there is a degree of perplexity regarding descriptive titles in the field of intraoperative monitoring. It is unclear how this distracting use of terms assists in patient care.
    This degree of confusion does not seem to be present in other aspects of clinical neurophysiology.

    As an example, electroencephalography technicians (EEG techs), electrodiagnostic technicians (EDX techs), evoked potential technicians (typically the EEG techs), do not claim the title of clinical neurophysiologist and / or surgical neurophysiologist. Similarly, radiology techs are not radiologists.

    The correct definition of a clinical neurophysiologist is that of a physician who has completed a neurology residency followed by a fellowship in clinical neurophysiology. This may be further supported by board certification by the American Board of Psychiatry and Neurology (ABPN) in various subspecialties such as; Clinical Neurophysiology, Neuromuscular Medicine, and Epilepsy (among others).

    While the ABPN is considered the most authoritative board by most, there are several other board certifications that are offered by the American Academy of Neuromuscular and Electrodiagnostic Medicine (AANEM), and American Clinical Neurophysiological Society (ACNS), and others.

    Clinical Neurophysiology is the practice of neurology as it pertains to the diagnosis and interpretation of various neurophysiological studies. These typically include; electroencephalography (EEG) and a variety of electrodiagnostic studies (EDX).

    The title “Clinical Neurophysiologist” is reserved for physicians who have clinical expertise in that field.

    The term “surgical neurophysiologist” does not seem to be a recognized term by any major accrediting institution.

    Other individuals who perform the technical portion of the intraoperative monitoring of neurological studies are technicians. The correct title for these individuals would be “IOM technician” or “CNIM” if applicable.

    Your passion for the field of IOM is admirable. As a Ph.D. in neuroscience, your correct title would be “Doctor of Neuroscience or Neuroscientist”. Personally, I consider that to be a highly respected title. This is not a title that a physician can or should claim. The field of neuroscience guides many aspects of the field of neurology and psychiatry. However, if you choose to transition to the field of IOM as a technician, your correct title would be “IOM technician”.

    Claiming false medical titles could very well be considered “practicing medicine without a license”. Using correct terminology is important in the field of medicine. Making false declarations about an individual’s level of training or competence could very well put patients at risk.

    It seems your claim of the title “clinical neurophysiologist” is incorrect. It would be more appropriate to claim an equally distinguished title of “Neuroscientist specializing in intraoperative monitoring”.

    The fact that individuals outside of the field of medicine have made advancements in medicine is a long established fact. Madame Curie may have discovered radiation. However, she was not a radiologist. The discovery of radiation was a great gift to humanity (excluding the Manhattan Project).

    The field of medicine is certainly in transition. Personally, I see my physician assistant for my health care needs. He does not need to be called a physician. I respect his opinion and follow his advice. Many of my referring practices are run by nurse practitioners. These healthcare providers are enormously competent despite having a different title.

    Take pride in your accomplishments, they seem many from review of your posts. However, it is good and reasonable to use appropriate terminology when describing the functions of medical professionals.

    I hope this input is of some benefit,

    James

    Here are a few links to help with these definitions:

    How to become a clinical neurophysiologist:

    http://doctorly.org/how-to-become-a-clinical-neurophysiologist/

    Clinical neurophysiology:

    https://www.healthcareers.nhs.uk/explore-roles/medicine/clinical-neurophysiology

    NYU neurophysiology:

    http://www.med.nyu.edu/neurology/training-education/fellowships/clinical-neurophysiology

    ABCN eligibility criteria:

    http://www.abcn.org/files/eligibility2015.pdf

    • Reply Richard Vogel October 10, 2016 at 10:43

      Dr. Armstrong,

      Thank you for contributing to this discussion. I read your comment with great interest, and I’d like to respond in an effort to clarify a few points.

      Perhaps the most important section of my original post was the very first paragraph in which I made the following statements:

      “…there is no consensus regarding which terms should be used, and under what circumstances…the list below does not represent a consensus…If the information presented below fails to provide any clarity, perhaps it will illustrate the urgent need for standardization of nomenclature in the field of IONM.”

      I believe it is critically important to take this statement into consideration as one reads the rest of my post. In writing this post, I was not attempting to establish new standards; rather, the intention was to illustrate how different people in the field of IONM use these job titles. I think it would help if I clarified this particular point in my post. Another aspect of this post that may have caused some confusion is that I took the time to clarify inaccuracies in how technical titles are used (i.e., pointing out the stark difference between technician vs technologist), but I didn’t do the same justice to the discussion of professional titles. With these two points in mind, I believe the post deserves a significant revision for the sake of clarity and consistency. I will update this post in the coming weeks.

      Having said that, I’d like to take the time to respond to some of your comments.

      From an historical perspective, job titles in the field of IONM have never been standardized or consistent. As illustrated in my post, a large cross-section of the field, irrespective of educational background, presently calls themselves titles such as clinical neurophysiologist, surgical neurophysiologist, electrophysiologist, etc. For better or for worse, this is the vernacular of the profession, and it is a legacy of the fact that non-physician doctoral practitioners were around and performing the lion’s share of the professional and technical work for decades prior to the entrance of medicine into modern IONM; at least in any mainstream sense.

      On a related topic, you stated that “this degree of confusion does not seem to be present in other aspects of clinical neurophysiology”; citing EEG and EDX techs who do not claim the title of clinical neurophysiologist and/or surgical neurophysiologist. In fact, there are major disagreements about job titles/responsibilities in these particular fields, and I’ll return to this topic later. For now, I would simply point out that the modern technical-professional division in IONM really evolved out of the integration of medicine into the field, the introduction of telemedicine, and the subsequent entrance of corporations; all of which happened with little in the way of guidance from any accrediting institutions. In many ways, the entire field was purposely left unchecked because everyone was making money hand over fist and no one saw a need to rock the boat. So, the confusion that we experience today is rather self-imposed.

      Regarding the term surgical neurophysiologist, you stated that this term “does not seem to be a recognized term by any major accrediting institution.” This is obviously correct; however, I would point out that many of the largest IONM companies in the country, who collectively perform a large volume of the monitoring, use this term to describe their employees. Many of these companies have doctoral-level clinical directors that worked in the OR in the 1970s-1990s, and surgical neurophysiologist was one of the more commonly-used terms to describe someone who performed the technical and professional components of IONM at that time. Once again, the title is a legacy of decades gone by. While these companies aren’t accrediting institutions, their financial power and political influence carry significant weight, which is not to be overlooked. Certainly you must be accustomed to using this term in your daily practice as you contract with at least one such corporation that uses the term surgical neurophysiologist (I read your CV on your website).

      Regarding the definition of a Clinical Neurophysiologist, your argument is compelling and largely correct. There are three challenges to this argument that immediately come to mind.

      First, there are some non-physician doctors working in this field of IONM who have used this term to describe their work for 40 years – long before it was adopted by the AEEGS (became ACNS in 1995), or even the ABQEEG (became ABCN in 1986). The practitioners’ use of the term clinical neurophysiologist is largely a legacy of the fact that the title was used by many before it was officially adopted and formally defined for the express use by a select few.

      The second challenge to your argument is related to the scope of practice in the chiropractic field. There are many chiropractors whose scope of practice also includes electromyography, and who therefore practice what you would define as clinical neurophysiology. They do this within the scope of their education/license and their state’s regulations. This work is the independent practice/interpretation of EMG, so they are not functioning in this role as a tech.

      The final challenge comes from the behind-closed-doors politics of neurology. As you may or may not be aware, a growing number of clinical neurophysiologists (members of ACNS, certified by ABCN and graduates of CN fellowships) would like to reserve this particular term for folks who have those specific qualifications; effectively revoking the use of this term from neurologists certified by the ABPN. I don’t know if this movement will gain any traction, but it further illustrates the fact that neurodiagnostic job titles at all levels are more dynamic than static. Even in the context of these challenges, you and I can agree that the most common use of the term clinical neurophysiologist is reserved for neurologists. Which neurologists ultimately maintain the privilege of using this title is not a topic in which I have any interest.

      There are a number of your statements with which I disagree rather strongly. If I understand you accurately, I find these statements to represent a rather black-and-white perspective of practitioners’ roles in IONM. In other words, it seems to me like you are suggesting that one is either a technician or a physician. For clarity, here are some examples of what you wrote:

      “Other individuals [non-physicians] who perform the technical portion of the intraoperative monitoring of neurological studies are technicians. The correct title for these individuals would be “IOM technician” or “CNIM” if applicable.”

      And, regarding my background as a neuroscientist:

      “The field of neuroscience guides many aspects of the field of neurology and psychiatry. However, if you choose to transition to the field of IOM as a technician, your correct title would be IOM technician’.”

      I don’t view this profession in such a binary sense. First, I am board-certified in the supervision and interpretation of IONM as a Diplomate of the American Board of Neurophysiologic Monitoring. Second, I sit on the Board of Directors for the ASNM and the ABNM, and I actively participate as a member in multiple other professional societies. So, I am privy to meetings, discussions and perspectives that many people are not. From this vantage point, I can tell you that none of the leading figures in the broad field of neurodiagnostics, and IONM in particular, share this binary view of job titles and/or responsibilities. Here are some examples:

      First, in a recent position statement by the ASNM, Skinner et al (2014) reviews rather extensively the role of non-physician doctors in the supervision and interpretation of IONM.

      Second, world-renowned neurologist and frequent ACNS spokesman, Dr. Marc Nuwer, has introduced the “advanced practice non-physician doctor” in multiple publications specific to IONM.

      Third, nation-wide state licensure efforts being spearheaded by ASET, and with the support of the ACNS and ASNM (among others), have introduced the multi-tier practitioner model in which supervision and interpretation of IONM falls under the purview of the D.ABNM or the AuD.

      Fourth, the model listed above is already the dominant practice model across the country. Indeed, every major IONM company in this country employs D.ABNMs for remote supervision in the role of a mid-level practitioner. Biotronic may have started this practice, but everyone else is doing it. There are simply too many IONM cases and not enough physicians, so delegation is a necessary alternative, particularly in light of CMS’s introduction of the G-code. Thus, while the technologist may be 1:1 with the patient, and the neurologist may supervise ~4 cases simultaneously, D.ABNMs frequently cover cases as needed to provide the necessary supervision and interpretation where physicians cannot (and sometimes will not).

      Finally, remember earlier when I stated that there are major disagreements about job titles/responsibilities in EEG and EDX? Well, those disagreements exist across all of neurodiagnostics, and IONM is no different. Perhaps the greatest argument against the binary classification of practitioners in IONM comes from a high-level project that I can’t really talk too much about… but I will say this… there are more than 20 people, equally representing 5 independent professional societies, presently collaborating on a project, two years in the making, which endeavors to establish specific job titles and classifications for individuals working in neurodiagnostics at all levels. As this project nears culmination, there are more than 20 job titles/classifications. Indeed, even the physicians have a pecking order with 5 different levels of practice being recommended.

      So, what is my title… what do I use? Well, I have used multiple titles over the course of my career, like many other people in the profession. As you pointed out, I am indeed a neuroscientist (I am also a psychologist). As a neuroscientist, my doctoral training was in neurophysiology (EMG and MER/DBS, in particular). So, before I entered the field of IONM, I introduced myself as a neurophysiologist. After I transitioned into the field of IONM, I used the term surgical neurophysiologist. That was my job title. After becoming board-certified by the ABNM, I tried different titles; Clinical Neurophysiologist was one of them. This decision was driven mostly by what I stated earlier – that many people who have been in the field for decades, my mentors and/or colleagues, use this title to describe themselves. When I read your comments on this blog, I didn’t initially understand what you were talking about when you mentioned that I claim to be a Clinical Neurophysiologist; that is, until I checked my LinkedIn profile, which is a relic of days when I used this title. I’ll have to go change that at some point. Recently, I have settled on board-certified intraoperative neurophysiologist. That title accurately reflects my education, training, certification and scope of practice; however, it’s problematic because it doesn’t differentiate me from CNIMs who use the same title. My personal perspective is that CNIMs should not use the title of neurophysiologist, and many CNIMs would agree with me.

      Finally, I would be remiss if I didn’t tell you that there were portions of what you wrote that I found to be a little insulting. We don’t know each other, so I can only assume that you didn’t intend to be insulting when you suggested in no uncertain terms that I put patients at risk by making false declarations about my level of training or competence through incorrect use of a professional title. As you recommend, I do indeed take great pride in my accomplishments, which are significant…and many. I have sacrificed much in devoting my life to the advancement of this field, and to treating each patient with the level of attention and care that he/she deserves. Indeed, I firmly believe that I provide the highest quality of patient care in IONM with a level of expertise that is rarely seen at any level in this field. My CV speaks volumes about my training and competence, as well as my devotion to advancing this field. If my accomplishments lack validity in the minds of skeptics, then I’m quite sure that my colleagues – many of the top neurologists and neurophysiologists in the field – would be happy to speak on my behalf.

      Thank you again for taking the time to contribute to this discussion.

  • Reply Navigating the Neuromonitoring Job Search | NeurologicLabs October 11, 2016 at 16:50

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  • Reply Where does Intraoperative Neurophysiological Monitoring stand in Canada in 2016? – Neurologic Labs December 26, 2016 at 18:13

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  • Reply The Dark Side of Neuromonitoring - Neurologic Labs March 20, 2017 at 10:22

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