Boots on the Ground

This post is the third in a 4-part series in which I’m discussing “What is happening in IONM.” If you haven’t already read the previous two posts (or listened to the episodes), you should really go back and check those out first, because each one builds on the next. Previously, I talked about many of the challenges that neuromonitorists and managers are facing in their work today, and the things that concern them. In this post, I’m going to be sharing what these folks need to know about what’s happening in IONM… beyond what I’ve already said in previous episodes and posts.

Before I jump in, one little disclaimer: A lot of what I talk about today is going to be focused on outsourced IONM providers, people who aren’t employed by hospitals. The main reason is because it’s what I know best, and I’d be making a lot of assumptions about what we call in-house IONM. For example, when I think about in-house IONM providers, I assume other hospital staff view you as a member of the team. You have a dedicated workspace in a lab, a badge, scrubs, access to patients and their records, and your neurology team is right there onsite to support you. You probably live close to the hospital, so your commute isn’t bad. You may have odd hours, but at least they tend to be predictable, and you likely have a team of coworkers who give you breaks and share responsibilities for taking call. I don’t know if that’s all accurate, but what I do know is there’s no way your life as rosy as I made it sound. I’m sure you have struggles that you face every single day, and I will definitely invite guests for interviews to set me straight.

Anyway…. So, everything I just mentioned – my assumptions about the in-house IONM experience – is virtually nonexistent in the outhouse, I mean outsourced setting, which comprises about 75% of all IONM. So, that will be today’s focus.

To kick things off, I want to share a day in the life of a neuromonitorist who works for a private IONM company so everyone can really understand what things are like out there…

You wake up at 4:45, do your morning routine, and leave the house by 5:15. If you have kids, they’re are still asleep. You arrive at the hospital by 6:30 and park in the visitors’ lot. You enter the lobby and sign into the Vendor system, assuming it works that day. You make your way through the hospital hauling all your IONM equipment and find the vending machine for sales reps. You insert your credit card, and it dispenses your paper scrubs and red hat. The paper scrubs have a giant sign on the front that says “Visitor.” It’s so embarrassing wearing that thing.

Your first case starts at 7:30, and you need to be in the OR by 7 AM so you have time to set up all your equipment, prep your electrodes, and connect with oversight. Only problem is you can’t set up anything until biomed checks your system… but they don’t start work until 7AM, and can’t get to you until 7:15. No matter how early you arrive at the facility, you’re forced to be late.

By the time biomed finishes checking your equipment, you have 10 minutes before the patient comes into the OR. You’re rushing to set up equipment, prep electrodes, open your monitoring prgram, interview and consent the patient (that’s IF they even let you into the holding area), talk to anesthesia/surgeon, connect with the neurologist, etc., etc.

When you walk into the OR it’s made perfectly clear no one wants you there. You look like a sales rep in those paper scrubs, and reps aren’t allowed in the OR until the patient is under anesthesia. You state your case with the circulating nurse, who points you over to the corner behind the anesthesia machine and the electrical boon. It’s a 3’ by 3’ space that’s difficult to reach behind all the wires, hoses and equipment. You have no clout. Everyone is mean to you. No one cares to hear your name. When they talk about you, when they talk to you, they refer to you as “SSEPs.”

When the patient comes in, you’re still setting up your program, but you rush to apply your electrodes and get baselines. The whole room is staring at you, the surgeon is yelling at you to hurry… or in some cases, just proceeding with positioning and draping the patient regardless of your baselines, always managing to dislodge a few of your electrodes along the way. This is the most hectic time of surgery. Meanwhile, the neurologist is sending you paragraphs of disclaimers and asking questions you don’t have time to answer. You just can’t seem to please anyone. Finally, things start to settle down and you’re monitoring the case, but you’re also trying to get ahead of your paperwork because you have 3 more cases to follow, and there’s no one there onsite to provide you relief or support.

So, things have settled down a bit, and you’re monitoring the data just praying there isn’t an alert so you don’t have to interrupt the surgeon who made it clear he doesn’t want to hear from you. In fact, a few months ago, he told you to sit in the corner and keep your mouth shut until he asks you for something. The last time you tried to tell him about a data change, he screamed at you like a child and made you feel like the lowest form of life on earth. Everyone in the OR laughed at you.

You’re very aware of the fact that, if you anger the surgeon, your company could lose the account, and you’ll be out of a job. Or, maybe the surgeon will just demand they fire you. You just want things to go smoothly.

So, the case finishes up and you spend the rest of the day doing the same, but you’re jumping between rooms, following the surgeon to cover his cases, and just can’t seem to catch up. A few years ago, there were 2 techs there to cover both rooms, but your workmate left for another job, and the company won’t hire a replacement. So, you hustle constantly all day… 12 straight hours.

You finish your work at 6PM and take your first bathroom break since 6:45 AM… sitting on the toilet, you’re cramming peanut butter crackers in your mouth and quietly admiring your own efficiency. Finally, the stress is beginning to subside. You head back to the locker room to get changed, hoping your clothes weren’t stolen because the hospital won’t allow you a safe place to store your belongings. Luckily, everything is there. A few minutes later, you’re in the hallway packing up your equipment, and the feelings of the day start to set in. You feel exhausted, under-appreciated, over-worked, marginalized, isolated, and alone. You don’t understand why they treat you this way. You’re just trying to do your job, but no one seems to care. No one will give you a chance. As you drive home, you contemplate looking for another job, but you can’t take the risk right now. Your family needs the money.

You get home at 7PM, just in time to tuck your kids into bed. You cram some food in your belly, watch 30 mins of TV to relax with your spouse, assuming you have one, then head to bed to do it all again tomorrow… probably at a totally different facility, maybe on the other side of the state. If you happen to be on call that night, and you actually get a call, you need to jump out of bed, go straight to the car, drive back to the hospital – 45 minutes away, and do it all again. Only difference is, now it’s 3 AM, everyone will be angry at you for taking so long – because you’re the only one driving in from offsite, and you start the whole process over again… keeping in mind it will now be 20 hours before you’re back home again because skipping tomorrow’s case is never an option. As you fall asleep, you often think, “Why am I living to work when I should be working to live?”

Whew! Damn! I mean, what a grind!!! I hope I did this justice because I know so many of you out there lead this life.

Being a neuromonitorist is a difficult job that so few people seem to understand. You work around people all the time, but no one thinks of you as being part of the team. No one is friendly to you. No one talks to you, no one appreciates you. Surrounded by people, and yet so isolated. Now, I know people have different experiences, and some people actually have the benefit of working at facilities that care, and treat you as a member of the team, but this is not the norm… not by a long shot.

Sometimes, I think this might be one of the worst jobs in all of healthcare, and then there are days that are so rewarding… there’s nothing else you’d rather do. Such is the life of a neuromonitorist working for an outsourced company.

Now I want to switch focus a little, and talk about how things have changed in recent years, and where they’re going. BUT, I’m going to focus quality and competency.

You know, there are so many things in this world that you can think of in terms of a spectrum. There are spectrums, or spectra, for light and sound that range from low frequency to high frequency. You can also think about salary, home values, and IQ… so many things… each as having a spectrum. Well, there’s also a spectrum in terms of quality and competency in IONM. There is high quality data and low quality data. And, there are highly competent neuromonitorists, and people with very low competence.

When you consider a spectrum of all neuromonitorists working in the US, I think, ideally and realistically, the best-case scenario would be what’s called a skewed distribution, meaning that the overwhelming majority of neuromonitorists would be well above 50% in terms of quality and competency. If that were true, it would mean a minority of people would fall below 50%, and maybe just a handful of people would be considered really, truly terrible at this job.

I could be wrong, but my perception is, if we went back in time 10-15 years, that’s exactly what we would find.

Things are different today. I feel like the curve has shifted, and many other people do, too. Today, I think it’s more of a normal distribution, or what some people refer to as a bell curve. In this case, the majority of people are sitting right there, square in the middle region, hovering around 50%… not perfect, not terrible, just mediocre. In some situations, like home values and IQ, that’s perfectly normal, and it’s OK. But, in patient care, it’s a problem because it means that fewer patients are getting high quality IONM by highly competent providers. And, at the extreme ends of the spectrum, as compared to the skewed distribution that I described a minute ago, now there are fewer people at the top – what we’d call superstars – and there are more people at the bottom.

It’s really interesting. You would think our profession would become more advanced, more refined as we mature from our early days, but it seems to be regressing.

I’m definitely not alone in this thinking. Over recent years, a lot of people have noticed the quality of IONM data being collected is getting worse, the documentation is getting worse, and the communication – whether in-person to surgeons or remotely to neurologists – is getting worse. I’m really concerned about this, and there’s a growing concern amongst neurologists, anesthesiologists, and surgeons. As neuromonitorists and managers, you should be concerned, too.

So, let’s talk about what’s driving this change…

What it LOOKS like to me, from the outside of these technical services companies, is corporate education programs have decreased in duration and depth, people are learning just enough the pass the CNIM, then forgetting what little they learned, and… frankly… it APPEARS as if there are more people working in IONM who don’t care about their work. I’m not saying this is the majority… there just seem to be more people who act this way than there used to.

The stress and burnout I get, but the lack of ownership over the work, the lack of understanding that there’s a patient on the table who is relying on the neuromonitorist to advocate for them, the apathy that seems to exist when it comes to self-improvement, education, continuing education, quality, being part of something bigger than one’s self, one’s company, is blindingly obvious in some cases, and the problem appears to be growing. How did this become OK?

A big part of the problem is that companies are investing less money in the initial education and training of neuromonitorists, and they’re allocating less money to continuing education. I’m going to the ASET annual meeting in a few weeks. It will be my third conference this year. To be fair, I go to a lot of conferences. BUT, when I was at the ASNM annual meeting back in May, there were maybe 150 people there. There are maybe 4,000 people working in IONM. It’s among the best educational opportunities money can buy, and 150 people showed up. Companies aren’t providing the financial support like the used to, and neuromonitorists aren’t willing to advance their education with an out-of-pocket expense. So, fewer people at getting the education they need.

Anyway, speaking of continuing education, what’s almost as bad (in my mind) is the people who have been in the field for a long time (and may or may not have learned things the right way), but they get stuck in these ways of doing things, and they think they know everything. So, they purposefully don’t participate in continuing education when the opportunity is available; and, worse yet, they teach the next generation of neuromonitorists the same methods and techniques they learned years before. Whether incorrect or outdated, it’s a terrible, vicious cycle that must be broken. If you’re not participating in continuous education – in a meaningful way, I mean really engaged in learning – at least 8 hours per year, you’re really missing out. The world is passing you by, and people who avoid continuing education are doing a great disservice by 1) using incorrect or outdated methods to care for patients, and 2) teaching younger practitioners to do the same. To make things just a little bit worse, there are actually a fair amount of people out there who think they’re high performers, but are actually low performers, and they have absolutely no clue about this fact because no one has told them, and they have no visibility to legit high performers for comparison.

Of course, I really can’t say this enough… I’m not talking about everyone. There are some stellar neuromonitorists out there, and there are some mediocre ones. Like I said, there’s a spectrum to everything. But, in my observation, the number of lower-performing neuromonitorists on the spectrum has increased significantly, and that’s really sad to me. We need to get this problem fixed… A-S-A-P!

It seems to me that what’s lacking here is adequate education and training, competent mentors, role models, people who will guide you, support you, empower you, etc. But, I also truly believe that anyone who really wants something, like advancing their competency as a surgical neurophysiologist is capable of achieving it. I guess the question to ask yourself is, how much do you want it? How much do you want to make a career of this? Even if this is just a stepping stone for you, maybe before going to medical school, don’t you want to be good at it for as long as you’re doing it?

I think there’s a lot of people out there who’ve been led to believe two things. First, that you don’t need to know much about IONM, surgery, anesthesiology, etc., and particularly conceptually, because you have a neurologist online to supervise and guide you; and, second, that your primary goal is to keep the surgeon happy. Let me tell you, these two things are patently false!

When it comes to knowledge, I don’t think there’s very good guidance out there for you, and I also think it may be difficult for you to extract the relevant information from published guidelines because they tend to be dense, even though they are readily available on society websites like ASNM, ASET and ACNS. So, lemme give you the basics.

At a very minimum, you need to understand how to use your IONM software inside and out… I mean total fluency. Your ability to make any adjustment in that software should be reflexive. You need to know the appropriate gains, filters, and displays for all modalities. You need to know the correct montages for SSEPs, and how they should be displayed. You need to know the generators of all evoked potentials, and how best to capture them. So, you need to know the correct electrode positions for EEG, SSEPs, MEPs and EMG. You need to know the best stimulating parameters for all modalities, and which changes will produce what effects (desired or not). You need to have enough knowledge of what you’re doing and why, so you can explain it to a surgeon or anesthesiologist. You need to know what to document, when, why, and how. Finally, you need to know how to administer a basic neuro exam with the ability, at a minimum, to perform manual muscle testing. Some people think this is outside their scope because they’re “making a diagnosis.” This is false. You are working under the direct supervision of a neurologist who is delegating this responsibility to you. So, you should do it before and after surgery whenever you have access to the patient. All of these basics that I mentioned are probably not comprehensive, but they do represent the absolute minimum knowledge every neuromonitorist should have – again, reflexively – before covering any case by yourself.

Beyond that, you can be far more effective in the care you deliver, and the influence you earn in the OR, by taking it up a notch. For example, if you understand anatomy along with the stages of surgery and the associated risks, then you will understand why certain modalities make sense to monitor. With that knowledge, you can make informed recommendations to the surgeon with an explanation as to why, instead of asking them what they want. You can take this a step further by learning the basics of reading imaging. If you have a deep understanding of how anesthetic agents effect the nervous system, and how they impact IONM data, you’ll be in a better position to explain why you want TIVA to an anesthesiologist (instead of just asking for it). By observing your surroundings and talking to other people in the OR, you can learn why they are doing what they’re doing. Do you notice a pattern here…? If you want to take your work to the next level, you need to gain a conceptual understanding of your work, to understand why… about everything!

Let’s talk about pleasing the surgeon. If your idea of pleasing the surgeon is being a quiet mouse in the corner, or tying their gowns, telling them jokes, playing good music, and answering their phones… I can tell you the surgeon may be friendly to you, but they won’t respect you. If you want to please the surgeon and earn respect, do a good job, demonstrate knowledge, communicate effectively, participate as part of the team, always stick around to see how the patient wakes up, and always keep it professional. Just keep this in mind, people want to know that you care before they’ll care what you know. So, show them you care… about your work, about the well-being of the patient, about everything. The rest will follow.

Here’s the thing… what I listed as the basics above, I think most people have some of that, to some degree, but very few have all of it. And, the consequence of not having all of it is… the data quality is poor, there are too many false positives (or negatives), there are so many surgeons who don’t have high opinions of IONM in general, and the neurologists are pulling out their hair on the other end of the internet. It’s really unfair to everyone, and particularly the patient, when you don’t have a high level of ownership over your work.

Oddly, many neuromonitorists don’t seem to be aware of the fact that they can be sued… or, what the potential consequences are of having that happen. Honestly, the last thing in the world you want is to have the quality of your work, and your competency, scrutinized by an attorney as you answer questions for 5 hours in a deposition, while you’re being sued for millions of dollars. Seriously, folks… not for one hot second should you think this hasn’t happened before, or that you are immune to the possibility of it happening to you. It has happened, it does happen, but don’t let medicolegal concerns be the driver of your work. When you work in healthcare, you need to get better at what you do every single day… for the next patient, and the next. Choosing to remain stagnant in your career is a very selfish decision, and there’s just no room for that on the front lines of patient care. There are plenty of opportunities out there for education, both free and cheap. Take advantage of them!

Recently, someone shared with me a commencement speech that Denzel Washington once gave at Dillard University. It’s so relevant to relevant. I have to read it to you.

So have dreams, but have goals, life goals, yearly goals, monthly goals, daily goals. Simple goals but have goals, and understand that to achieve these goals you must apply discipline and consistency every day, not just one Tuesday and just two days, you have to work at it.

Every day you have to plan, every day you heard the saying, we don’t plan to fail, we fail to plan – hard work works, working really hard is what successful people do. Just because you’re doing a lot more, doesn’t mean you’re getting a lot more done, don’t confuse movement with progress.

And anything you want good you can have, so claim it, work hard to get it. When you get it, reach back, pull someone else up, each one teaches one. Don’t just aspire to make a living. Aspire to make a difference.

That’s it. That’s the attitude you need to have if you’re going to work with patients.

The next topic I want to cover is these perspectives that many neuromonitorists hold about neurologists. I hear people say things like, (QUOTE) “It’s easy for them to put all these things in chat because they’re not the ones being yelled at by surgeons.” Or, I hear people making assumptions that neurologists don’t know what it’s like working in the OR. I think that’s really unfair to neurologists.

Making assumptions about other people without knowing them or understanding their circumstances shows a lack of empathy. You’re supposed to be a team. They went through years of medical training, including school, residency, and fellowship to learn to do what they do, and how they do it. All they want from you is to collect high-quality data, share with them what’s happening at any given moment in the OR, and communicate their comments to the relevant people in surgery. It’s not a huge ask. But, this aversion to working with neurologists isn’t benefiting anyone. Sure, sometimes it sucks answering questions and communicating things to surgeons that they don’t want to hear, or that make them angry, but that’s kind of your job. It comes with the territory. The patient is laying there under anesthesia hoping you’ll do your job, and do it well, no matter how difficult, no matter how uncomfortable it makes you. Everyone must work together and communicate for IONM to work well. It’s a two-way street. So, try to give those neurologists some slack, and a find a way to work together.

Note: this is the transcript from a podcast episode. At this point in the episode, I brought in Beth Wells for a discussion about neuromonitorist salary expectations when they are inexperienced hires.

I think everyone working in IONM should have some appreciation of the idea that more money comes with providing more value!

There are many ways in which you can provide added value, but here are two important ones to consider… First, if you have all those basics that I mentioned earlier down pat, and you can execute a case flawlessly – every day – with high quality data and documentation, then you can train other people to do the same, and you’re reducing the malpractice risk for your company by just being competent. Second, if you can transform those difficult facilities, work with difficult surgeons and speak on their level, guide them through changing their practices to optimize IONM, and transform the entire relationship – essentially adding stickiness – then you’re keeping that account on stable ground. But, you can only do this when you’ve taken it up a notch as I mentioned earlier… really becoming an expert.

Remember this: just because a surgeon appears to like you because you’re a decent tech who doesn’t cause problems, doesn’t mean he or she will go to bat for you (or your company) when the hospital is considering contracting with other companies to cut costs. If your level of knowledge, expertise, and participation in patient care as a member of the team is obvious to everyone in the room (every day), they’ll go to bat for you… because they value you. That’s not always the same as being liked. If the clients truly value you, then your company will, too. That’s how you move up the income ladder. That, and time, and certification, and, and, and… etc., etc.

So, before you take your first job interview, I just want you to understand what is realistic in terms of salaries and positions, and the level of work and commitment it takes to advance in this field.

In the words of Chris Tucker’s character Smokey from the movie Friday, “Take your time. You gotta crawl before you walk.”

The second thing I want to say to the newer folks in the field is there’s a lot of jumping around between jobs, and it doesn’t look good. I’ve seen resumes from neuromonitorists who have been in IONM for six years at four or five different companies. It’s one of the first things hiring managers notice when looking at resumes because they don’t want to hire and train someone, only to lose them in a year or two. I understand the need to change jobs happens sometimes, but you need to demonstrate that you’re someone who won’t jump ship when things get tough, or the grass appears greener on the other side. You need to demonstrate that you can make a commitment.

OK, I think I’ve beaten that topic to death. Let’s move on to managers now. Don’t worry, I’m not going to spend as much time on this for two reasons:

  1. I think a lot of what I would say to you I’ve already said to executive leaders and neuromonitorists.
  2. I have some great interviews lined up with managers sharing their experiences and ideas about management, so I don’t want to steal their thunder.

Let me just start by saying that your perspective is critical, because you essentially serve as a bridge connecting neuromonitorists, hospital staff, surgeons, schedulers, and executive leaders. You’re in the best position to understand everyone’s concerns and share them with the others. In fact, you represent everyone’s concerns. It’s important to build relationships, build trust, and communicate with everyone often. This means managing up, down, and side-to-side.

If you’re like most managers in IONM, you found your way into this role because you had tenure over your peers, or maybe you were better clinically. But, you probably got zero management training. That’s kind of a problem if you think about it, but it’s also somewhat understandable. I mean, many companies need managers, but they don’t have the resources to put you through school, or other types of formal management training.

It’s impossible to give comprehensive advice in a podcast episode. I mean, there are college and graduate programs dedicated to management, entire podcast series dedicated to management, and probably tens of thousands of books out there.

With limited time and budget, the best advice I can give to you in a single podcast episode is read. Here are a couple of starter recommendations:

Also, I think it’s really important to keep in mind that management in IONM isn’t just about scheduling cases, assigning neuromonitorists to cover them, and approving PTO. People are relying on you to defend, develop and empower them. You need to balance being a friend and being a boss.

The fact is, leadership is difficult. If there is one common factor that all leaders experience, it is criticism. The very people that you work closely with as a manager will probably talk about you, but they’ll still love and respect you as long as they know you’re always willing to do two things: First, always be willing and able to jump in and help out. Just because you’re a manager, you’re not better or more important than anyone else, and you’re not exempt from doing the difficult and dirty work. Second, always defend, protect and empower your team.

I would not get flustered if you team is venting to you, or about you. You know what, people need to vent, and they need the space to do it. Right or wrong, it’s going to happen, and you may be the one they vent about because you sometimes have to make difficult decisions. It may wax and wane, but it doesn’t ever fully go away. It does get easy, though, as you gain more experience and comfort in your leadership role. But, no matter how good of a leader you are, it comes with the territory at one point or another. Don’t try to friend your way out of it, and don’t try to buy favoritism. Just be a good leader.

The way I think about it is this: If you can look yourself in the mirror every night and honestly tell yourself that you navigated your day with integrity, supported the people around you, and empowered those reporting to you, then sometimes, some days, that’s the best you can do. It never hurts to explain your decisions and actions. People will be more receptive to your difficult decisions if they understand the context in which the decision was made, and why.

One issue you will definitely deal with as a manager is employee turnover. Don’t get flustered by the mere fact that someone leaves, and don’t take offense to the passive aggressive posts that people make about managers on LinkedIn. Just be there to support your team, your company, and your clients. The rest will follow. In the meantime, do whatever you can to learn business, and learn management. Start with the books I mentioned earlier, and try to find yourself a good, competent mentor in management. That person doesn’t need to be in IONM, but they do need to have enough expertise in management to teach you something, and they need to have the time to take you under their wing, and mentor you properly.

OK. That’s all for today. I hope you found some of this useful. Please join me next time when I’ll be sharing what oversight professionals need to know about what’s happening in IONM.

In the meantime, please feel free to leave a comment below, or send your questions and comments to [email protected]. I’d love to hear from you!

I’m Rich Vogel, and that was Stimulating Stuff!

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