We thank Drs. Wilkinson and Kaufmann for their interest in our study1 and their considered response to it. We thank them for highlighting the Canadian Association of Neurophysiological Monitoring course through the Michener Institute in Toronto, and point out that a training scheme has been approved by the Alberta College of Medical Diagnostic and Therapeutic Technologists (www.acmdtt.ca) at the University of Alberta Hospital, and is also being used in Saskatoon. We agree that patient safety can be improved through the use of highly skilled, well-trained individuals in the operating room.
We differ from Wilkson and Kaufmann with regard to the issue of interpretation, however. In our view, the IOM situation should not be different from that in the outpatient laboratory. A skilled individual performs the technical aspect of the task and provides an impression of the test. The test itself is interpreted by a clinical practitioner. The patient’s physician (most responsible physician; MRP) integrates this interpretation with other clinical signs and knowledge to form a diagnosis and treatment plan. Indeed, many reports from the electroencephalography laboratory (or the radiology department, which also follows this model) end with the statement that “clinical correlation is required.” In the intraoperative neuromonitoring (IOM) setting we see this as being a Certification of Neurointraoperative Monitoring (or a Canadian equivalent when/if available) technologist placing electrodes, running the tests and providing an impression and a doctor or clinically trained doctoral-level neurophysiologist providing real-time interpretation to the surgeon (MRP). It is the surgeon’s responsibility to decide what to do with the interpretation.
In our survey most surgeons did not want to provide interpretation of the data, and we believe most are not suitably trained or experienced to do so. Although our practice patterns differ from those in the United States it is worth noting that the American Medical Association (Policy H-410.957) states that IOM is the practice of medicine and that its interpretation requires a suitably trained individual (Policy H-35.971). The Canadian Medical Association does not have equivalent policies, but also does not define what is the practice of medicine.