In this fourth post from the series Transitioning to a Career in Neuromonitoring, Dr. Adam Doan tells his personal story about leaving the world of chiropractic care and navigating a new career in IONM.
Previous posts in this series include Navigating the IONM Job Search, Transitioning from Benchtop Electrophysiology to IONM and Transitioning from Academic Neuroscience to IONM.
If you currently practice intraoperative neurophysiology (i.e., neuromonitoring or IONM), take a look at the makeup of the company or hospital where you work; chances are, one of your colleagues, staff members or peers is a chiropractor. If not, ask one of your friends in another group, and it’s likely that they do indeed work with a chiropractor who has transitioned from their original field into our current profession. I have no idea what the overall IONM clinical workforce pie-chart actually looks like, but I’d venture to guess that a decent sliver of this is comprised of chiropractors. What leads someone to matriculate through almost eight years of formal secondary education only to leave it behind to forge a new clinical path? I can surely share my story, but I also know from interviewing and talking to many chiropractors over the years that there are more similarities than not in these transitional driving forces.
Entering the Chiropractic Field
Like many doctors of chiropractic (DC), I originally entered the field because of positive experiences following failed allopathic interventions for sports-related injuries in high school. The treatment methodology seemed fairly straight forward and was cost-effective. Most importantly, it was successful. Nothing can shape an impressionable young mind like first-hand outcomes. At the time, it seemed like an ideal career; one could enter into a profession where you are afforded strong practitioner-patient relationships, where the outcomes were usually favorable, where you usually become your own boss and where there was money to be made. Open your door, hang your shingle and wait for the masses to flock in. After all, almost everyone will experience low back pain or another pain-related musculoskeletal disorder at some point in their life, right?
My time in chiropractic school was a period of focus and hard work. Not unlike many or most of the readers, the undergrad experience was as much (or more) about exploring newfound freedom and having a good time, as it was about optimizing the opportunity for education. That all changed upon graduation and a move to the Midwest. In chiropractic school the days were longer, the content (and examinations) were more difficult and the classes were piled up. This was a time to take advantage of a different social atmosphere and really buckle down. For those of you who come from different (non-chiropractic) backgrounds, much of the first two years of chiropractic school are similar to the initial years of the medical school experience. There is a lot of focus or (re)emphasis on the basic sciences, with deeper dives into some of the specifics that are the focus of the profession. We have the typical gross anatomy with cadaver labs, pathology, biochemistry, cellular physiology, etc., but we also have more specific neuroanatomy, spinal anatomy, radiology and multiple neurophysiology classes to compliment the clinical and laboratory rotations. Rather than list the specifics, feel free to peruse the listed curriculum from my alma mater:
Let’s just say that I soaked this all up. Patient care was definitely for me and I was very glad that I had made the decision to enter this world. I spent the next several years working as hard as I could to learn as much as I could. I focused not only on chiropractic education, but tried to familiarize myself as much as I could with different aspects of healthcare and medicine. I surrounded myself with like-minded individuals and I was in my element. I was ready to take the world by storm.
My first job out of school was working for someone else where I had a steady pipeline of patients and a salary. Not a bad gig, but it was only a purposeful stepping stone as I plotted my future. I ultimately set up shop as an independent contractor with a multidisciplinary group as I ventured off to build a practice of my own. I enjoyed the collegial atmosphere that came with being able to refer patients (and receive referrals) in the same building. Year one of this relationship saw the referral network grow and the numbers increase. I should mention that, by “numbers”, I’m referring to the total number of patients, and not the financials. Over the course of a few years, I grew to a point where I found myself maxed out, while still performing what I thought to be quality care. This sounds great, but the issue was that I was fighting harder and harder with the Centers for Medicare & Medicaid Services (CMS), as well as commercial payers and patients to recoup what I thought to be a fair price for the service rendered. I don’t want to come off as overly naïve or idealistic, but working much harder in year three and making less money than in year one was not exactly what I had in mind when I started.
Transitioning to Neuromonitoring
The decision to try my hand in IONM was a means to another end. My then girlfriend (now wife) and I were looking for a NYC exit strategy. I knew enough about neuromonitoring due to the referral network of surgeons that I had established, and when I saw an advertisement for a one year fellowship in PA listed in the NY Times Health & Science section, I thought that this may be a good way to exit stage right. We told ourselves that we would go to PA, and I would learn this field as I applied for a state licensure with the PA chiropractic professional board. After all, if someone was going to pay me to learn, I’d take that job more often than not. Best of all, it was only going to be for a year, or as long as it took me to get my feet on the ground in a new location.
I was not alone as I set out on my new educational adventure. I started my career in neuromonitoring with a group of three other like-minded fledgling neurophysiology professionals who were also embarking on their second careers (well, second for them…I was only doing this in the meantime). There was a Ph.D. neuroscientist and,….you guessed it, two other chiropractors in our group. Entering into this with a couple of other initiated brethren was comforting, as I realized that the experiences that lead me here were not unique, and I’d have other colleagues with whom to share the experience. Simultaneously, I felt rather sad about the chiropractic world, as there sat some pretty sharp, eager young folks who would no longer be providing the care in the profession that they had worked so long for the right to deliver.
Now, my IONM educational experience was very different than my chiropractic educational experience in some ways, and very similar in others. The group I started with took the training very seriously, and there was a lot of expectations placed on the individual trainees with several benchmarks to meet. We had two to three days per week of didactic classes with one teacher (and the occasional guest lecturer), and two to three days per week of practical training in the operating room. The program continued in this manner for several months as stage-one of the program. I quickly learned that those not keeping up with the expectations were either weeded out by the practice, or weeded themselves out by throwing in the towel. In a way, I kind of enjoyed this aspect, as only a clinical workforce with a solid base would be left in the end. Work hard, study hard, and I would be left standing. Wait though…did it really matter since this was only temporary? Never one to back down from a challenge, it absolutely did matter!
I found many aspects of this curriculum a breeze: neuroanatomy, neurophysiology, the H&P, etc., were more or less a review. However, applying this knowledge to a new way of thinking was novel. For example, I knew the boundaries of the (spinal) disc space, the pathway of the vertebral artery and how an action potential works. I understood summation, basic pharmacology and knew the different neural pathways that one could monitor. What I didn’t understand was how the surgeon approached the spine through the disk space, what predisposes one to iatrogenic vertebral artery injury, how summation is used to overcome the effects of anesthesia, or how signals change at different points along their pathway secondary to both physiologic and pathophysiologic stressors. The extrapolation of knowledge from one field to another was super fun at times, and perplexing at others; yet, once again, I felt that I was in my element and was soaking it all in.
Other aspects of the curriculum were more foreign to me, or harder to apply. For example, our lectures on audiology and the ABR definitely went over my head on the first around. I also entered the profession as the remote model (internet-based supervision) was becoming more popular. So, going from a professional sense of autonomy where I could diagnosis, refer and treat patients, to one where I was part of decision making team definitely took some getting used to. It also took a while before I developed my “OR persona”, where I felt the confidence to stand behind all of my calls with authority. FYI, any of you that are in the earlier stages of your career and are experiencing this, just know that it gets easier and easier with time and experience…now my OR persona is no longer in quotes.
By the end of my yearlong training, I had graduated from the didactic portions of the IONM training program and was working independently on many cases. This was in addition to my continual training on other, non-spine case types. I realized by then that I was fairly well-hooked, and knew that my original one-year term was out the window. Many members of my group were Diplomates of the American Board of Neurophysiologic Monitoring (D.ABNM), and I figured that I would stick it out at least long enough to achieve this goal. Like I had mentioned, I don’t want to back down from a challenge, and I wasn’t going to be satisfied as long as many of my colleagues (and now friends) had this credential and I didn’t. Of course, I’m sure you’ve all realized by now that I’m obviously still in this profession, or Rich probably would have found someone else to write this for his Blog.
I hope that I’m not painting too easy a portrait of such a career transition. Any move from one field to another has plenty of challenges and tribulations. In some ways, this transition is natural; in other ways, not so much. Although it’s not as formal of a process as the schooling to which you may be accustomed, that’s not to say that it’s less difficult. At this stage in my career, I’ve interviewed and hired countless individuals. What I’ve found is that, despite your background, this profession often comes down to how self-motivated you are. Despite the great training that I was afforded, it still took a lot of work on my “down time” to learn what I thought that I needed to know. This is despite a fairly in-depth, robust curriculum filled with expectations by a lot of very knowledgeable and well-versed mentors. It behooves anyone transitioning from one field to another to really do your homework about what you may be signing up for. What sort of process will your education entail? What are the expectations? What sort of model will they employ and is this in concert with your clinical philosophy and ultimate goals? What will the training look like and where does the prospective group provide services? Who will actually be training you and what makes them a suitable teacher? You should know all of this information on the front end of your decision making process and your career. Armed with this knowledge, your ability to rise and be a superstar is basically on your shoulders. You need to read the literature, join your professional societies and never accept “because that’s how I learned it” as an answer. I was blessed with some sound mentors who pushed my limits and created an atmosphere where if I wasn’t growing I was dying on the vine.
There is a chiropractic axiom, that the profession is a science, an art and a philosophy. Isn’t this true of all healthcare disciplines? It’s pretty much the case in IONM. In the end, how successful you become will not be based solely on the foundation you bring into the field and how hard you work. There is the whole other side to quality and competence that is comprised of quick, clinical decision making. Whereas in one world you have the luxury of time to examine, assess, refer and send for imagining or further testing before making a decision, the world of IONM relies on decisions made in the moment, and in the context of numerous confounding variables. We all had friends in school who aced every test, but perhaps it didn’t translate to their hands, or their people/communications skills weren’t the best, so they never thrived in practice. Like this analogy, to excel in the world of neuromonitoring, one should have the core didactic academic background, but then this also needs to translate into the real world.
If you’re a D.C. and thinking about making this transition, you can always reach out to me for advice. In the era of LinkedIn and other social media, it’s also easy enough to find others that made this transition, most of whom are likely more than happy to let you pick their brain(s). I would suggest that you also ask yourself why you are personally contemplating this move, and what you hope to get out of the career change. What do you want out of your personal career? Perhaps you can use a bit of this piece to help steer you towards the right questions you can ask of any program, hospital, school or company that may be willing to take you on.
It’s like déjà vu all over again– Y. Berra
Many of the aspects that lead me to this profession were financial. I saw reimbursements declining, despite my increased efforts to have a sound revenue cycle. Partially at the time, and even more in hindsight, I realized that I had entered my original profession after the “golden era”, when practitioners used to get reimbursed close to 100% of charges. Such is the theme of healthcare; the novel or misunderstood often reimburses, and eventually third-party payers catch up and start chipping away. In the chiropractic world, often a chainsaw was used to chip. Of course, this isn’t unique, and all healthcare disciplines are essentially seeing this same process unfold. So, is this a bleak time for you to consider such a transition into neuromonitoring? Will you essentially run into the same result no matter your chosen avenue? You’ll find both short-term and long-term forecasts that speak to whatever story you want to hear, but the fact of the matter is that the use of IONM has grown and this growth is predicted to continue for the foreseeable future. As we have entered the world of evidence-based healthcare, the onus is on the profession to prove both efficacy and cost-effectiveness, but who’s backing down from that challenge? Despite the advances in both technology and academic understanding, we have a long way to go, and I’m confident that we will get there.
You’ll also run into another similar story. We don’t always see eye-to-eye in this profession regarding many aspects of neuromonitoring: what is the best training model or the best clinical model; how to define competency or quality; what lexicon do we use so that we are all speaking the same language? Additionally, it’s not quite as neatly defined as “straight” versus “mixers,” and it takes some time to parse out the different opinions and methods out there.
In the end, the decision to transition is often a difficult one, but it’s good to be able to choose between two rewarding pathways. If you’re doing it for the right reasons, and are ready to work hard to review what you already know and learn what you don’t, we will always welcome smart, motivated and dedicated professionals into the field of neuromonitoring.
About the Author:
Dr. Adam Doan is Director of Clinical Services at Safe Passage Neuromonitoring. He has coauthored textbook chapters and articles related to intraoperative neurophysiology, and has been invited to speak to both hospitals and the IONM community. He has held leadership positions in IONM for years, and is passionate about delivering the highest quality patient care. He is an avid reader, enjoys making and listening to music, and loves to spend his free time with his family and friends. For more information, look under the Guest Writers tab.
This post is Part III in a series about Transitioning to a Career in Neuromonitoring. You can read other stories by following the links below.
Would you like to share the story of your transition? Contact Rich Vogel.