In this third post from the series Transitioning to a Career in Neuromonitoring, I tell my personal story about leaving the elite world of academic neuroscience and navigating a new career in IONM. Along the way, I’ll tell you about the skills that helped me to succeed, the challenges that I faced, the skills that I had to acquire, and I’ll tell the stories of my best and worst experiences. If you’re thinking about leaving academia and not quite sure where to go or what to do, then this post is for you. Happy reading…!
Previous posts in this series include Navigating the IONM Job Search and Transitioning from Benchtop Electrophysiology to IONM.
A few weeks ago, I was delighted to receive a good friend and colleague for an impromptu visit. Dr. Jane (name changed for privacy) and I grew to know each other in the early 2000’s while I was a doctoral student and she a postdoctoral fellow. We hadn’t seen each other in several years, so it was nice to catch up over beers and barbecue on my back patio.
If you ask anyone in academia what it takes to be successful, they will cite the exact list of accomplishments that are outlined on Dr. Jane’s curriculum vitae. She did everything right. She was an Ivy League-trained neuroscientist who had endured a very successful 6 year postdoctoral fellowship and landed a tenure-track position at a prestigious institution. Now finishing the fourth year of a 5-year grant that funded the research, her laboratory is doing quite well. Dr. Jane has a long list of publications, to which she has added four already this year. She has two graduate students and a research technologist to run her day-to-day. She is well-liked by her students and respected by her peers. Her application to renew the 5-year NIH grant received a very high score. Dr. Jane is now up for tenure. It seems like she has it made in the shade. There’s just one problem: a year from now, Dr. Jane will be unemployed.
You see, before Dr. Jane can even be considered for tenure, she must get her grant renewed. So, the tenure committee gave her a 1-year extension before they formally review her file. Here’s the problem, despite receiving a high score on her grant application, Dr. Jane was informed by NIH that her line of research is no longer being funded…not by NIH, not by NIMH, not by the DOD, not by anyone. In other words, her career in research is over. Her contract at that university will not be renewed, and there’s nothing that can be done.
“I may be back in a year…looking to you for a job,” Dr. Jane said to me somewhat facetiously, “or maybe I’ll teach in a community college.” She was quite serious about that.
We both grew silent, and then she broke the silence and began to tell me the stories of all the well-known, established neuroscientists who are retired before their time (or retiring earlier than expected) because they suddenly lost their funding and refused to continue begging the government for money. I was stunned. I knew academic research was a tough row to hoe for those seeking tenure, but the people that she named were famous neuroscientists and considered untouchable.
She said, “You did the right thing…getting out [of academia] when you did…” Then she took a long sip of her beer, set it down, looked me straight in the eye and said, “…but I’m too old, too far along…” She was probably right. Again, we fell into silence.
This story continues to haunt me, and it’s one reason why I composed this post.
Why I left Academia:
The Sad Truth About Grant Funding:
As the story of Dr. Jane illustrates, if you want to work at a university, teaching and doing research, and you want to achieve tenure, then you must have a perpetual line of funding; otherwise, your career is over.
The success rate for securing a research grant is a closely watched indicator of how well investigators are doing in the struggle for funds. When I entered graduate school in 2002, the success rates were greater than 30% and stable over the better part of the prior decade. So, the outlook was good, or so we thought, but success rates began to decline in 2004, and reached all time lows in 2011, 2012 and 2013, respectively. The reasons for this decline didn’t really matter. I saw the trend of dramatically declining success rates, and I knew my days were numbered. That wasn’t the only issue, though. Money was tight.
The Grim Financial Outlook:
People are often surprised at how low the salary is for a PhD. Everyone assumes you make a lot of money because you spent all that time in school, and because you’re a doctor. In truth, the financial outlook for an academic is awful.
Just like Dr. Jane, I too did everything right. I entered one of the top graduate programs in the nation armed with multiple publications and a clear vision of my future. I was going to be an academic neuroscientist, devoting my life to research and teaching. After several years, I graduated from that program with 2 PhDs and began a postdoctoral fellowship at an Ivy league Medical School. In my first job as a doctor, I was paid $42,000/year, which amounted to take-home pay of $2300/month. I was 33 years old, working 60 hours/week and making less money than I did when I graduated from college a decade beforehand. The rent for my small loft above a very noisy street was $1200/month. My student loan payment was $600/month. After that, I had $500/month to pay for food, utilities, auto insurance, gas, tolls, etc. I was literally broke and in need of a second job. So, I took a position teaching neuroscience at a different university across town. For teaching 1 course, I was compensated $2900/semester without benefits. Because I had never taught neuroscience before, it was a lot of work composing lectures and such. During my semesters teaching and doing research at 2 different universities, I was working 120 hours/week and saving nothing. My life was hell and I wasn’t willing to continue on this path. So, I started looking for a new career.
The Decision to Leave:
It wasn’t all about money and grants for me. The fact is, when I started working in neuroscience, I was working with Alzheimer’s patients. I was, as they say, working next to the problem. I was doing neuropsych testing and MRI research, I was involved in clinical trials for Alzheimer’s drugs, and I was doing basic research on animal models of aging and Alzheimer’s. In graduate school, my focus shifted to working directly with the brain. So, I would implant micro-electrodes in rabbit brains and then train them in behavioral tasks while characterizing learning-related changes in neuronal firing patterns. When I graduated, I had worked at every level of neuroscience (translational, cognitive, behavioral, systems, cellular)… except molecular. So, I took a postdoctoral position that combined molecular neuroscience with behavioral and cellular neuroscience. I spent most of my days working with test tubes and petri dishes. It really wasn’t my thing. Even though I was still helping people by working on a model of PTSD, I was too far from the problem. Being so far removed, it was all too theoretical for me, and I couldn’t see the benefits of my work as closely as I would have liked. I wanted to get back to working with people. So, I started to look for jobs that had a more “clinical” focus. That’s when I learned about IONM.
Finding Intraoperative Neurophysiology:
I knew about IONM in graduate school, but only in a peripheral sense. Certainly I knew a lot about evoked potentials, but I didn’t know they were being used in surgery to monitor nervous system function. I had no clue that neuromonitoring was an actual field of study, an industry. I first learned about the field of neuromonitoring through an advertisement on the NeuroJobs Career Center, an extension of the SFN website. I didn’t know what it was, but it sounded interesting. The ad was placed by a private practice called Surgical Monitoring Associates. It said that I would be working in surgery, monitoring and mapping human nervous system function… “all training provided, no experience necessary, must have a doctorate.” It was an opportunity to do clinical work again, to work closely with patients. It sounded great, but I needed more information. So, I hit the internet.
I just needed to find some basic information about the field before I would consider applying for a job. After all, this was a major career change from academic neuroscience to IONM. What I really wanted to know was some very basic information… Is the field exciting and demanding? What are the opportunities for advancement? What is the salary range? Can I still do research and publish? How would you describe the typical day? As I searched the web for these answers, I actually found very little information.
As I recall, a google search comically returned exactly 1 personal web page devoted to IONM. It was a blog, but it lacked any formal structure and was far too congested with information to be helpful (at least to me). Next I found a bunch of corporate websites from companies that provide IONM services to hospitals. These sites were good for learning about IONM modalities and their applications, but none of the websites answered my questions. Back then, LinkedIn was only used by corporate types (suits), so I didn’t even have an account. Also, the idea of looking for groups related to IONM probably didn’t occur to me. There was nothing about IONM on facebook. Maybe I wasn’t looking in the right places, but I couldn’t find any answers to my questions online.
My next step was to ask around to some of my colleagues. They, too, knew of neuromonitoring in a peripheral sense, but no one really knew much about the field. Some people were skeptical of any field close to medicine (PhDs notoriously deride MDs). Others were skeptical of any field outside of the ivory towers of academia. I was really on my own.
So, I took the plunge. I applied for the job, went to the interview and got the answers to my questions there.
Why was it such a challenge to find answers to my questions? I think one reason is that there are lots of dirty little secrets in the field of IONM…secrets that are tightly held by large corporations. These secrets involve employment contracts, hours, travel time, salary, education, practice models, etc. In order to save you lots of time searching for answers to the basic questions, and questions that you wouldn’t even think to ask, I created a webpage for you! The present post will focus on my personal story of transitioning from academic neuroscience to neuromonitoring.
First Day in the OR
Before I was even hired, my prospective employer had to determine whether or not I was cut-out for work in the operating room (OR). I was uniquely prepared for this, though. Having worked in an OR implanting electrodes into animals’ brains in graduate school, I knew a lot about how ORs function…contrary to popular belief, large animal surgery is remarkably similar to human surgery. The OR visit is not just a test of your ability to handle blood and guts, though, it is also a test to see if you possess certain critical traits of personality and intelligence.
First up is common sense. It is a sad fact that many PhDs, in all of their brilliance, lack common sense. It is also sad that they don’t even know it! The employer wants to know if you will do stupid things. Real life examples include: getting lost on your way to the hospital, showing up late to surgery, touching the sterile field, texting with your friends, keeping food in your pocket, and grabbing a nurse’s butt. These things actually happen, and it’s better to know that someone lacks common sense before you invest time and money in hiring and training them.
Next up are empathy and curiosity. Regarding empathy, the employer needs to known that you readily understand the needs of others, that you can fit right into any team. How do you react when someone needs help? Do you step right in, or do you look to someone else to act? Do you readily understand when you are in someone’s way, and do you actually move? How do you react when something goes wrong, or things get tense? Do you focus, or do you check facebook? Regarding curiosity, the employer needs to know that you are actually interested in the work. Do you ask questions? Are you the kind of person that will one day make important contributions to the field, or at least start a blog?
Finally, the employer needs to know if you can handle blood…lots of blood. And, can you meet someone in the morning and then see their body opened wide with bones and organs exposed several hours later? Can you do this without being affected? Can you focus on your work? I attended a pediatric scoliosis correction surgery. So, my first time in the human OR I saw a child with his spine exposed from his neck to his butt. It really wasn’t a big deal for me, but some people can’t handle it.
Several days after my visit to the OR, I was offered a job as a Surgical Neurophysiology Fellow. I would undergo one year of intense postdoctoral training and evaluation. If all went well, I would then be promoted to Surgical Neurophysiologist.
Because I actually signed a contract, I can’t tell you a whole lot about my personal experience with signing a contract. I have written about contracts elsewhere, though.
I will reiterate one fact: if you are new to the field, you will have zero negotiating power. My employer intended to spend a lot of time, money and resources to train me. Aside from the appropriate educational background and the right personality traits, I had nothing to offer this company in exchange. They assumed the majority of the risk in hiring me, or so they thought, and the contract was written to transfer 100% of that risk to me. I did the right thing, though. I hired an attorney to review the contract and guide me through the process. Basically, the attorney told me that I’d be crazy to sign the contract. She red-lined a bunch of things, changed some phrasing and told me which parts would never hold up in court. When I went back to the company prepared for a negotiation, I was stonewalled. They basically said, “The contract is non-negotiable. You can take it or leave it. There are tons of PhDs out there and we don’t need you.” It wasn’t a bluff. I folded. Against the advise of a very expensive attorney, I signed the contract.
Two months later, after I finished a teaching obligation, I packed away every remnant of my academic life and started my new career in IONM.
Challenges of the Transition:
Persona Non Grata
I always heard that you enter academics with the understanding that you will never be invited back if you ever decide to leave. I haven’t tried to get back in, so I don’t know if that’s true, but I do know that people hate it when you leave…probably because they feel like training you was a waste of time. Who knows…? Like I said, I don’t know if it is true or not. Rumor has it that people just stop talking to you, like you’re suddenly blacklisted. No one responds to your e-mail, no one returns your phone calls. Blah, blah, blah. I can’t speak for others, but I personally did not have that experience. I continue to have very good relationships with my colleagues and mentors. I like to think that I could find a job working in academics, if I were really desperate, but I’d have to take a big step back both professionally and financially.
If you leave research, you can’t easily return and start your own lab because you’d never get funded. You would also lose touch with the literature base in your area of expertise. So, you’d have lots of catching up to do. The only entry back to the path of having your own lab at a university would probably be to take a post-doctoral training position. And, the older you get, the harder that is to achieve/endure. If you wanted to go and teach somewhere, without doing research, then your options would be limited, but the endeavor would certainly be feasible.
If you are considering leaving academics, you may feel like you’re “selling out”…I certainly did. To be honest, I was really scared. I didn’t know what people would think of me…what people would say about me. Would they think I gave up? Would they think I was a failure? In the end, I couldn’t focus on these thoughts. I had to move forward. This choice wasn’t about my mentors, colleagues and friends. It was about me…my goals, my career, my life. That’s how you have to think.
On my first day of work, I sat in a small room with our Director of Education. He showed me a picture of a totem pole on a PowerPoint slide.
“No matter where you were before,” he started, “this is where you are now.” Pointing at the bottom of the totem pole, “You can certainly make your way back to the top,” his pointer sliding upward, “but you’re starting now at the very bottom. Are we clear?”
I remember thinking that it wasn’t a big deal…I already understood that I was starting a new career, and I’d have to earn my stripes. I nodded my head, “Yes.”, and the lesson began. It was at that very moment that I gave up my career in basic neurophysiology and began a new career in clinical neurophysiology.
The training program was intense, but I had certainly been through worse. I would spend the first three months alternating between classroom education and hands-on training in the OR under a senior clinician. For the didactic portion of the training, I spent 2-3 days/week in the classroom learning core concepts. During months 3-6, I continued training in the OR, gradually becoming independent in the most basic procedures. During months 6-12, I continued independent work on basic procedures, and trained under senior clinicians on more advanced procedures. After 1 year of training, I mostly worked independently with the understanding that I was practicing to ultimately become board-certified after 3 years.
For now, I was back in the classroom…at the bottom of the totem pole.
Who’s the Boss?
Not you! Not from the bottom of the totem pole, anyway. As an academic neuroscientist, you are your own boss, and while the hours are long and the work complex, you can make your own hours and take vacation at will. Since you spend a lot of time writing grants and papers, you can work from just about anywhere. If you have insomnia, you can work through the night. If you’re tired, then you can sleep in. If you don’t like the direction of your work, then you find a new path. If you screw off, you’re the one who suffers the consequences. You can do whatever you want, and there aren’t a whole lot of people to whom you answer. IONM is very different because you are always working on someone else’s schedule.
Surgery happens 24/7/365. Some procedures are planned, some are emergent. You must constantly attend to your phone or pager, and you must answer it if it rings. When you are needed for surgery, your presence is not optional. If the surgery goes 20 or 30 hours, you will often be expected to work that entire time. Your days of being late for work are over. In some cases, calling out sick is not an option. In some cases, vacation must be requested more than a year in advance, and your request can be denied. I literally planned my wedding date around our clinical practice schedule. I had no choice. On several occasions, I asked for vacation a full 18 months in advance and was denied. I missed many events and holidays with friends and family.
Even if you climb to the top of the proverbial totem pole in your field, if you don’t work directly for a hospital, you will always answer to someone else…usually nurses and hospital administrators who have little or no understanding of, or respect for, what you do. That really sucks. Here you are, with the highest possible degree that one can earn – a PhD – and you sometimes get treated like a mosquito. Nurses will boss you around because they think you’re a salesperson. Physicians may talk down to you because they think you are a tech. Even if they know you’re a doctor, some physicians will sneer at you because they’re ignorant (which is the same reason why PhDs notoriously deride MDs). You’re always finding a balance between doing your job, defending yourself, proving yourself, educating people and making them happy.
Losing the War
Bertrand Russell once said, “War does not determine who is right – only who is left.” The problem in neuromonitoring is that there is a long-standing war between PhDs and neurologists, both of whom worked together to develop this field. I have described the situation more completely elsewhere. In the not-too-distant past, neurologists finally convinced the AMA to declare IONM to be “the practice of medicine.” The AAN hired high-priced lobbyists to convince insurance companies and policy makers that only physicians can perform IONM. Toward this end, the AAN systematically discredited all non-physician doctors who were actually qualified to interpret neuromonitoring data and, importantly, to bill for it. Neurologists started hiring techs to do all of the work in the operating room, and they began referring to the PhDs as “techs” when dealing with insurance companies, policy makers and hospital administrators. Physicians began telling everyone that PhDs require their supervision. Things have gotten worse in recent years, not better for PhDs, and physicians continue to rule the roost in neuromonitoring. Because of these events, many people say that Neurologists have “won the war”, and I’m afraid they are correct. So, even though you have a PhD (with lots more knowledge about neurophysiology than probably 99% of physicians in the world), and even if you become “board certified” you will still ultimately, probably work under the supervision of a physician. For this reason, you will be considered a “tech” by most people in and around the field of IONM.
Discrimination is a pervasive problem in neuromonitoring, a problem with which I continue to struggle. In all fields related to healthcare and medicine, no matter how distant the relation, you are either a physician, or you are not. If you are a physician (MD or DO), lots of people will kiss your rear-end. Indeed, they will do things for you, buy you things, pretend to be your friend and do anything to make you happy. That’s because some people make a lot of money just by working closely with physicians, and also because some physicians demand that kind of treatment. In this twisted world, no one cares what kind of a doctor you are, or how hard you worked to become a doctor. All of that is meaningless unless you are a physician. Perhaps the only people you will ever meet in IONM who are impressed by your PhD are physicians, many of whom find it refreshing to work with someone who understands the complexities of neurophysiology, anesthesiology and surgery.
When you go to work for a company that hires both physician and non-physician doctors, don’t be surprised when your employer does everything for the physicians and absolutely nothing for you. For example, your employer may take care of all physician credentialing at hospitals and, at the same time, make you do it all by yourself. Your employer may give physicians different and better benefits. Your employer will certainly pay the physicians more money than you (because they can bill insurance companies and bring in the money). I get why they make more money, but I don’t fully understand why they get different benefits. Perhaps it is ignorance on the part of folks who assume that a PhD is like a fancy master’s degree. Or, maybe they discriminate against PhDs, DCs and AuDs because the physicians support it and the law allows it. Who knows…? It is certainly something that continues to irk me. So, you should be ready for it, too.
For some people, the immediate effect of leaving academia is the feeling of isolation. As an academic scientist, you are also a philosopher. You may be used to spending your lunch time talking with colleagues about the Hard Problem of Consciousness. Maybe you spend your evenings drinking craft beer and debating the existence of God with academic friends. As an academic, you tend to live and breathe and think constantly about life’s big questions. That tendency slowly slips away when you leave academia. While you can never change the way that you learned to see the world and solve problems, you will meet very few like-minded people outside of academia. One problem is that there aren’t many academic transplants in the field of neuromonitoring. The company where you go to work will likely hire lots of people out of high school or college. Some may even have master’s degrees, which is refreshing. While they may be very bright, people outside of academia just don’t think about the world in the same way, to the same depth, as you. And, neither do physicians…they are trained to act, not think…memorize, not conceptualize. So, you will begin to change in some ways, because you’re no longer surrounded by the best and brightest people in the world. You will begin to feel isolated.
I love to be around people and socialize, so working alone was something that was difficult for me. While you may be with a team of people in the OR each day, your interaction with that team could vary quite a bit, and the members of that team may change every day as you travel around the region to different hospitals. So, you may have trouble making friends and building a network. Of course, you don’t need to sacrifice the friends that you have. Just make sure you find time to spend with them.
Living with Uncertainty
Everything about neuromonitoring is uncertain, from the daily schedule to the data you collect and interpret. Personally, I deal very well with uncertainty. In fact, I don’t just “deal” with it, I actually thrive in uncertainty and chaos. Most academic scientists aren’t like me, though…they’re analytical to a fault. They don’t deal well with uncertainty. They can’t make decisions without analyzing all of the possible outcomes. They suffer from analysis paralysis. Imagine this common scenario:
Your phone rings at 5 am. There is a surgery planned for 7 am. The operating surgeon has known about this surgery for weeks, but the hospital forgot to schedule you. You have the patient’s last name “Smith” and a procedure “Crani for tumor”. You’ve never been to this hospital before, but it’s an hour away in a town that you’re only vaguely familiar with. You don’t know where to park. You don’t know where the OR is. Will there be issues getting all of your equipment into the hospital? How many different types of supplies should you bring into the hospital? You can’t make 2 trips between your car and the OR. You’ve never met the surgeon or anyone else in the entire hospital. Will the OR team be nice, mean, informative, dismissive? Where will you find the patient? How will you access the medical records and imaging? There’s no time to shower. There’s no time for breakfast, or even coffee. If the surgeon is slow, you may miss lunch and dinner, too. Off you go.
In some cases, you will get all the way to the OR and find out that the surgery was cancelled and they forgot to call you…again. More frequently, the surgery will proceed. As you settle into your work monitoring and/or mapping the patient’s brain, you will deal with tons uncertainty. You need to make very important decisions based on very little data. Some evoked potentials are inherently variable, and they are altered by everything…electrical instruments, temperature, anesthesia, etc. You need to know what is important, what is real, and what is not. Indeed, neuromonitoring is application of signal detection theory at it’s finest. And there’s no room for error.
As you can see from this example, you have to work well under uncertainty.
Giving Up Research:
You don’t need to give up on research completely, but you won’t be doing research for a long time. You will at least need time to learn enough about the field to develop interests and identify problems that merit research. There are some major obstacles, though. For one, if you work for a company or a private practice, you are essentially a contractor at any given hospital, and hospitals want to control research. Some surgeons will expect you to hand over data so that they can publish your ideas under their names, without giving you an ounce of credit. Your company may allow them to do it, too, because they want to keep their “clients” happy.
You may also have problems following the literature. You may not have access to appropriate library resources in order to acquire books and articles. How will you follow the literature?
There are certainly opportunities to publish, though. There are meetings of professional societies where you can present posters and talks. If you get in with the right crew, you may even have opportunities to write book chapters. The easiest way to continue research and publishing, though, is to work for a hospital and establish yourself as an academic clinician. In this role, you can work with the same colleagues every day, you have access to all kinds of records, you can follow a specific patient population, and your have the support of the hospital and its resources.
Skills I Came With:
As a graduate student, I learned about evoked potentials and their applications in diagnostics and research. I also learned about all of the scientists and physicians who mapped the brain with electricity. And, I read a lot about brain mapping in contemporary neurosurgery. Beyond that, I acquired a strong background in neuroanatomy, physiology and pharmacology. Knowledge of these topics is essential. I think it really benefits one to have a background in cognitive neuroscience, too, particularly when you get into higher-end brain mapping. Finally, understanding research design and statistical analyses will help when you get into the literature, as both a reader and a contributor. All of these things have been beneficial to me in my career.
My dissertation was on systems neurophysiology, so I specialized in waveform analysis and interpretation. Above all, this is fundamentally what we do in IONM. I also spent a lot of time doing multi-unit recording from different regions of the brain. This is a skill essential to IONM in DBS surgery, in which you lower electrodes into basal ganglia structures and identify the regions along the track and target based on the neuronal firing patterns. With this background, I also came into IONM with an understanding of electrophysiology (nerve conduction, EMG, etc), all of which I did in the lab. From a technical perspective, understanding theoretical and practical electronics is helpful to me. Finally, troubleshooting is a critically-important skill in IONM. If you’ve worked in a lab with electrophysiology equipment, then you are probably an expert in troubleshooting, and this will serve you well.
I also gained lots of management skills in the lab. People management, project management, money management, etc. As you move up the ladder in IONM, you may find yourself taking a management role, and it is likely that your lab skills be an asset in many different ways.
If you want to be good in clinical neurophysiology, you have to be confident and outgoing. You have to be willing and able to carry-on high level discussions with physicians about patient care. Your communications have to be brief and pointed. You have to be knowledgeable, and you have to be right. You are frequently charged with the task of advocating for a patient who is asleep on the OR table. If you see a problem, you need to be able to get the attention of the surgeon in a loud and chaotic environment, to take control of the room. This isn’t as easy as it sounds sometimes. It takes a very special personality to manage these situations with ease.
Skills I Had to Acquire:
I came in with a very strong background in neuroanatomy, neuropharmacology and electronics. Now I had to branch beyond neuro and learn gross anatomy and applied pharmacology (anesthesiology). I also had to learn about human physiology, disease processes, surgical procedures, and more. Why are we doing the procedure? What are the stages of the procedure? What are the injury rates? What are the risks? How can I help? After all, how can you understand risk if you don’t understand anatomy and surgery? I had a lot to learn. Luckily the practice that I joined provided the training. The didactic portion of my training was 3 months long. I spent 2-3 days/week in the classroom learning core concepts and 2-3 days/week learning application in the OR.
Beyond that, I had to learn a whole new literature base. Coming from academia, I was becoming an expert in one specific line of research. Now I had to learn something entirely new. That’s a big task…doing it all again. It will take a couple years to catch up, and then it gets easier.
I thought it might be helpful to the reader to hear about my best and worst experiences in the field of IONM. It gives perspective regarding the wide range of experiences that one can have. Neither experience is the daily norm.
I didn’t want to work at this particular hospital because my grandfather died there and the memory was painful and fresh, but this was my unlucky day…I drew the proverbial short straw. It was a Catholic hospital, which makes this story all the more appalling (I suppose). The procedure was a lumbar decompression and fusion with a lateral trans-psoas approach. This is a risky procedure in terms of possibility of iatrogenic injury, a procedure in which I would typically be heavily involved. I knew the procedure quite well, and I had successfully mapped the psoas muscle in many dozens of procedures before this. I knew exactly what I need to do.
Upon being introduced to the surgeon, he shook my hand and we engaged in some small-talk outside of the OR. He was a nice guy. The surgeon excused himself and I went about my preparations for surgery. I thought it was going to be a good day, but the OR nurse warned me that the surgeon had two opposing personalities. Apparently, I had just met Dr. Jekyll, but he would soon return as Mr. Hyde.
Before I continue, I want to apologize for any offensive language that I’m about to use. These aren’t my words, and I have taken no poetic/artistic license in recreating these events.
When the surgeon returned, I went to discuss the procedure with him. These cases require a high level of communication and everyone needs to be on the same page. As I began to tell the surgeon how I would perform the monitoring and mapping, he said, “You’re not gonna do a fucking thing unless I tell you to…So, go sit down in the fucking corner and don’t say a fucking word.”
OK, stop and think about this for a second… The surgeon is performing a risky procedure. He calls me in to assist him in making it as safe as possible. I try to communicate with him and establish a plan of care, and he literally curses me out and banishes me to the corner for eternity. What a jerk! While I was stunned by his words, I didn’t really do what he said. I just left the OR and came back when the patient was in the room.
After the patient was asleep, I started placing EMG electrodes in the arms, legs and head. Given the risk of this particular procedure, I had to place electrodes in the external anal sphincter muscle. Again, the surgeon started with me… He said, “We’re not really into that where I come from.” I ignored him and went about getting my baseline motor and sensory data. When I started testing motor function, he flipped out. “No fucking motors unless I say!”, and then he continued, “You’ll get exactly 2 motors in this case…one now and one when I say…and that’s it. Do you understand?” I sheepishly replied yes and then he turned to anesthesia and said, “I want the patient paralyzed for the entire procedure.” In case you don’t know, that completely eliminates my ability to have any participation in the surgery.
During the surgery, as predicted, the surgeon refused to do any of the important physiologic mapping that is used to avoid iatrogenic neurologic injury. I had to sit there in silence for hours on-end, with nothing to do, as the surgeon joked openly about “the queer who places the needles in the asshole.” That would be me, I guess. LOL. It gets worse.
Toward the end of the procedure, the surgeon began placing screws in the spine, but he was having trouble with the screwdriver. Now he was cursing and screaming at the instrument sales rep, calling him a “fucking moron” at least a half-dozen times. Meanwhile, he threw a screwdriver across the room, missing the sales rep and it ricocheted off the wall. These screwdrivers are quite large, by the way, about the size of a crowbar. It would hurt bad if one hit you. And then, the second time, with the screw still attached, he threw the screwdriver down on the patient, causing a laceration in the patient’s head. The anesthesiologist had to go under the drapes and staple it closed. The surgeon continued cursing and screaming at the instrument sales rep until the procedure was over. He could not have cared even a little that he injured the patient, for he never heard the phrase “Primum Non Nocere“.
The surgeon left the room near then end of the procedure. He probably switched back to his nice personality and went to talk to the patient’s family. No doubt he lied about the cause of the laceration in the head. He certainly never said another word to me.
During my time in that operating room in that Catholic hospital, which took the better part of that day, I was repeatedly subjected to verbal abuse. On top of that, I didn’t monitor or map any neural structures because the surgeon insisted that the patient remain pharmacologically paralyzed. I had absolutely no purpose there. At the end of that awful day, I went home and wrote an e-mail to a senior member of my practice. I simply said, “if you ever ask me to go there again, I will quit.” Never in my life had I ever threatened to quit a job, but nothing was worth this kind of abuse.
So, why didn’t I just walk out? Why not curse back at the surgeon? Why not punch him? The short answer is that the patient always comes first. Walking out on the surgeon is really abandoning the patient. Even if I didn’t do anything, I had to be available because that”s what the patient needed, if not the surgeon. Fighting with the surgeon doesn’t accomplish anything, either. You really need to pick and choose your battles. If you want to argue over patient care, there is a time and a place. This just wasn’t it, and the battle couldn’t be won. So, you just go home and forget about it…and then put it in your blog years later.
This kind of experience probably happens to everyone at some point in their IONM career, but it isn’t common. It is more often the case that your experiences are positive, like the one that I’m about to describe below.
I had a few “best experiences” from which to choose, but this one seemed easiest to tell.
I had been to this hospital just once before and everyone there was nasty. From the charge nurse, to the OR nurses, to the scrub techs… everyone hated neuromonitoring. I wasn’t happy about the assignment, and this was a complicated case. The patient was a middle-aged male with a tumor directly beneath his primary motor cortex, and extending through the corona radiata into the internal capsule. The objectives would be to identify the central sulcus, identify the primary motor cortex, find the safest pathway to the tumor and guide the surgeon through resection in an effort to limit iatrogenic injury. This is easier said than done because the biggest challenge in neuromonitoring is convincing a new surgeon that you are a competent neurophysiologist (the field is overwhelmingly riddled with incompetence).
After examining the patient, I found the surgeon in the hallway outside the OR. We spoke briefly. During that conversation, I recommended a strategy for mapping the brain. I told him what I could do, how I would do it, and how his cooperation would literally make or break this patient’s surgical outcome. I was much more tactful and convincing than I sound, but I demonstrated knowledge and confidence, and the surgeon elected to let me run the show.
In surgery, we identified the central sulcus with the SSEP Phase Reversal technique. After that, I recommended that we map the entire region. Using electrical stimulation, we marched up-and-down the pre-central and post-central gyri, as well as surrounding regions, and we identified critically-important motor regions. As it turned out, the tumor was just below the region that represented the patient’s dominant hand. It we destroyed tissue, it was likely that the patient would have permanent loss of function in that hand. I suggested to the surgeon that we enter the brain through a physiologically-silent region and map as we go. In other words, we don’t take any tissue without stimulating it first. He agreed and we proceeded. We mapped cortical structures, and we mapped subcortical pathways. Using this approach, I guided the surgeon to the tumor. All throughout the case, and during tumor resection, I continued to run independent tests of motor and sensory function, all of which showed no change from baseline. Ultimately the tumor was removed and the patient woke with no deficits.
I can tell you from experience that most surgeons would not have gone along with my plan. Most would have sacrificed hand function, or entered through sensory cortex and sacrifice sensation to preserve movement. Most surgeons aren’t used to having someone like me in the room for a case like that. This particular surgeon took a chance on me (with a lot to lose or preserve) and it payed off. The best part of the story is that the patient woke with no deficits (after going to sleep with the understanding that there was a very good chance he would wake with weakness or paralysis). The second best part of the story is that the surgeon requested to work with me on every one of his subsequent procedures. It feels good to be appreciated.
IONM is a rewarding career that takes knowledge, dedication and a special personality. As an academic neuroscientist, you likely have the educational background and technical skills necessary to make the transition to IONM. Of course, you have to be willing to start over at the bottom of the totem pole and with an entirely new literature base. In the face of dissipating grant funds and a bleak financial outlook, a career in intraoperative neurophysiology is an alternative well worth considering. Nearly 5 years after leaving academic neuroscience, I love my career and I’m financially secure. I get to do research and publish, and I never have to worry about grant funding. Life is good (on most days) and I love that I get to see the immediate impact of my work.
About the Author:
Dr. Rich Vogel is a neuroscientist and board-certified neurophysiologist. He received his BS and MS degrees in Psychology from St. Joseph’s University (Philadelphia, PA), and doctorates in Neuroscience (PhD) and Psychology (PhD) from Indiana University (Bloomington, IN). He completed a post-doctoral fellowship in neuropharmacology and electrophysiology at the University of Pennsylvania School of Medicine (Philadelphia, PA), and a Clinical Neurophysiology fellowship with Surgical Monitoring Associates (Springfield, PA). Dr. Vogel is a Diplomate of the American Board of Neurophysiologic Monitoring and an active member of multiple professional societies, including ACNS, ASNM, ASET and SFN. Dr. Vogel has received national awards for clinical excellence and team leadership. His professional interests include neurophysiological mapping of the brain, research, teaching, lecturing and writing. He also enjoys traveling, hiking, climbing, snowboarding, surfing, playing pool, playing cards, spending time with friends & family, and otherwise exploring the world. Dr. Vogel presently works for Safe Passage Neuromonitoring. He is the owner of the NeuroLogicLabs and StimulatingStuff websites, and serves as the lead contributing author.