When I tell people that I am a pediatric infectious diseases (PID) specialist (insert comment about hoping I’m not contagious; funny every time), I am often asked what exactly it is I do. It is a good question. A surgeon might describe a consultation as telling a patient, “I am going to take you to surgery.” A gastroenterologist might say “I am going to scope you.” In PID, we essentially tell patients, “I am going to think about you.”
Specialists such as those in PID, neurology, rheumatology, developmental pediatrics, hospital medicine, primary care, and many more are commonly referred to as “cognitive” specialists. These are physicians with additional training in a specific field of medicine who primarily provide evaluation and management (E&M) services to people with complex medical conditions that require a level of expertise that the referring physician is not trained to diagnose or qualified to treat.1 This is not to say that “noncognitive” specialists do not think; of course they do. But procedures generate the most insurance reimbursement. Rather than being able to code for a procedure, cognitive specialists must rely on E&M codes, which do not reimburse as generously for the critical thinking involved in data gathering and analysis, patient management, communication, and decision-making.2 This is not a new problem; it has been well described for decades.3 Nonetheless, little has been done to remedy the disparity. In a recent study, it was found that revenue for physician time spent performing common procedures was more than triple that of cognitive service for a similar amount of time.4 This issue is believed to contribute to ongoing dwindling numbers in cognitive specialties.5 In addition, many traditionally cognitive specialties have taken on procedural responsibilities to help support their programs, such as point of care ultrasounds, sedation, and circumcisions.6
Nonetheless, cognitive specialists play an important role in health care and especially in communication with families around complex medical issues. In this month’s issue, Szymczak et al7 present the results of a qualitative study in which they look at provider and administrator perceptions of the value of PID specialists. Their findings, although not surprising, exemplify the challenges cognitive specialists face: the services provided are important for good patient care, continuity with complex patients, and system-wide efforts, but administrators would like the services to be provided by fewer and fewer specialists. It is not hard to see how burnout could develop among existing specialists and that trainees would not be eager to enter a cognitive specialty in the first place.
Szymczak et al7 should be commended for their well-designed and well-executed study. Their effort was immense, gathering information and feedback for their questionnaire and completing and analyzing 97 interviews. Their study is a master class in iterative design and saturation that is often challenging to achieve but essential for informative qualitative research.8
In the study, they also achieve the goal of many qualitative studies: hypothesis generation.8 Rather than trying to jump to testing outcomes, Szymczak et al7 lay the groundwork for future research and advocacy by opening a conversation about the value of nonprocedural efforts and how to pay for them in a procedure-based system. Health care reform in today’s political climate is a moving target, with possible cessation of funding streams relied on by pediatric hospitals and providers.9 Studies such as this one can be used to serve as reliable evidence and fuel for advocates such as the Cognitive Care Alliance, a group of cognitive specialty organizations who seek E&M codes that capture the complexity and intense work performed by their members.10 We can only hope that such organizations successfully influence lawmakers to take into account the value of nonprocedural work when designing our future system.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
- ↵American Academy of Neurology. The cognitive specialty coalition commends MedPAC for recognizing cognitive care crisis. 2011. Available at: https://www.aan.com/PressRoom/Home/PressRelease/964. Accessed April 3, 2018
- Kumetz EA,
- Goodson JD
- ↵American Society of Internal Medicine. Reimbursement for physicians’ cognitive procedural services: a white paper. 1981. Available at: https://www.acponline.org/acp_policy/policies/reimbursement_for_physicians_cognitive_procedural_services_1981.pdf. Accessed April 3, 2018
- Sinsky CA,
- Dugdale DC
- ↵George Washington University Health Workforce Institute. Analysis of the NRMP-SMS match for infectious disease for 2016-17 appointment year and trends over-time. 2016. Available at: www.idsociety.org/uploadedFiles/IDSA/Careers_and_Training/Program_Director_Resources/Match/Infectious%20Disease%20Match%20Results%20and%20Trends%20Report.pdf. Accessed April 3, 2018
- Szymczak JE,
- Lee G,
- Klieger SB,
- et al
- van Rijnsoever FJ
- Goodnough A,
- Pear R
- Goodson JD
- Copyright © 2018 by the American Academy of Pediatrics