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President's Message - September 2019

Posted By Administration, Thursday, September 5, 2019

Dear Members,

 

Summer is winding down and the cool winds of fall are beginning to make their way to my home state of Pennsylvania. This is my favorite time of year, but right now my thoughts are with the people affected by hurricane Dorian. I hope all of our members, as well as their loved ones, in affected areas are somewhere safe.

 

Over the past month, we’ve been busy getting ready for the upcoming Board Meeting, which will be held on Friday September 13th, just before our Fall Symposium in Boston, Massachusetts. More on the symposium in a few minutes. 

 

If you’ve ever wondered what goes on at our Board Meetings, you can always attend one as they are open to all members. In general, we discuss the business of running a society and shaping a profession. Each Committee gives reports to update us on their projects. We discuss various topics and takes votes on proposals that will shape the direction of the ASNM. I think it is excellent experience to serve on a board, and I’d encourage everyone to run for office at some point in their career. If you’re looking for a good entry point to get some experience, I’d strongly encourage you to start by serving on one of our Standing Committees. Feel free to contact me if you’d like to get involved. 

 

One big project we’ve been working on in August is a major update to our 2019 Industry Prospectus for 2020. You may remember from my Incoming President’s Addressthat I wanted to work more closely with our industry partners. In doing so, I created an Industry Partner Taskforceto advise us on certain topics that impact our partners. In developing our 2020 Industry Prospectus, we’ve worked closely with this Taskforce to ensure it works well for the ASNM and our partners who support our Society. The Board still needs to vote on the 2020 Prospectus, so it won’t be available for a few weeks. Stay tuned!

 

In the middle of August, I traveled to Kansas City to attend ASET’s Annual Meeting. The Neurodiagnostic Society celebrated its 60thyear. I had the opportunity to meet with ASET leadership to continue our close collaboration. As usual, I had a wonderful and productive conversation with ASET Immediate Past President Susan Agostini and the new ASET President, Connie Kubiac. I look forward to our continued collaboration. 

 

In late August, neuromonitoring was again in the national spotlightand, sadly, not in a positive light. I think we are on the verge of seeing more national news stories related to out of network (OON) billing for neuromonitoring. While the OON status of many companies is mostly the fault of the insurance industry refusing to allow us to be in-network, the news stories will sensationalize this and blame the IONM profession as a whole. Those of you who are engaged in business practices of questionable ethics (you know who you are), you’re not helping matters because stories that break about you will only make the rest of us look bad. 

 

Anyway, I’m sure you’re all aware of the NPR story about IONM that broke on June 17th. Well, a different version of this story also aired on NBC Nightly News with Lester Holton August 18th. In this segment, Ms. Cannon’s story was reported by Catie Beck in the Your Money Your Lifesegment. This particular story did not use quotes or comments from me, but it did talk about surprise bills and paint IONM in a negative light. 

 

On a more positive note, there was also a recent story about IONM published in Neurosurgery Market Watch. Among those interviewed for the story include myself, Dr. Faisal Jahangiri (ASNM President-Elect), Dr. Jay Shils (ASNM Secretary) and Dr. Marc Nuwer (longtime ASNM member and Fellow).

 

Turning to the future, the ASNM Fall Symposium will be held September 13-15at the Hyatt Regency Boston. You can view the program online and register here . There will be three pre-conference workshops covering the 10-20 system, TCD and electrode safety. As usual, the main conference will feature a variety of new speakers covering a variety of new topics. If you’re one of those people who continues to think of that ASNM as presenting stale topics with the same old speakers, I’d encourage you to set aside your prejudice and check out our program. Also, if you can’t make the fall symposium, I’d strongly encourage you to plan to attend our 2020 Annual Meeting in St. Louis, MO. We’re planning a bunch of new activities that will transform your meeting experience.

 

So, that’s my President’s Message for September 2019. In my October President’s Message, I’ll tell you about how our Fall Symposium went, and give you important updates from our Board Meeting. I hope you’re all enjoying the closing days of summer. I’ll be back in October with another update from the front lines. Thanks for being a valued member!

 

Rich Vogel, PhD

ASNM President

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President's Message - August 2019

Posted By Richard W. Vogel, Wednesday, July 31, 2019

Members,

My last President’s Message was in June. This has been a busy month. On the personal front, I moved to a new home and took a week’s vacation to unplug and recharge. Now, I’m back to work for you.

I want to give you an update on some of the things we’re working on, as well as make some comments related to the NPR storyabout IONM that broke on June 17th.

Here’s a bullet point list of some projects we’re working on presently.

  • Reviewing contracts for upcoming meetings. Our management partner, Affinity Strategies, is working hard trying to secure locations and hotels. In that process, our Executive Committee is working to select the best locations and review potential contracts with hotels.
    • As you know, a primary goal of mine is to get our hotel prices down and make them affordable for all.
    • Our 2020 Annual Meeting has been moved from Chicago to St. Louis. It will be held May 15-17, 2020. 
  • Collaborating with other societies, like ASET, to coordinate various projects that we’re collaborating on. One example is patient awareness and advocacy.
  • Our Taskforce on Diversity is off the ground and presently being coordinated by Dr. Tara Stewart
  • We also launched a “Sponsor Taskforce” to seek input from our industry partners. This taskforce is being led by Leah Hanson. They are presently working on our 2020 prospectus.
  • I’ve been working with Affinity Strategies to update our branding and communications.
    • We’ll no longer bombard you with emails. You can expect to see e-blasts from us approximately every 2 weeks. The President’s Message will come in the first e-blast of the month.
    • You’ll get a reminder to register on the day of a webinar.
    • Everything that comes from the ASNM will be branded the same and look clean and consistent.
  • We’ve made a few changes to the membership application:
    • Removed CV requirement for membership application. Students must still upload proof of student status in a relevant program.
    • I am personally reviewing every question on the membership application and we will update/alter them as needed to ensure we are attracting a diverse membership. Remember, the ASNM is open to anyone with an interest in IONM, regardless of background, education, training, experience or role in IONM.
  • We’ve made a few changes to the website:
    • We included headshots on leadership page so you can see who represents you.
    • While it is in the very early stages, we are working to develop a section of the website dedicated to educating patients about IONM. We have some awesome volunteers working on this project. I expect it to take the better part of a year to complete. 

Now, I’d like to spend the rest of my message commenting on the NPR Story:

Unless you’ve lived in a cave for the last two months, I’m sure you are aware of the story that NPR broke about a patient in Texas receiving an Explanation of Benefits for IONM to the tune of $94K.

The first thing I want to say is my heart goes out to the patient, Liv Cannon, and her fiancé, Cole Chiumento. It’s bad enough having a complex spine disorder and a complex spine surgery, but to receive a large EOB is certainly scary for anyone. The anxiety Liv and Cole must have felt wondering if they would ever receive a bill, well, I can only imagine.

The second thing I want to say is that I spoke to NPR for about 30 minutes, but they only used 2 quotes from me. Both of them were used out of context. I want to give you a couple of examples taken directly from the article. What you see below in italicsis what NPR reported in print. Anything in [brackets]is my comment on that particular statement.

There is an ongoing debate about whether neuromonitoring is needed for all spinal surgery. But it is standard for a complicated operation like the one Cannon had, says Richard Vogel, president of the American Society of Neurophysiological Monitoring[There are no quotation marks here. So, this is not a quote. This is a summary of a conversation I had with the reporter in which I talked about regional differences in the use or nonuse of IONM by surgeons, and how some surgeons feel that lower risk cases do not require IONM. Regardless, I stand behind the accuracy of this statement as it is printed.].

On the other hand, a $94,000 charge for the service can't be justified, Vogel says. [Again, no quotation marks, not a quote. This is the reporter’s interpretation of the quote below].

"You're not going to meet anybody who believes that a hundred thousand dollars or more is reasonable for neuromonitoring," Vogel says. [This statement is surrounded by quotation marks. This is a direct quote, and the context of this quote was related to the cases in Colorado which the reported asked me about. As an independent individual, I stand behind this statement. The ASNM, however, is not in a position to determine what one can or cannot charge for IONM. If you want to read why, you’ll have to read my statement that I gave to NPR in the paragraphs that follow below].

Most neuromonitoring companies charge reasonable fees for a valuable service and are upfront about their ownership and financial arrangements, he says. But some companies are greedy and submit huge bills to an insurance company, hoping they won't be challenged, he adds. [Again, no quotation marks, not a quote. This is a summary. I stand behind the accuracy of this comment].

Even worse, "some neuromonitoring groups charge excessive fees in order to gain business by paying the money back to surgeons," Vogel says. [This statement is surrounded by quotation marks. You can review my written statement for context. I stand behind the accuracy of this statement, too.].

Last year, Vogel's group published a position statement condemning these "kickback arrangements" and other unethical business practices. [Again, the primary context was the Colorado story.].

 

Now that I’ve given you some info about my quotes, I thought it might be helpful to our members to read some of what I actually said to NPR, so you can see the context for some of my comments, AND so you can see all the good stuff they never even used: What you see in bold below are the questions I was asked, and then you can see below each how I responded.

What is the evidence that neuromonitoring (IONM) is beneficial for patients?

In general, the evidence is quite good in support of neuromonitoring’s benefits across the wide range of surgical procedures in which it is used. Aside from any risk to the nervous system coming directly from the surgical procedure, studies also show that IONM can detect and prevent positioning related injuries that may result from a patient laying in the same position for a long time during surgery. So, the utility of neuromonitoring is greater than what many people initially consider.

Recently, a number of studies have been published in prestigious journals questioning the utility and value of neuromonitoring, but those studies are so fundamentally flawed, the very fact that they were even published is a testament to how broken our peer review system is in the scientific and medical literature. At the end of the day, these studies have little merit, but their publication brings to light some important considerations regarding evidence for neuromonitoring. Specifically, evaluating the neuromonitoring literature is challenging because there’s tremendous variability in how surgeons use it. This heterogeneity confounds many comparative studies. Also, critics argue that there are no class I studies evaluating neuromonitoring, but the same is true for many medical interventions, including spinal decompression and fusion surgery. In order to develop class I studies, patients would have to be randomized to groups receiving IONM or no IONM in high risk surgery, and the ethics of withholding a treatment which is largely considered standard is questionable. 

Which patients need neuromonitoring?

Neuromonitoring is performed in a wide variety of surgeries, including brain, spine, cardiothoracic and ear/nose/throat, just to name a few. All of these procedure pose some risk to the patient’s nervous system, which can result in weakness, paralysis, loss of sensation, loss of hearing, loss of sight, loss of bowel/bladder control, etcetera. So, it may be indicated for any surgical procedure in which the patient’s nervous system is at risk. 

What has led to the rapid expansion of neuromonitoring?

Many people have argued that use of neuromonitoring expanded secondary to the availability of personnel created when we introduced the telemedicine model of one physician remotely supervising many technologists, but there’s no evidence to support this. Indeed, a highly qualified and educated workforce was available long before this model was introduced.

The real drivers of the expansion are education and liability. Regarding education, many surgeons now understand the utility and value of neuromonitoring for protecting their patients. Whereas neuromonitoring started in spine surgery, it has now expanded to include surgery on other parts of the body. The number of surgeries performed in the US continues to grow, and the types of surgeries that neuromonitoring benefits continues to expand as well.

Regarding liability, there’s tremendous pressure on surgeons and hospitals from the medicolegal community. There’s always a fear of being sued. Using neuromonitoring is thought to reduce a surgeon’s liability, so they use it for their own protection.

How much does neuromonitoring typically cost?

I think we need to break this down two different ways, so I going to rephrase your question both ways and answer each independently:

How much does it cost to perform the service?

We can start by asking how much does it cost a neuromonitoring company (or hospital) to perform the service on a single patient. Neuromonitoring is like any other business where you have salaries, equipment, supplies, travel and overhead. The break-even amount can vary significantly from one group to another. Hospitals and insurance companies often want to pay as little as possible, but they’re just bargaining for lower quality patient care. The unfortunate consequence of driving down prices is a less educated and competent work force using lower quality equipment. So, neuromonitoring can be done inexpensively at the risk of lower quality patient care, or it can be more expensive to get expert neurophysiologists working in the operating room with the most advanced monitoring equipment. 

How much is the average cost to consumer (payor)?

The next question is, how much should it cost the insurance company, or the patient. I have to start by saying that I’m not an expert in medical billing, which is extremely complex, and neuromonitoring is no exception. The cost to consumer (payor) can vary simply depending on the type of monitoring performed and the length of surgery, but these factors alone do not account for the exorbitant charges that are billed for neuromonitoring. Those charges come from a fee schedule that each neuromonitoring group generates to determine what they will charge insurance companies for performing the service. This is based on CPT codes (current procedural terminology) that identify which neuromonitoring tests were used. The usual, customary and reasonable fees associated with these codes are updated annually in a medical fee manual published by Practice Management Information Corporation. For each code, PMIC publishes rates in the 50th, 75thand 90thpercentile based on national averages. In developing a fee schedule, neuromonitoring groups use these numbers, and adjust them by their geographic location. So, there is a basis for developing specific fees for specific neuromonitoring tests. The problem is that some groups are greedy, and they can just double or triple the end product to get more money, and insurance companies are simply unaware or don’t care. The other method that some companies use to develop their fee schedule is to see what Medicare recommends from their fee schedule, then charge a multiple. The basis for determining the multiple is beyond the range of my expertise. 

There have been news reports of some patients receiving very high bills for neuromonitoring. Is that a problem in the field?

The first thing we have to do is differentiate between what is a bill, and what is not a bill. Most frequently, patients receive something in the mail from their insurance company called an Explanation of Benefits. It’s a summary of charges and coverages, and it always says somewhere “this is not a bill”, but patients often get scared and come to expect an impending bill when they see some amount of money listed under a section entitled “your responsibility” or “provider may bill you”. The amount listed is just the difference between what the doctor charged the insurance company and what the insurance company is contracted to pay. Attempting to collect that difference from the patient is called “balance billing”, which is prohibited in some states, but not all. So, patients may or may not be responsible for some portion of the balance. How much the patient actually owes depends mostly on the patient’s co-insurance, deductible and co-pay. It’s all related to the patient’s individual insurance plan. So, if the patient owes anything, it may be far less than expected.

In rare circumstances, patients do actually get very large bills. Unfortunately, many patients these days have high deductible plans with no OON benefits. So, they’re going in to have what is often a very expensive procedure with little in the way of financial protection.  The best thing a patient can do is contact the doctor and the insurance company and ask them to advocate for you. There are ways to reduce costs. Even then, most neuromonitoring groups don’t put patients into collection unless they received a check from the insurance company and failed to turn it over to the rendering provider.

The biggest concern for our field is the fact that some groups charge excessive fees in order to gain business by paying the money back to surgeons. It’s a big enough problem that the ASNM took the bold step last year of publishing a position statement on business practices in neuromonitoring. We’re not in a position to tell providers how much they can charge insurance companies, but we are in a position to express concern over why they charge such high fees and what they do with the money. A growing problem in the US right now is groups paying surgeons a kickback to use neuromonitoring. So, some percentage of that patient’s large bill is funneled back to the surgeon as an incentive to use a specific neuromonitoring group. While the practice is technically legal in a few states, the AMA is clear in their view that the practice is unethical, and we feel the same way. 

How and when should patients be informed that neuromonitoring services will be an out-of network service?

Best case scenario, the patient should be informed by the surgeon or hospital at the time when the surgery is booked. Unfortunately, 99% of IONM is considered elective. So, surgeons and hospitals may fear that, if they tell the patient IONM is OON, the patient will choose not to have their surgery at that location. Hospitals/surgeons are afraid of losing the business. So, the patient is often informed in the minutes just before surgery when they sign the consent for neuromonitoring.

The most unfortunate part of all this is that the OON status of most neuromonitoring companies is actually the fault of the insurance companies who are supposed to be advocating for their patients. Many IONM groups actually try to go in network, but the insurance companies only accept a limited number of neurologists in their network, most of whom don’t do neuromonitoring. So, a neuromonitoring group attempting to bring their neurologists in network is often denied.

On top of that, the fees are driven up by insurance companies’ refusal to negotiate with neuromonitoring groups, which would only make charges more reasonable for all. That alone could save the insurance industry tens of millions of dollars per year.

Neuromonitoring’s pervasive OON statues is mostly the result of the fact that insurance companies don’t understand IONM, and they’re not willing to listen.

How can consumers avoid a surprise bill for neuromonitoring?

If the patient actually receives a bill in the mail, the best thing to do is to call the provider. They can usually help to reduce the cost by working with the patient to appeal to the insurance company to reprocess the claim at in-network prices. This could save hundreds or thousands of dollars.

In terms of actually avoiding a surprise bill, some states have laws against surprise bills, while others do not. So, it’s difficult to know if you are protected. The best thing a patient can do is ask his/her surgeon which ancillary services will be used during surgery. Neuromonitoring is just one type of ancillary service. From there, the patient can find out of the provider is in-network, or ask their insurance company what they can do to process the claim at in-network prices. 

 

So, that’s my President’s Message for August 2019. I hope you’re all enjoying your summer. I’ll be back in September with another update from the front lines.

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President's Message - May 2018

Posted By Joseph J. Moreira, M.D., Monday, May 14, 2018

Dear Membership,

The time has come to pass the gavel, officially, to Jeff Gertsch. I will make this brief but just wanted to thank the membership for making this past year possible. The commitment you all made to this society year after year keeps us moving forward and flourishing as a profession. We have excellent educational offerings and make progress in the field due mainly to your support and participation. Your ongoing interest and support is what drives us on the ASNM board. To that end I ask that all of you consider serving in any capacity possible. The new year comes quickly, and many hands are needed. Please consider running for office, joining a committee, speaking at a meeting, running a webinar, searching for and recruiting new members etc.

I want to thank our amazing board of directors and members of the executive committee as well as Apex Management for all their efforts and support. We accomplished a great many things this year but there is a tremendous amount of uphill work to be done. I will give all my efforts and support to the new President and board members and will do my best to keep things moving forward in our field. I ask you all to do the same.

Thank you again for this humbling experience and I am always available to help in any way. All the best to our new leadership, we are in excellent hands.

Best, Joe

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President's Message - December 2017

Posted By Joseph J. Moreira, M.D., Thursday, November 30, 2017

Greetings,

I hope this message finds you all well and that you had a wonderful Thanksgiving.  It is now a family tradition that when things are either not going well, or we are complaining about life in general, that we force ourselves to think of 5 positive things. Yes, my partner is a psychotherapist! I am proud to update you on a number of items that I hope will brighten your day a bit.

The first order of business is to congratulate everyone on a well-run and successful election. I am very grateful to all the candidates that had the courage and spent the time to throw their hats in the ring and run for an office. It is a wonderful process to undertake as it gets you thinking about our field and what needs to be done to keep it moving in the right direction. It also gives each candidate a bit of exposure and helps them to network some and be recognized for their accomplishments. I urge all our members to consider being a part of this process and get involved in an election, a committee, a meeting, or whatever you have time for.

Our new President-Elect is Rich Vogel. He will become president after the Annual Meeting in 2019.

We also have 4 new Directors who will take office in 2019: 

I am excited about our new board members and am looking forward to working with all of them. This society is in excellent hands and we owe the entire group that participated in this election a thank you for getting involved.

 

The second item I am grateful for is the recent board approval of our new Practice Guidelines for the Supervising Professional: Intraoperative Neurophysiologic Monitoring. This was over a year and a half in the making with the great efforts of an ad hoc committee comprised of original authors, board members, executive Committee members and general members. Great pains were undertaken to assure that the new document was properly updated. We strove to have the document reflect current practices while maintaining the highest quality of patient care. We will now submit the revision to other societies for their review and accept comments from them if any. The document will then be published after a final run through and consideration of any comments generated during the review period.

 

Item number three. We had one of our most successful Fall meetings ever in Baltimore. The main thrust was IONM and Medical-legal issues. Our Mock trial was a tremendous success and is the start of an all new type of creative format for our future meetings playing off a theme and using a more practical method of delivering the message.

 

That brings me to number four. Our Annual meeting will be held February 23-25 at the Swan and Dolphin in Disney World, Orlando, Florida. This will be held during President’s week off so please consider bringing the family. The meeting will be a new format of 2 tracks on day 1. Each session will have its own lectures, panel discussions and E poster presentations. The topics are cutting edge and all promise to be excellent. Please check out the agenda on our website.

 

Finally, number five. In keeping our promise to collaborate with other societies, May 1-6, 2018 we will be contributing to the 31st International Congress of Clinical Neurophysiology (ICCN) in Washington, DC. This is a great opportunity to hear from international neurophysiology experts and attend workshops and lectures. Note that this meeting is taking place during our usual Annual Meeting and that our Winter Meeting in Orlando is our Annual Meeting.

 

I look forward to seeing you all at the meetings and wish everyone a Happy, Joyous and Healthy Holiday Season.

 

Best Wishes, Joe

 

Joseph J. Moreira, MD

President, American Association of Neurophysiologic Monitoring

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President's Message - September 2017

Posted By Joseph J. Moreira, M.D., Thursday, August 31, 2017

Greetings to all in the IOM community. If you are reading this address then you are looking to the ASNM for information of some kind, or just curious to see what we have to offer. If you have visited us previously or are a member then you will notice that we just launched our new website. I want to extend a thank you to our two board members that orchestrated the new web design from the start, Dr. Richard Vogel and Dr. Bryan Wilent. Great job! Here is a brief message from Rich and Bryan:  

“We're very excited to announce that our website has been redesigned to enhance your experience as a member of the ASNM. The new website features a modern, responsive design with a new menu system that simplifies navigation on any device. The website now contains a blog, which replaces the old Monitor Newsletter. From the blog, you can expect frequent posts from the ASNM to keep you up-to-date on news and announcements from the ASNM, including upcoming meetings and webinars, interesting case studies, clinical commentary, recently-published literature, and other news from around the neuromonitoring community. Finally, the website will include a member community, like a social network, that provides a new way to connect with fellow colleagues, share information across the ASNM network and manage your membership preferences. We encourage you to explore the new website and all of its features, and don’t forget to subscribe to our blog!”

 

I had the honor of taking the reigns over during our Annual Meeting in Cleveland. We celebrated the 40th anniversary since the first IOM meeting was held there. I was humbled by the experience of meeting the pioneers of our field. It was an amazing sight to see our youngest and brightest at the meeting mingling with the likes of Dr. Tamaki, Schramm, Nuwer, Nash, Kartush, Moller, Sloan and Koht. Drs. Koht and Eccher and the rest of the planning committee did an outstanding job of coordinating and creating this event. Thanks to all involved.

One of this year’s themes is about growth as a field and as a society. We are considering a corporate membership plan that would give IOM companies and institutions a discounted rate for a group membership. The larger we grow as a society the more presence and influence we will have. Our offerings will also grow with a larger membership base. I encourage our current members to recruit others in the field to join and perhaps participate on a committee or in any way possible.

Another main theme is about improving communication. One of the messages I have taken away from my few months as President is that we all aspire to improve the ground operations of the IOM field. It all comes back to a common theme of excellent communication with the patient as the central focus. We have recently heard many different messages and ideas of how our field can improve, but the common theme is communication. The link between the personnel in the OR and the supervising professional, the surgeon/anesthesiologist and the IOM team, and so on, are critical to the benefit of the patient. As there is always room for improvement, I urge all of us to step back and examine how we communicate daily before, during and after our surgeries and enhance the process in any way possible.

Our third theme this year is about collaborating with other societies. I had the opportunity to attend the annual ASET meeting this month along with the ASNM’s Executive Director Carol Ingmanson. We participated as a vendor and promoted the ASNM. Carol did a great job of setting up and coordinating the trip and we added several members and potentially a few more corporate sponsors. We are also planning a joint meeting May 1-6, In Washington DC, just before the International Congress of Clinical Neurophysiology (ICCN). More details to follow.

If you have not already made plans to attend please look at our upcoming Fall Meeting in Baltimore on September 9-10. We have a very interesting and practical agenda. “What to do When Something Goes Wrong and Hot Topics” We are featuring a Mock Trial and several talks on managing and avoiding potential legal issues. Drs. Eva Ritzl, Trey Lee and Robert Minahan and the rest of the planning team have done an excellent job of creating a very new and innovative meeting. Thanks to all!

Our Annual 2018 Meeting will be held early this year on February 23-25 at Disney’s Swan and Dolphin Resort in Orlando. Great family destination!

Last but certainly not least please check out our Webinar schedule. Our next webinar is on 10/11 with Dr. Charles Yingling, “A Comprehensive Guide to Corticospinal Tract Mapping and Monitoring”

Thank you all for logging in, I look forward to seeing you all in Baltimore and at future meetings.

Best,

Joseph J. Moreira, M.D.

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