"Trolls"

Hey everyone! The title of this episode is a joke, a nod to Joe Hartman who claimed to be my first troll on LinkedIn. I love trolls! They give me energy, like Red Bull. Today is all about listener feedback. I’m Rich Vogel, and this is Stimulating Stuff. Let’s goooooo! -- Welcome back to Stimulating Stuff. I’m Rich Vogel, and you are.... I don’t know. I need a name for you all. You know how there’s Swifty’s, Beliebers, Directioners, Mahomies and Katy Kats...? What should I call you? Send me your comments. OK, so today I’m reading the mail. This is an opportunity for me to share with my listeners feedback that I’ve received from some of you on recent topics. I really want you all to get a balanced perspective, and hear what others think. This is supposed to be a conversation, after all. I want my listeners to know that you can write to me with anything, and I’ll never quote you unless you ask me to, give me permission to, or if you write something publicly on socials. Let’s jump in. The first listener will remain anonymous. This person says… I think I do an okay job of getting newcomers in the field super psyched about absorbing as much info and training as possible, owning their craft, and taking pride in their work and growth...and then they get into the daily grind surrounded by their elders in the industry doing sub-par work, and they quickly become jaded wondering why their ambition would matter. They are surrounded by that mean of the bell curve you reference. But does the root lie within us – the educators? I think it's cultural - in some areas surgeons are running a factory that rewards efficiency without hiccups. This means people who are super fast with electrode placement and do the same cases the same way day after day without questions...these are our WEAKEST technologists (the weakest students who barely know their anatomy) who consistently get praise from surgeons for being great. What does "great" even mean? Their bosses and their bosses' bosses love them too, because all they hear is great, great, great from the customer, and all they see are dollar signs. So it gets perpetuated while the super intelligent ambitious superstars ask me for recommendation letters to medical school - and I gladly write them as I develop my own sense of apathy. Daaaaaaaaang!!! There a so many great points in this email. So, the next question we have to ask ourselves is “who sets the bar for quality and competency in IONM?” I mean, the surgeon orders IONM, the hospital contracts with the technical services company, and that company contracts with a neurologist, or maybe they employ a neurologist. So, the hospital and surgeon are ultimately the client… the customer. If the surgeon is happy with the service they’re getting, if the bar they set is “quick setup and no disruption of surgery,” then that’s the bar, right?? So, what if a neurologist sets a different bar, one that focuses on quality of IONM and competency of the neuromonitorist? And, what if this bar produces the very “disruption” that the surgeon, the end-user, the “client,” the “customer” wants to avoid? This probably happens more often than everyone appreciates, and it’s exactly what I was talking about when I said neuromonitorists are often caught between physicians with competing interests. It’s a really difficult position to be in. Who do you focus on making happy when it’s impossible to make everyone happy. I think most neuromonitorists would choose to make the surgeon happy because that’s their client. … But, most neurologists would want to be one chosen to be made happy because they’re the ones providing oversight and ultimately responsible for IONM. There’s no perfect decision for the neuromonitorist, and that’s part of what makes working in that role so difficult! I often think… you can never make everyone happy. Sometimes the only goal is to keep them all from being so angry. So…. the reason we have people in this field who don’t know their anatomy, who don’t have a great understanding of what they’re doing… who don’t have all the basics that I listed in my third episode, is because the surgeons ultimately set the bar. That’s one of the reasons I got involved with [NASS] years ago. It was obvious to me that the real decision makers in IONM are the surgeons. And, if you ask surgeons who makes the decisions about IONM… including when and how it is performed, many strongly believe there’s only one cook in the kitchen, and it’s them. So, in NASS, we try to educate surgeons about IONM. What makes for good, high quality IONM? When should it be used, and why? We try to drive change there, because that’s who ultimately determines where that bar is regarding the quality and competency with which IONM is performed in their OR. One of my favorite quotes is, “Whatever you’re not changing, you’re choosing.” Not sure who said that, but I definitely believe it. We’ve made some great strides in surgeon education, and particularly through NASS, but there’s still much work to be done. OK, on to my next feedback email… This listener will also remain anonymous. Here’s what this person says… I really like the podcast. I think the presentation is good, and professional. However, I think you take some things too far. I don’t think the reality of the collective field is as bad as you say it is. For example, I don’t think the majority of neuromonitorists have bad relationships with surgeons or get yelled at. Some do, but most don’t. Also, the for-profit companies are part of the problem, but so are the in-house groups and the professional societies. I’m willing to bet that the larger IONM companies out there have better education and training programs than any in-house program out there. Also, the oversight professionals are probably as much or more to blame than any group out there. You mentioned your meetings with Cigna representing the IONM field, and the fact these letters to payers are written by surgical societies… you’re doing all this extra work when you don’t even directly benefit. There are very few oversight professionals actively engaged in making things better. Wow, great feedback. There’s a lot to unpack there. Let me first acknowledge that I do take some things too far. To be perfectly transparent, my goal in the first few episodes was to be strategically, and carefully controversial. You sorta have to do that if you want to get people talking about your podcast, if you want to build a listenership. When I share my email at the end of each podcast, I’m putting it on you, the listener, to challenge me. Let’s talk about this stuff. I’m an open book! That being said, I totally agree that most neuromonitorists don’t have a bad relationship with surgeons or get yelled out. It certainly happens, but it’s not the majority. I do think most are treated like reps and are largely marginalized by the experience of not being made to feel like they are part of the team. Have you ever met anyone working in IONM who feels that wearing those paper scrubs and red cap has been helpful in any way? Probably not. I only think it serves to marginalize. I would also agree very strongly that the larger IONM companies have the best education and training programs out there, and that those programs have become increasingly sophisticated over the years. I also mentioned a lack of high quality research in previous episodes, but I’ll point out that some of the best research has come out of the larger IONM companies who are able to leverage their databases for research. I mean, when I was in that meeting with Cigna, at least 2 or 3 papers by Bryan Wilent were cited by surgeons or neurologists as evidence for the utility and benefit of IONM. Larger companies have the infrastructure and resources to deliver high quality research and education at scale. I think that’s wonderful. I also think people don’t take advantage of the education like they could or should. In a previous group I worked for who is no longer in existence, we gave the entire company annual memberships to ASET and ASNM, and we gave all employees the ability to attend one conference in person per year, all expenses reimbursed. Less than 10% of the employees took advantage of those benefits. On a similar note, some of the professional societies have very high-quality continuing education, but participation isn’t what it should be, so few people overall benefit from this, and that perpetuates the problem. Regarding me and a small group of other nonphysician doctors being the ones representing physicians. You know, I will be perfectly transparent and say that this has vexed me a bit over the years. On the one hand, we’ve historically not been considered “professionals,” while on the other hand, we’ve been the face of IONM in fighting these changes in professional reimbursement – as my listener noted, when we don’t even benefit directly. In addition to being the face of the effort, we’ve also been the authors (often working as ghost writers) of multiple letters, literature summaries, and other position statements that have come from the neurology societies. Sometimes, when they need something written, they come to us nonphysician doctors. I’m not saying we write everything, and I’m not saying we represent everything, but we’re there… always… either being the face, or working behind the scenes to support and advance this profession. I’m not saying this to be controversial, to tout my own efforts, or to detract from the efforts of others. It’s simply a matter of fact. And, the people who are listening who are very well aware of this would be right to question my motives and my legitimacy if I didn’t acknowledge this publicly. So, in the spirit of total transparency… Yes, I do a lot of this work, I wish people would acknowledge this work, and I wish more people would get involved. But, this is just how things work. It simply is what it is, and wishing isn’t a strategy that has ever worked for me. The last point my listener made was there are very few oversight professionals actively engaged in making things better. I would agree, but I would also counter that there are very few neuromonitorists doing the same. If you look at the number of OPs and you look at the number of NPs, I’d be willing to bet the percentages of people who are working to make things better within those groups are probably the same. It’s always a small percentage of people who are willing to do the lion’s share of the work. The next listener says… I noticed you use the term “neuromonitorist” in referring to CNIMs. I never heard that word before. Where did it come from? I just made it up. I know there are people who are uncomfortable with technician or technologist, and there are people who are uncomfortable with NP or SNP. Also, the department of labor has very specific definitions for technician or technologist in healthcare, and people don’t fall into those buckets. Technician: academically, has no more than high school degree, and may possess additional certification. Technologist, has no more than a master’s degree, and may possess additional certification. The nonphysician doctoral CNIMs don’t fall into these categories. So, I thought neuromonitorist was the most neutral word I could come up with. OK, let’s take a quick break here for a word from our sponsor. -- And, we’re back. I’m reading the mail today and responding to some of the questions and comments that came from my listeners... The next listener says… What are your thoughts on the new guidelines on qualifications for neurodiagnostic professionals? Great advancement for our field when there’s a lot of confusion surrounding nomenclature for different roles, and what the pathway is to advance. Also, a great advancement because it was a collaboration between 4 societies. I also know it’s not perfect. It doesn’t fit well with the outsource neuromonitoring model, and there’s lots of confusion around the CNIM. I do know it is a living document, which is intended to be continuously updated over time. So, if you have confusion, or if you’re looking for specific updates in the future, talk to the leadership in your favorite society... ASET, ASNM, ACNS, AANEM. The next message comes fromJoe Hartman … Just to be fair to the listener who didn’t see the whole post, I cut some out for brevity. In general, Joe seems to believe we’ve gotten better at (what we often call) the technical aspects of IONM over time. He says... We've always been on a bell curve. There used to be fatter tails and less curve, but that's actually worse. The entire curve shifted towards an area of improvement and the tails got skinny. It's harder to be exceptionally good or bad. Today, information is much easier to access. Plus, our equipment is less likely to cause as many issues, which is where the experience really pays off. There's less need for long training programs (but more than what's currently happening, for sure). He goes on to say that... More is placed on the individual. Each individual has to recognize all the resources available to them plus the restriction placed on them and their company. And where should things be going? Comparing what we had (didactically starved, computer novices, and experienced rich) vs what we have today (didactically strong, computer literate, and experienced poor), the solution seems to be more along the lines of developing simulations over creating a new certification. Well, there’s a lot to unpack there, too. You know, I like the idea of simulations to train people. While I believe the larger companies with big educational infrastructures are didactically strong, the majority of the field just doesn’t have resources. I mean, there are people out there that don’t know professional societies even exist, they aren’t aware of text books, articles, etc., etc. The majority of the field may be computer literate, but there are definitely people out there that don’t know how to display data, perform basic troubleshooting, communicate with OR staff, document cases, etc., etc.... all of the basics I mentioned earlier. So, if these things are happening, literally every day, then we’re not didactically strong because people aren’t learning how to do the job. Again, I’m not talking about everyone. There are great monitorists out there, but I don’t agree with Joe when he says the competency curve has shifted for the better. OK. That’s it for the mail today. A very special thank you to those listeners for sharing their thoughts. Please continue sending me your comments, critiques, and thought provoking questions. If you don’t agree with me, please share your perspectives. I’m not the final word on anything, and I really want this to be a group conversation. Again, don’t worry, I won’t quote you unless you ask me to, or if you grant me permission. You can send your thoughts to [email protected]. I’d love to hear from you! I’m Rich Vogel, and that was Stimulating Stuff!