I first became aware of the IONM field, or intraoperative neuromonitoring, through a friend and former colleague from my years as a principal research scientist at Wyeth Neuroscience Discovery Research. I’d had a twenty-something year career at Wyeth, hired in with a B.A. in neuroscience from Colgate University and a couple years of industry experience at Merck. By the end of my Wyeth tenure, I had personally generated most of the critical electrophysiological synaptic plasticity findings produced by one of the world’s most prolific and highly regarded neuroscience drug discovery groups. I published papers in top-tier journals, presented my work many times at the Society for Neuroscience’s annual meetings. I’ve found one of my findings cited in a textbook. Just a footnote, mind you, but something: a little smudge in history. It’s nice.
But it had been clear for a decade that drug discovery was a shrinking field, particularly neuroscience drug discovery, particularly for traditional electrophysiologists like myself. Too much capital had failed to produce a return for too long, as too many drug discovery and development efforts had failed to prove viable in the clinic, particularly neuroscience ones. All I had ever done for employment, since before even graduating college, was drug discovery research, mostly neuroscience, mostly traditional electrophysiology. Over the decade leading up to Pfizer’s swallowing of Wyeth, as I recall, the pharmaceutical industry had shed some 300,000 jobs, a third of those attributable to Pfizer’s decade-long acquisition spree alone.
The writing had been on the wall, as they say, and though the narrative I contribute here reflects my own of personal experience as a big pharma research scientist, I know many academic researchers facing a similar landscape: too many enormously gifted candidates for far too few jobs; part of the broader landscape of long-term unemployment and underemployment in the US economy. Those nearest the outskirts of the employment experience bell curve suffer most: they are either too close to the left of the curve, thus not cost effective due to inexperience, else too close to the right of the curve, their experience too costly due to their “seniority.” The dynamics are simple: employers prefer the benefits to the costs of their employees’ employment experience. Can’t blame them. Supply and demand in today’s labor market allows them to be decadently picky in their new hires, extending to maddening delays in final hiring decisions.
I finally came knocking on IONM’s doorstep with serious intent after two years of unsuccessfully struggling to land a research position, any position, neuroscience or other, industry or academia—any form of capitalization of my nearly three decades of neuroscience research experience and depth of knowledge. Yet one year after exhausting what had seemed a more than generous severance package, I was nowhere on the job front, one promising lead after another collapsing into radio silence. Oh, yeah, it’s for real, the abandonment to the wolves of the long-term unemployed. If he’s so good, why hasn’t anyone hired him yet? It was a brutal and humbling experience that forced me to reconsider my entire mindset regarding earning a living, not an uncommon experience these days. But I did have the IONM clue in the back of my mind, plus a contact or two.
The friend and former Wyeth colleague I mentioned had made a successful transition from benchtop electrophysiologist to certified neurophysiological intraoperative monitor, that is a CNIM, as such professionals are known; but more on that point later on. In effect he performed electrophysiology on anesthetized surgical patients undergoing procedures which put their nervous system at risk, giving live, actionable feedback to the surgeon in the operating room. It was something I could readily envision myself doing; at least, it seemed like a possibility.
Three months passed between the day I came to the conclusion that IONM was the shortest distance between myself and a new career and the day an IONM company offered me a job. At that juncture in my professional life, IONM proved a field where I could begin earning a living again, a field contiguous enough intellectually with what I had done before for me to present as a serious candidate to prospective employers, and a field into which my professional network reached deeply enough to get my foot in a door. Only one company offered me a job in two and a half years of looking for work. I had previously been a well-regarded neuroscience drug discovery scientist with a twenty-plus-year track record. It was sobering, yet perfectly consistent with the hundreds of testimonials by the long-term unemployed I’ve encountered across the web. It wasn’t so much about, “Why, me?” as much as, “Why not me?” More importantly, “Now that it’s me, how best to start over?”
For an experienced electrophysiologist, especially a neurophysiologist with a working knowledge of human neuroanatomy, the technical aspects of IONM are easy to master. Delivery of healthcare is done according to very specific medical codes. When a patient enters the operating room, the OR, he has been scheduled for and has consented to one or a series of surgical procedures defined by their medical codes. As a surgical neurophysiologist with an IONM company, you will likewise have been scheduled to appear in that OR to perform the IONM modalities constituting best of practice given the neuroanatomy at risk during the patient’s surgical procedure.
As an IONM trainee, your cases will most likely consist of ninety percent spinal repair and fusion. One example should provide an overview of handling an IONM case. A patient presents with a fractured neck due to a motor vehicle accident. He requires surgical repair and fusion of several cervical vertebra. The neuroanatomy at risk is the spinal cord, which traverses the vertebra, as well as the nerve roots exiting through intervertebral foramen. Such a case would require several IONM modalities: 1) electromyographic (EMG) recordings from the muscles of the upper extremities, as these are innervated by nerve roots in the surgical field and are at risk due to stretching or other manipulations; 2) somatosensory evoked potentials (SSEP), induced by stimulation of distal sensory nerves and recorded as averaged cortical evoked potentials, serve to monitor neurophysiological stability of the dorsal columns of the spinal cord; 3) motor evoked potentials (MEP), induced by transcranial electrical stimulation and recorded as compound muscle action potentials (CMAP) in the extremities, serve to monitor neurophysiological stability of the lateral and ventral spinal column; 4) the train-of-four test (TOF), used to determine the integrity of the neuromuscular response, is used to establish the reliability of the EMG and MEP modalities. In totality, these modalities would represent a healthcare delivery best of practice for a such a hypothetical cervical repair case. The precise IONM plan for the case is typically determined in conjunction with the surgeon and a remote reading clinician.
Beyond the purely technical aspects of the work, IONM is far, far afield from benchtop scientific research. Upon entering the field, you are unlikely to immediately find it as rewarding a line of work as the one you just exited. In almost all cases, the first year or two on the job is a simple matter of paying one’s dues, learning the ropes. There is a great deal to learn as you march toward your CNIM. But IONM is far from a “technical only” field, even though many are forced into that mold by virtue of their entry into the field as a trainee. There are research jobs in the IONM field. Indeed the field is new, and there’s much work to be done in terms of developing evidence-based practices. Entering IONM, as in any career, requires starting at the bottom of the ladder, an innately humbling experience for those who’ve recently stood on a bit of higher ground. The trick is to focus on where you will be driving your new career down the road, not where you’re starting. There’s much to be done in a new and growing field that is currently hungry for talent.
Allow me to back up a bit to when I was first learning about the IONM field and to linger on this perhaps most important point: IONM work is plentiful and growing. When I finally, reluctantly began to fully reconsider my livelihood, I quickly noted many IONM jobs posted. These invariably required board certification, the CNIM, or Certification in Neurophysiologic Intraoperative Monitoring. This certification is administered by ABRET, American Board of Registration of Electroencephalographic and Evoked Potential Technologists, the 150 year old credentialing institute for the field. By joining UNPA, the United Neurodiagnostic Professionals of America, I discovered comprehensive national salary data for IONM healthcare practitioners, parsed by education, experience, geography, etc. Finally, LinkedIn brought me to informed connections. From all such sources, I felt optimistic on the job front for the first time in a very long while.
Very good: at last I had a realistic employment goal. So, how do I go about getting myself a CNIM? Ah, right away a catch-22. Certainly, a CNIM will get you an IONM job, but it turned out you need an IONM job to get the CNIM in the first place. To qualify to sit for the CNIM exam, you need to log a minimum of one-hundred-fifty documented cases in which you are the primary neurophysiologist performing the IONM modalities on the patient in the operating room. I found only two routes leading to the OR: by making an internal lateral move as an accredited medical technologist already working in a hospital; or by landing a job with an IONM company. Only the second route was viable for me at the time; I needed to get myself to a paycheck with medical benefits fast.
A good IONM company will hire you as a new trainee into its fellowship program. They will have developed a comprehensive internal education program, through which they will train you from the ground up to perform in the OR as well as prepare you for, and encourage you to take, the CNIM exam. But first, they will need to be convinced you are fully on board, completely flexible in your schedule and willing to go where they need you with minimal advanced notice. If they doubt your commitment, the company will simply not invest in you. Like every other employer, IONM companies are not at a loss for job seekers. Prior expertise will help land you that initial interview. Particularly if you’re an electrophysiologist, they will already know you can quickly learn to do the job; but they will have to believe you’re also willing to do it.
The first surgical neurophysiologist who trained me had a college degree in sound engineering; in his previous job, he had worked on the soundtrack of a video game. Others had been chiropractors, hospital orderlies; a few actual graduates of accredited academic IONM training programs. IONM companies themselves can train almost anyone to do the job. But more and more now, the larger, better IONM companies are inclining toward recruiting and developing surgical neurophysiologists with deeper understanding of the craft, preferably degreed neuroscientists. They want us to be knowledgeable, eloquent evangelists for the IONM field through our professional interactions, some of which require intestinal fortitude.
I need to emphasize here one aspect of transitioning from a career in research to IONM. It was a brutally humbling experience to pay my dues all over, work my way up from the very bottom of a new field in which most of my professional accomplishments count for very little, if at all. In 2007, I gave a talk at the annual meeting of the Society for Neuroscience about my rationale and early data on a novel target I was developing for Parkinson’s disease. Some of that data was pretty sophisticated whole cell recordings from substantia nigra neurons in slices of mouse midbrain; not my personal work, but part of a project I was overseeing. In 2013, I was yelled at by a surgeon in the middle of a spine operation. He was insisting that I didn’t know what I was doing. I wasn’t giving him the numbers he expected, you see. He didn’t believe me when I told him I knew what a stimulus artifact looked like in a stimulus-evoked potential, or some such rudimentary nonsense. My spine arched. This occurred ten hours into a twelve hour case, during which I’ve worked my monitoring station without any breaks. There followed a brief, fierce encounter between that surgeon and me, and then we moved on, as the patient still lay on the table with her spine splayed open. Handling such professional interactions effectively is part of the job. The surgeon is not your boss in the OR. You’re there primarily to advocate for the patient, not to meet the surgeon’s expectations. Sure, that surgeon and I had a brief fierce encounter, but it seems it convinced him I knew what I was doing. Since that day we get along fine, and my employer values my ability to handle “personalities” like his.
Those sorts of fierce encounters are rare, though. Some people are jerks, plain and simple, in any profession. But most people you get to know and like and look forward to working with again. My favorite surgeon works out of the hospital closest to my home, twenty miles up a scenic coastal road; sweet older guy; always a pleasure to work in his OR. He does first-start carotids, which are typically short cases. Required modalities are electroencephalographic (EEG) recordings of cortex from the scalp, and somatosensory evoked potentials (SSEP) which particularly monitor the deeper, sub-cortical internal capsule. Those days, I leave for the hospital at 7 AM and am back home for lunch, done for the day. Love helping that doc with his carotids!
I go into that surgeon’s OR one fine morning for one such quick, routine case, contemplating already what I’ll be having for lunch in a few hours. No such luck that day. The case turned into an immensity, beginning with protracted IT-related interactions, online support and phone calls, cable swaps, etc.—technical tasks all outside my required competencies, all related to the unusable quality of the hospital guest WiFi, the only means through which the EEG and SSEP data I was recording from the patient would be visible to the remote reading clinician, my ally and incomparable second pair of eyes by which to legally interpret the live patient data feed. I was able to solve the IT issues because I had prior experience with computers, and also because the exposure portion of that particular carotid artery endarterectomy, instead of taking three hours, wound up taking seven. For multiple reasons related to the patient’s prior medical history, the case was quite complicated.
Then I saw changes in my signals—dreaded changes!—both in the EEG and the SSEP, indicating the cortex and deeper brain structures had become ischemic due to poor collateral circulation through the Circle of Willis. The reading neurologist saw the changes as well. The patient was experiencing a stoke ipsilateral to the clamped internal carotid artery. We alerted the surgeon and he placed a shunt circumventing the carotid clamp, restoring blood flow to the compromised cerebral hemisphere. This happens once in a hundred carotid cases and is the primary reason they are monitored by a surgical neurophysiologist. With blood flow restored, my signals recovered and returned toward baseline. Post-operatively, the patient was unable to move his limbs contralateral to the surgery, but full function had returned twenty-four hours post-operatively.
I never got to eat lunch that day; forgot all about it, actually. You emerge from such a case feeling in your bones the importance of your work. A tiny part of the world is better off; that tiny part is the whole world to a stranger you’ll never know. One or two cases out of hundreds in a year will make you feel that significance, the importance of your work. These are the ones for which you prepare, never knowing when today is the day your resolve and endurance will be tested. Sure, the work can be boringly rote at times. But that one in a hundred days tends to bring up the overall average on the excitement meter.
Did function return to my patient’s limbs because of the shunt the surgeon placed due to the changes my reading clinician and I saw in my signals? If so, what else will take place in that patient’s life and in the lives of his loved ones surrounding him? That is unknowable. All I’ll ever know for sure is whether I did everything I knew how to do to advocate for that patient during that critical time. Uncertainty abounds. But I’ll vouch for one certain thing I know from experience: you’ll never have a day like that one working in a lab.
About the Author:
Robert Arias is an intraoperative neurophysiologist with Sentient Medical Systems, previously a principal research scientist in the neuroscience drug discovery research divisions of Pfizer and Wyeth. Broadly knowledgeable in a variety of electrophysiological techniques and in their application to the assessment of neurobiological health. Technical proficiency in numerous techniques, from whole-cell patch clamp of native and recombinant cell lines, through ex vivo tissue preparations, to in vivo recordings and intraoperative neuromonitoring of surgical patients. Intellectual facility working within diverse interdisciplinary scientific teams. Currently making incremental progress on handling surgeons and navigating the healthcare delivery labyrinth which they populate.