‘Embrace the diversity’

In the information age, where social media is anything but representative of reality, Dr. Richard Vogel is certainly something of an ‘influencer’.

Hailing from Philadelphia, Dr. Vogel was in Australia as one of three international speakers invited to speak at a conference hosted by the University of Sydney in 2019 centred around ‘Intraoperative Neurophysiology’ (IONM), which involves the application of electrophysiological testing during various surgical procedures where there is a risk of neurologic injury. I was fortunate to sit down with Dr. Vogel prior to the conference during an impromptu, sit-down interview on campus.

Rich is the proud owner of two PhD’s; one in psychology and one in neuroscience, and recently served as the President of the American Society of Neurophysiological Monitoring (ASNM), Director of Strategic Projects at NuVasive and is currently the President and CEO of Neurological Monitoring Associates LLC. Dr Vogel is also an examiner of the American Board of Neurophysiological Monitoring (ABNM), co-chair of the neuro-monitoring section of the North American Spine Society (NASS) and an elected board member of the ASNM. In the last ten years Rich has been a vocal advocate of proper scientific practice in IONM, where there are a number of grey areas concerning who can and cannot perform these highly important tests. Indeed, his advice is essential for the small but rapidly growing IONM industry in Australia. However he almost didn’t make it to Australia thanks to a visa-hiccup.

Fortunately, and in stark contrast to the border-security tactics currently employed amidst a global pandemic, Rich was able to land a visa almost instantaneously. ‘It would’ve taken at least six months for this to happen in the U.S.’ I quipped that if we can ‘strongly encourage’ Johnny Depp and Amber Heard to promote our biosecurity laws, why wouldn’t we have efficient visa application process. Fast- visa-action aside, this is Dr Vogel’s first time in Australia. Being forced to undertake a breathalyser test before reaching the summit of the Sydney Harbour bridge was a particularly strange instance for Rich, but a necessary foreshadowing of the social side of the conference that would follow. His journey towards Australian shores is one worthy of exploration. As a young professional, Rich recalls the moments that defined his ambition.

‘I think I had two moments of clarity. One of them was when I was working in bench science, and I realised… the type of work I was doing was not where I wanted to be. I wanted to be doing clinical work. In my graduate career I was doing micro-electrode recording in rabbits. I would do surgery to implant

the electrodes into their brains and watch the patterns of their cells change over time as they learned’. Rich then went down the path of genetics. ‘No offence to anyone out there in genetics, but it just wasn’t my thing’. His moment of clarity, the moment he realised his calling, was when he decided he had journeyed too far from the problem he originally set out to solve — patients suffering from Alzheimer’s Disease. ‘By the time I went through graduate school and ended up in a post-doctoral program, I was studying mental disorders but it was in genetic mouse models…I wanted to get back to clinical work’.

Generally speaking, IONM is employed in various surgical procedures that place risk to the human nervous system. This ‘risk’ refers to the potential damage to neural structures in the brain, spine and vasculature systems that can result debilitating conditions for patients, and can sometimes jeopardise a patient’s quality of life. Brain mapping, in particular, refers to the electrical stimulation of so-called ‘eloquent’ areas of the brain’s surface that are responsible for various function. There are well- understood cortical regions that permit us to move, feel and speak. However we still don’t have a comprehensive understanding of the neural networks involved in higher-order, complex cognitive functions, such as creativity, arithmetic, and multilingual networks. When brain cancer, in the form of tumours, invades these areas it can result in serious infiltration and disruption of these functions. Patients often present with seizures, difficulty speaking, or problems with movement. Surgery to remove these tumours must carefully ‘map’ and monitor these neural networks, which can be a very rigorous procedure.

‘The first case I ever saw, was a brain mapping case’. Rich is quick to point out that he was in observation-mode only, under the tutelage of Dr Jeremy McCallister. ‘The level of control over the direction of the surgery, and the interaction between him and the surgeon as two members of a team with a singular focus…I’d made a very big decision to make a leap at that point, but it was the moment that I knew that I’d found what I wanted to do’.

There is a distinct contrast between Dr Vogel’s clinical aspirations involving Alzheimer’s Disease and his research experience in rabbit models of mental disorders, and genetics. I suggest to Rich that perhaps he finds comfort or satisfaction providing meaningful intraoperative information that aids in the safe removal of tumours, which directly contributes to an immediate and positive clinical outcome in patients with brain cancer. ‘Absolutely…spinal cord stimulators, you turn them on and a patient’s intractable pain is suddenly treated. Microelectrode recordings, you know, you place a DBS (deep brain stimulation) electrode for Parkinson’s…and the tremor stops — it’s immediate.’ Fortunately for Dr Vogel, there may be an opportunity for his original dream to come true, with advances in neuromodulation technologies now targeting parts of the brain to reduce or reverse the devastating symptoms of dementia and Alzheimer’s, ‘that would bring me full circle from many years ago’.

Training programs and standardisation of approaches to IONM are variable around the world, and there is also widespread diversity of the backgrounds of those involved in IONM, which varies from neurology,

clinical neuroscience, chiropractic medicine, audiology, anaesthesia, and other various and sometimes non-tertiary backgrounds. Early on in our conversation, Dr Vogel was enthused to announce that he is still learning after ten years in the field, a sentiment I wholeheartedly share myself. Despite the vast and complex learning of how the human nervous system can be recorded and modulated, it is not uncommon for practitioners to embrace the ‘see one, do one, teach one’ approach to clinical education. Further to this, advances in surgical technologies has contributed to the development of ‘surgeon- driven’ systems, which negates the requirement of scientist or technologist to generate, interpret and communicate neural signals during surgery.

‘Neural monitoring is only forty-three years old as a profession’, Rich recounts. Though he is quick to acknowledge that there are numerous events or publications that can be recognised as the genesis of clinical neurophysiology applied within surgical settings, some as far back as the 1800’s. ‘In the U.S., there are in-house academic units that work as a single-unit in the hospital, then you’ve got outsourced groups. And those outsourced groups can be private practice or corporations that range from small to large…some of the larger corporations have 550 clinicians that are covering over 100,000 cases a year. For me, we had a twelve month training program, the first 6 months of which were 2–3 days in the classroom, and 2–3 in the operating room. After 6 months it was the OR every day, and after a year, you start to become independent’.

Several years into his neural monitoring career, Dr. Vogel’s advocacy efforts culminated in an independently-run blog. I suggested that it’s sometimes possible for scientists and medical professionals to use industry guidelines defensively, which can inhibit learning or analytical thinking in emerging fields. In IONM, this theory might explain why his blog was so successful — and controversial. Rich describes why he started the forum that created a much-needed commentary on the ambiguity of expertise in neural monitoring; ‘two reasons. First is passion; I love to teach and I love to write. This gave me the opportunity to do both. The second was that I had come from a private practice that was a ‘trade-secret’ group. We were always told we were the best. If that was really true, we didn’t want to tell people how we were really doing things because then they could learn it and steal our business.’ A far-cry from the teaching prowess Vogel has since become recognised for.

‘One thing I noticed, when I got out of that microcosm, was that…most people didn’t have resources for learning. None. All across the country there were technologists working in hospitals, they don’t have continued education. They don’t have access to articles. There’s nobody there teaching them anything, at all. And they’re starved for information.’

‘Not only that, I started to see that the rest of the monitoring in the U.S. was really bad. I’ve always made decisions for patients first. The patient is the centre of everything. What decision am I going to make today or tomorrow that benefits patient’s in general as it relates to neural monitoring. So that was a big reason for me to start that blog, because I realise people needed some resource to learn

something about neural monitoring. And I think that’s how I ended up with two thousand readers a month. Every time I published something it just exploded.’

Despite the importance of preventing or reducing the incidence of neurologic morbidity, the U.S. government does not subsidise the cost of IONM in hospitals. Australia’s own Medicare doesn’t either. This is largely because IONM has not been validated by ‘level one evidence based medicine’, wherein there is no data to support the hypothesis that it is impactful in reducing the incidence of surgical injury of the nervous system. It will likely never happen, as it would require a large scale randomised control trial. This would involve one group with spinal tumours with monitoring, and another spinal tumour group without it. It’s unethical.

Fortunately, neural monitoring is still endorsed by a number of reputable medical advocacy groups and societies. Scientific literature describes the use of IONM as having either interventional, diagnostic, therapeutic or medicolegal value. It’s easy to link the latter to the abundant litigious happenings in the U.S., even if this is stereotypical. However the application of IONM has been steadily on the rise around the world in the last decade, including Australia. This continued growth is likely related to the increasing ageing population, however Rich suggests that a significant portion of surgeons would probably use monitoring primarily for medicolegal purposes. In doing so, surgeons demonstrate that all safety precautions were employed to reduce the risk of injury. ‘There are a number of surgeons that will tell you that it is of tremendous benefit to their practice, but there are (also) a number of surgeons who would prefer to go without it, I’m sure’. There is more at play here, with a handful of American enterprises under scrutiny for ‘kick-back’ arrangements. This has created serious implications for clinical education. “Reimbursements (for IONM) have changed in the United States. We don’t have the ability to train people for a very long time. You know, what used to be a year’s worth of (classroom) training might now be four weeks of training…still, there’s a ton of variability”. This is more eloquently affirmed in Dr Vogel’s presidential address to the ASNM earlier this year. ‘You cannot take someone from behind the counter of Jimmy Johns, give them two weeks of training and stick them in an operating room, running electricity through patient’s brains. That’s just unethical, and it should be illegal. I don’t give a damn if they have physician supervision or not — it’s wrong’.

‘As the ASNM President, one of the things I’m trying to do is get everybody on the same page of what we need to do to make some meaningful changes and move forward, to advance our profession’. This lead me to the penultimate question; what can Australia learn from the growth of IONM in the U.S?

‘Embrace the diversity.’

‘We had a group of people who have essentially founded the profession of monitoring in the U.S. They had no idea what they were doing, but they knew neuroscience and they knew how to build stimulation and recording equipment. So they took these giant refrigerator-size computers into the operating room

and the recorded one channel of SSEPs (Somatosensory Evoked Potentials, a measure of sensory function in the spinal cord) during scoliosis surgeries. It advanced from there. They went into work every day, scared to death that something would go wrong, and they learned from the ground up. Anyone that was interested in it, became an expert in it.’

‘Then one day it became a money-maker. All of a sudden there were people interested in it for financial reasons. In the United States, when neural monitoring became the practice of medicine, it was done for financial reasons. It wasn’t done for patient safety reasons — this is all documented. But unfortunately, the founders of the field — the very people of who were in the operating room who learned, who developed these techniques, were suddenly marginalised. They were suddenly no longer considered to be the people who were competent. It’s really unfortunate”. Rich suggests that the industrialisation of neural monitoring is one of the core contributors of disparity, but also because a dividing line was created among practitioners wanting to claim ownership.

‘We never embraced the diversity. We never stepped back and said ‘you’re an expert in this, you’re an expert in this, let’s all work together and create a new field.’ It’s something of a crippling moment for Vogel. ‘If I were to go back 20 years and change the direction of the field, it would’ve been to embrace the diversity’.

Dr Vogel also recognises that this marginalisation of expertise was perhaps a major contributor to a professional model that mightn’t favour the accountability of practitioners. ‘People practice in such a way that you get a technologist in the O.R. who really doesn’t need to know anything because they’re being overseen by a physician somewhere’.

Remote oversight, contemporaneously categorised under ‘telemedicine’, is something of a standard of care in the U.S. In short, there’s a neurologist, physician, or an M.D-equivalent somewhere in the hospital, or 5000 kilometres away, looking at one or multiple screens. This physician is responsible for looking at these screens and interpretation of signal change during surgery. This is not a model that has been reproduced in Australia. Whilst this may be surprising to readers who recognise the substantial liabilities involved in a model purportedly designed to reduce liabilities, it is widespread in the U.S.

The overseeing physician, sometimes in a different state, also receives financial reimbursement from the insurance companies despite not having to step foot in the operating room — but only if there’s ‘meaningful dialogue recorded in a web-based chat’. Dr Vogel is quick to highlight that, in his experience, there was rarely any meaningful dialogue that assisted his training or practice. It is just a standard that is accepted, and one mandated by insurance companies who incur the cost of monitoring during surgery.

‘One of the arguments for remote oversight is that it helps to deliver care that would not otherwise be available to remote regions’. Rich agrees that whilst this approach might actually have merit, oversight shouldn’t be introduced as a measure of accountability. ‘No matter how junior or senior you are, you’re always going to come across something…either it’s a problem you don’t know how to solve, or it’s a data change you don’t know how to interpret because there’s just something you’ve seen, that you’re questioning. It might not happen every day, it might happen every six months or every few years…there’s always somebody you can reach out to. But you don’t need 24/7 surveillance.’

Practical competency in IONM involves preoperative planning, accurate placement of electrodes, generation and optimisations of signals, interpretation of signals and signal change, communication with the surgical team, and intraoperative annotation with postoperative documentation. There is a stark difference in placing electrodes on a patient and pushing ‘go’, and providing a meaningful contribution in the O.R. ‘In order to become competent in neural monitoring, you need to be able to answer the most important question…why? Why do you use certain filters? Why are you doing this test? That shows that you’ve conceptualised what you’re doing. You’re going from a trainee that’s process-oriented to showing that you understand why the patient is having surgery, why the surgeon is doing this, what is the risk, what modalities should I be using in order to monitor the risk, and what is the neurophysiology behind the testing. At the end of the day, the only people I would trust to do the monitoring of me, if I was going under the knife, are the people who have conceptualised their work’.

Marginalisation, corporate-political conflict and ethical ambiguity are the hallmarks of an industry that is confused. ‘What’s killing neural monitoring is a lack of professionalism, a lack of experience and a lack of education’. In combination with the concerns Dr Vogel has put forth in his address, there are pressing issues concerning standardised clinical education and certification, prerequisites to procure that education, subsequent accountability in the O.R., meaningful contributions to the scientific community via peer-reviewed research and a neutral and ethical scientific society to create, maintain and uphold a standard of care.

‘One of the worst things that ever happened to neural monitoring was the day someone walked into a hospital and began selling a cheap widget instead of a real patient-care service. On that day, neural monitoring was commoditised. We sold our profession down the river, became vendors, we accepted little or no credentialing in exchange for expeditious access to the facility at the expense of our own pride, our own dignity and our patient safety.’

Rich is pessimistic when considering the industry’s past, but optimistic going into the future. If you look closely in the background of his presidential address, you’ll notice a ‘Make IONM Great Again’ cap, complete in Republican red. This is the type of humour that resonates well with Australians; a healthy combination of cynicism and irony, especially given that Dr. Vogel is staunchly opposed to President Trump as the leader of the free world.

‘Neural monitoring as we know it is in trouble’. The address is a vulnerable and honest description of his past and his vision for the future of such a fractured industry, often times partnered with troubled tales from his upbringing by a single parent battling their own demons. ‘I played dice and cards on the street corner, I got into fights, I had no plans in life. No one told me to be a doctor, a lawyer, a teacher, a policeman. Statistically speaking, I was supposed to be dead, or in jail, or living on the edge of life just trying to survive.’

Not all hope is lost. Whilst Dr Vogel has observed first-hand the negative impact of narcissism in the medical industry, at the heart of it all should be a cohesive unit that share a common goal; look after the patient, and do it well. Rich poignantly closes his presidential address with a quote from David Goggins, a retired Navy SEAL and ultra-athlete.

‘When you want a bonfire, you don’t start by lighting a big log. You collect some witch’s hair — a small pile of hay or some dry, dead grass. You light that, and then add small sticks and bigger sticks before you feed your tree stump into the blaze. Because it’s the small sparks, which start small fires, that eventually build enough heat to burn the whole f***ing forest down’.

In Australasia, small sparks have started a fire. Sticks are at the ready. They just need to be organised in such a way that the fire burns for a controlled, and lengthy, period of time. When a tree stump is introduced it might destroy the flame. Though if carefully executed, it will provide a comfortable and substantive heat to all that surround it.

Only then will we learn how to keep that fire burning.