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Letters to the Editor

From the July ACP Hospitalist, copyright © 2008 by the American College of Physicians

Is CAM a sham?

In response to the question raised in April’s “Integrative medicine: Coming to a hospital near you”, yes, CAM (complementary and alternative medicine) is absolutely a sham, or a placebo at best. It is hard for me to believe that well-trained, scientifically based internists could accept the mystical practices of CAM. Massage, OK, but isn’t that physical therapy? It’s easy to see why the insurance companies won’t pay for that stuff. Therapeutic touch should be mentioned only in the sense that it is a form of quackery and a ripoff if patients have to pay for it.

I was pleased that you mentioned R. Bausell Barker, PhD, but would have felt better if you mentioned his book, “Snake Oil Science.” I don’t know how any ethical, honest physician could read his book and not come away feeling that CAM is a sham. Also, physicians who believe in CAM need to read the writings of physics professor Bob Parks at the University of Maryland on acupuncture.

Carl Bartecchi, FACP
Denver

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Alternative scheduling models

I read with some interest May’s article “No signouts? No problem” on David Yu’s innovative scheduling model. My hospitalist group in a somewhat larger city, Seattle, has this exact model. It has worked well for us for the past 10 years. I was glad to see others using it.

Michael E. Dorney, ACP Member
Seattle

Our on-call internists in the past as well as our hospitalists for the last five years manage all patients through discharge except for signout on weekends. Continuity of care, as it has for the last 2,000 years, trumps virtually all other patient care variables. The rapid-cycle rotating hospitalist model doesn’t reduce cost or improve quality of care as compared to a quality conventional (continuous care) baseline—it simply can’t. Continuity of care as an innovative care model? Sort of.

Coke R. Smith, MD
Sunnyside, Wash.

“No signouts? No problem” states that there are three hospitalists on for seven days who round on their patients daily and take beeper call for those patients 24 hours a day during each seven-day block. Do they work in eight-hour shifts? If there is someone doing admits overnight and on weekends, then those patients need to be signed out and dispersed to the three hospitalists. Is one of the three hospitalists on overnight, say from 11 p.m. to 7 a.m.? If so, when does he or she round on his or her patients?

This model would be fine providing:

1. The hospitalists live close to the hospital, as these hospitalists do.
2. Their workday is only eight hours (three shifts of eight hours each), so that they get out of the hospital and have some life other than working. If I work 14 hours, I need to sleep for at least six uninterrupted hours, with my pager off, to function the next day. But if I only worked eight hours a day, keeping my pager on and with me the rest of the time wouldn’t be so bad. I agree that it would be better for the patients and for the person on during the night.
3. The patient load is about 12 per hospitalist. The article doesn’t mention the average census.

I don’t like the seven-day-on, seven-day-off model, because it leads to high burnout. If you have a short weekend day without doing admits, a weekday shift of only eight hours and pager call the rest of the time, this model sounds very doable. I also like the idea of a detailed face-to-face signout on Mondays to the new team coming on.

Thanks for an interesting and provocative article.

Lenny Husen, ACP Associate Member
Lafayette, Calif.

Dr. Yu responds:
The average patient census at our hospital is about 15 patient encounters per day. Our schedule was created so that there is no difference between a weekday and a weekend. All the hospitalists on for the week are present even on the weekends, rounding on their own patients. Since the hospitalists always perform their own admissions and round on their patients daily, there are no patients to be dispersed and no cross-coverage.

Each week consists of three-day cycles. For example, a hospitalist will admit new patients on the first day from 7:30 a.m. to 4:30 p.m. and on the second day from 4:30 p.m. overnight to 7:30 a.m. The hospitalist on the overnight call does not have to stay in-house, and can come in for admissions and leave at any time. For admissions after midnight, the hospitalist, at his or her discretion, can have holding orders written by the ED physician. The hospitalist evaluates all unstable patients or ICU admissions in the ED in real time. On the third day, the hospitalist has no admission responsibilities. The three-day cycle repeats until signout to the next team at the end of the week on Monday mornings.

On the weekends, hospitalists can leave the hospital as soon as they are finished rounding. On the weekdays, it’s at the hospitalist’s discretion. On the days that the hospitalist has no admission responsibilities, he or she is coming off the overnight call and is encouraged to leave as soon as rounds are finished. This gives the hospitalists greater flexibility with their time and lets them feel as though they are true attending physicians, since the schedule is more patient-focused than schedule-focused.

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Caring for sexual minorities

I was bothered by May’s politically correct article on “sexual minorities”. First, to call these groups minorities is to put them in the same class as minorities over which people have no control, such as race and handicapped status. Acting on sexual urges is a choice that we are all called to control—no matter what form it takes. Second, as physicians, we are constantly in the position of caring for people with lifestyle choices we may not agree with. Why do we need a special article for these lifestyle choices as opposed to those who make other lifestyle choices, such as those with addictions, those who drive drunk, and prisoners? I feel as though you have caved to special interest groups and are contributing to normalizing a lifestyle that leads to an earlier death.

Nancy P. Lawless, ACP Member
Gaithersburg, Md.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated