In Reply We agree with Rustgi and colleagues that primary care specialties, which are dependent on cognitive services, are underpaid relative to specialties that derive a larger portion of their revenues from procedural care. We also agree that screening colonoscopy is a valuable service for which the health care clinician should be adequately trained and compensated.
Rustgi and colleagues do not disagree with our findings of a significant gap between Medicare payment for cognitive vs procedural services. They defend the payment gap with respect to screening colonoscopy on the basis of training and intensity of work. Determining whether training time to competency for screening colonoscopy differs from the training time to competency in the management of a patient with multiple complex comorbidities is beyond the scope of our article.1 Nonetheless, there is evidence to suggest that performance of 50 colonoscopies is associated with proficiency and safety,2 a number that could plausibly be performed in a training period of a matter of weeks. We do not believe a physician would become proficient in the care of a patient with complex gastroenterological problems, such as ulcerative colitis or chronic liver disease, or in the management of multiple morbidities, such as atrial fibrillation, congestive heart failure, diabetes, and gastrointestinal bleeding, in a similar period.