Eyes in the Sky

There’s a quote I really like that’s attributed to Charles Darwin all-over the internet, but Darwin never said it, and no one really knows the origin. Goes to show you shouldn’t believe everything you read on the internet. Anyway, the quote goes like this:

“It is the long history of humankind (and animal kind, too) that those who learned to collaborate and improvise most effectively have prevailed.”

The field of neuromonitoring needs more collaboration if it’s going to prevail!

This is the fourth and final post in a 4-part series in which I’m discussing “What’s happening in IONM.” If you haven’t already read or listened to the previous three posts/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 episode, I’m going to be sharing what oversight professionals need to know about what’s happening in IONM… beyond what I’ve already said in previous episodes…  and how we might address some of the challenges you experience in the course of your work.

I’m going to break this out into 2 parts. First, I’m going to speak to the nonphysician doctors with the DABNM credential. Then, second, I’m going to speak to the neurologists. I decided to not address audiologists because I don’t really good understanding of their specific challenges. That being said, I think some of what I say today will be relevant.

Let’s jump in…

I know there are DABNMs out there that are US-licensed physicians, including neurologists, surgeons and anesthesiologists. In this episode, when I talk about DABNMs, I’m talking about nonphysician doctors… the PhDs, DCs, AuDs.

So, let’s break down your current state of affairs. You’re board certified in the professional aspects of IONM… Having undergone direct training under multiple board-certified neurophysiologists, having personally performed the professional aspects of IONM for at least several years, and for hundreds of cases across all surgical categories, having completed the rigorous and extensive process of passing the DABNM, you are both qualified and certified to supervise technical personnel, interpret neurophysiologic data, elaborate differential diagnoses related to IONM, and make recommendations for therapeutic interventions if needed. Only problem is, you’re not a physician, and therefore, according to the 2009 resolution passed by the AMA House of Delegates, you’re not allowed to do this work without some form of physician supervision… at least in states where the practice of medicine has been clearly defined. Also, even if you do perform the professional aspects of IONM, insurance generally won’t reimburse you anymore, except in some states with some payers, and the case of licensed audiologists, but – again – only in some states. So, what exactly are all you DABNMs out there doing?

Well, know many of you, like me, transitioned away from providing clinical care in the years following the 2009 AMA resolution. I honestly don’t know where most of you work these days. I know some of you work in academic centers providing professional-level IONM patient care, but I know a lot of you left clinical practice and work in upper management at IONM companies. Some of you are unemployed because your upper management position had to be cut to save the business. Some of you left the field entirely and probably won’t be listening to this podcast.

It’s interesting… the theme here is, for the most part, patient care has lost you, despite the fact that you’re incredibly talented and competent. Some of you may be performing the professional aspects of IONM, perhaps a few work in the role of a neuromonitorist, but most of you are probably teaching, doing QA, managing people, running businesses, or something else… but not doing what you’d really love to do, and what you’re great at.

It’s a shame for patients to not have your expertise, but I also think it’s a shame for neurologists to not have your support. It semms that neurologists are overworked, stressed out, burned out, and could really use the extra hands. Well, there may be some good news.

As I briefly mentioned in a previous episode, recently the AANEM, ACNS, ASET, ASNM published a joint guideline on Qualifications for practitioners working in NDX. To my knowledge, this is the first time all 4 societies come together to publish a guideline. What’s relevant to this conversation is what it says about the nonphysician doctor holding the DABNM. And, keep in mind, this section of the guideline was written by physicians. It says, the DABNM scope of work/duties include:

  1. Interpretation of IONM data
  2. Supervision of technologists
  3. Rendering of professional report
  4. All working under the general supervision of a clinical neurophysiologist physician (who must be immediately available, if needed).

If you think about it, this is a major shift from perspectives of years past when there was significant aversion to this idea in the physician community. What’s driving this change? I think three things came together:

  1. Nonphysician doctors have a persistent desire to be recognized as professionals.
  2. Physicians desire to have greater support in providing professional-level IONM patient care.
  3. Recognition amongst physicians that the DABNM is actually a really good vetting process for those who want to perform the professional aspects of IONM.

This is a great opportunity, which is a win-win for both DABNMs and neurologists. DABMNs can perform the work they are certified to do in terms of interpreting data and supervising neuromonitorists… in this case, essentially serving as midlevel practitioner with a level of independence somewhat reminiscent of the early 2000s. And, for neurologists this model helps to lessen some of the burden, particularly as surgical volumes grow.

The question that always comes up here is: Well, most insurance companies won’t recognize the DABNM without a license and appropriate taxonomy, so how do you get paid…? My answer to that is: we’re talking about a practice model here, not a billing model. Nothing changes about billing. If a practice can safely take on more cases by distributing the volume under the same physician supervision, they can make more money, and they can afford to pay the DABNM.

Now, obviously, there’s some logistics to work through there in terms of facility privileging and delegation, for example, but it’s an avenue worth pursuing.

Now I’m gonna switch gears and talk to the neurologists.

In the last episode/post, I talked about the neuromonitorist’s typical workday. Now, let’s talk about your day. You wake up at 5AM, do your morning routine and rush your kids off to school. In the outsourced world, which represents the overwhelming majority of IONM, you work from a home office, and that’s where you spend your day. You log onto the chat platform just before 6 am and wait for the monitorists to connect with you in the eastern time zone. You start your morning with 4 cases… 2 cervicals, a lumbar, and a crani. When the neuromonitorists connect with you, at least 2 of the patients are already in the room, and the IONM plan is in motion. You’re frustrated by the late connection and the fact that no one consulted you on the plan, but you do your best provide input and feedback to support the team. Your first order of business is to confirm each patient’s identity, the diagnosis, the procedure, the H&P, and the plans for IONM and anesthesia. You’ve got 4 chats going, sending out messages trying to get information, and no one is telling you anything. Finally, after about 20 minutes, the data collection starts. Still no information communicated back to you.

OK, so, baselines are collected. Signals in the crani look good, but the signals are inverted in one cervical (and the channels are all mislabeled), the other cervical has motors from only half the myotomes and lower extremity SSEPs are absent, and the lumbar case has nothing. Nothing. The neuromonitorist can’t even seem to troubleshoot the TOF. You still haven’t confirmed any of the information you requested 30 minutes ago, except for the patients’ identities… when, suddenly, you get undated with information, in some cases passive aggressively, as the monitorists all work furiously to catch up with documentation and troubleshoot. You try to assist with troubleshooting, but they’re not doing anything you’re asking them to do.

Finally, after about an hour, you have all the information you need, signals are as good as they are gonna get, and now you just need to watch the data and keep up with stages of surgery as they evolve. Problem is, the neuromonitorists aren’t giving you stages, anesthesia/vital values, or anything really. It’s so frustrating trying to imagine what’s happening in the OR. You saw these cases plenty of times during fellowship, but it was so much easier when you were onsite to assist. You wonder how neuromonitorists can routinely make so many technical errors, be unable to perform basic troubleshooting, be unable to communicate necessary information, and give you pushback when you ask them to do anything, particularly when it comes to communicating information to the surgeon.

You really hope there isn’t an alert because you don’t know if you can trust the person on the other end to manage the situation in the OR. You have constant concerns about medicolegal ramifications of this. You’ve done your best to protect yourself by populating the chat with your typical disclaimers and caveats, but the medicolegal risk is always in the back of your mind. While a technologist is statistically more likely to have a lawsuit closed against them, even being named in a lawsuit is hassle for neurologists because every hospital where you’re privileged needs to be informed. Also, the process of being named in a lawsuit, and having to defend yourself is stress and frustration you just don’t need.

So, you’re mid-way through those 4 cases, and that’s when you get 2 more cases. Now you’re monitoring six cases, which is fairly common for a remote neurologist, and you experience the same issues as you did this morning, except 1 of the two cases connected with you after baselines and incision, and you can’t help but wonder why they couldn’t connect with you earlier to establish a plan and give you opportunity to interpret baselines. Your day goes on like this, managing concurrency, communicating with neuromonitorists, interpreting data, charting your cases, and just trying to provide the best care you can.

At the end of your monitoring day, you hand off whatever cases are still going to another physician. That’s when you start on your CME work. Your licensed in 35 states, which means you need to do somewhere between 10 and 30 hours of CME per month to keep up. Your day ends late, the kids have been home for hours, and you’ve been isolated in this room by yourself with no human contact for the last 12 hours. You’ve been chatting with people all day, but you don’t really know any of them, and you don’t really live in their world. Surrounded by people, at least virtually, and yet so isolated.

You leave your home office to join your family in the other room. They’ve already eaten dinner. The kids are finishing homework. Just in time to say good night. You unwind with your spouse for a little while before going to bed, only to wake up and do it all again tomorrow.

Of course, what I left out of all this is the independent contractors who also have to manage all their own state licensure, CME, hospital privileging, scheduling, etc., etc., and maybe even their own insurance billing. And, I didn’t talk about the minority of neurologists who hold academic positions and perform the professional aspects of IONM onsite. That’s a totally different world. In the outsourced world, where most of us work, a lot of people think the neurologists have an easy job because you work from home and don’t have to deal with the stresses of working in the OR… it’s not!

I hope I did this justice. I mean, in the days when I did remote professional oversight, it was kinda like that. I think the overall clinical quality and competency on the neuromonitorist side was better back then, certainly better than what I described, but the stress was still the same.

Before I go on, I want all of my listeners to know that I didn’t describe a day in the life of neuromonitorists (in the last episode), and neurologists (in this episode) to draw a comparison, or show that one job is more difficult than the other. I did this to show that both jobs are extremely difficult and stressful. I did this to try and spark some empathy between the two roles because I think it’s sorely missing. If you understand each other’s challenges and needs, if you’re willing to give the other some slack, some credit, again – some empathy, if you start there and work on better communication, everyone’s lives will be much easier!

If you’re a neurologist listening to this, I hope you can see from what I said in the last episode that the issues you’re seeing on the technologist side are related to a bunch of factors, particularly:

  1. An uninviting work environment on the facility side where neuromonitorists are marginalized and even mistreated.
  2. Lack of financial resources in tech services companies to provide adequate education and training, likely due to the fact the insurance reimbursements and facility technical fees have declined precipitously in recent years.
  3. Employee turnover with people jumping between companies and/or leaving the profession entirely.
  4. Exhaustion on the technical side with limited time to engage in continuing education.

And, frankly, on top of that, most of the skills necessary to perform IONM at the level often desired are not tested for on the CNIM exam. So, some people don’t really learn these skills. It’s a pervasive problem worsening throughout IONM. In my mind, the best thing you can do to drive change is advocate for better CNIM testing in the ACNS who have close ties with ABRET… they’re the ones who administer the CNIM exam. Unfortunately, I don’t believe there’s much motivation to do that on the part of neurologists, perhaps because no one wants to rock the boat in the ACNS, but it’s really the only meaningful thing that can be done to raise the bar across the entire profession. Now, I know ABRET is working on an advanced exam for people to elevate beyond the CNIM, but the content is unknown to me, and there’s no telling who will take it, and who will pass it.

Speaking of rocking boats… I’ll tell you where the boat should be rocked… concurrency. I want to share something with you that I read earlier this year. It’s from a 2023 textbook on IONM… a chapter authored by highly respected and influential individuals. The relevant phrase reads – and remember this is a 2023 publication –

“The literature shows good outcome for IONM based on monitoring 1 or 2 or occasionally 3 patients simultaneously.”

It cites a paper from 1995. It goes on to say there is insufficient literature to support monitoring more simultaneous cases due to the effects of divided attention. The potential result, it says, is signal changes may be missed.

Honestly, why is a concurrency limit of “1-2, occasionally 3” being touted as “the norm” in 2023? No one does it, and it isn’t even possible with the number of available neurologists in the context of the volume of surgeries being monitored. Everyone takes on what they are comfortable with, it’s independent professional judgment, and you’re being expected to maintain a practice that is consistent with the results of a survey of a handful of academic neurologists from 1995. Lawyers are using this against neurologists, and the argument is bunk.

Let’s look at how concurrency actually works in the real world, and I’ll use the example that I used earlier when describing the typical day of an oversight professional. In that example, the person started the day with 4 cases – 2 cervicals, a lumbar, and a crani… but those cases don’t have much overlap when it comes to important stages.

So, maybe case 1 makes incision at 7:30, case 2 makes incision at 7:40, case 3 makes incision at 8:00 and case 4 makes incision at 8:05. So, though technically concurrent, the communications, data acquisition, setting of baselines and opening interpretations are staggered and rarely occur simultaneously for the oversight professional. Then, depending on the case type and length of exposure, the surgical stages and associated risks to neural structures are also staggered.

Therefore, while 4 cases might be monitored “concurrently,” each patient is likely still receiving independent attention and data interpretation from the oversight professional during their case’s high risk times while the others are in a low-risk stage. Hell, case 4 might still be exposing when case 1 is closing. Then, when 2 or 3 of the 4 first-start cases are closing (again, variable timing), the oversight professional accepts 2 additional cases which puts their “concurrency” temporarily at 6, but the 3 cases that are closing and generally require very low-attention which allows the oversight professional to focus on the staggered entry of the 2 additional cases to their workload.

This is not like starting 4 movies at one time and claiming you can pay attention to all 4 plots simultaneously; it’s more like having 4 children who were each born several years apart. Sure, you can watch all 4 at one time, and there are certain contexts, depending on the specific child (and age) that may require more or less attention.

It’s interesting to me that this level of concurrency is basically the norm. It’s standard. Everyone does it. Yes, for some unknown reason to me no one has put it into writing. Instead, we’re citing practices from the last century, the last millennium, and acting as if that’s the standard. Someone needs to speak up, speak out, about concurrency. Our profession needs a guideline supporting what is already done in standard practice, and not what a small handful of academic neurologists did 30 years ago. If there’s one thing you all should strongly advocate for in the ACNS, AANEM, ASNM, and AAN it’s a common sense guideline on concurrency. If there’s a second thing, it’s demanding significant improvements in entry-level competency assessment for neuromonitorists.

So, what do you do in the meantime when it comes to interacting with neuromonitorists? Several things immediately come to mind:

  1. Don’t jump to assumptions. Give people a chance to explain their actions by asking “why.”
  2. Have empathy for the NP. The OR is chaos. The treatment is largely terrible, and they’re nonphysicians – often with a bachelor’s degree – stuck between physicians with competing interests.
  3. Understanding/appreciating the “busy time” of the case and limiting rapid fire communications to non-busy times.
  4. Communicate your needs with a why… studies in psychology show strong evidence you’re more likely to get buy-in when you simply explain why you want something done.
  5. Maybe consider the serenity prayer (accept the things you cannot change; change the things you can; have the wisdom to know the difference). If nothing else, it will help to reduce your stress.

I also realize stress and burnout are real issues you all struggle with. As I mentioned in a previous episode, burnout is a byproduct of isolation and loneliness. Whatever you can do to interact with people will be helpful. Go out of your way to do it. Create a network of people you can talk to, and bond with in a meaningful way… particularly within your profession. It will do you wonders.

When it comes to stress, workload, and just trying to manage the sheer volume of cases that need to be monitored, I’ll point out that DABNMs are a viable solution for you, as I mentioned before. Consider implementing a 3-tier practice model. You can monitor more cases and distribute the work accordingly. It’s really a win-win. Obviously, there are regulatory issues to consider. Some states allow you to delegate your work, some don’t, so you need to know the rules, but it’s definitely possible, and it could dramatically improve your stress levels.

When it comes to medicolegal issues, I know everyone gets concerned. I think what makes this more stressful is you hear stories through the grapevine of an attorney making an allegation against a neurologist of having done something wrong. The allegation alone, or hearing someone else’s allegation, can drive one to consider radical changes to their practice… just to make sure you don’t do that one thing in the future… that was alleged to have been wrong. The risk for the physician, of course, is practicing defensive medicine, which can actually look worse under the scrutiny of a savvy expert witness.

I’ve been working as an expert witness for a long time. I’ve worked for plaintiffs and defendants. I’ve done it all, and I’m happy to share some important information with you.

For example, keep in mind that accusations are never made about negligence and malpractice because an accusation is a term used when stating that a defendant is guilty of a criminal offense. By contrast, an allegation is an unproven claim that a defendant has done something wrong, and it’s commonly used in civil cases. The fact is, attorneys make lots of allegations in an effort to support their theories of negligence. They attempt to call your competence and integrity into question by throwing everything at the wall that could possibly, potentially be considered wrong.

That doesn’t mean it was wrong, and it doesn’t mean you should change your practice. I’ll give you an example. Years ago, there was a neurologist who was under questioning in a case that had a negative outcome. The question was raised… why didn’t you order a wakeup test? The question was ask, and the question was appropriately answered. Ultimately, that person was dismissed from the case because plaintiff’s attorney realized there was really nothing to purpose. No worries, right? Wrong. That person went on to change their practice as a result of that single question, and they recommended wakeup tests in every alert in every case after that. And, they recommended to anyone who would listen that they do the same.

Well, this change in practice was met with fury from a surgeon after a wakeup test was recommended following loss of an MEP from the TA with preservation of all other MEP and SSEP data during a posterior cervical when the patient’s head was in pins, and the spine was destabilized. It actually got worse from there, but I’ll keep it that for now. The point is, while you can certainly learn a lot from the terribly stressful experience of a lawsuit, and may consider making some changes to your practice – particularly if they improve your workflow or the overall quality of care, you should not feel the need to adapt your practice in response to every single allegation that gets flung at you, or that got flung at one of your colleagues as heard through the grapevine. Attorneys are just trying to make an argument, and there’s a major difference between allegations made in a deposition, and what constitutes “negligence” and “malpractice.”

By the way, for the general audience or anyone who isn’t familiar with how these lawsuits work, a deposition is essentially a formal proceeding in which someone is questioned by attorneys, under oath, and a record of the questioning is later use in court. People like me who work as expert witnesses read deposition transcripts all the time, and sometimes we’re asked to give our opinions on the case under oath… in a deposition

Anyway, allegations shouldn’t rock your world. I’m sure you all know… if you just do good work, provide good patient care as you normally do, everything will be fine. Seriously. I know some of you will automatically dismiss what I say because I’m not a physician and you believe I can’t understand your world. I’m ok with that, but I’ve done the work you’re presently doing, and I know the med-mal world better than most people working in our field.

So, I was just getting ready to write this post, when I read a daily email that I get from Harvard Business Review. I thought it was so relevant to this topic, so I wanted to include a couple notes from it. The title was: “How to Manage Your Anxiety When Mistakes Are Costly.” It says:

If you work in a role where mistakes must be avoided at all costs (think medical, security, financial, and transportation professions), it’s natural to feel terrified of messing up. But you can reduce both your stress and the risk of making an error. First, distinguish between critical and not-so-critical risks—and focus (most of) your time and energy on the former. Then, rather than trying to reduce mistakes through willpower and perfectionism, adopt systems and sustainable habits to mitigate those critical risks. Enlist support from colleagues to address your weaknesses and pain points. Address any self-sabotaging behaviors, like not asking for support when you need it. Finally, tackle some of the not-so-critical risks—or delegate them—to reduce any potential distraction from the big stuff. Remember, the goal here isn’t to become a perfect person who doesn’t make mistakes; it’s to design a sustainable system around you that diligently reduces risks.

If you want to learn more about this topic, the email was adapted from an article entitled “Managing Anxiety When There’s No Room for Error,” by the very well known and respected Clinical Psychologist, Alice Boyes. I always like the advice they give in those emails.

Anyway, if it hasn’t happened already, at some point in your career, you’ll probably be named in a lawsuit. The approximate odds are about 1:400,000. It is highly probable that you’ll get dropped from the lawsuit… meaning that, after reviewing the facts of the case, the plaintiff’s attorneys find no reason to proceed. If you ever get deposed, it will be a stressful experience, no doubt, but you’ll get through it. I was named in a lawsuit once, but it wasn’t a bad experience for me. My deposition was about 15 minutes long, and I was dropped immediately afterwards. No repercussions except time out of my day sitting around a conference table in a lawyer’s office.

I think I went out for a cheesesteak afterwards… not one of those crappy touristy grease mops from Pat’s or Gino’s… no, I probably went to Delassandro’s in Roxborough. Anyway, I was never really concerned about the legal case, and neither were the attorneys. They said it was obvious from my documentation and communication that I cared about the quality of my work, I gave great attention to detail, and I provided good patient care. That’s the ultimate goal, I suppose… and a high-quality cheesesteak made with thinly shaved ribeye, American cheese, and a nice, soft, fresh hoagie roll.

So, try not to let possibilities drive the bus. Try not to get hung up on the minutia. Just do good patient care, like you always do. Empathize with those technologists who are struggling in their own daily grind. The rest will follow. Teamwork makes the dream work.

Please 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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