A Surgeon’s Response to “The Cultural Divide”

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.”

Comments

[Maggie Mahar]

Ken--

thanks-- we're fixing it.

[ken cohn]

Maggie,

Thanks so much for your post and for drawing attention to the important issues in healthcare today.

Only one minor point, the link on your blogroll to Collaborative Confession does not work because collaboration is mispelled

The correct link should read http://healthcarecollaboration.com/blog

Thanks
Ken

[Gregory D. Pawelski]

I want to state something from the book of a dear friend and cancer surgeon, who saved my wife's life.

Surgical skill - both the technical aspect and the intellectual aspect - are critically important. But, even the best of surgeons, in both categories, can do a complete and thorough dissection and a tumor still comes back, or occurs distally. There is so much about the disease process that we don't understand.

A complete resecton may be done, even with poor surgical technique, and the patient does well. Again, this is the complex interaction between the tumor, its stage, its location, size, biochemical/genetic makeup, and the surgeon actually has little to do with it.

Or, it is a relatively benign lesion, peripherally located, small, no lymph node mets, and a superb surgeon - same outcome. Or, a complex tumor, centrally located, relatively large, a supberb surgeon, and voila - with luck, besides the tremendous skill - a cure occurs.

Either way, one prefers the good surgeon - and hopes for characteristics that allow for a complete, truly complete resection, no matter what their personalities.

[Dr.Rick Lippin]

Excellent post by a thoughtful and caring physician. But this surgeon unfortunately is among the minority among his surgeon colleagues.

Dr. Rick Lippin
Southampton,Pa