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Centers of Excellence for Neuromodulation: A Critical Proposal

As a field, we have struggled with methods to increase the efficacy of our procedures, decrease their risks, and improve patient outcomes. By doing so, we further legitimize our field, improve patient satisfaction, and demonstrate the cost-effectiveness that is necessary to drive reimbursement and thus patient access to neuromodulation procedures. One important way to improve results in our specialty is to ensure that neuromodulation practitioners have, indeed, practiced, and practiced quite a lot. In his book, Outliers, Malcolm Gladwell points to the correlation between the level of practice and excellence. “The idea that excellence at performing a complex task requires a critical minimum level of practice surfaces again and again in studies of expertise. In fact, researchers have settled on what they believe is the magic number for true expertise: ten thousand hours” (1). Although Gladwell discusses excellence in sports, music, and computer science, this correlation appears to hold for virtually any discipline. He quotes Daniel Levitin, a neuroscientist whose research focuses on the development of excellence,“The emerging pictures from such studies is that ten thousand hours of practice is required to achieve the level of mastery associated with being a world-class expert—in anything” (2). Gladwell goes on to state that “practice isn’t the thing you do once you’re good. It’s the thing you do that makes you good.” Gladwell suggests that it takes about ten years to develop such excellence. “And what’s ten years? Well, it’s roughly how long it takes to put in ten thousand hours of hard practice. Ten thousand hours is the magic number of greatness” (Figs. 1 and 2). Although the actual amount of practice required may be debated, the recognition that excellence derives, at least in part, from experience cannot. Unfortunately, there appears to be a conflict between the way in which neuromodulation is practiced and our desire to ensure excellence for our patients and our health care economies. That is to say that only 10% of spinal cord stimulator implanters, for example, perform 90% of these procedures, leaving 90% of implanters to do no more than 10% of SCS implants. The vast majority of implanters perform less than ten such procedures a year, far too few to ensure quality, much less excellence (personal communication, Bradley Maruca, November 25, 2013).