Proceduralists *SHOULD* make more because their training requires more time in order to become proficient at high risk procedures. Access to comprehensive care should be improved by increasing mid-level providers in primary care specialties. Cognitive specialties are not well reimbursement because cognitivists did not advocate well for themselves at RUC and CPT meetings.

I received this comment yesterday.  I have read it at least 5 times, and each time I scratch my head and go ‘Huh?’

I will address each sentence.  First, I have never said that proceduralists should not make more money than me.  If you read my posts, my complaint is the relative difference.  One commenter suggested 1.75 as a multiplier.  That would be a great improvement for generalists.  Please, please reread my pay for time rant.  If a generalist “deserves” $100/hr, then perhaps an orthopedic surgeon “deserves” $150/hr.  The differential today is much greater, and that is my point.

Second, we have to address the “mid-level provider” insult.  Yes, this is an insult to cognitive specialists.  The writer equates outpatient medicine with simple medicine.  He/she disregards the challenge of cognition.  I would argue that “mid-level providers” could learn many procedures and do them as well as physicians.  Why do we go to medical school?  I would argue that we should learn to think and therefore diagnosis and adjust treatment intelligently.

Finally, the commenter has no concept of the RUC.  Please read – The primary care reimbursement mess.

The RUC is STACKED against cognition.  The link to John Goodson’s wonderful article from JAMA will make this clear.