I confess to being a fan of Maggie Mahar's Health Beat posts. In Health Care Spending: The Basics; Spending on Physicians' Services-Do We Spend Too Much? Part II, she detailed meticulously what lies behind the 22% of the $2.1 million spent last year on physician services. I agree with her that income disparities between general practitioners and invasive cardiologists, radiologists, and some surgical specialties need to be resolved. Many contracting decisions about physician compensation seem arbitrary and capricious to me.
As a practicing general surgeon, I maintain that the distinction between cognitive practitioners and proceduralists is a false distinction. A spectrum of cognitive behavior is present across all branches of medicine. Cognition is not an on-off, all-or-none phenomenon, as the story below illustrates.
My father, George A. Cohn, was a neurosurgeon at the Buffalo General Hospital for 40 years until his death in 1991. Approximately 20 years ago, he was asked to see a SUNY undergraduate, who had been knocked unconscious in a frisbee football game. On the patient's CAT scan was a miniscule vascular malformation in an uncommon location, and the question asked was did this malformation contribute to the patient's loss of consciousness and should it be removed?
Because of the rarity of this malformation, my father consulted the literature and discussed the case with neurosurgical and neuroradiology colleagues throughout the country. They came to the hypothesis that the malformation and the loss of consciousness were unrelated and that the patient did not need surgery at that time, provided that he developed no symptoms from the vascular malformation.
The student's parents came from New York City to discuss their son's condition. After a brief introduction, my father said, "After conferring with colleagues across the country, I think,"
"What do you mean, 'I think,' Doctor," the patient's father interrupted, to which my father replied, "You should be damn glad that I think!"
In a specialty that would be labeled procedural, my father took a history, performed a physical examination, interpreted laboratory tests and brain scans in conjunction with colleagues, made a diagnosis, and derived a treatment plan in conjunction with the patient and family.
Like primary care practitioners, surgeons interview patients, perform physical diagnosis, review laboratory tests, and make diagnoses. In addition, we lead teams, coordinate both surgical and non-surgical care, and serve on hospital committees. Especially in fields like trauma and surgical oncology, many of the decisions we make involve non-operative care. Cognitive skills are equally important in the operating room, especially when "the patient does not read the book," i.e., there are unexpected findings at the time of operation that require sophisticated decision-making, i.e., judgment.
If I ever need surgery again, I will seek care from a competent, compassionate cognitive surgeon. The words "cognitive" and "surgery" are not an oxymoron.
I welcome your input.
Kenneth H. Cohn
www.healthcarecollaboration.com
