In the Star Wars movie franchise, the force is an energy field created by all living things that binds the universe together. There are two sides to the force, the light side and the dark side, respectively representing good and evil. The light side of the force is used by individuals who draw their power from emotions like compassion, mercy, self-sacrifice and honesty. The dark side of the force is used by individuals who draw their power from darker emotions like anger, fear, hatred, greed and aggression.
The Dark Side of Neuromonitoring
In the field of intraoperative neurophysiology (IONM), there certainly exist both a light side and a dark side. On the light side, IONM is a wonderful profession in which to be involved. We dedicate ourselves to tireless pursuit of knowledge and experience in an effort to deliver the highest quality of care to our patients. Our endeavor to reduce neurological injuries that occur in surgery requires us to draw our power from all of the light side emotions.. Unfortunately, there’s a dark side of neuromonitoring dominated by the Sith who denigrate their competition, devalue education, misinform the public, publish bad research, and get involved in kick-back deals with surgeons to get their business. These individuals draw their power from all of the dark side emotions.
In one way or another, we’re all affected by the dark forces that plague our field. So, I thought I’d write a blog post about the dark side of neuromonitoring, and how we might “use the force” to defeat the purveyors of evil.
Publishing Bad Research
I spend a lot of time reading research, and I also review papers for several journals. I’ve written previously about the worst IONM paper ever, but bad research is everywhere. Unfortunately, it can sometimes mask as decent research, even though it actually has methodological flaws that completely invalidate the results. Case in point, here are two recently-published papers that immediately come to mind because they paint IONM in a negative light, but they should be retracted because they have fatal flaws in methodology:
- Ajiboye RM, D’Oro A, Ashana AO, Buerba RA, Lord EL, Buser Z, Wang JC, Pourtaheri S. Routine Use of Intraoperative Neuromonitoring During ACDFs for the Treatment of Spondylotic Myelopathy and Radiculopathy Is Questionable: A Review of 15,395 Cases. Spine (Phila Pa 1976). 2017 Jan 1;42(1):14-19.
- Ajiboye RM, Zoller SD, D’Oro A, Burke ZD, Sheppard W, Wang C, Buser Z, Wang JC, Pourtaheri S. The Utility of Intraoperative Neuromonitoring for Lumbar Pedicle Screw Placement is Questionable: A Review of 9957 Cases. Spine (Phila Pa 1976). 2016 Nov 15. [Epub ahead of print]
What’s the problem with bad research? Aside from the fact that it fills the scientific arena with false information, many important policy decisions are made based on papers like this. Should a surgeon or hospital use IONM for a certain procedure? Should the insurance company reimburse for IONM? Research papers in journals form the bedrock for these decisions.
How can you fight this dark force? Publish your data!! Did you know that the vast majority of papers written on the topic of IONM do not contain a single author that is a neurophysiologist? That’s embarrassing. Our literature is authored primarily by surgeons, and their understanding of IONM tends to be rudimentary at best. When you see bad research, take the time to write a letter to the editor. Also, we need to start publishing more of our work. Publish anything. Just get it out there. Don’t take anything for granted. What else can you do? Join the editorial boards of journals as a subject matter expert in IONM. You will review papers on this topic and be on the front line to make sure quality research is published and the garbage is kept out.
Denigrating the Competition
Several months ago, I was contacted by a high-level hospital administrator who was concerned because a representative of a big IONM company was just in his office giving a sales pitch and saying very negative things about me specifically. On several occasions, this local Director of Operations dropped my name, as well as the name of one of my colleagues, in an attempt to smear our reputation and convince this hospital administrator that we were frauds. This person, a sales guy who knows little-to-nothing about the service he sells (IONM), went on to state that the D.ABNM is a meaningless credential. Furthermore, he even attempted to cite IONM literature in an attempt to demonstrate his superior knowledge of the subject.
What this local Director of Operations didn’t know is that the hospital administrator is a long-time acquaintance of mine, and he’s also a quick study. He did some research into the D.ABNM and wrote down those literature references to research. Ultimately, he decided that this other IONM group couldn’t be trusted because the sales guy mixed up the literature that he tried to reference, he was wrong about the D.ABNM, and he spent too much time denigrating the competition. In other words, he tried to play the administrator for a fool, and he got caught red-handed. When the administrator came to me to talk about his experience and ask me if I knew the IONM sales guy and what did I think of him, I told him very simply, “I have no comment. The proof is in the pudding.”.
Why didn’t I say equally negative things about this sales guy or the group that he represents? Why didn’t I use my precious time with the hospital administrator delivering counter-blows to the competition? Well, one of the first lessons that I learned in observing the successful acquisition of an account is that you cannot demonstrate competence, quality and trustworthiness by trashing the competition. Trash talk quickly erodes trust in all arenas. It is wasted time in the sales pitch because enduring business relationships are built on a number of important factors, with trust being primary among them.
In this particular circumstance, the big IONM company didn’t get the contract because their sales guy was so focused on denigrating the competition that he failed to convince the hospital of the idea that his group was the better option. He failed to use those precious moments in the C-Suite to build trust. What’s funny is that the sales guy didn’t learn his lesson. Just recently, he was at it again in another hospital, saying the same nasty things about me, misquoting literature, and eroding trust. It wasn’t long before I got the very same phone call. The proof is in the pudding.
How can you fight this dark force? Well, you could write a blog post to draw attention to the problem, but I think that’s already been done. So, I say turn the other cheek and just be good at what you do. If you can deliver high quality care with a level of expertise that is unquestionable and hard to match, if you can do it with reliability and consistency at a reasonable price, then you’re well on your way to winning or keeping your account.
Politics and Misinforming the Public
For a long time now, representatives of the AAN and the ACNS have been making political moves to eliminate board-certified non-physician doctors from professional practice by advancing the idea that IONM requires “physician” supervision. Here are just a few examples of what they’ve done:
- They publish practice guidelines and billing guidelines which state that neuromonitoring must be performed by a physician, purposefully misquoting the AMA CPT Coding Document, which actually uses the phrase “Physician or other Qualified Healthcare Professional”.
- They lobbied CMS and private insurance carriers to require an MD or DO to get reimbursed for interpretation/oversight of IONM.
- They successfully lobbied the AMA, an opinion body and lobbying group, to declare IONM the practice of medicine.
- For nearly a decade, their representatives have been publishing book chapters and journal articles which purposely use the word “physician” to describe professional oversight in IONM.
- In these same chapters and articles, authors knowingly and purposefully write false statements about the American Board of Neurophysiological Monitoring (ABNM). In particular, and as recently as 2014, they still argue that certification by the ABNM requires only Master’s Degree (not true), and they ignore the real requirements for passing the exam, which are much more extensive than those required by neurology and CN boards.
- They state that the ABNM exam is only for non-physicians and that ABNM itself is affiliated with the ASNM, neither of which are true.
- They cite “lack of formal training” as a reason why non-physician doctors should not be allowed to practice IONM as professionals, but they have done nothing to admit these individuals to existing formal fellowship/training programs which could be easily adapted to accommodate such individuals.
- They have weighed-in heavily at the state level where various licensure efforts for technologists and non-physician doctors have been underway for years.
I could go on-and-on, but you get the idea. One of the unfortunate repercussion of this madness is that many people coming out of neurology or CN fellowships have been brainwashed to think that everyone in IONM who isn’t an MD/DO is a technician. Not all of them will openly say this (some actually will), but they mostly think of all non-physicians, regardless of education, as low-level technicians whose job it is to apply electrodes, push buttons, know technical stuff, and otherwise remain ignorant. More frequently than I’d like to admit, I meet people who think like this and talk like this. It’s astounding. Want to see a good example, go here, scroll to the bottom of the page and read the comments made by Dr. Armstrong, including my response.
So, how can you fight this dark force? The key is to educate others. As a board-certified non-physician doctor, you may think that you’ve already demonstrated your competency, but you will spend the rest of your life proving yourself to the nay-sayers. They all just need to be educated. Be sure to engage neurologists, surgeons, anesthesiologists, hospital administrators, MSOs, insurance companies, CMS representatives, and legislators at the local, state and federal levels. Get involved in professional societies, run for the board, and engage the society’s members in conversation. Do everything you can to become part of the solution. If you sit there and do nothing, then you are just part of the problem. As you embark on your journey to educate the masses, just remember that changing someone’s mind is often more of a marathon than a sprint.
There is an obvious inverse correlation between the length of time a technologist is in training and the quality of IONM care that he/she can possibly deliver. I know of IONM groups that train their technologists for a year or more before they are solo in the OR, and I know of other groups that train them for less than a week. Some would argue that a year of training is too long and poses significant operational and financial challenges. There’s a lot of truth to that. Almost everyone would agree that little-to-no training puts patients at risk. That’s axiomatic.
So, why would anyone make a decision to train a technologist for just a few days or weeks before sending them to an OR to monitor a patient’s nervous system? The answer is greed. There are many small IONM groups out there, mostly owned by investors and “metal reps” who just want to make a quick buck with the lowest overhead possible. They hire people with no background in sciences, give them little training, then send them to the OR. How do I know? These techs write to me all the time. Last month they were waiting tables. This month they’re monitoring scoliosis corrections. They’re starved for training.
That entire business model is a scam. It’s a lawsuit waiting to happen. It brings down our profession and makes everyone look bad. Those investors and metal reps don’t give a damn. They will bleed this profession dry, then drop the company like a hot potato and move on to the next venture.
How can you fight this dark force? Don’t work for these companies. Any IONM group whose training program is less than 4-6 months is to be avoided. And, you should be sure to get both classroom and in-OR training.
Giving Kick-Backs to Surgeons
In 1991 New Jersey Senator Richard Codey introduced legislation prohibiting physicians from making referrals to health care services in which they held ownership interests. This New Jersey “Codey Law” would eventually be modified by US Congressman Pete Stark who pushed for prohibitions against physician self-referrals of Medicare and Medicaid patients (now known as the “Stark” law). Many states have similar laws making it illegal for a surgeon to self-refer for IONM. Interestingly, in 2015 in New Jersey, the very birthplace of the Stark Law, the Codey Law was altered to allow surgeons to self-refer to an IONM company in which they have ownership interests.
As a result of changes to the Codey Law, we now have neuromonitoring groups building business partnerships with surgeons in NJ, promising them extra cash to use the company. It’s one thing for a surgeon to own an IONM company, and I don’t see anything wrong with that if it’s done right. The problem comes when an established IONM company promises a surgeon money by giving him/her ownership interest in the company in exchange for the extra business. Some companies don’t even hide the fact that they’re doing this. After all, it’s perfectly legal in NJ. I’m not sure how they avoid violating federal Stark laws, but maybe they just don’t bill medicare.
Then, of course, there’s the Anti-kickback statute, which provides criminal penalties for people who pay surgeons in order to induce business. I’ve heard stories about IONM groups in Texas setting up shell corporations to funnel money back to surgeons. They’re basically paying the surgeon to use them.
How can you fight this dark force? I would say don’t work for these companies, but you’d probably have no way of knowing that they’re engaged in these practices. Aside from that, you could write to your legislators and lobby them to change the Codey law back by removing IONM as an exemption.
The Hostage Crisis
Many companies hire neurologists to perform their IONM oversight, and the starting salary is fair market for a staff neurologist. It takes a lot of time and costs a lot of money to get your neurologists licensed in every state and credentialed at every hospital that you cover. So, having a neurologist on staff is a significant investment; so much of an investment that losing a neurologist could result in loss of business if you can no longer cover your IONM cases with someone who is appropriately licensed and credentialed. That’s when the neurologists start making demands. They want their salary doubled, for example. How can the IONM company say no? They need that neurologist to stay in business. I heard a story that this happened to a large IONM company years ago. That company isn’t around anymore because it was acquired by another group, but it caused significant problems within the organization, as you can imagine.
How can you fight this dark force? First, build the right employment contract that prohibits behavior like that. You can also make sure you have multiple professionals credentialed at each account, so you can easily replace one if you have to part ways. You could also use an outsourced provider of professional readers.
Other Experiences with the Dark Side of Neuromonitoring
I can think of a lot more examples of stories from the dark side, but I’d like to hear from you . Tell me about your experiences with the dark side by leaving a comment below.