Dr.  Kenneth Cohn, a surgeon and blogger, offered a particularly thoughtful response to my post “Surgeons and Other Physicians: The Cultural Divide.” First, let me introduce him.

On his blog, Cohn describes himself as a “board-certified general surgeon currently splitting time between providing locum tenens surgical coverage in New Hampshire and Vermont and working as a consultant at Cambridge Management Group, which specializes in physician-physician and physician-administrator communication issues. I am a recovering academic surgeon who is passionate about helping physicians, nurses, hospital leaders, and board members work together.”

Let me add that I’m impressed by his blog, Collaborative Confession, and that we’re adding it to our blogroll.

In his comment here on Health Beat, Cohn explained that his training was very different from the surgical training I described in the post:

“As a general surgeon who trained at the Harvard Surgical Service
affiliated with the New England Deaconess Hospital, I did not face the
humiliation that others have decried. My chairman, Bill McDermott
embodied the gentleman surgeon and hired people who behaved
respectfully toward their teams. I felt the same way at Roosevelt
Hospital in NY where I did my surgical sub-internship during medical
school.

“Caring for surgical patients with teams is a long and proud tradition
that continues to this day with surgeons thanking the nurses and
anesthesiologist at the end of the procedure.

“I know that I will be drowned out by the voices of many others who
feel that they have been abused. I do not deny that surgery has abusive
people. I just wanted to say that my memories remain full of the
camaraderie of taking care of patients under trying circumstances, such
as multiple admissions, long nights and weekends, and dynamically
changing physiology.”

Then, he directed those convinced that there are two distinct camps of surgeons and cognitive physicians, to a post on his blog titled, “Collaborative Distinction.”

In the post he first addresses the disparities between how much general
practioners are paid and how well some surgeons and other specialists
are paid:

“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.”

Nevertheless, he argues, “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.”