Hospital Practice
ISSN: 2154-8331 (Print) 2377-1003 (Online) Journal homepage: http://www.tandfonline.com/loi/ihop20
‘Noncognitive’ Comes Home to Roost Allen B. Weisse To cite this article: Allen B. Weisse (1992) ‘Noncognitive’ Comes Home to Roost, Hospital Practice, 27:3, 30-39, DOI: 10.1080/21548331.1992.11705377 To link to this article: http://dx.doi.org/10.1080/21548331.1992.11705377
Published online: 17 May 2016.
Submit your article to this journal
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ihop20 Download by: [La Trobe University]
Date: 17 June 2016, At: 19:16
Allen B. Weisse------------------.
'Noncognitive' Comes Home to Roost cognitive adj. pertaining to the mental processes of perception, memory, judgment. and reasoning.
Downloaded by [La Trobe University] at 19:16 17 June 2016
The frrst time I heard about noncognitive physicians was a few years back at a monthly meeting of our department of medicine. Since then, the term has cropped up increasingly in the medical literature and at meetings-especially those attended by nonsurgeons. Mention of the term is usually accompanied by a smug smile and acknowledged with smirks and head nodding of all those nonsurgeons who, unquestionably, have long harbored some resentment oftheir surgical colleagues. To some extent, such an attitude may be justified. After all, surgeons are no more worthy than the rest of us, even though they receive more public recognition and significantly more money. I must admit to being a frequent nodder along with my fellow internists, although my smile at poking such fun has perhaps not been quite so wide or malicious as those around me. After all, I owe my life to a surgeon. As a medical student, I was surgically cured of a malignant tumor after months of visits to reputable internists failed to convince them that I was harboring this threat to my life. Professional jealousy tends to diminish considerably in the wake of such a compelling personal experience. As a student, I even toyed with the idea ofbecoming a surgeon. The aggressive approach of surgeons to disease was much more to my liking than the fiddle-faddling of some internists, who often times seemed to be doing little more than observing their patients with morbid fascination and making copious notes while the patients simply "went down the tubes." But ultimately, I decided against a surgical career. I just did not have the feet for it; my susceptible arches could not bear standing around the operating table for two to three hours at a clip. (The fact that, as an academic cardiologist, I later found myself spending five or six hours doing a study in the cath lab and with a 10-pound lead apron on to boot-is
30
Hospital Practice March 15, 1992
simply one oflife's ironies.) Yet in my private life I have frequently been reminded ofwhn it means not to be a surgeon. When I identify myself as a cardiologist at nonmedical social functions, the response of many laypersons is "Oh, so you operate on hearts?" My modest disclaimer, despite attempts to convince them that my efforts really are of some importance, invariably dispels the incipient glow of admiration and respect that had initially been accorded me. How could it be otherwise? When was the last time you read a novel or saw a film about doctors who were not surgeons? Fictional work always concerns some surgeon who undergoes a crisis-it is always a "he"-and comes through it even more brilliant and admirable than before. Perhaps it is a great surgeon losing a patient through only one isolated error in an otherwise spotless career. Or perhaps it concerns one of his acolytes who devised a new operation for the conquest of a previously incurable condition. These scenarios are infinitely more gripping than one about a dermatologist who mistakes poison ivy for poison oak, or fmds he had been treating a patient for atopic dermatitis when it really was psoriasis. And, by the way, can you recall a single nonsurgeon who ever appeared regularly on M*A *S *H? While the rest of us in medicine have remained either vaguely or explicitly resentful of what we may characterize as undeserved adulation, the surgeons have remained, at least outwardly, pretty tolerant of us "medical creeps." Mter all, as the saying goes, "living well is the best revenge," and surgeons depend on us for referrals. The suggestion that surgeons are doers rather than thinkers harks back to medieval times when medical savants theorized about airs and vapors, continued to read from Galen, (continues)
Dr. Weisse is Professor of Medicine, University of Medicine and Dentistry-New Jersey Medical School, Newark.
Downloaded by [La Trobe University] at 19:16 17 June 2016
Allen B. Weisse
rconttnuedJ - - - - - - - - - - - - - - - - - ,
and perched in high chairs while directing dissection, without even approaching the objects of their anatomy students' concern. Meanwhile, barber-surgeons-considered unworthy of any academic respect-attended more directly to the needs of many patients. Of course, they often bungled, just as the medical doctors did, but they also included the likes of Ambroise Pare. And in later years, surgeons such as John Hunter obviously contributed a great deal to our understanding and treatment of disease. My own epiphany about the injustice of such attitudes toward surgeons came from reading a recent article in which the considerable fmancial reward of a "procedure-oriented" medical subspecialty, gastroenterology, was contrasted with that of a "cognitive-oriented" medical subspecialty, rheumatology. The study concluded that, considered as a financial decision, training in rheumatology or some other "cognitiveoriented" specialty was a "poor investment." 1 What these authors were saying about gastroenterologists could certainly be applied to cardiologists and, as one of the latter, I was acutely aware of being tarred with the same irresponsible brush. I now saw clearly the injustice of implying that the act of opening up patients' bodies in order to diagnose or treat them was essentially not preceded, accompanied, or evaluated by any meaningful thought process. Of course, such attitudes are as insulting as they are untrue. I must add that I am also offended by surgical apologists who suggest that their higher incomes are simply the result of working longer or harder. In my own field it is a lot easier to schedule patients' coronary bypasses than their coronary occlusions. It is true that trauma surgeons, obstetricians, orthopedists, and many general surgeons are often at the mercy of chance catastrophes. Thus, the professional lives of eye surgeons, plastic surgeons, cancer surgeons, and others are infinitely better regulated than those of busy internists, pediatricians, or family practitioners. There is no doubt that fmancial rewards are skewed toward those whose practices are procedure-oriented, and it is only proper that some attempt be made at redressing this imbalance. The recently introduced Resource-
Based Relative Value Scale is certainly a step in this direction and, provided we can all bone up sufficiently on advanced mathematics to understand it and install main-frame computers in our offices to implement it, perhaps it will accomplish its purpose. 2 In the meantime, by continually bickering about income, we run the risk of appearing to be in league with those auto executives who squeeze multimillion-dollar annual incomes from their failing industry and then journey to Japan to complain about economic inequities. The standard reply to the complaining nonsurgeon has been to the effect that if he wanted to have a surgeon's income, he should have become a surgeon in the frrst place. Thank goodness the "penalty" of not being a surgeon is not all that severe, and physicians continue to do much better than the vast majority of other Americans in economic terms. Furthermore, preoccupation with personal income deflects attention from much larger problems with the health care system in this COl.lptry. The last time I checked, physicians' income accounted for only about 20% ofthe national health cost. Reducing their income by as much as a third would reduce the total by only about 7%, hardly a dent in the overall problem. Rather than focusing on our own incomes, we should be concerned about our inability to control the costs of the medical economic tiger. which we don't have by the tail; we apparently are the tail. We should also be more concerned with how to provide adequate and affordable care to the 37 million Americans who have no medical insurance, not to mention the large numbers without adequate policies to meet their needs. Historically, the American medical profession has seemed inordinately prone to and incredibly adept at shooting itself in the foot. The plea here is to direct our combined efforts to more appropriate goals in solving our nation's health care problems.
References 1. Prashker MJ, Meenan RF: Subspecialty training: Is it financially worthwhile? Ann Intern Med 115:715, 1991 2. MaloneyJV Jr: A critical analysis of the ResourceBased Relative Value Scale. JAMA 266:3453, 1991
Hospital Practice March 15, 1992
39
ISSN: 2154-8331 (Print) 2377-1003 (Online) Journal homepage: http://www.tandfonline.com/loi/ihop20
‘Noncognitive’ Comes Home to Roost Allen B. Weisse To cite this article: Allen B. Weisse (1992) ‘Noncognitive’ Comes Home to Roost, Hospital Practice, 27:3, 30-39, DOI: 10.1080/21548331.1992.11705377 To link to this article: http://dx.doi.org/10.1080/21548331.1992.11705377
Published online: 17 May 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ihop20 Download by: [La Trobe University]
Date: 17 June 2016, At: 19:16
Allen B. Weisse------------------.
'Noncognitive' Comes Home to Roost cognitive adj. pertaining to the mental processes of perception, memory, judgment. and reasoning.
Downloaded by [La Trobe University] at 19:16 17 June 2016
The frrst time I heard about noncognitive physicians was a few years back at a monthly meeting of our department of medicine. Since then, the term has cropped up increasingly in the medical literature and at meetings-especially those attended by nonsurgeons. Mention of the term is usually accompanied by a smug smile and acknowledged with smirks and head nodding of all those nonsurgeons who, unquestionably, have long harbored some resentment oftheir surgical colleagues. To some extent, such an attitude may be justified. After all, surgeons are no more worthy than the rest of us, even though they receive more public recognition and significantly more money. I must admit to being a frequent nodder along with my fellow internists, although my smile at poking such fun has perhaps not been quite so wide or malicious as those around me. After all, I owe my life to a surgeon. As a medical student, I was surgically cured of a malignant tumor after months of visits to reputable internists failed to convince them that I was harboring this threat to my life. Professional jealousy tends to diminish considerably in the wake of such a compelling personal experience. As a student, I even toyed with the idea ofbecoming a surgeon. The aggressive approach of surgeons to disease was much more to my liking than the fiddle-faddling of some internists, who often times seemed to be doing little more than observing their patients with morbid fascination and making copious notes while the patients simply "went down the tubes." But ultimately, I decided against a surgical career. I just did not have the feet for it; my susceptible arches could not bear standing around the operating table for two to three hours at a clip. (The fact that, as an academic cardiologist, I later found myself spending five or six hours doing a study in the cath lab and with a 10-pound lead apron on to boot-is
30
Hospital Practice March 15, 1992
simply one oflife's ironies.) Yet in my private life I have frequently been reminded ofwhn it means not to be a surgeon. When I identify myself as a cardiologist at nonmedical social functions, the response of many laypersons is "Oh, so you operate on hearts?" My modest disclaimer, despite attempts to convince them that my efforts really are of some importance, invariably dispels the incipient glow of admiration and respect that had initially been accorded me. How could it be otherwise? When was the last time you read a novel or saw a film about doctors who were not surgeons? Fictional work always concerns some surgeon who undergoes a crisis-it is always a "he"-and comes through it even more brilliant and admirable than before. Perhaps it is a great surgeon losing a patient through only one isolated error in an otherwise spotless career. Or perhaps it concerns one of his acolytes who devised a new operation for the conquest of a previously incurable condition. These scenarios are infinitely more gripping than one about a dermatologist who mistakes poison ivy for poison oak, or fmds he had been treating a patient for atopic dermatitis when it really was psoriasis. And, by the way, can you recall a single nonsurgeon who ever appeared regularly on M*A *S *H? While the rest of us in medicine have remained either vaguely or explicitly resentful of what we may characterize as undeserved adulation, the surgeons have remained, at least outwardly, pretty tolerant of us "medical creeps." Mter all, as the saying goes, "living well is the best revenge," and surgeons depend on us for referrals. The suggestion that surgeons are doers rather than thinkers harks back to medieval times when medical savants theorized about airs and vapors, continued to read from Galen, (continues)
Dr. Weisse is Professor of Medicine, University of Medicine and Dentistry-New Jersey Medical School, Newark.
Downloaded by [La Trobe University] at 19:16 17 June 2016
Allen B. Weisse
rconttnuedJ - - - - - - - - - - - - - - - - - ,
and perched in high chairs while directing dissection, without even approaching the objects of their anatomy students' concern. Meanwhile, barber-surgeons-considered unworthy of any academic respect-attended more directly to the needs of many patients. Of course, they often bungled, just as the medical doctors did, but they also included the likes of Ambroise Pare. And in later years, surgeons such as John Hunter obviously contributed a great deal to our understanding and treatment of disease. My own epiphany about the injustice of such attitudes toward surgeons came from reading a recent article in which the considerable fmancial reward of a "procedure-oriented" medical subspecialty, gastroenterology, was contrasted with that of a "cognitive-oriented" medical subspecialty, rheumatology. The study concluded that, considered as a financial decision, training in rheumatology or some other "cognitiveoriented" specialty was a "poor investment." 1 What these authors were saying about gastroenterologists could certainly be applied to cardiologists and, as one of the latter, I was acutely aware of being tarred with the same irresponsible brush. I now saw clearly the injustice of implying that the act of opening up patients' bodies in order to diagnose or treat them was essentially not preceded, accompanied, or evaluated by any meaningful thought process. Of course, such attitudes are as insulting as they are untrue. I must add that I am also offended by surgical apologists who suggest that their higher incomes are simply the result of working longer or harder. In my own field it is a lot easier to schedule patients' coronary bypasses than their coronary occlusions. It is true that trauma surgeons, obstetricians, orthopedists, and many general surgeons are often at the mercy of chance catastrophes. Thus, the professional lives of eye surgeons, plastic surgeons, cancer surgeons, and others are infinitely better regulated than those of busy internists, pediatricians, or family practitioners. There is no doubt that fmancial rewards are skewed toward those whose practices are procedure-oriented, and it is only proper that some attempt be made at redressing this imbalance. The recently introduced Resource-
Based Relative Value Scale is certainly a step in this direction and, provided we can all bone up sufficiently on advanced mathematics to understand it and install main-frame computers in our offices to implement it, perhaps it will accomplish its purpose. 2 In the meantime, by continually bickering about income, we run the risk of appearing to be in league with those auto executives who squeeze multimillion-dollar annual incomes from their failing industry and then journey to Japan to complain about economic inequities. The standard reply to the complaining nonsurgeon has been to the effect that if he wanted to have a surgeon's income, he should have become a surgeon in the frrst place. Thank goodness the "penalty" of not being a surgeon is not all that severe, and physicians continue to do much better than the vast majority of other Americans in economic terms. Furthermore, preoccupation with personal income deflects attention from much larger problems with the health care system in this COl.lptry. The last time I checked, physicians' income accounted for only about 20% ofthe national health cost. Reducing their income by as much as a third would reduce the total by only about 7%, hardly a dent in the overall problem. Rather than focusing on our own incomes, we should be concerned about our inability to control the costs of the medical economic tiger. which we don't have by the tail; we apparently are the tail. We should also be more concerned with how to provide adequate and affordable care to the 37 million Americans who have no medical insurance, not to mention the large numbers without adequate policies to meet their needs. Historically, the American medical profession has seemed inordinately prone to and incredibly adept at shooting itself in the foot. The plea here is to direct our combined efforts to more appropriate goals in solving our nation's health care problems.
References 1. Prashker MJ, Meenan RF: Subspecialty training: Is it financially worthwhile? Ann Intern Med 115:715, 1991 2. MaloneyJV Jr: A critical analysis of the ResourceBased Relative Value Scale. JAMA 266:3453, 1991
Hospital Practice March 15, 1992
39
