Who Would Surgeons Prefer to Interpret IONM Data?

There is an interesting paper that was just published in the Canadian Journal of Surgery. It is free to access and download, so just click here for the pdf. Also, for those of you who don’t like to read, the paper is short is mostly filled with tables!

The research took place in Canada which, just like the US, has a significant shortage of personnel to perform IONM. So, the authors created a survey, using Survey Monkey, and sent it out to surgical societies representing spine surgery, neurosurgery, ENT and cardiothoracic surgery. Basically, they asked surgeons 1) who is interpreting your IONM data now, and 2) who would you prefer to interpret your data. The surveys were left open for 6 months, and the results were pooled.


I think one of the most striking results is that the majority of respondents (surgeons) are performing their own interpretation of IONM, but they’d rather not. A second striking finding is that, given the choice, more than 90% of spine-, neuro- and ENT-surgeons would prefer that a PhD neurophysiologist interpret their IONM data. Neurologist fell much lower on the preference scale. I wonder why (and I’m not being sarcastic, I really do wonder why).

The study has a couple of design flaws, which leave it open to criticism. For example, it’s a survey, with a small number of respondents, who may or may not represent the population. These points aside, it’s a start. I wonder what surgeons in the US would say. I think we all know that Dr. Dormans (2010) argues for qualified, board-certified individuals. He seems to care less for whether it is an MD, PhD, DC, AuD, etc, as long as it’s a doctoral-level individual.

Wouldn’t it be great if we had a survey like this in the US, with many thousands of respondents? I would just be interested to see the findings.

Dr. Rich Vogel is board-certified intraoperative neurophysiologist working for Safe Passage Neuromonitoring. He started the Neurologiclabs website and blog to connect with others in the field of neuromonitoring.


11 thoughts on “Who Would Surgeons Prefer to Interpret IONM Data?

  • Reply John N. Gardi May 20, 2015 at 15:51

    Nice post Rich.

    I suspect it would be much the same in the US, although I also feel that Canadians have always been more enlightened than most of us in the US. Nevertheless, the real issue here isn’t who would be best to perform IONM interpretation, instead it has been about who can bill and how many procedures could be billed simultaneously if a telemedicine approach was utilized (especially outside of major university hospitals). The ability to bill comes down to a state by state licensure issue and the recognition by private insurance companies as well as CMS and managed care programs to recognize the right of such appropriately licensed individuals to bill for these services. Historically, this is why myself and people like Dan Schwartz and others with state licenses as audiologists could bill for services (at least to 3rd party insurance companies) because we had a state license in either California or Pennsylvania and other equally qualified Ph.D.’s could not bill because there was no state licensure for such trained individuals (think Chuck Yingling or Jeff Balzer). Others found more exotic ways to gain state licensure, like through experimental psychology or chiropractic medicine licenses.

    The second major issue, in my opinion, is lack of sufficient numbers of such Ph.D. level individuals. If you could immediately grandfather in all the D. ABNMs in the country and add them to the group of equally trained and experienced MD neurologists, physiatrists and audiologists, there still would be significant shortages.

    Dentistry, osteopathic medicine, audiology, speech pathology, clinical psychology, nurse practitioners, podiatric medicine and chiropractic medicine gained recognition by first and foremost establishing accredited training programs to justify their positions within medicine. In fact I would suggest, that these fields would never have progressed and flourished without a somewhat purposeful neglect within traditional medicine. And even within traditional medicine, there were just two types of physicians – diagnosticians and surgeons. These later branched off into pediatrics and general medicine which branched off into specialty branches like internal medicine, psychiatry, radiology, cardiology, otolaryngology, urology, dermatology, neurology and gastroenterology. At the same time, surgical specialties arose in cardiothoracic surgery, gynecological surgery, urological surgery, head and neck surgery, plastic surgery, pediatric surgery, vascular surgery, orthopedic surgery and neurosurgery which then begat further specialties, including vascular neurosurgery, neurotology and ortho- and neuro-spine surgery. There has been cross over between and among surgery and diagnostic medicine disciplines as well, such as ortho- and neuro-spine surgery; and neurosurgery, vascular surgery and neurology. Finally, we get to today, where in neurosurgery one finds two basic types – spine and cranial based neurosurgery. This has led to neurovascular neurosurgery, trauma and neoplastic based surgeries. All of these medical disciplines or specialties share one thing in common – they have demonstrated the need for establishing training programs to certify the practice of their subspecialty services. We need to do the same for IONM, regardless of our varied backgrounds.

    John N. Gardi, Ph.D., D. ABNM, F. ASNM, CCC-A, BCS-IOM

    • Reply Richard Vogel June 8, 2015 at 12:00


      As always, thanks very much for your insightful comment. Sorry I took so long to respond. Actually, I’ve been working on a piece for the ASNM Monitor Newsletter on this very topic. It should be published in the next few days. I’m interested to hear your thoughts after you read it. Thanks again.

  • Reply Marat Avshalumov May 22, 2015 at 16:26

    Very good post Rich. Thank you

  • Reply Jonathan Norton May 23, 2015 at 18:42

    Thank you for posting this, and the comments. As the author its always nice see some interest in a paper. John Gardi raises an important point early on about billing, and that maybe the reason why in Canada at least surgeons are not enthusiastic about neurologists monitoring. There tends not to be a fee code for neurologists to bill for iOM, and so there is a tendency for neurologists to ‘monitor’ whilst performing other activities, such as running clinics.
    I absolutely agree that we need a formal, regulated, rigorous training programme for those who interpret IOM.

    • Reply Richard Vogel June 8, 2015 at 10:10

      Thanks for the information, and thanks for the feedback. Great paper!

  • Reply The Economics of IONM Expertise - Blog by Dr. Richard Vogel– Blog by Dr. Richard Vogel June 16, 2015 at 15:11

    […] a recent blog entry, I reviewed a paper by Canadian Neurophysiologist Jonathan Norton, PhD. The paper addressed the […]

  • Reply Qualifications for Interpreting Neuromonitoring DataNeurologicLabs August 12, 2015 at 13:10

    […] very strong opinion about what qualifies one to interpret IONM data. Other surgeons have expressed similar opinions as reported by Norton et al […]

  • Reply Susan Morris, PhD September 4, 2015 at 11:36

    As a neurophysiologist practising IONM in Canada, I would like to point out a major piece of information that has been missing from these discussions. In 2014, the Canadian Association of Neurophysiological Monitoring (CANM) launched a comprehensive training program in IONM in concert with the Michener Institute for Applied Health Sciences (Toronto, Canada). The program is a 2-year graduate certificate program (B.Sc. in a health science discipline is one of the admission criteria streams) that is offered online to make it accessible to students across Canada and around the world. The 6 interactive courses span everything from basic IONM-related clinical sciences to advanced IONM topics and techniques. The courses were designed and written by subject matter experts that were hand-picked by the CANM Education Committee. CANM will also be introducing a hospital-based practical component to the certificate program to compliment the didactic course work. Details can be found on the CANM website (www.canm.ca). In short, there is now a CANM-vetted training program in Canada that will produce highly qualified IONM practitioners, essentially eliminating any personnel shortage issues that might currently exist. CANM is very proud of this new training program in IONM and we enthusiastically invite anyone interested in becoming an IONM professional to apply (www.michener.ca/ce).

    Susan Morris, PhD
    Chair, CANM Education Committee

  • Reply Where does Intraoperative Neurophysiological Monitoring stand in Canada in 2016? – Neurologic Labs December 26, 2016 at 18:14

    […] Who Would Surgeons Prefer to Interpret IONM Data? […]

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