From the Editor
The distinction between cognitive and procedural medical services has long been a part of physician discourse, particularly since the discussions of resource-based relative value scales (RBRVS) began in the early 1980s. One can argue that this distinction has been useful for analyzing cost, effort, and other aspects of providing medical services. But when it is extrapolated from medical services to medical specialties—labeling entire disciplines as cognitive and others as procedural—the distinction transforms from a useful one to a false dichotomy that is simplistic, counterproductive, and has the potential to cause harm.
In fact, all areas of medicine—surgical and non-surgical specialties, office-based and hospital-based medicine, diagnostic and therapeutic approaches—require a mix of cognition and procedure to treat patients effectively. And, almost always, procedures and technical skills subserve the cognitive tasks of high-quality decision making, clinical reasoning, and expert judgment.
For example, in a field like surgery, while it may be tempting to describe the entire discipline as primarily procedure-based, the fact is that every aspect of patient care, from pre-operative assessment and planning through post-operative care, is highly dependent on sound, expert judgment. Even the surgical procedure itself requires the same kind of high-level cognitive skill and complex decision making that is needed in any other aspect of patient care, often in the face of uncertainty, time constraints, and insufficient information. And, of course, judgment plays an even more critical role in the face of unanticipated findings, unexpected anatomic variation, or unforeseen events.
Thus, it is timely and important that Andersen,1 writing in this issue of the journal, underscores the fact that medical educators and simulation developers have not focused sufficient attention on using simulation to help surgical trainees develop the advanced cognitive skill and expert judgment that are so essential to success in the operating theater. His article makes clear that there is a critical need both to develop applications that support cognitive simulation and cognitive rehearsal—useful in teaching and assessing surgical judgment—and also to undertake new studies of the soundness and validity of these advanced simulation-based tools.
Of course, cognitive simulation and cognitive rehearsal are important for improving physician performance in any specialty of medicine—surgical and non-surgical alike—no matter what the proportion of cognitive and procedural services. And simulation applications that could support the teaching and assessment of expert judgment would be valuable to medical education programs across all disciplines and throughout the continuum of medical education.
And so, as you read Andersen’s article, I hope you will think about the progress to date in simulation applications to teach and assess clinical skills. And I invite you to think about how medical educators and simulation developers can make better use of current findings from studies of expertise and reasoning to build advanced simulators that have an even better capability to teach and assess expert judgment across all specialties and stages of learning.
Steven L. Kanter, MD
1. Andersen DK. How can educators use simulation applications to teach and assess surgical skills? Acad Med.. 2012;87:934–941