[00:00:13] Speaker A: Hey, yo. Today I'm coming to you live and direct from the annual meeting of the North American Spine Society in Los Angeles, California. In my last episode, I mentioned that the fall conference season is in full swing. Today I'm going to talk about that. I'm rich, Vogel, and this is stimulating stuff. Let's go.
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Stimstuffod that's S-T-I-M-S-T-U-F-F-P-O-D.
[00:01:43] Speaker A: Welcome back to the stimulating stuff podcast. I'm Rich Vogel, and I'm on the road like Jack Carawack. I don't have my fancy microphone today, so apologies if the audio quality isn't what you're used to. So, as I mentioned in the intro, I'm out in La. At the annual meeting of the North American Spine Society, and I'm going to talk about my work with Nas today. But first, I want to tell you about my experiences with a couple of other conferences that I had this month. So a few weeks ago, I had the honor and privilege of attending the annual meeting of the Southern Neurodiagnostic Society, otherwise known as Esset, in San Antonio, Texas. It was a great conference, and I'd like to send a special shout out to the Esset leadership, and especially to Claire Gale and Rudy Garza for inviting me. As usual, they had two concurrent sessions, one on neuromonitoring and one on EEG, and those were over the course of two days. And I actually gave talks on both sides on the exact same topic. The talk I gave was one that I conceived several months ago. If you know me well, then you know that one of my passions is empowering other people. That's really one of the most sacred benefits of being a leader, in my opinion. So I'm always thinking about how I can empower others. And with that in mind, I start to think about my skills, like, what are my personal skills, where I really shine, and how I can transfer those skills to other people. And one thing that came to mind was public speaking. I've been doing this for about 30 years, really dating back to my high school graduation speech. And I've gone through formal and intense training in public speaking, and I've given over 200 lectures in my life. And over the past ten years, things have really ramped up as I've given more than 100 invited lectures at conferences I've spoken to live in person audiences both small and large, with up to 2000 people sitting in front of me. I'm really good at delivering a message, I think, and capturing attention, reading audiences, body language and influencing and persuading people. Those are the skills that I wanted to teach other people. So I thought about how many times I've heard people complain that they go to conferences and they hear the same people speak every year and they get bored by that. The fact is, it's really difficult to find people who are willing to speak, and that's a big part of the problem.
So I thought maybe I could teach people, give them the right tools and direction. Help them to understand how to develop and organize a talk. Help them to feel comfortable with public speaking, empower them to volunteer to speak and let them know that they have a voice, an important perspective that people need to hear, and the power to drive change.
All of these thoughts culminated in the idea to give a talk entitled Public Speaking for the Neurodiagnostic Professional. So that's the talk I gave at Esset, but it really applies to anyone, regardless of the space in which they work. I think the talk was a success. The audience was really engaged and I had a lot of people come up to me afterwards and thank me. Not only that, they also told me that they're interested in public speaking and plan to do so in the next year or so. So mission accomplished. I can't tell you how good that makes me feel. I also want to give kudos to everyone who spoke at Esset. It really was a fantastic conference. People put a lot of work into their talks. And as someone who is both a speaker and a member of the audience, I just want to give a shout out to everyone who participated.
A few days after Esset, I had the honor of speaking in a virtual conference, which was the annual meeting of the Rocky Mountain Neurodiagnostic Society. I actually gave the same exact talk there. It's always hard to tell what the audience thinks in a virtual meeting because people don't turn their cameras on. And you really can't read body language the same way you can in front of a live audience. And people are usually less likely to ask questions and they don't really have the ability to come up to you afterwards in the hallway, like at conferences, and share their perspectives. So in any case, that was a great conference too. And I just want to send a big thank you to Chris Halford for inviting me to speak.
Moving on to this week. As I mentioned, I'm out in La. At Nas, the North American Spine Society. It seems like to me a really good opportunity to tell you more about Nas and the work that I do in that society. So let's start, I guess, with what Nas is. And I'm going to read this because it comes from their website. Nas is a global, multidisciplinary medical organization dedicated to fostering the highest quality, ethical, value based and evidence based spine care through education, research and advocacy. The membership is mostly made up of noro and Orthospine surgeons.
And this is not from the website. This is just my personal experience and what the numbers say. But membership is really open to anyone who has an interest in spine care. Membership is actually quite diverse, and it consists of scientists, anesthesiologists, neurologists, PM and or, docs, chiropractors, physical therapists, mid level practitioners, nurses and more.
And while my primary interest has always been related to the brain, it's really in the spine where we do most of our work in neuromonitoring. So I've been a member of Nas for a long time.
I have to say it's really a wonderful community that fosters inclusion and collaboration.
And that's kind of how my involvement transitioned from being a member to being a leader in the organization.
Some of you may know that we have this neuromonitoring section in Nas, but I'm guessing most people don't know much about it. So I thought maybe I'd tell you a little bit about this endeavor, how we got started, what we've done and where things are now.
So in 2017, I attended a local town hall that was hosted by Nas at the Union League in Philadelphia. Also in attendance were Doctors Adam Doane and Nancy Meraki, both of whom would also become founding members of our section, with Adam being my co founder and co chair.
Anyway, so I went to this town hall to network, really, because I have a lot of friends who are spine surgeons and the Union League is actually a really cool venue. But the purpose of the town hall, to my recollection, was for Nas to visit different cities, interact with members at the local level and understand how Nas can better support its membership. So I'm at this thing, and after some socializing, we sit around this really long table. And the conversation was led by a friend of mine, Dr. Tod Wetzel, who was an orthopedic surgeon at Temple University Hospital at the time before he moved on to Cooperstown, New York. He went around the table and he gave everyone a chance to speak. And when it came to me, he introduced me to the group and said something about my role being somewhat different because most of the people in the room were surgeons. He then turned back to me and said, rich, what can Nas do for you?
And I was actually really honored to be asked that question.
So I took the opportunity to talk about how the neuromonitoring community had just celebrated the 40th anniversary of the first neuromonitoring publication in Spine at the ASN M annual meeting in Cleveland. Again, this was in 2017. I talked about how neuromonitoring used to be collaborative between surgeons, anesthesiologists and neurophysiologists neurologists, but I thought those collaborations had fallen apart over the years. I talked about the major shift that had occurred from in house to outsourced neuromonitoring and the systematic marginalization of the service.
I talked about the importance of getting clinical outcomes data, evaluating the literature to see where neuromonitoring was truly useful, effective, valuable, and cost effective. And I sort of turned the question back. I said, how can we collaborate? How can we share our knowledge about neurophysiology of spine care with the Nas community and break down those barriers?
And Dr. Wetzel turned to the group and said, this is a perfect opportunity to create a section for neuromonitoring. He went on to explain Nas governance, how there are councils and committees and sections. And just so you know, examples of other sections include mis, surgery, access surgery, spinal deformity, spinal oncology, biologics, robotics, and others.
A section devoted to neuromonitoring would, in my mind, give our community visibility in Nas and provide the ideal avenue for collaboration between the neuromonitoring community and the spine surgery community. So over the next year, the neuromonitoring section was created and formally approved by Nas, and we wrote a mission, and I'm going to read that mission here. The Nas section on neuromonitoring represents the breadth of clinical and scientific specialties sharing a common interest in the application of neuromonitoring for nervous system preservation during spine surgery. Dedicated to advancing high quality ethical evidence and value based neuromonitoring for patients and other stakeholders. Develops and participates in educational opportunities for dissemination of knowledge regarding best practices related to neuromonitoring. Advocates for practice models that maintain quality and reduce costs in the ever changing healthcare environment.
So the Nas section has been very active in educating surgeons about neuromonitoring and representing the efficacy of neuromonitoring relative to surgical procedures of the spine. Our section has been, frankly, the most active and productive section in Nas, a model to other sections, and it really does serve as a source of pride for the North American Spine Society. In fact, I had a wonderful conversation with a member of the Nas Board of Directors just last night who was just gushing over how successful our section has been and how proud Nas is of all that we've done. So I was thinking in this episode of the podcast, I thought, well, maybe I'll give you some examples of our accomplishments.
We organized and hosted seven neuromonitoring symposia, mostly at Nas annual meetings, but also including one in Antwerp in 2019 at the World Congress on Low Back Pain and Pelvic Girdle Pain. In fact, the symposium that we did just yesterday, nas told us that we had the highest audience engagement of any symposium at the entire conference. I mean, just amazing.
We produced 29 podcast episodes on the Nas podcast channel, and leaders in Nas tell us that it is by far the most listened to podcast that Nas produces.
Our group is giving 15 international lectures. We've published three papers in the Spine Journal and four articles in Spineline, which is a Nas publication for its members.
We've organized one Webinar style symposium on the medical legal aspects of neural monitoring that, to this day, is the most widely attended Webinar that Nas has ever hosted. We've done at least four Ask the Experts videos, which are available on YouTube, and we just recorded another one yesterday on neuromonitoring and intramedular spinal cord tumor surgery with Dr. Larry Lowe. Our section has engaged with payers insurance companies like Cigna who don't want to reimburse neuromonitoring and risky spinal procedures. And we've been the driving force behind letters written to Cigna and others from Nas, the Scoliosis Research Society, the Cervical Spine Research Society, and the American Academy of Orthopedic Surgery. In fact, we've had some success with this stuff. Cigna recently agreed to update their coverage policy on neuromonitoring to reimburse the service in surgeries that include diagnoses of OPLL and myelopathy. Collectively, over the past six years, we've educated hundreds, if not thousands, of spine surgeons from the US. And around the world about how neural monitoring works, how it's optimally performed, and what the benefits are to comprehensive spine care. Oh, and on top of that, we advocated for developing evidencebased coverage recommendations for neuromonitoring, which no other society has ever published in the history of our profession. And we did this at a time when the entire neuromonitoring community was beginning to struggle with declining reimbursements. So that's what I want to talk about next these coverage recommendations, what they are, why they're important, and why there's been so much buzz about them in the neuromonitoring community over the last month or so. But first, let's take a break for a word from our sponsors.
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[00:20:57] Speaker A: And we're back. If you've really had your ear to the ground over the last several weeks, you probably heard some rumblings about the draft neuromonitoring coverage recommendations from the North American Spine Society. So what are coverage recommendations, and why are they important?
The project is essentially a systematic review of the literature that culminates in evidencebased recommendations to insurance companies regarding circumstances under which the evidence in the literature suggests use of neuromonitoring is warranted, and importantly, by extension, when insurance reimbursement for neuromonitoring services is warranted. When Nas publishes these recommendations, every insurance company in the country uses them to develop or update their coverage policies. In an era of plummeting reimbursements, this may actually be the single most important project that has ever been done in the history of Nord monitoring. Again, as I said before, no other society has ever done anything like this. And there's two critical variables that make Nas a great vehicle for such a project. First, they are largely considered to be a neutral organization, devoid of any political agendas.
And second, they have their own evidence grading system that is considered to be rather strict and empirically sound. So now I want to share some background info about these coverage recommendations.
Several years ago, I saw an announcement from Nas that they were planning to develop and publish coverage recommendations on neuromonitoring. So I reached out to the Nas coverage committee and expressed interest in being involved. They were excited by this, and I was paired up with a surgeon who was going to work on these coverage recommendations for a project connected to her master's degree program.
So Nas then went and pulled thousands of abstracts that are essentially article summaries that are about neural monitoring and the surgeon and I basically split the duty of going through every one of them to determine if the paper was relevant or not. And we sort of just took them and put them into piles. Okay, this is relevant. This is not. And then after that, we sorted the remaining abstracts into topics like degenerative, deformity, tumor, et cetera, and that's basically when the project died because two things happened. First, the surgeon bowed out because it was a ton of work that she just couldn't commit to. And I kind of felt the same way. So we paused. But second, COVID hit and everything in the world just shut down, including this project.
Then it came time to revamp the project, and our section was contacted to see if anybody wanted to participate. And I bowed my head down and said, no, thank you. I declined. But two of our members volunteered and they dug in and did a ton of work on this, and they really are to be congratulated for their efforts.
Our section, frankly, went on with our normal business, like organizing symposium, podcast, et cetera, while the two members of our section worked in the background, essentially reporting to the Nas Coverage Committee, although I really don't know how much involvement the committee had.
Anyway, at some point I remember hearing the initial draft was done and had been submitted to the coverage committee, and some time passed. And suddenly last month I got an email, along with all other members of Nas announcing the release of the draft coverage recommendations, which were published online for public comment. And it's really the final stage of the process. The comment period is open for 30 days and then the comments are reviewed, edits are made, and the final product gets posted on the Nas website, where people or organizations, mostly insurance companies, can purchase it for a fee. So what's all the buz about? Well, there's a subsection in this document called Provision of IONM and it reads like this. It says, multimodality IONM should be performed by a credentialed technologist and overseen by a physician with training experience in IONM who is not the operative surgeon or anesthesiologist or a doctorate level professional who is board certified to interpret IONM signals and supervised technologists, end quote. Later in the document, it references the as M practice guidelines for the supervising professional. And it goes on to say, quote, and this is kind of long here, so I'll let you know when it's done. But it says the ASNM guideline recognizes AMA Policy h 410 nine five seven that the supervision and interpretation of intraoperative neurophysiologic monitoring constitutes the practice of medicine, but also recognizes that the delivery of professional IONM is within the scope of practice of non physician IONM. Doctorate level professionals who are board certified in professional IONM and are privileged at the facility. Professional IONM supervision is within the scope of practice of persons with doctorate degrees in parentheses, PhD, AUD, or DC and parentheses who are diplomats of the American Board of Neurophysiologic Monitoring Dab, Ms, or board certified specialists of the American Board of Intraoperative Monitoring BCS IONM. End quote.
And that's really what caused all the buzz, because the as M has been on record multiple times stating that neuromonitoring is the practice of medicine that must be ultimately supervised by a physician, and this is in perfect alignment with the positions of other societies like Aan, the American Academy of Neurology, ACNS, Asset, and Aan.
But the wording of this document, the coverage recommendations, made some people think there was risk to their scope of practice protections, and rightfully so, in my opinion. If I were a physician, I wouldn't be happy with the wording in this document. So here's the thing. I don't think the writers were intending to undermine physicians. In fact, I know they weren't. One of them is a neurologist. What they were attempting to do, and what they've told me that they were attempting to do, was to not undermine some of the non physicians, and particularly audiologists, who presently oversee and interpret IONM within the legal scope of their practice in some states and who are presently reimbursed for their services by some payers. In other words, the writer's intent wasn't to exclude physicians so much as it was to include or capture what is presently and explicitly permitted by some state laws. So the intent was positive, but the fallout was nuclear or nuclear, as they say in Texas.
I'm assuming a lot of people probably don't know that multiple individuals and societies actually submitted comments to Nas regarding the draft coverage recommendations. And the ASNM was one of those societies. And my name is on the letter that recommends correcting these statements or removing the section about provision of neural monitoring entirely. After all, the document, these coverage recommendations, they're supposed to be evidenced based recommendations, and there's no empirical scientific evidence that any one person or profession should or shouldn't be doing any specific job in any division of neurodiagnostics. It really just comes down to the fact that the overwhelming majority of people in our profession agree that neuromonitoring is the practice of medicine.
Unfortunately, I took a lot of blame for all of this, both publicly and privately, for what was written in the draft Ion M coverage recommendations, because a lot of people assumed they were written by the Nas Ion M section. And the fact is that I am the public face of the IONM section because I'm a co founder and co chair, and I write and speak publicly about our section, mostly because I am so very proud of what we've done for the spying community. And I gave you some examples earlier.
I think a lot of the misinformation that circulated about me has been cleared up, and I will say that there was a while there where I was upset by all this, not because I was taking the blame. I mean, taking the blame is just something that comes with leadership in general. But I was mostly upset because not one single person reached out to me for clarification to understand the facts of the matter. And it's not like I'm hard to reach. I'm a public figure, for better or for worse, so everyone knows how to reach me, but I have two PhDs, one in neuroscience and one in psychology. And the psychologist in me should know, does know that that's just how people function as they go about their lives on this pale blue dot of a planet.
Anyway, I'm over all of that now, I admit I get a little butthurt sometimes, and that's because I'm a human being with feelings. It is what it is, as they say. And sometimes I have to remind myself that this too, shall pass. I have the Latin phrase amorphati tattooed on my arm. Look it up. It's not because I'm good at living amorphati. It's because I strive to be good at living it. And sometimes I need a reminder that some negative circumstances are inevitable and inescapable. And sometimes the only option you have is to embrace the fate life has given you.
Well, I hope you enjoyed this overview of conference season and Nas and all the things that we've done in it and what's happening with the coverage recommendations. That's it for today. Thank you so much for listening. Please continue sharing this podcast on socials and through word of mouth. I really do appreciate it when I see people sharing my episodes. Also, many thanks to everyone who's been sending me emails and texts. I love reading your comments. Please continue sending your comments, insights, critiques, pushback, validation, and thought provoking questions to [email protected]
I always love hearing from you. I'm Rich Vogel and that was stimulating stuff.
[00:33:25] Speaker C: The information and opinions provided in this podcast are those of the individual speakers and do not represent the opinions of their employers, affiliates, or other third party individuals or organizations. Sponsorship and other advertising messages do not constitute support of or preference for specific products or services. This podcast is not designed to and does not provide medical advice, diagnosis, opinion, treatment or services. This podcast is host and all participants, including guests and sponsors collectively. Participants provide general information for entertainment purposes only. The information provided in this podcast is not a substitute for medical or professional opinion and you should not use the information for that purpose. Participants shall not be held liable or responsible for any advice, course of treatment, diagnosis, or any other information, services, or product you obtain or render. This podcast should not be used in any legal capacity whatsoever, including but not limited to establishing a standard of care in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the podcast. Thank you for listening.