Here you will find the basics about finding a neuromonitoring job and launching your career.
Where to Look for Jobs:
If you are looking to find a job in neuromonitoring, or looking to make a move and advance your career, take advantage of apps and websites like Indeed, Monster & Glassdoor. Make sure you join LinkedIn and become a member of groups related to neuromonitoring. Make connections on LinkedIn and ask if anyone is looking for help. Join professional societies, attend meetings and network with other professionals. Go to the websites of hospitals in your area and search their job postings. Check out major companies that provide neuromonitoring and neurodiagnostic services.
Types of Employers:
There are generally 3 types of employers that you can work for in the field of neuromonitoring: Hospitals, Private Practices and Corporations.
When IONM services are provided by individuals that work for a hospital, we call this “in-house”, meaning that the service isn’t contracted out. Usually, you work for a neurodiagnostics department, which usually falls under the clinical leadership of the Neurology or Audiology department. It may also fall under the budget of that department, or it may be separate. Generally speaking, hospitals tend to hire and train either inexperienced or experienced recruits and employ them as technicians or technologists, depending on their educational background. Training is likely to be informal and very basic. Depending on the practice model (see below) and your credentials, your boss may be a technician or technologist, or he/she may be a physician or non-physician doctor. In terms of advancement opportunities, hospitals tend to have titles like “Tech I, II, III”, for example. So, you may move up the ladder after meeting certain career objectives. If a hospital doesn’t use an in-house group for neuromonitoring, then they likely outsource the service to a private practice or corporation (see below).
Some IONM companies operate as a small group of professionals, all with doctorates (PhD, AuD, MD, DC, DPT) and most with professional board certification (DABNM). These companies tend to hire and train only people with doctorates in the health sciences. Most private practices still in existence have been around for decades and are run by well known neurophysiologists. They tend to have extremely high standards and very good training programs. In terms of advancement, you may become a Mentor, a Partner, or change direction and ultimately work on the business side of things as the practice works to expand. Private practices usually work at hospitals providing IONM services under contract. Because private practices are small, they may only work at a small number of hospitals in a limited geographic region.
IONM services are also provided by major national or multinational corporations. Some are privately owned, some are owned by private equity investment firms, and some are publicly traded. These companies tend to hire people from a wide variety of backgrounds, their training programs range from awful to superior, and they tend to provide good benefits. In terms of advancement, corporations tend to have both clinical and business/operations branches, and you can work your way to the top of either. Corporations usually work at hospitals providing IONM services under contract. Because corporations are so big, they tend to work at a large number of hospitals in a wide geographic range. This may effect your daily commute, but it allows you to move around the country and stay within the same company.
There are 2 practice models in the field of IONM:
- Technical: Clinicians connect electrodes to patients in the OR, collect IONM data, maintain an internet connection with someone who interprets the data, serve as a liaison between the interpreter and the OR staff, complete all paperwork, maintain equipment, etc.
- Professional: Clinicians interpret all IONM data and work with the OR team as an equal member of the team, as opposed to a subordinate. Clinicians may also perform all of the duties listed above under technical.
The practice model of an organization will greatly affect how you learn and how you work. There are companies out there that hire people of all educational backgrounds (high school to doctorate) and train clinicians to be Techs. In this case, employees are trained to follow very specific protocols, and all decisions about IONM are made by physicians. There are also companies out there that hire people of more advanced educational background (master or doctor) that train clinicians to make independent decisions, as well as interpret and communicate IONM data. In this case, all decisions about IONM are made by the clinician. If you’d like, you can learn more about qualifications for interpretation.
It is very challenging to transition from one model to the other if you change employers. If you come from a technical model into a professional model, you may have to start over with your training at square one, even if you have years of experience. I have seen lots of people make this transition, and very few were successful. On the other hand, if you come from a professional model to a technical model, you will face a very different set of challenges. People will tell you that you aren’t allowed to make decisions, and you have to follow certain protocols, even if you know that it isn’t the best practice. You will feel somewhat degraded and limited in your career pathway. So, something to think about when you are getting into the field of IONM is whether or not the company that you are joining will allow you to engage in professional practice. If the company dances around the question, then you might be able to tell by the job title alone.
One important thing that you will want to find out about a prospective employer in IONM is what their training program consists of. Some companies will give a you a multi-day seminar and send you to the operating room with a computer, a box of electrodes and an internet connection to your boss. This is rare. More commonly, companies have some sort of formal training program that lasts weeks, months or years. Usually you will go through both classroom and OR training. From my perspective, the ideal training program will have you in a live classroom 2-3 days per week, and in the OR 2-3 days per week. This way, you get to apply what you are learning in the classroom directly to real life situations, and you can bring questions from the OR back to the classroom for detailed discussion. Some companies will have you spend a few weeks to a few months in the classroom before they ever let you go into the OR, while other companies do things in the opposite order. Also, some companies substitute offline distance learning and in-home studying of handbooks for live classroom learning. This is a huge mistake.
In the course of your training, do they teach you about electrical principles, physiology, anatomy, pharmacology, surgery, anesthesiology, audiology, disease processes, etc? If you are working for a technologist-based practice model, then you will learn some of this, but not in depth. If you are working for a professional-based practice model, then you will learn all of this, and in depth.
Who will be your teacher(s), both in the classroom and in the OR? A basic expectation is that your mentors will have appropriate credentials (e.g., DABNM) and/or years of experience in the field of IONM. You should be particularly suspicious if the director of education at an IONM company doesn’t have a doctorate, or equivalent.
You should find out what kinds of learning resources will be offered to you, in addition to classroom and OR training. Does the company provide you with books, journal articles, access to library resources, continuing education seminars, reimbursement for professional meeting attendance, etc, etc, etc.
You should find out how you will be evaluated. Ideally, you will be tested on the didactic portion of your training, and your performance will be evaluated in the OR. If the company doesn’t have a very specific, objective method for evaluating your performance, you should be suspicious.
Clinical Case Variety:
Find out what types of cases you will be doing over the course of your training. Some companies focus on spine surgery, while other companies do spine, brain, vascular, joints, etc. You will want to develop a wide range of skills. So, make sure you will have that opportunity. You do not want to spend the rest of your life doing basic spine cases.
Hopefully you are searching for a career and not just a job. In a career, you will be looking 2, 5, 10+ years down the line as you chart your career pathway. When looking at an IONM company, ask about the specifics of a career pathway. There should be very specific goals identified for advancement. For example, you need to have done X, Y and Z over the course of 3 years in order to be promoted from Tech I to Tech II, for example. You must be able to chart your own advancement, and you can’t set all the goals yourself. Some goals must come from your company. After all, they are the ones that ultimately decide your fate. Ask them what specific goals must be reached over what period of time in order to move up the ladder.
Also, take a look at the company as a whole as see what types of advancement opportunities exist. Maybe you like doing clinical work now, but you can easily see yourself involved in business development down the line. Many larger companies have multiple avenues for you to pursue.
Work schedules vary greatly in the field of IONM. Because we work in surgery, and some surgeries are emergent, you can expect to have to work odd hours, including nights, weekends and holidays. It is totally common for people to work 1 or 2 holidays per year, and the very occasional weekend. It is not common to work every holiday and every weekend. As a new person, expect to get shafted with the holiday assignment until you work your way up the ladder. No matter what, you should get specific compensation for working weekends or holidays. Some companies pay a flat rate, while other companies give you extra time off. Make sure you ask.
In terms of hours, there is a lot of variability. Some companies will work you to death. They won’t admit it in an interview, but employees regularly work 70-90 hours/week. Other companies will cut you off at 40 hours no matter what. Still other companies may have very relaxed work hours, preferring that you have time to spend with family and come to work refreshed. If you don’t mind working lots of hours, make sure you get paid for it. Ask how overtime is compensated.
In terms of a work day, there is a lot of variability here, too. Don’t be surprised if you hear the random horror story about the 24 hour day. It happens, but rarely. I have worked a 30 hour day before, but I have had random days off with no work as well. Ask about the typical day. I would say that a typical day should not exceed 8-10 hours, and that’s a long day.
Make sure a company will guarantee you breaks for food and bathroom. Labor laws vary from state-to-state but, in general, companies are not required to give you any form of break unless it is under contract. It isn’t uncommon for an IONM clinician to come to work at 6 am and not get a food or bathroom break until 5 pm. I’m not saying it is ok. Some companies do an excellent job at getting you breaks, and some could care less.
Everyone has different experiences with taking call, depending on where they work. These differences are probably related to three things: 1) how frequently you take call, 2) how long you are on call for each period, and 3) how frequently your phone rings when you are on call. In my particular experience when I entered the field, I was on call for 1 weekend every 5-6 weeks. Call began at 5 pm on Friday and ended at 06:00 on Monday. So, 61 straight hours every 5-6 weeks, but I didn’t work that entire time.
Being on call means that you have to stay within 30 minutes drive of a hospital, you must answer your phone if it rings, and you must be able to drop whatever you are doing and immediately get in your car and drive to the hospital. Making dinner? Putting the kids to bed? Cutting the grass? Drop it, forget it, leave now. This drastically limits what you can do and where you can go, but it really isn’t bad every 6 weeks.
In my particular situation, my phone would ring 1-2 times per weekend on average. There were weekends were I never got called in, and there were weekends where I got called in 4 times. It was draining and the week after sucked, but I guess it made my other weekends that much more enjoyable.
In terms of daily travel, this will depend on the type of company for which you work. Some people go to the same hospital every day, and some people travel all around the region to different hospitals. Some people tend to travel 10-20 miles per day, while others are frequently asked to drive more than 100 miles round trip. Find out how far you will be expected to travel. Have the company put it in writing.
If you work at different hospitals, it is very likely to be the case that you will need to have a driver’s license, auto insurance, and enough room in your trunk to haul around a lot of computer equipment. You will not be compensated for any of that. You will not get a company car. Your trunk and/or back seat will always be full of work supplies. You will be expected to carry that equipment in and out of different hospitals every single day.
Most companies reimburse mileage in excess of 30 miles/day at the standard government rate, which I believe is presently approximately $0.56/mile. Companies will also reimburse your parking and toll expenses. These things can add up, though. For example, most Philadelphia hospitals have parking for approximately $25/day. So, you may have to spend $500/month out of pocket to park, but you’ll get the money back after you submit expense reports. Very few companies pay these things for you upfront.
In terms of travel by plane, some companies will require you to fly here and there for different reasons (professional meetings, talks, case coverage, etc). Expect to pay for airfare, hotel, rental car and all other incidental expenses up front, and to have 100% reimbursed after you submit an expense report. This actually comes as a surprise to a lot of people, but that’s just how businesses work, and it isn’t an IONM thing.
No matter what type of employer you have in IONM, you will need to maintain certain credentials. Because you work in a hospital, you will need to have all of your vaccinations up to date. Because you will have access to patients and their private medical records, you will need to pass background checks and drug tests. Also, you will need to demonstrate certain competencies, such as being CPR certified. You will also need to become certified as a technologist by passing the CNIM, or as a professional by passing the DABNM. Your company should pay for all of this.
If you don’t work directly for a hospital, then you are considered a contractor, and it is likely that you will have to sign into the hospital each morning. There are credentialing companies that maintain all of your information (listed above) and certify to the hospital that you are compliant with their rules and regulations. These companies usually have a kiosk in the hospital lobby where you can sign in and have a temporary badge printed. It costs money to have your information stored with these companies (Reptrax, Vendormate, VCS). Your employer should pay these fees up front. Also, your company should have people who handle all of the profile maintenance so that you don’t spend your nights and weekends uploading documents for 30 different hospitals. All of your credentialing should be handled by the company for you, but this isn’t always the case. Ask the HR representative about this. If the company doesn’t do the work for you, then don’t be surprised if you have a lot of extra work to do after hours, which you might not be paid for.
Also, when you take the CNIM or DABNM tests, you will need to submit a log of all your IONM cases over the course of your career. Make sure the company tracks all of this for you. Some don’t. Again, this will be extra work that you won’t necessarily get paid for.
This is a nasty topic, but it is the most critical to cover. I don’t know about hospitals, but all companies and private practices require you to sign a contract, which outlines the specific terms of your employment. The contract is a legally binding document, an agreement of terms between you and your employer. It is critically important that you hire a lawyer to review a contract and help you to negotiate the terms, before you sign it.
Bait and Switch:
A company may promise you X amount of money, and then present you with a contract that states less money. Companies make all kinds of verbal promises that they have no intention of fulfilling. Good recruiters are masters of the bait and switch. Be very careful! The most critical, most important thing that you need to know is this: if a prospective employer doesn’t put a promise in writing, then it does not exist. If they promise you promotions, bonuses, time off, etc., but it isn’t written in the contract, then don’t expect it.
Think about the duration of the contract and what that means for your life plans. If you sign a 5 year contract, and life circumstances change, what are the repercussions? Lawyers always think about worst case scenario, and for good reason. What if your spouse gets cancer and you need to quit your job suddenly, what are the consequences if you are locked into a contract? Don’t listen to HR people who say, “Well, that’s an extreme circumstance. Of course we’d let you out of the contract.” Bullshit…you are bound to the terms of the contract, so be careful.
It isn’t totally uncommon for companies to force “financial responsibility” or “obligation” for your training, especially if you are new to the field. In other words, a company may ask you to sign a 2 year contract and, if you leave in the first year, you will owe the company $30,000. Contracts are written by company lawyers in an effort to protect the company from risk. So, all of the risk is transferred to you. Companies may spend a lot of money training you, and they may want to get paid if you take that training and then just leave. I totally understand the argument, but what you need to think about is this: what if you hate the job? What if your circumstances change, as with the example of your spouse getting sick? What if you have to leave the company? Are you willing and able to fulfill that payment obligation? If you think for a hot second that a big company won’t come after you and try to take your home over a silly little contract, then think again. Be very careful about this when you sign a contract.
No Compete and No Solicitation Clauses:
Contracts also usually contain No Compete and No Solicitation clauses. This is a common business practice that can be challenging to negotiate. Corporations want to make sure that you don’t quit one day and take all their clients and employees with you. So, they may say something like….”for a period of 2 years after you leave this company, you can’t work at these specific client hospitals.” You may be able to negotiate the duration of a non-compete. Companies can’t legally keep you from working, though, so it is usually the case that no-compete clauses beyond a 50 mile radius from your house do not hold up in court. Again, seek counsel from a lawyer.
In the field of IONM, companies are bought and sold like stock sometimes. If you sign a contract with company A, and they are bought by company B, then the contract is usually transferred to company B. This means they own your contract. Usually a contract will state that the company can transfer the terms of the contract to anyone for any reason without your consent, but you have no such rights in equity. Usually, but not always, companies include this clause when they are preparing to be sold. Many employment websites will tell you that inclusion of this clause is a red flag. I don’t know if that’s true or not. There are 2 ways out of an assignment clause: 1) work for a company that is an “at-will” employer (meaning you can leave any time for any reason), or 2) require consent for transference in your negotiations.
The Experience Variable:
The final thing that I want to say about contracts is that you may be screwed if you are totally inexperienced. You have very little bargaining power because you aren’t worth anything to the company yet, no matter what your educational background. You may be offered very little money, and may be expected to sign a multi-year contract with a steep repayment clause. You are going to have to look at your own situation and weigh the risks and benefits.
The only known salary study for IONM was published in 2011 from a very small sample size. I don’t have permission to reproduce it (I never even asked), but I can tell you that across all people in all regions from all backgrounds, the following numbers emerged:
- Mean: $85,000
- Median: $80,000
- Min: $48,000
- Max: $300,000
I can tell you that no one trusts these numbers. Starting salary for someone with no experience is likely to be somewhere in the neighborhood of $45,000. If you have a CNIM, you’ll probably make $60-70,000. If you have a D.ABNM, you’ll probably make $100-200,000.
Cost of Living:
Someone once wrote to me and asked if it is common in IONM for a company to offer a salary below the cost of living. The answer is complicated by where you live. Certainly the cost of living in San Francisco, CA is well above that in Lawrence, KS. Yet, if you are new to the field of IONM, you may be asked to start at a salary of $40-55,000. You would barely survive on that salary in CA, but you’d be able to afford a nice house and car on that salary in KS. What do you do? Well, look down the road. The fact is, in our field, once you get a CNIM (which takes about 12 months), your earning potential skyrockets, along with your negotiating power. It isn’t uncommon for people to get their CNIM and then ask for a $20-30,000 raise, or leave for a company that will pay that salary. That’s why companies try to contract you into multi-year obligations with financial penalties if you leave. They want to protect their investment.
As you may know, benefits vary widely by company regardless of the field. There are certain things that you want to pay particular attention to in the field of IONM. Ask about the following:
How will you learn and grow, and will the company pay for it? Beware of companies that give you didactic (classroom) training, and then provide no additional training beyond that. Neuromonitoring is a dynamic field and you will need to stay on top of changes. How will you do that and will the company pay? Will you be reimbursed for attending conferences, purchasing books, getting board-certified, etc.? Will you have access to learning resources?
Paid Time Off:
Maybe your contract states that you will get 20 days PTO per year, but will the company actually let you take the time off? Or, will they force you to work without taking time off, and just pay you for the extra time at the end of the year? Ask around with employees and find out what percentage of PTO requests get denied, and how far in advance do you have to ask for PTO? If you have to plan your vacations and random days off 6-12 months in advance, your life will be hell.
What dates are considered holidays? Some companies have 5 official holidays, and some have 10. Will you be expected to work holidays? Commonly the answer is yes, but you should only be expected to work occasional holidays and you should expect to rotate/share that responsibility with your coworkers. Can you get time off for specific holidays (e.g., Muslim or Jewish holidays)? How are you compensated for working on a holiday?
What happens if you make a mistake in surgery and you get sued by the patient? You could lose your home, everything. Make sure your company carries appropriate malpractice insurance coverage on you, and that they pay it up front. Companies will tell you that you won’t get sued, or that someone else is legally responsible for making decisions, etc. False. If something goes terribly wrong in the OR, every single person in that OR gets sued.
Not specific to IONM, but important for everyone. Find out if the company participates in 401K. Will they match your contribution? Maybe the company has profit sharing instead. See what they offer. I highly recommend hiring a wealth manager or financial planner to help you work through the numbers.
When you are looking at a company as a potential employer, make sure you ask around. Find people in the field and ask them what kind of reputation a company has. Check out websites like glassdoor.com. If you want to know insider information, try talking to present employees. They will usually give you the scoop. If you get stonewalled, identify employees on LinkedIn.com and then go and find their facebook profiles and look at their status feeds. You will be surprised at how many people complain about work on facebook (a practice that I strongly discourage). Also, you can get information about a company from previous employees (who are willing and able to talk), but don’t put too much stock in what they say, because they could be disgruntled. Before you sign any contract, hire an attorney to help you understand the legalese. It is a very common and critical mistake to sign a contract without having an attorney review it with you. Spend the money – It’s worth it. Also, never quit your job before you sign a contract with a new company…in case things go south, you aren’t out of a job!
Navigating the landscape of any job search is intimidating and stressful. It’s a particular challenge when you can’t find any helpful information on the internet. I hope that the information here will help you to find the right job for you, and I wish you luck. If you are considering the transition from another field, check out previous posts about transitioning to IONM from Industry and Academia.