Editorial

Since the term hospitalist was coined in 1996,1 the field of hospital medicine has grown exponentially. Hospitalists are caring for increasing numbers of adultsincluding Medicare beneficiaries in hospitals across the United States.2 Pediatric hospital medicine has grown in parallel. By 1998, 50% of pediatric department chairs across the US and Canada had implemented hospitalist programs, with another 27% reporting they were soon to do so.3 A bit more than a decade later, pediatric hospitalists can be found in nearly every major academic medical center, and in a large proportion of community hospitals throughout the US and Canada.

In the past several years, major advances have begun to occur in the manner in which hospital medicine research is conducted. In this article, we will describe the manner in which pediatric hospital medicine research has advanced over the past several years, culminating in the conduct of several large multicenter research projects through the Pediatric Research in Inpatient Settings (PRIS) Network. We believe that lessons learned in the development of PRIS could help foster the growth of other current and future networks of hospitalist researchers, and lay the groundwork for national improvement efforts.

HOSPITAL MEDICINE RESEARCH: GROWTH AND DEVELOPMENT

In 2001, a small group of thought leaders in pediatric hospital medicine (see Acknowledgements) conceived the notion of starting a hospitalist research network, which they named the Pediatric Research in Inpatient Settings (PRIS) Network.4 PRIS was modeled in part after a successful pediatric primary care network.5 Since hospitalists in institutions across the country were being tasked to improve the care of hospitalized patients, and to lead diverse quality and safety initiatives, why not create a network to facilitate identification of high priority problems and evidence‐based approaches to them, and coordinate improvement efforts? The ambitious goal of the fledgling network was to conduct transformative research into inpatient healthcare delivery and discover both condition‐dependent and condition‐independent processes of care that were linked to patient outcomes.

PRIS began as (and remains) an open research networkfrom the outset, any hospitalist could join. The notion of this network, even in its earliest stages, was sufficiently appealing to professional societies that the Society of Hospital Medicine (SHM), the Academic Pediatric Association (APA), and the American Academy of Pediatrics (AAP) agreed to cosponsor the network, fostering its early growth. The community of pediatric hospitalists was tremendously supportive as well; over 300 hospitalists initially signed up to participate. Initial studies were generated through surveys of members, through which variability in systemic organization and variation in the management of clinical conditions and systems‐based issues across inpatient settings was identified and quantified.68

In the 2000s, as PRIS grew as a network, the research capacity of individuals within the field also grew. An increasing number of hospitalists began dedicating their academic careers to pursuing rigorous methodological training and conducting pediatric hospital medicine research. A series of studies began to emerge analyzing data from large administrative datasets that described the variation in hospital care (but lack clinical results and clinical outcomes outside of the hospital setting), such as the Pediatric Health Information Systems (PHIS) database operated by the Children's Hospital Association (formerly known as the Child Health Corporation of America).913 Pediatric hospital medicine fellowships began to appear,14 and over time, a cohort of hospitalist investigators with sufficient independence to mentor others arose.

THE REDESIGN OF PRIS

In 2009, a Pediatric Hospital Medicine Roundtable of 22 international leaders was convened under the guidance of SHM, APA, and AAP.15 This initiative, roughly a decade after the inception of the field, was critical to bringing pediatric hospitalist research and PRIS to the next level. It was recognized in that meeting that while PRIS had made a good start, it would not be possible to grow the network to the point of conducting top quality multicenter studies without the active involvement of a larger number of rigorously trained hospitalist researchers. To stimulate the network's growth, the existing PRIS Steering Committeea diverse group of clinical, educational, administrative, and research leaders in the fieldfacilitated the transfer of leadership to a new Executive Council led entirely by trained researchers (see Table 1), with the support of the APA. The Executive Council subsequently developed a series of standard operating procedures (see Table 2) that have created a transparent process to deal with important, but often difficult, academic issues that networks face.

DEVELOPMENT OF MULTICENTER RESEARCH PROJECTS

The redesign of PRIS did not alter its objective: to build the evidence base regarding the optimal inpatient management of children. Evidence on how best to care for many pediatric conditions remains lacking, largely due to the facts that: a) death, the most definitive and readily measured of outcomes, is rare in pediatric hospitals; b) many pediatric conditions are relatively uncommon in any single hospital; and c) few validated, well‐developed metrics of inpatient pediatric quality exist.

As PRIS sought to launch multicenter studies of inpatient care quality, it continued to receive strong support from the APA, SHM, and AAP, and gained the support of a new partner, the Children's Hospital Association, which is comprised of a large group of children's hospitals across Canada and the US. The membership of PRIS grew to involve over 600 pediatric hospitalists from more than 75 hospitals.4 With a core group of funded hospitalist investigators, and strong support from partner organizations, the network sought and received funding for 3 major studies that are currently underway. Release of the federal government's Affordable Care Act and Comparative Effectiveness Research portfolio stimulated much of this work, stimulating the network to reach out to existing and new stakeholders and successfully compete for several multicenter studies.

RELEVANCE TO OTHER NETWORKS

We believe that the story of PRIS' development, current studies, and future plans has relevance to other adult, as well as pediatric, hospital medicine networks (see Table 3). As in pediatrics, a growing group of midcareer adult hospital medicine investigators has emerged, with proven track records in attracting federal funding and conducting research germane to our field. Some have previously worked together on large‐scale multisite studies.2023 A core group have come together to form the HOspital MEdicine Reengineering Network (HOMERUN).24 HOMERUN has recently secured funding from the Association of American Medical Colleges (AAMC) for a project that is linking clinical data from several hospitals to a centralized database, a project analogous to PHIS+, and will allow for Comparative Effectiveness Research studies that have more accurate case ascertainment (by using clinical data to build cohorts) and ensuring additional power by securing a larger number of cases. Defining which clinical questions to address first will help establish this new entity as a leader in hospital medicine research. Attracting stakeholder involvement will help make these endeavors successful. In recent months, PRIS and HOMERUN jointly collaborated on the submission of a large Centers for Medicare and Medicaid Innovation (CMMI) proposal to extend the work of I‐PASS to include several internal medicine and additional pediatric resident and hospitalist care settings. Future collaborations between networks may help foster more rapid advances in care.

Another pediatric hospitalist network has also emerged in the past few years, with a focus on quality improvement across inpatient pediatric settings, the Value in Pediatrics (VIP) Network.25 Although still early in its development, VIP has already successfully engaged in national quality improvement work regarding benchmarking care provided for children with bronchiolitis, reducing patient identification (ID) band errors, and improving discharge communications. VIP recently became part of the AAP's Quality Improvement Innovation Network (QuINN) group through which it is receiving infrastructure support.

As they develop, hospital medicine research and improvement networks will seek to systematically design and rigorously execute multicenter projects that provide answers to those clinical questions which practicing hospitalists face on a daily basis. As they do so, mentoring of both junior investigators and novice investigators will be necessary for the longevity of networks. To foster junior investigators, PRIS has undertaken a series of workshops presented at various national conferences, in addition to working with junior investigators directly on its currently funded studies.

CONCLUSION

Hospitalists' engagement in research and quality improvement networks builds upon their already successful engagement in clinical care, education, and quality improvement at a local level. A research and improvement mission that is tightly coupled with the day‐to‐day needs of these other important hospitalist activities creates a synergy with the potential to lead to transformative advances in patient care. If hospitalists can discover how best to deliver care, train the next generation of providers, and work to implement needed improvements at a local and national level, they will have an unprecedented opportunity to improve the care and health of children and adults.

Since the term hospitalist was coined in 1996,1 the field of hospital medicine has grown exponentially. Hospitalists are caring for increasing numbers of adultsincluding Medicare beneficiaries in hospitals across the United States.2 Pediatric hospital medicine has grown in parallel. By 1998, 50% of pediatric department chairs across the US and Canada had implemented hospitalist programs, with another 27% reporting they were soon to do so.3 A bit more than a decade later, pediatric hospitalists can be found in nearly every major academic medical center, and in a large proportion of community hospitals throughout the US and Canada.

In the past several years, major advances have begun to occur in the manner in which hospital medicine research is conducted. In this article, we will describe the manner in which pediatric hospital medicine research has advanced over the past several years, culminating in the conduct of several large multicenter research projects through the Pediatric Research in Inpatient Settings (PRIS) Network. We believe that lessons learned in the development of PRIS could help foster the growth of other current and future networks of hospitalist researchers, and lay the groundwork for national improvement efforts.

HOSPITAL MEDICINE RESEARCH: GROWTH AND DEVELOPMENT

In 2001, a small group of thought leaders in pediatric hospital medicine (see Acknowledgements) conceived the notion of starting a hospitalist research network, which they named the Pediatric Research in Inpatient Settings (PRIS) Network.4 PRIS was modeled in part after a successful pediatric primary care network.5 Since hospitalists in institutions across the country were being tasked to improve the care of hospitalized patients, and to lead diverse quality and safety initiatives, why not create a network to facilitate identification of high priority problems and evidence‐based approaches to them, and coordinate improvement efforts? The ambitious goal of the fledgling network was to conduct transformative research into inpatient healthcare delivery and discover both condition‐dependent and condition‐independent processes of care that were linked to patient outcomes.

PRIS began as (and remains) an open research networkfrom the outset, any hospitalist could join. The notion of this network, even in its earliest stages, was sufficiently appealing to professional societies that the Society of Hospital Medicine (SHM), the Academic Pediatric Association (APA), and the American Academy of Pediatrics (AAP) agreed to cosponsor the network, fostering its early growth. The community of pediatric hospitalists was tremendously supportive as well; over 300 hospitalists initially signed up to participate. Initial studies were generated through surveys of members, through which variability in systemic organization and variation in the management of clinical conditions and systems‐based issues across inpatient settings was identified and quantified.68

In the 2000s, as PRIS grew as a network, the research capacity of individuals within the field also grew. An increasing number of hospitalists began dedicating their academic careers to pursuing rigorous methodological training and conducting pediatric hospital medicine research. A series of studies began to emerge analyzing data from large administrative datasets that described the variation in hospital care (but lack clinical results and clinical outcomes outside of the hospital setting), such as the Pediatric Health Information Systems (PHIS) database operated by the Children's Hospital Association (formerly known as the Child Health Corporation of America).913 Pediatric hospital medicine fellowships began to appear,14 and over time, a cohort of hospitalist investigators with sufficient independence to mentor others arose.

THE REDESIGN OF PRIS

In 2009, a Pediatric Hospital Medicine Roundtable of 22 international leaders was convened under the guidance of SHM, APA, and AAP.15 This initiative, roughly a decade after the inception of the field, was critical to bringing pediatric hospitalist research and PRIS to the next level. It was recognized in that meeting that while PRIS had made a good start, it would not be possible to grow the network to the point of conducting top quality multicenter studies without the active involvement of a larger number of rigorously trained hospitalist researchers. To stimulate the network's growth, the existing PRIS Steering Committeea diverse group of clinical, educational, administrative, and research leaders in the fieldfacilitated the transfer of leadership to a new Executive Council led entirely by trained researchers (see Table 1), with the support of the APA. The Executive Council subsequently developed a series of standard operating procedures (see Table 2) that have created a transparent process to deal with important, but often difficult, academic issues that networks face.

DEVELOPMENT OF MULTICENTER RESEARCH PROJECTS

The redesign of PRIS did not alter its objective: to build the evidence base regarding the optimal inpatient management of children. Evidence on how best to care for many pediatric conditions remains lacking, largely due to the facts that: a) death, the most definitive and readily measured of outcomes, is rare in pediatric hospitals; b) many pediatric conditions are relatively uncommon in any single hospital; and c) few validated, well‐developed metrics of inpatient pediatric quality exist.

As PRIS sought to launch multicenter studies of inpatient care quality, it continued to receive strong support from the APA, SHM, and AAP, and gained the support of a new partner, the Children's Hospital Association, which is comprised of a large group of children's hospitals across Canada and the US. The membership of PRIS grew to involve over 600 pediatric hospitalists from more than 75 hospitals.4 With a core group of funded hospitalist investigators, and strong support from partner organizations, the network sought and received funding for 3 major studies that are currently underway. Release of the federal government's Affordable Care Act and Comparative Effectiveness Research portfolio stimulated much of this work, stimulating the network to reach out to existing and new stakeholders and successfully compete for several multicenter studies.

RELEVANCE TO OTHER NETWORKS

We believe that the story of PRIS' development, current studies, and future plans has relevance to other adult, as well as pediatric, hospital medicine networks (see Table 3). As in pediatrics, a growing group of midcareer adult hospital medicine investigators has emerged, with proven track records in attracting federal funding and conducting research germane to our field. Some have previously worked together on large‐scale multisite studies.2023 A core group have come together to form the HOspital MEdicine Reengineering Network (HOMERUN).24 HOMERUN has recently secured funding from the Association of American Medical Colleges (AAMC) for a project that is linking clinical data from several hospitals to a centralized database, a project analogous to PHIS+, and will allow for Comparative Effectiveness Research studies that have more accurate case ascertainment (by using clinical data to build cohorts) and ensuring additional power by securing a larger number of cases. Defining which clinical questions to address first will help establish this new entity as a leader in hospital medicine research. Attracting stakeholder involvement will help make these endeavors successful. In recent months, PRIS and HOMERUN jointly collaborated on the submission of a large Centers for Medicare and Medicaid Innovation (CMMI) proposal to extend the work of I‐PASS to include several internal medicine and additional pediatric resident and hospitalist care settings. Future collaborations between networks may help foster more rapid advances in care.

Another pediatric hospitalist network has also emerged in the past few years, with a focus on quality improvement across inpatient pediatric settings, the Value in Pediatrics (VIP) Network.25 Although still early in its development, VIP has already successfully engaged in national quality improvement work regarding benchmarking care provided for children with bronchiolitis, reducing patient identification (ID) band errors, and improving discharge communications. VIP recently became part of the AAP's Quality Improvement Innovation Network (QuINN) group through which it is receiving infrastructure support.

As they develop, hospital medicine research and improvement networks will seek to systematically design and rigorously execute multicenter projects that provide answers to those clinical questions which practicing hospitalists face on a daily basis. As they do so, mentoring of both junior investigators and novice investigators will be necessary for the longevity of networks. To foster junior investigators, PRIS has undertaken a series of workshops presented at various national conferences, in addition to working with junior investigators directly on its currently funded studies.

CONCLUSION

Hospitalists' engagement in research and quality improvement networks builds upon their already successful engagement in clinical care, education, and quality improvement at a local level. A research and improvement mission that is tightly coupled with the day‐to‐day needs of these other important hospitalist activities creates a synergy with the potential to lead to transformative advances in patient care. If hospitalists can discover how best to deliver care, train the next generation of providers, and work to implement needed improvements at a local and national level, they will have an unprecedented opportunity to improve the care and health of children and adults.

Since the term hospitalist was coined in 1996,1 the field of hospital medicine has grown exponentially. Hospitalists are caring for increasing numbers of adultsincluding Medicare beneficiaries in hospitals across the United States.2 Pediatric hospital medicine has grown in parallel. By 1998, 50% of pediatric department chairs across the US and Canada had implemented hospitalist programs, with another 27% reporting they were soon to do so.3 A bit more than a decade later, pediatric hospitalists can be found in nearly every major academic medical center, and in a large proportion of community hospitals throughout the US and Canada.

In the past several years, major advances have begun to occur in the manner in which hospital medicine research is conducted. In this article, we will describe the manner in which pediatric hospital medicine research has advanced over the past several years, culminating in the conduct of several large multicenter research projects through the Pediatric Research in Inpatient Settings (PRIS) Network. We believe that lessons learned in the development of PRIS could help foster the growth of other current and future networks of hospitalist researchers, and lay the groundwork for national improvement efforts.

HOSPITAL MEDICINE RESEARCH: GROWTH AND DEVELOPMENT

In 2001, a small group of thought leaders in pediatric hospital medicine (see Acknowledgements) conceived the notion of starting a hospitalist research network, which they named the Pediatric Research in Inpatient Settings (PRIS) Network.4 PRIS was modeled in part after a successful pediatric primary care network.5 Since hospitalists in institutions across the country were being tasked to improve the care of hospitalized patients, and to lead diverse quality and safety initiatives, why not create a network to facilitate identification of high priority problems and evidence‐based approaches to them, and coordinate improvement efforts? The ambitious goal of the fledgling network was to conduct transformative research into inpatient healthcare delivery and discover both condition‐dependent and condition‐independent processes of care that were linked to patient outcomes.

PRIS began as (and remains) an open research networkfrom the outset, any hospitalist could join. The notion of this network, even in its earliest stages, was sufficiently appealing to professional societies that the Society of Hospital Medicine (SHM), the Academic Pediatric Association (APA), and the American Academy of Pediatrics (AAP) agreed to cosponsor the network, fostering its early growth. The community of pediatric hospitalists was tremendously supportive as well; over 300 hospitalists initially signed up to participate. Initial studies were generated through surveys of members, through which variability in systemic organization and variation in the management of clinical conditions and systems‐based issues across inpatient settings was identified and quantified.68

In the 2000s, as PRIS grew as a network, the research capacity of individuals within the field also grew. An increasing number of hospitalists began dedicating their academic careers to pursuing rigorous methodological training and conducting pediatric hospital medicine research. A series of studies began to emerge analyzing data from large administrative datasets that described the variation in hospital care (but lack clinical results and clinical outcomes outside of the hospital setting), such as the Pediatric Health Information Systems (PHIS) database operated by the Children's Hospital Association (formerly known as the Child Health Corporation of America).913 Pediatric hospital medicine fellowships began to appear,14 and over time, a cohort of hospitalist investigators with sufficient independence to mentor others arose.

THE REDESIGN OF PRIS

In 2009, a Pediatric Hospital Medicine Roundtable of 22 international leaders was convened under the guidance of SHM, APA, and AAP.15 This initiative, roughly a decade after the inception of the field, was critical to bringing pediatric hospitalist research and PRIS to the next level. It was recognized in that meeting that while PRIS had made a good start, it would not be possible to grow the network to the point of conducting top quality multicenter studies without the active involvement of a larger number of rigorously trained hospitalist researchers. To stimulate the network's growth, the existing PRIS Steering Committeea diverse group of clinical, educational, administrative, and research leaders in the fieldfacilitated the transfer of leadership to a new Executive Council led entirely by trained researchers (see Table 1), with the support of the APA. The Executive Council subsequently developed a series of standard operating procedures (see Table 2) that have created a transparent process to deal with important, but often difficult, academic issues that networks face.

DEVELOPMENT OF MULTICENTER RESEARCH PROJECTS

The redesign of PRIS did not alter its objective: to build the evidence base regarding the optimal inpatient management of children. Evidence on how best to care for many pediatric conditions remains lacking, largely due to the facts that: a) death, the most definitive and readily measured of outcomes, is rare in pediatric hospitals; b) many pediatric conditions are relatively uncommon in any single hospital; and c) few validated, well‐developed metrics of inpatient pediatric quality exist.

As PRIS sought to launch multicenter studies of inpatient care quality, it continued to receive strong support from the APA, SHM, and AAP, and gained the support of a new partner, the Children's Hospital Association, which is comprised of a large group of children's hospitals across Canada and the US. The membership of PRIS grew to involve over 600 pediatric hospitalists from more than 75 hospitals.4 With a core group of funded hospitalist investigators, and strong support from partner organizations, the network sought and received funding for 3 major studies that are currently underway. Release of the federal government's Affordable Care Act and Comparative Effectiveness Research portfolio stimulated much of this work, stimulating the network to reach out to existing and new stakeholders and successfully compete for several multicenter studies.

RELEVANCE TO OTHER NETWORKS

We believe that the story of PRIS' development, current studies, and future plans has relevance to other adult, as well as pediatric, hospital medicine networks (see Table 3). As in pediatrics, a growing group of midcareer adult hospital medicine investigators has emerged, with proven track records in attracting federal funding and conducting research germane to our field. Some have previously worked together on large‐scale multisite studies.2023 A core group have come together to form the HOspital MEdicine Reengineering Network (HOMERUN).24 HOMERUN has recently secured funding from the Association of American Medical Colleges (AAMC) for a project that is linking clinical data from several hospitals to a centralized database, a project analogous to PHIS+, and will allow for Comparative Effectiveness Research studies that have more accurate case ascertainment (by using clinical data to build cohorts) and ensuring additional power by securing a larger number of cases. Defining which clinical questions to address first will help establish this new entity as a leader in hospital medicine research. Attracting stakeholder involvement will help make these endeavors successful. In recent months, PRIS and HOMERUN jointly collaborated on the submission of a large Centers for Medicare and Medicaid Innovation (CMMI) proposal to extend the work of I‐PASS to include several internal medicine and additional pediatric resident and hospitalist care settings. Future collaborations between networks may help foster more rapid advances in care.

Another pediatric hospitalist network has also emerged in the past few years, with a focus on quality improvement across inpatient pediatric settings, the Value in Pediatrics (VIP) Network.25 Although still early in its development, VIP has already successfully engaged in national quality improvement work regarding benchmarking care provided for children with bronchiolitis, reducing patient identification (ID) band errors, and improving discharge communications. VIP recently became part of the AAP's Quality Improvement Innovation Network (QuINN) group through which it is receiving infrastructure support.

As they develop, hospital medicine research and improvement networks will seek to systematically design and rigorously execute multicenter projects that provide answers to those clinical questions which practicing hospitalists face on a daily basis. As they do so, mentoring of both junior investigators and novice investigators will be necessary for the longevity of networks. To foster junior investigators, PRIS has undertaken a series of workshops presented at various national conferences, in addition to working with junior investigators directly on its currently funded studies.

CONCLUSION

Hospitalists' engagement in research and quality improvement networks builds upon their already successful engagement in clinical care, education, and quality improvement at a local level. A research and improvement mission that is tightly coupled with the day‐to‐day needs of these other important hospitalist activities creates a synergy with the potential to lead to transformative advances in patient care. If hospitalists can discover how best to deliver care, train the next generation of providers, and work to implement needed improvements at a local and national level, they will have an unprecedented opportunity to improve the care and health of children and adults.

Antibiotic resistance is a particularly troublesome problem in healthcare institutions, and is clearly linked to antibiotic usage.12 The total annual cost of antimicrobial resistance was estimated to be as high as $35 billion or more in the United States in 1989,3 and much higher in current US dollars. Approximately 5 of every 100 patients admitted to a US hospital develops a nosocomial or hospital‐associated infection (HAI),4 and many of these infections involve bacteria resistant to 1 or more antibiotics.5 This is important because hospitalized patients infected with antibiotic‐resistant bacteria spend a longer time in the hospital, at increased cost, and are at higher risk of death compared to patients with similar infections due to antibiotic‐susceptible bacteria.6 Furthermore, choice of antimicrobial agents across all hospitalized patients is being driven by the concern for these resistant organisms, potentially contributing to medication costs and hospital length of stay.3

Awareness of the problem of HAIs and their frequent association with multidrug‐resistant pathogens, led The Joint Commission of the United States to identify reduction in risk of HAIs as one of their national patient safety goals.7 While The Joint Commission's primary focus is on infection control measures (eg, hand hygiene),7 antimicrobial stewardship can and should play a key role in reducing the emergence and subsequent transmission of antimicrobial‐resistant pathogens within the hospital or other healthcare settings.

Antimicrobial stewardship has been defined as the optimal selection, dose, and duration of an antimicrobial that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance. Hospitalists will instinctively find the element of an antimicrobial stewardship to be inherently valuable to their clinical practice.8 By instituting and adhering to optimal antimicrobial usage within one's own practice and across their institutions, patient care is improved through better clinical outcomes, reduced microbial resistance, and shorter hospital stays.

This supplement of the Journal of Hospital Medicine examines key aspects of antimicrobial stewardship in 4 interrelated papers with respective focuses on appropriate initiation and selection of antibiotics (Dr Snydman), antimicrobial de‐escalation strategies (Dr Kaye), duration and cessation of treatment (Dr File), and the hospitalist's role in antimicrobial stewardship (Dr Rosenberg). Three case studies, interwoven through 3 of the 4 papers, are used to highlight the application of antimicrobial stewardship principles discussed in the respective papers, in patients commonly encountered in the hospital. The clinical cases deal with healthcare‐associated pneumonia, intra‐abdominal infections (diverticulitis), and central line‐associated bacteremia. The final paper by Rosenberg reviews trends in antimicrobial resistance, costs of hospital‐acquired infections, and lays out the argument for Hospitalist participation and, at times, leadership in antimicrobial stewardship programs.

Antibiotic resistance is a particularly troublesome problem in healthcare institutions, and is clearly linked to antibiotic usage.12 The total annual cost of antimicrobial resistance was estimated to be as high as $35 billion or more in the United States in 1989,3 and much higher in current US dollars. Approximately 5 of every 100 patients admitted to a US hospital develops a nosocomial or hospital‐associated infection (HAI),4 and many of these infections involve bacteria resistant to 1 or more antibiotics.5 This is important because hospitalized patients infected with antibiotic‐resistant bacteria spend a longer time in the hospital, at increased cost, and are at higher risk of death compared to patients with similar infections due to antibiotic‐susceptible bacteria.6 Furthermore, choice of antimicrobial agents across all hospitalized patients is being driven by the concern for these resistant organisms, potentially contributing to medication costs and hospital length of stay.3

Awareness of the problem of HAIs and their frequent association with multidrug‐resistant pathogens, led The Joint Commission of the United States to identify reduction in risk of HAIs as one of their national patient safety goals.7 While The Joint Commission's primary focus is on infection control measures (eg, hand hygiene),7 antimicrobial stewardship can and should play a key role in reducing the emergence and subsequent transmission of antimicrobial‐resistant pathogens within the hospital or other healthcare settings.

Antimicrobial stewardship has been defined as the optimal selection, dose, and duration of an antimicrobial that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance. Hospitalists will instinctively find the element of an antimicrobial stewardship to be inherently valuable to their clinical practice.8 By instituting and adhering to optimal antimicrobial usage within one's own practice and across their institutions, patient care is improved through better clinical outcomes, reduced microbial resistance, and shorter hospital stays.

This supplement of the Journal of Hospital Medicine examines key aspects of antimicrobial stewardship in 4 interrelated papers with respective focuses on appropriate initiation and selection of antibiotics (Dr Snydman), antimicrobial de‐escalation strategies (Dr Kaye), duration and cessation of treatment (Dr File), and the hospitalist's role in antimicrobial stewardship (Dr Rosenberg). Three case studies, interwoven through 3 of the 4 papers, are used to highlight the application of antimicrobial stewardship principles discussed in the respective papers, in patients commonly encountered in the hospital. The clinical cases deal with healthcare‐associated pneumonia, intra‐abdominal infections (diverticulitis), and central line‐associated bacteremia. The final paper by Rosenberg reviews trends in antimicrobial resistance, costs of hospital‐acquired infections, and lays out the argument for Hospitalist participation and, at times, leadership in antimicrobial stewardship programs.

Antibiotic resistance is a particularly troublesome problem in healthcare institutions, and is clearly linked to antibiotic usage.12 The total annual cost of antimicrobial resistance was estimated to be as high as $35 billion or more in the United States in 1989,3 and much higher in current US dollars. Approximately 5 of every 100 patients admitted to a US hospital develops a nosocomial or hospital‐associated infection (HAI),4 and many of these infections involve bacteria resistant to 1 or more antibiotics.5 This is important because hospitalized patients infected with antibiotic‐resistant bacteria spend a longer time in the hospital, at increased cost, and are at higher risk of death compared to patients with similar infections due to antibiotic‐susceptible bacteria.6 Furthermore, choice of antimicrobial agents across all hospitalized patients is being driven by the concern for these resistant organisms, potentially contributing to medication costs and hospital length of stay.3

Awareness of the problem of HAIs and their frequent association with multidrug‐resistant pathogens, led The Joint Commission of the United States to identify reduction in risk of HAIs as one of their national patient safety goals.7 While The Joint Commission's primary focus is on infection control measures (eg, hand hygiene),7 antimicrobial stewardship can and should play a key role in reducing the emergence and subsequent transmission of antimicrobial‐resistant pathogens within the hospital or other healthcare settings.

Antimicrobial stewardship has been defined as the optimal selection, dose, and duration of an antimicrobial that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance. Hospitalists will instinctively find the element of an antimicrobial stewardship to be inherently valuable to their clinical practice.8 By instituting and adhering to optimal antimicrobial usage within one's own practice and across their institutions, patient care is improved through better clinical outcomes, reduced microbial resistance, and shorter hospital stays.

This supplement of the Journal of Hospital Medicine examines key aspects of antimicrobial stewardship in 4 interrelated papers with respective focuses on appropriate initiation and selection of antibiotics (Dr Snydman), antimicrobial de‐escalation strategies (Dr Kaye), duration and cessation of treatment (Dr File), and the hospitalist's role in antimicrobial stewardship (Dr Rosenberg). Three case studies, interwoven through 3 of the 4 papers, are used to highlight the application of antimicrobial stewardship principles discussed in the respective papers, in patients commonly encountered in the hospital. The clinical cases deal with healthcare‐associated pneumonia, intra‐abdominal infections (diverticulitis), and central line‐associated bacteremia. The final paper by Rosenberg reviews trends in antimicrobial resistance, costs of hospital‐acquired infections, and lays out the argument for Hospitalist participation and, at times, leadership in antimicrobial stewardship programs.

Injectable furosemide was first approved for use by the US Food and Drug Administration in 1968.1 For more than 40 years, loop diuretics have been the mainstay of therapy for relief of congestion and fluid removal in patients admitted with acute decompensated heart failure (ADHF). Despite the widespread use of loop diuretics in clinical practice, robust data supporting their role is scarce. Furthermore, the optimal approach to the management of the patient with acute volume overload has not been well defined.

In this issue of the Journal of Hospital Medicine, Amer et al.2 present a meta‐analysis of randomized controlled trials comparing continuous infusion to bolus doses of furosemide in hospitalized patients with ADHF. The study demonstrates that continuous infusion is superior to bolus in terms of weight loss and urine output over 24 hours. Specifically, patients receiving a continuous infusion of furosemide had 240 mL/day (95% CI, 462.42 to 18.66) more urine and lost an additional 0.78 kg (95% CI, 1.54 to 0.03) in their hospital stay compared with patients receiving a bolus infusion. The heterogeneity in study designs for urine output and wide confidence intervals for urine output and weight loss create uncertainty about the superiority of continuous infusion. The small difference in daily urine output questions the clinical significance of the results. Many of the studies evaluated in the meta‐analysis lacked rigorous design and/or appropriately dosed furosemide.

Despite the shortcomings of the available studies, the authors have published a sound and reasonable meta‐analysis. This is the first meta‐analysis comparing the use of furosemide alone as a continuous infusion versus bolus dose in patients with ADHF. Additionally, Amer et al. are the first to include recent data from the DOSE trial,3 which showed no difference in volume loss between heart failure patients receiving bolus versus continuous infusions dosing of loop diuretics. Although the benefits of continuous infusion in the meta‐analysis by Amer et al. represent only a modest clinical advantage over bolus infusions, the authors should be commended for addressing an important controversy in the management of patients with volume overload.

Although the method of dose delivery is an important issue in the management of such patients, we believe that a number of critical factors must be taken into consideration to assure sufficient fluid removal and quick relief of congestion. Ensuring the delivery of an adequate loop diuretic dose is critical. Additionally, the dose response must be assessed at an appropriate interval so adjustments can be made in a timely manner. Using this method, diuretic dosing can be individualized based on response.

Current guidelines jointly published by the American Heart Association (AHA) and American College of Cardiology (ACC) do not provide clinicians with specific details about the optimal approach to volume‐overloaded patients.4 In a 2009 update, the ACC and AHA recommend diuretic use to optimize volume status and relieve signs and symptoms of congestion without inducing excessively rapid reduction in intravascular volume.4 They further recommend that patients already receiving a loop diuretic who present with volume overload should receive a dose of diuretic equal to or higher than the outpatient dose. Urine output and congestion should be reassessed serially, and diuretics should be titrated accordingly. Current guidelines do not adequately address several topics, including: (1) appropriate urine output in 24 hours, and how frequently urine output should be assessed; (2) optimal frequency of diuretic dosing; and (3) appropriate choice of diuretic.

An understanding of the pharmacokinetics of loop diuretics helps answer these questions. Intravenous furosemide and bumetanide have similar elimination half‐lives of 1 to 2 hours and peak intravenous action at 30 minutes.5, 6 Intravenous torsemide has not been widely available, but has a longer half‐life of 3 to 4 hours, with peak action in 1 to 2 hours.5, 6 The magnitude of a patient's diuretic response compared with the amount of drug administered is best represented by a sigmoid curve.5 Therefore, after a specific dose threshold, further natriuresis is not achieved. Based on the elimination half‐life, proper bolus dosing of furosemide or bumetanide should be every 4 to 8 hours in patients with volume overload and adequate blood pressure.6 The administration of a loading dose of loop diuretic is of paramount importance to rapidly achieve therapeutic levels immediately before initiating a continuous infusion. Without a proper loading dose, it can take up to 20 hours to achieve steady state serum levels of diuretic during continuous infusion.5 The ACC and AHA acknowledge this point in their guidelines for chronic heart failure by recommending a bolus dose before initiation of continuous infusion.7 The negative results of the DOSE trial may have been due to lack of a loading dose before infusion initiation.3 Additionally, the total volume loss during continuous infusion compared with bolus dosing might be greater if loading doses were consistently given before starting infusions in published studies. Overall, individual patient response to a diuretic dose is variable and dependent on several factors, including serum albumin level, renal and liver function, and diuretic resistance.5

Teamwork and collaboration are essential to overcome barriers to proper diuretic dosing and provide patients with safe and effective care. Closed loop communication between nurses, physicians, and pharmacists in structured daily interdisciplinary rounds appears to reduce adverse drug events in hospitalized patients.8 The increased mortality9, 10 associated with high doses of diuretic, as well as registry data suggesting that over 50% of patients are discharged with significant heart failure symptoms and minimal weight loss,11 call for a more structured approach toward fluid removal. A team‐based protocol that directs titration of medication, monitors response, and clearly outlines communication channels to adjust doses allows for more efficacious medication administration with lower rates of serious events. This method was used with a dosing algorithm for the administration of opioids for patients with acute pain syndromes.12 Serious or fatal opioid‐related adverse drug events were reduced to zero using this communication‐enhancing approach.12 A similar approach should be used for diuretic dosing in patients who are admitted with ADHF.

We believe frequent follow‐up of diuretic response is critical in the successful treatment of the volume‐overloaded patient. Many clinicians who treat hospitalized patients with ADHF prescribe a fixed daily diuretic dose and evaluate the natriuretic response based on 24‐hour urine output and weight loss. This can lead to unnecessary increases in length of hospital stay. We recommend using a protocol for diuretic administration that includes more frequent assessment and follow‐up of dose response. After a diuretic dose is given, nurses communicate with the physician about the amount of urine output after a prespecified time based on an understanding of the pharmacokinetics of the medication administered. If the urine output is not within the desired range, then the diuretic dose can be increased and immediately administered. If the urine output is above a desired range, doses can be decreased, delayed, or held. With optimal protocol dosing for loop diuretics, continuous infusion may be superfluous. In one study, Peacock et al.13 evaluated a diuretic protocol used to treat patients with ADHF who were admitted to an observation unit. This protocol set 2‐hour urine output goals after loop diuretic bolus doses were administered. If the urine output goals were not met, the diuretic dose was doubled and 2‐hour urine measurements were repeated.13 Limits were set on maximum dosing to ensure patient safety, and electrolytes and renal function were monitored. Using this protocol with other ADHF multidisciplinary interventions, 90‐day heart failure readmission rates decreased by 64% (P = 0.007) with a trend toward decreased 90‐day mortality.13 Although the multidisciplinary approach may have been the major contributor to these outcomes, the diuretic protocol allowed rapid achievement of euvolemia in an observation unit patient population with ADHF. Future investigation needs to specifically evaluate dosing protocols and patient safety because of the association between high doses of diuretics and increased mortality. However, studies showing that high diuretic doses are harmful may simply reflect the fact that patients who require high doses of diuretic have more advanced cardiac or renal disease. In such situations, the clinician needs to be aware of the possibility of decreased cardiac output, hypotension, and intrinsic renal disease as potential barriers to diuresis.

Currently, clinicians have no clear evidence‐based strategies for using diuretics to safely reduce congestion in patients with ADHF. As shown by Amer et al.,2 continuous furosemide infusion may provide more effective weight and volume loss than bolus injections. More rigorous studies comparing effectively dosed diuretics regimens are needed. These studies should optimize diuretic use by accounting for individual patient characteristics and drug pharmacokinetics, using a protocol that monitors response in an appropriate interval, and facilitates care team communication. Ultimately, the mode of diuretic administration is only 1 part of developing a process to remove fluid in patients with ADHF.

Injectable furosemide was first approved for use by the US Food and Drug Administration in 1968.1 For more than 40 years, loop diuretics have been the mainstay of therapy for relief of congestion and fluid removal in patients admitted with acute decompensated heart failure (ADHF). Despite the widespread use of loop diuretics in clinical practice, robust data supporting their role is scarce. Furthermore, the optimal approach to the management of the patient with acute volume overload has not been well defined.

In this issue of the Journal of Hospital Medicine, Amer et al.2 present a meta‐analysis of randomized controlled trials comparing continuous infusion to bolus doses of furosemide in hospitalized patients with ADHF. The study demonstrates that continuous infusion is superior to bolus in terms of weight loss and urine output over 24 hours. Specifically, patients receiving a continuous infusion of furosemide had 240 mL/day (95% CI, 462.42 to 18.66) more urine and lost an additional 0.78 kg (95% CI, 1.54 to 0.03) in their hospital stay compared with patients receiving a bolus infusion. The heterogeneity in study designs for urine output and wide confidence intervals for urine output and weight loss create uncertainty about the superiority of continuous infusion. The small difference in daily urine output questions the clinical significance of the results. Many of the studies evaluated in the meta‐analysis lacked rigorous design and/or appropriately dosed furosemide.

Despite the shortcomings of the available studies, the authors have published a sound and reasonable meta‐analysis. This is the first meta‐analysis comparing the use of furosemide alone as a continuous infusion versus bolus dose in patients with ADHF. Additionally, Amer et al. are the first to include recent data from the DOSE trial,3 which showed no difference in volume loss between heart failure patients receiving bolus versus continuous infusions dosing of loop diuretics. Although the benefits of continuous infusion in the meta‐analysis by Amer et al. represent only a modest clinical advantage over bolus infusions, the authors should be commended for addressing an important controversy in the management of patients with volume overload.

Although the method of dose delivery is an important issue in the management of such patients, we believe that a number of critical factors must be taken into consideration to assure sufficient fluid removal and quick relief of congestion. Ensuring the delivery of an adequate loop diuretic dose is critical. Additionally, the dose response must be assessed at an appropriate interval so adjustments can be made in a timely manner. Using this method, diuretic dosing can be individualized based on response.

Current guidelines jointly published by the American Heart Association (AHA) and American College of Cardiology (ACC) do not provide clinicians with specific details about the optimal approach to volume‐overloaded patients.4 In a 2009 update, the ACC and AHA recommend diuretic use to optimize volume status and relieve signs and symptoms of congestion without inducing excessively rapid reduction in intravascular volume.4 They further recommend that patients already receiving a loop diuretic who present with volume overload should receive a dose of diuretic equal to or higher than the outpatient dose. Urine output and congestion should be reassessed serially, and diuretics should be titrated accordingly. Current guidelines do not adequately address several topics, including: (1) appropriate urine output in 24 hours, and how frequently urine output should be assessed; (2) optimal frequency of diuretic dosing; and (3) appropriate choice of diuretic.

An understanding of the pharmacokinetics of loop diuretics helps answer these questions. Intravenous furosemide and bumetanide have similar elimination half‐lives of 1 to 2 hours and peak intravenous action at 30 minutes.5, 6 Intravenous torsemide has not been widely available, but has a longer half‐life of 3 to 4 hours, with peak action in 1 to 2 hours.5, 6 The magnitude of a patient's diuretic response compared with the amount of drug administered is best represented by a sigmoid curve.5 Therefore, after a specific dose threshold, further natriuresis is not achieved. Based on the elimination half‐life, proper bolus dosing of furosemide or bumetanide should be every 4 to 8 hours in patients with volume overload and adequate blood pressure.6 The administration of a loading dose of loop diuretic is of paramount importance to rapidly achieve therapeutic levels immediately before initiating a continuous infusion. Without a proper loading dose, it can take up to 20 hours to achieve steady state serum levels of diuretic during continuous infusion.5 The ACC and AHA acknowledge this point in their guidelines for chronic heart failure by recommending a bolus dose before initiation of continuous infusion.7 The negative results of the DOSE trial may have been due to lack of a loading dose before infusion initiation.3 Additionally, the total volume loss during continuous infusion compared with bolus dosing might be greater if loading doses were consistently given before starting infusions in published studies. Overall, individual patient response to a diuretic dose is variable and dependent on several factors, including serum albumin level, renal and liver function, and diuretic resistance.5

Teamwork and collaboration are essential to overcome barriers to proper diuretic dosing and provide patients with safe and effective care. Closed loop communication between nurses, physicians, and pharmacists in structured daily interdisciplinary rounds appears to reduce adverse drug events in hospitalized patients.8 The increased mortality9, 10 associated with high doses of diuretic, as well as registry data suggesting that over 50% of patients are discharged with significant heart failure symptoms and minimal weight loss,11 call for a more structured approach toward fluid removal. A team‐based protocol that directs titration of medication, monitors response, and clearly outlines communication channels to adjust doses allows for more efficacious medication administration with lower rates of serious events. This method was used with a dosing algorithm for the administration of opioids for patients with acute pain syndromes.12 Serious or fatal opioid‐related adverse drug events were reduced to zero using this communication‐enhancing approach.12 A similar approach should be used for diuretic dosing in patients who are admitted with ADHF.

We believe frequent follow‐up of diuretic response is critical in the successful treatment of the volume‐overloaded patient. Many clinicians who treat hospitalized patients with ADHF prescribe a fixed daily diuretic dose and evaluate the natriuretic response based on 24‐hour urine output and weight loss. This can lead to unnecessary increases in length of hospital stay. We recommend using a protocol for diuretic administration that includes more frequent assessment and follow‐up of dose response. After a diuretic dose is given, nurses communicate with the physician about the amount of urine output after a prespecified time based on an understanding of the pharmacokinetics of the medication administered. If the urine output is not within the desired range, then the diuretic dose can be increased and immediately administered. If the urine output is above a desired range, doses can be decreased, delayed, or held. With optimal protocol dosing for loop diuretics, continuous infusion may be superfluous. In one study, Peacock et al.13 evaluated a diuretic protocol used to treat patients with ADHF who were admitted to an observation unit. This protocol set 2‐hour urine output goals after loop diuretic bolus doses were administered. If the urine output goals were not met, the diuretic dose was doubled and 2‐hour urine measurements were repeated.13 Limits were set on maximum dosing to ensure patient safety, and electrolytes and renal function were monitored. Using this protocol with other ADHF multidisciplinary interventions, 90‐day heart failure readmission rates decreased by 64% (P = 0.007) with a trend toward decreased 90‐day mortality.13 Although the multidisciplinary approach may have been the major contributor to these outcomes, the diuretic protocol allowed rapid achievement of euvolemia in an observation unit patient population with ADHF. Future investigation needs to specifically evaluate dosing protocols and patient safety because of the association between high doses of diuretics and increased mortality. However, studies showing that high diuretic doses are harmful may simply reflect the fact that patients who require high doses of diuretic have more advanced cardiac or renal disease. In such situations, the clinician needs to be aware of the possibility of decreased cardiac output, hypotension, and intrinsic renal disease as potential barriers to diuresis.

Currently, clinicians have no clear evidence‐based strategies for using diuretics to safely reduce congestion in patients with ADHF. As shown by Amer et al.,2 continuous furosemide infusion may provide more effective weight and volume loss than bolus injections. More rigorous studies comparing effectively dosed diuretics regimens are needed. These studies should optimize diuretic use by accounting for individual patient characteristics and drug pharmacokinetics, using a protocol that monitors response in an appropriate interval, and facilitates care team communication. Ultimately, the mode of diuretic administration is only 1 part of developing a process to remove fluid in patients with ADHF.

Injectable furosemide was first approved for use by the US Food and Drug Administration in 1968.1 For more than 40 years, loop diuretics have been the mainstay of therapy for relief of congestion and fluid removal in patients admitted with acute decompensated heart failure (ADHF). Despite the widespread use of loop diuretics in clinical practice, robust data supporting their role is scarce. Furthermore, the optimal approach to the management of the patient with acute volume overload has not been well defined.

In this issue of the Journal of Hospital Medicine, Amer et al.2 present a meta‐analysis of randomized controlled trials comparing continuous infusion to bolus doses of furosemide in hospitalized patients with ADHF. The study demonstrates that continuous infusion is superior to bolus in terms of weight loss and urine output over 24 hours. Specifically, patients receiving a continuous infusion of furosemide had 240 mL/day (95% CI, 462.42 to 18.66) more urine and lost an additional 0.78 kg (95% CI, 1.54 to 0.03) in their hospital stay compared with patients receiving a bolus infusion. The heterogeneity in study designs for urine output and wide confidence intervals for urine output and weight loss create uncertainty about the superiority of continuous infusion. The small difference in daily urine output questions the clinical significance of the results. Many of the studies evaluated in the meta‐analysis lacked rigorous design and/or appropriately dosed furosemide.

Despite the shortcomings of the available studies, the authors have published a sound and reasonable meta‐analysis. This is the first meta‐analysis comparing the use of furosemide alone as a continuous infusion versus bolus dose in patients with ADHF. Additionally, Amer et al. are the first to include recent data from the DOSE trial,3 which showed no difference in volume loss between heart failure patients receiving bolus versus continuous infusions dosing of loop diuretics. Although the benefits of continuous infusion in the meta‐analysis by Amer et al. represent only a modest clinical advantage over bolus infusions, the authors should be commended for addressing an important controversy in the management of patients with volume overload.

Although the method of dose delivery is an important issue in the management of such patients, we believe that a number of critical factors must be taken into consideration to assure sufficient fluid removal and quick relief of congestion. Ensuring the delivery of an adequate loop diuretic dose is critical. Additionally, the dose response must be assessed at an appropriate interval so adjustments can be made in a timely manner. Using this method, diuretic dosing can be individualized based on response.

Current guidelines jointly published by the American Heart Association (AHA) and American College of Cardiology (ACC) do not provide clinicians with specific details about the optimal approach to volume‐overloaded patients.4 In a 2009 update, the ACC and AHA recommend diuretic use to optimize volume status and relieve signs and symptoms of congestion without inducing excessively rapid reduction in intravascular volume.4 They further recommend that patients already receiving a loop diuretic who present with volume overload should receive a dose of diuretic equal to or higher than the outpatient dose. Urine output and congestion should be reassessed serially, and diuretics should be titrated accordingly. Current guidelines do not adequately address several topics, including: (1) appropriate urine output in 24 hours, and how frequently urine output should be assessed; (2) optimal frequency of diuretic dosing; and (3) appropriate choice of diuretic.

An understanding of the pharmacokinetics of loop diuretics helps answer these questions. Intravenous furosemide and bumetanide have similar elimination half‐lives of 1 to 2 hours and peak intravenous action at 30 minutes.5, 6 Intravenous torsemide has not been widely available, but has a longer half‐life of 3 to 4 hours, with peak action in 1 to 2 hours.5, 6 The magnitude of a patient's diuretic response compared with the amount of drug administered is best represented by a sigmoid curve.5 Therefore, after a specific dose threshold, further natriuresis is not achieved. Based on the elimination half‐life, proper bolus dosing of furosemide or bumetanide should be every 4 to 8 hours in patients with volume overload and adequate blood pressure.6 The administration of a loading dose of loop diuretic is of paramount importance to rapidly achieve therapeutic levels immediately before initiating a continuous infusion. Without a proper loading dose, it can take up to 20 hours to achieve steady state serum levels of diuretic during continuous infusion.5 The ACC and AHA acknowledge this point in their guidelines for chronic heart failure by recommending a bolus dose before initiation of continuous infusion.7 The negative results of the DOSE trial may have been due to lack of a loading dose before infusion initiation.3 Additionally, the total volume loss during continuous infusion compared with bolus dosing might be greater if loading doses were consistently given before starting infusions in published studies. Overall, individual patient response to a diuretic dose is variable and dependent on several factors, including serum albumin level, renal and liver function, and diuretic resistance.5

Teamwork and collaboration are essential to overcome barriers to proper diuretic dosing and provide patients with safe and effective care. Closed loop communication between nurses, physicians, and pharmacists in structured daily interdisciplinary rounds appears to reduce adverse drug events in hospitalized patients.8 The increased mortality9, 10 associated with high doses of diuretic, as well as registry data suggesting that over 50% of patients are discharged with significant heart failure symptoms and minimal weight loss,11 call for a more structured approach toward fluid removal. A team‐based protocol that directs titration of medication, monitors response, and clearly outlines communication channels to adjust doses allows for more efficacious medication administration with lower rates of serious events. This method was used with a dosing algorithm for the administration of opioids for patients with acute pain syndromes.12 Serious or fatal opioid‐related adverse drug events were reduced to zero using this communication‐enhancing approach.12 A similar approach should be used for diuretic dosing in patients who are admitted with ADHF.

We believe frequent follow‐up of diuretic response is critical in the successful treatment of the volume‐overloaded patient. Many clinicians who treat hospitalized patients with ADHF prescribe a fixed daily diuretic dose and evaluate the natriuretic response based on 24‐hour urine output and weight loss. This can lead to unnecessary increases in length of hospital stay. We recommend using a protocol for diuretic administration that includes more frequent assessment and follow‐up of dose response. After a diuretic dose is given, nurses communicate with the physician about the amount of urine output after a prespecified time based on an understanding of the pharmacokinetics of the medication administered. If the urine output is not within the desired range, then the diuretic dose can be increased and immediately administered. If the urine output is above a desired range, doses can be decreased, delayed, or held. With optimal protocol dosing for loop diuretics, continuous infusion may be superfluous. In one study, Peacock et al.13 evaluated a diuretic protocol used to treat patients with ADHF who were admitted to an observation unit. This protocol set 2‐hour urine output goals after loop diuretic bolus doses were administered. If the urine output goals were not met, the diuretic dose was doubled and 2‐hour urine measurements were repeated.13 Limits were set on maximum dosing to ensure patient safety, and electrolytes and renal function were monitored. Using this protocol with other ADHF multidisciplinary interventions, 90‐day heart failure readmission rates decreased by 64% (P = 0.007) with a trend toward decreased 90‐day mortality.13 Although the multidisciplinary approach may have been the major contributor to these outcomes, the diuretic protocol allowed rapid achievement of euvolemia in an observation unit patient population with ADHF. Future investigation needs to specifically evaluate dosing protocols and patient safety because of the association between high doses of diuretics and increased mortality. However, studies showing that high diuretic doses are harmful may simply reflect the fact that patients who require high doses of diuretic have more advanced cardiac or renal disease. In such situations, the clinician needs to be aware of the possibility of decreased cardiac output, hypotension, and intrinsic renal disease as potential barriers to diuresis.

Currently, clinicians have no clear evidence‐based strategies for using diuretics to safely reduce congestion in patients with ADHF. As shown by Amer et al.,2 continuous furosemide infusion may provide more effective weight and volume loss than bolus injections. More rigorous studies comparing effectively dosed diuretics regimens are needed. These studies should optimize diuretic use by accounting for individual patient characteristics and drug pharmacokinetics, using a protocol that monitors response in an appropriate interval, and facilitates care team communication. Ultimately, the mode of diuretic administration is only 1 part of developing a process to remove fluid in patients with ADHF.

Beginning in January 2012, version 2.0 of the Journal of Hospital Medicine will begin with the talented and capable Andrew Auerbach, MD, MPH taking over as Editor‐in‐Chief. A premier hospital medicine researcher, he possesses experience as a journal editor and practicing hospitalist. With Andy at the helm, JHM will certainly get an upgrade. As my 7‐year tenure comes to an end, I look forward to moving on to new activities, but will dally a bit and reflect on this wonderful opportunity provided to me by the leadership of the Society of Hospital Medicine.

Undertaking with trepidation my role as the founding Editor‐in‐Chief in 2005, I recognized that a talented team of editors would be needed to achieve the expected goals for JHMindexing in MEDLINE (Medical Literature Analysis and Retrieval System Online) and selection for impact factor coverage by Thomson's Institute of Scientific Information (ISI) services. Thankfully, I learned from George Thibault, my egalitarian and brilliant residency program director at Massachusetts General Hospital, that successful leaders succeed by recruiting colleagues smarter than them. With no experience in journal editing beyond writing and reviewing articles, I leaned on numerous people more clever than me. Guided by Kathy Alexander and Vickie Thaw at Wiley‐Blackwell, we put together the framework for the journal. Fortunately, remarkable people agreed to serve as the founding Associate Editors. The abilities of Scott Flanders, Karen Hauer, Jean Kutner, James Pile, and Kaveh Shojania are reflected in their subsequent selection for leadership positions at their institutions and internationally.

JHM's leadership team evolved with replacements and the addition of superbly talented members: Thomas Baudendistel, Daniel Brotman, Vincent Chiang, Lakshmi Halasyamani, Brian Harte, Daniel Hunt, and Sunil Kripalani joined Jim Pile as Deputy Editors. Numerous Associate and Assistant Editors listed on our masthead also contributed their time and thoughtful reviews. Integral to our efforts, the exceptional Managing Editor Phaedra Cress kept us organized, cajoled everyone to meet deadlines, and offered a responsive and affable face to authors.

And succeed this team did! Midway through its second year of publication, JHM was selected for indexing and inclusion in the National Library of Medicine's MEDLINE. After just 2 years of publication, Thomson's ISI services selected JHM for impact factor coverage, and the journal received its first impact factor (3.163) in 2009. The nearly 100,000 article downloads this past year reflect JHM's acceptance beyond hospital medicine, becoming a valuable and respected resource across medicine.

In my first editorial, I remarked that the goal is for JHM to become the premier forum for peer‐reviewed research articles and evidence‐based reviews in the specialty of hospital medicine.¹ This journal is on its way to achieving this ambition, possibly further and faster than expected, thanks to all the authors who confidently selected JHM as the publication venue for their scholarly work, the innumerable hours contributed by reviewers who volunteered their time and diligently evaluated thousands of manuscripts, and the terrific work by all the Deputy, Associate, and Assistant Editors. JHM never would have succeeded without their contributions, and I never will be able to thank them enough. Now trusted colleagues and lifelong friends, they deserve the bulk of the credit for JHM's success.

In my life, any accomplishments I achieve stem from the values and work ethic my father inculcated in me. Reportedly known as Bucket Seats by his Army Air Force colleagues because of his muscular size, required of a B‐24 bomber pilot who flew in World War II as a member of the 8^th Army Air Force in Europe, a description of the B‐24 by Stephen Ambrose in The Blue Yonder aptly described my father's demeanor and power. It could be sternly unforgiving. It always required, and sometimes demanded, almost superhuman strength to fly. My siblings and I knew him as Smoky, a nickname attached to him by his military buddies after he fell asleep in bed with a cigarette setting his mattress on fire. Sadly, though he miraculously survived fighter plane bullets, flak and fire, unlike many of his fellow pilots and crew, kidney cancer ended his life before age 60, just after I finished my first year of medical school. The attentive and considerate hospital care he received, as well as compassionate care from my mother, who previously worked as a nurse and attended to him at home in his final months, influenced me throughout my career. I hope hospitalists everywhere never forget that patients and their caregivers should remain the primary focus of all our efforts. Document your work and share it with your colleagues through JHM, and all of us will benefit.

A 7‐year journey now ends for me, and I hope much less time sitting on the couch, as I will no longer be spending chunks of my weekends and evenings assigning work to the tireless editors of JHM, reviewing manuscripts, and editing articles. Coincidentally, our youngest child Caroline moved out this autumn, joining her older brothers Stephen and Jason to pursue their dreams. With an empty nest, my wife Karee and I look forward to exploring more of the world.

Lastly, I thank the members of the Society of Hospital Medicine and the readers of JHM, whose kind and frequent compliments provided the fuel for my efforts. Always grateful for this opportunity, I will never forget the unique and indescribable experience of serving as the founding editor of the Journal of Hospital Medicine. Take care, and best wishes to the new leadership as they upgrade the journal to the next level. Out the door I go, on to other endeavors.

Beginning in January 2012, version 2.0 of the Journal of Hospital Medicine will begin with the talented and capable Andrew Auerbach, MD, MPH taking over as Editor‐in‐Chief. A premier hospital medicine researcher, he possesses experience as a journal editor and practicing hospitalist. With Andy at the helm, JHM will certainly get an upgrade. As my 7‐year tenure comes to an end, I look forward to moving on to new activities, but will dally a bit and reflect on this wonderful opportunity provided to me by the leadership of the Society of Hospital Medicine.

Undertaking with trepidation my role as the founding Editor‐in‐Chief in 2005, I recognized that a talented team of editors would be needed to achieve the expected goals for JHMindexing in MEDLINE (Medical Literature Analysis and Retrieval System Online) and selection for impact factor coverage by Thomson's Institute of Scientific Information (ISI) services. Thankfully, I learned from George Thibault, my egalitarian and brilliant residency program director at Massachusetts General Hospital, that successful leaders succeed by recruiting colleagues smarter than them. With no experience in journal editing beyond writing and reviewing articles, I leaned on numerous people more clever than me. Guided by Kathy Alexander and Vickie Thaw at Wiley‐Blackwell, we put together the framework for the journal. Fortunately, remarkable people agreed to serve as the founding Associate Editors. The abilities of Scott Flanders, Karen Hauer, Jean Kutner, James Pile, and Kaveh Shojania are reflected in their subsequent selection for leadership positions at their institutions and internationally.

JHM's leadership team evolved with replacements and the addition of superbly talented members: Thomas Baudendistel, Daniel Brotman, Vincent Chiang, Lakshmi Halasyamani, Brian Harte, Daniel Hunt, and Sunil Kripalani joined Jim Pile as Deputy Editors. Numerous Associate and Assistant Editors listed on our masthead also contributed their time and thoughtful reviews. Integral to our efforts, the exceptional Managing Editor Phaedra Cress kept us organized, cajoled everyone to meet deadlines, and offered a responsive and affable face to authors.

And succeed this team did! Midway through its second year of publication, JHM was selected for indexing and inclusion in the National Library of Medicine's MEDLINE. After just 2 years of publication, Thomson's ISI services selected JHM for impact factor coverage, and the journal received its first impact factor (3.163) in 2009. The nearly 100,000 article downloads this past year reflect JHM's acceptance beyond hospital medicine, becoming a valuable and respected resource across medicine.

In my first editorial, I remarked that the goal is for JHM to become the premier forum for peer‐reviewed research articles and evidence‐based reviews in the specialty of hospital medicine.¹ This journal is on its way to achieving this ambition, possibly further and faster than expected, thanks to all the authors who confidently selected JHM as the publication venue for their scholarly work, the innumerable hours contributed by reviewers who volunteered their time and diligently evaluated thousands of manuscripts, and the terrific work by all the Deputy, Associate, and Assistant Editors. JHM never would have succeeded without their contributions, and I never will be able to thank them enough. Now trusted colleagues and lifelong friends, they deserve the bulk of the credit for JHM's success.

In my life, any accomplishments I achieve stem from the values and work ethic my father inculcated in me. Reportedly known as Bucket Seats by his Army Air Force colleagues because of his muscular size, required of a B‐24 bomber pilot who flew in World War II as a member of the 8^th Army Air Force in Europe, a description of the B‐24 by Stephen Ambrose in The Blue Yonder aptly described my father's demeanor and power. It could be sternly unforgiving. It always required, and sometimes demanded, almost superhuman strength to fly. My siblings and I knew him as Smoky, a nickname attached to him by his military buddies after he fell asleep in bed with a cigarette setting his mattress on fire. Sadly, though he miraculously survived fighter plane bullets, flak and fire, unlike many of his fellow pilots and crew, kidney cancer ended his life before age 60, just after I finished my first year of medical school. The attentive and considerate hospital care he received, as well as compassionate care from my mother, who previously worked as a nurse and attended to him at home in his final months, influenced me throughout my career. I hope hospitalists everywhere never forget that patients and their caregivers should remain the primary focus of all our efforts. Document your work and share it with your colleagues through JHM, and all of us will benefit.

A 7‐year journey now ends for me, and I hope much less time sitting on the couch, as I will no longer be spending chunks of my weekends and evenings assigning work to the tireless editors of JHM, reviewing manuscripts, and editing articles. Coincidentally, our youngest child Caroline moved out this autumn, joining her older brothers Stephen and Jason to pursue their dreams. With an empty nest, my wife Karee and I look forward to exploring more of the world.

Lastly, I thank the members of the Society of Hospital Medicine and the readers of JHM, whose kind and frequent compliments provided the fuel for my efforts. Always grateful for this opportunity, I will never forget the unique and indescribable experience of serving as the founding editor of the Journal of Hospital Medicine. Take care, and best wishes to the new leadership as they upgrade the journal to the next level. Out the door I go, on to other endeavors.

Beginning in January 2012, version 2.0 of the Journal of Hospital Medicine will begin with the talented and capable Andrew Auerbach, MD, MPH taking over as Editor‐in‐Chief. A premier hospital medicine researcher, he possesses experience as a journal editor and practicing hospitalist. With Andy at the helm, JHM will certainly get an upgrade. As my 7‐year tenure comes to an end, I look forward to moving on to new activities, but will dally a bit and reflect on this wonderful opportunity provided to me by the leadership of the Society of Hospital Medicine.

Undertaking with trepidation my role as the founding Editor‐in‐Chief in 2005, I recognized that a talented team of editors would be needed to achieve the expected goals for JHMindexing in MEDLINE (Medical Literature Analysis and Retrieval System Online) and selection for impact factor coverage by Thomson's Institute of Scientific Information (ISI) services. Thankfully, I learned from George Thibault, my egalitarian and brilliant residency program director at Massachusetts General Hospital, that successful leaders succeed by recruiting colleagues smarter than them. With no experience in journal editing beyond writing and reviewing articles, I leaned on numerous people more clever than me. Guided by Kathy Alexander and Vickie Thaw at Wiley‐Blackwell, we put together the framework for the journal. Fortunately, remarkable people agreed to serve as the founding Associate Editors. The abilities of Scott Flanders, Karen Hauer, Jean Kutner, James Pile, and Kaveh Shojania are reflected in their subsequent selection for leadership positions at their institutions and internationally.

JHM's leadership team evolved with replacements and the addition of superbly talented members: Thomas Baudendistel, Daniel Brotman, Vincent Chiang, Lakshmi Halasyamani, Brian Harte, Daniel Hunt, and Sunil Kripalani joined Jim Pile as Deputy Editors. Numerous Associate and Assistant Editors listed on our masthead also contributed their time and thoughtful reviews. Integral to our efforts, the exceptional Managing Editor Phaedra Cress kept us organized, cajoled everyone to meet deadlines, and offered a responsive and affable face to authors.

And succeed this team did! Midway through its second year of publication, JHM was selected for indexing and inclusion in the National Library of Medicine's MEDLINE. After just 2 years of publication, Thomson's ISI services selected JHM for impact factor coverage, and the journal received its first impact factor (3.163) in 2009. The nearly 100,000 article downloads this past year reflect JHM's acceptance beyond hospital medicine, becoming a valuable and respected resource across medicine.

In my first editorial, I remarked that the goal is for JHM to become the premier forum for peer‐reviewed research articles and evidence‐based reviews in the specialty of hospital medicine.¹ This journal is on its way to achieving this ambition, possibly further and faster than expected, thanks to all the authors who confidently selected JHM as the publication venue for their scholarly work, the innumerable hours contributed by reviewers who volunteered their time and diligently evaluated thousands of manuscripts, and the terrific work by all the Deputy, Associate, and Assistant Editors. JHM never would have succeeded without their contributions, and I never will be able to thank them enough. Now trusted colleagues and lifelong friends, they deserve the bulk of the credit for JHM's success.

In my life, any accomplishments I achieve stem from the values and work ethic my father inculcated in me. Reportedly known as Bucket Seats by his Army Air Force colleagues because of his muscular size, required of a B‐24 bomber pilot who flew in World War II as a member of the 8^th Army Air Force in Europe, a description of the B‐24 by Stephen Ambrose in The Blue Yonder aptly described my father's demeanor and power. It could be sternly unforgiving. It always required, and sometimes demanded, almost superhuman strength to fly. My siblings and I knew him as Smoky, a nickname attached to him by his military buddies after he fell asleep in bed with a cigarette setting his mattress on fire. Sadly, though he miraculously survived fighter plane bullets, flak and fire, unlike many of his fellow pilots and crew, kidney cancer ended his life before age 60, just after I finished my first year of medical school. The attentive and considerate hospital care he received, as well as compassionate care from my mother, who previously worked as a nurse and attended to him at home in his final months, influenced me throughout my career. I hope hospitalists everywhere never forget that patients and their caregivers should remain the primary focus of all our efforts. Document your work and share it with your colleagues through JHM, and all of us will benefit.

A 7‐year journey now ends for me, and I hope much less time sitting on the couch, as I will no longer be spending chunks of my weekends and evenings assigning work to the tireless editors of JHM, reviewing manuscripts, and editing articles. Coincidentally, our youngest child Caroline moved out this autumn, joining her older brothers Stephen and Jason to pursue their dreams. With an empty nest, my wife Karee and I look forward to exploring more of the world.

Lastly, I thank the members of the Society of Hospital Medicine and the readers of JHM, whose kind and frequent compliments provided the fuel for my efforts. Always grateful for this opportunity, I will never forget the unique and indescribable experience of serving as the founding editor of the Journal of Hospital Medicine. Take care, and best wishes to the new leadership as they upgrade the journal to the next level. Out the door I go, on to other endeavors.

Ten years ago, leaders in Hospital Medicine saw the need for a peer‐reviewed Hospital Medicine journal, a key step in the growth of the field. However, there was no small amount of uncertainty as to whether there was room for another medical publication, or whether Hospital Medicine was ready for its own journal.

It's clear now that we should not have been worried. Our specialty has grown in size and influence, and the Journal of Hospital Medicine's growth has progressed along a similar track, linked to the success of the many leaders in our field, including the founders of the Society of Hospital Medicine: John Nelson, MD, MHM, Win Whitcomb, MD, MHM, and Bob Wachter, MD, MHM. Support from them in selecting the Founding Editor, Mark V. Williams, ensured his success in assembling an outstanding editorial team, developing JHM's editorial process, and setting this journal as the bestand not just the onlyjournal for hospitalists to publish their work. JHM serves as both a beacon and a mirror for the field of Hospital Medicine, and I am honored for the opportunity to lead this dynamic journal. I also owe special thanks to the Society of Hospital Medicine and the outstanding team at Wiley‐Blackwell, who have made my transition to this role a smooth one.

After the transition, JHM will continue to be a mirror for Hospital Medicine in that it will reflect the scholarship and innovation of hospitalists' scholarly work in research, quality improvement, education, and clinical excellence. From a practical standpoint, this means JHM will continue to do what it has done so successfully to date: provide fair, insightful, and rapid evaluation and publication of articles that are scientifically rigorous and have an impact on hospitalists and their patients. Being an effective mirror also means the journal will need to be in tune with technological advances in publication and learning. Few of us read paper journals any longer, and the move from print to digital and mobile media provides an important opportunity for this journal. Expanding the means by which we disseminate JHM's findings, highlight evidence, and promote knowledge that impacts our field is a clear direction for the journal.

At the transition from JHM 1.0 to JHM 2.0, the journal is positioned to be a beacon for the field by publishing papers that address new and rapidly evolving issues that will affect hospitalists and their patients. JHM and my editorial team eagerly seek submission of manuscripts on these issues delineated below.

Even if health care reform legislation evolves or changes after the 2012 elections, the need to improve health care value across multiple phases of care is unlikely to disappear. The medical home and accountable care organizations will prompt hospitalists to work with outpatient partners to achieve improvements; focus on readmissions and high‐utilization patients may catalyze integration even without larger changes. This evolution plays to hospitalists' traditional strengths as innovators and leaders of health system innovations while erasing the boundaries between inpatient and outpatient phases of care. How the field adapts toor even better, anticipateschanges in care delivery is a momentous opportunity.

Hospitalists will continue to be leaders in quality and safety improvement, but the need to develop innovations that are effective, scalable, and widely adoptable is growing even more acute. Stated alternately, we need to develop innovations quickly and rigorously, so that neither time nor resources are wasted. Fortunately, there is likely to be financial support for projects that link improvement and evaluation from the Center for Medicare and Medicaid Innovations (CMMI). It is a fair bet that a large number of the CMMI's target issues will be ones that hospitalists also find important, and which are ripe for inquiry.

Shifting from quality to outcomes will prompt a revisiting of how we measure our success as hospitalists. Achieving success in process benchmarks will no longer be sufficient, as our practices will increasingly be measured by our patients' experience, functional status, quality of life, and clinical events (of which measures of safety are a part)both within the walls of the hospital and afterwardrather than solely relying on whether patients appropriately received a drug or procedure during their stay. The need to improve outcomes will immediately bump up against the disappointingly small proportion of measures or evidence that apply to the typical Hospital Medicine patient. Developing these new measures, and the evidence for how to improve them, will be a key challenge for the field of Hospital Medicine. Outcome development and comparisons are a clear focus of the Patient‐Centered Outcomes Research Institute. Again, studies documenting such research will find a welcome home at JHM.

The role of information technology in how hospitalists provide care to patients, decide on best practices, communicate with physicians and patients, and manage their practices is becoming central. A huge, nationwide natural experiment is underway as health systems work to meet meaningful use criteria, and oftentimes hospitalists are central to these efforts. Disseminating best practices, implementing innovative systems, and creating workflows that meet the needs of hospitalists' patients is a key short‐term need, and one our field is uniquely positioned to address.

Finally, the practice of Hospital Medicine continues to evolve. In teaching centers, hospitalists are leading educators of medical students and residents; developing training models that reflect newer thinking about how to teach a 21^st‐century physician is a key need for the field. The importance of adaptations to work‐hour reductions for residents cannot be overstated, but attention must be paid to how hospitalists' work hours impact patient care as well. Comanagement systemswhether for medical subspecialties (ie, cancer or heart failure) or surgical specialtieshave yet to fulfill their promise, yet demand for comanagement grows. How might comanagement systems be adapted and targeted so that they become more effective?

Not being a futurist or even slightly omniscient, I am sure this list is neither exhaustive nor final. In my 15 or so years in Hospital Medicine, I know firsthand that the field is vigorous, innovative, and full of surprises. Fortunately, JHM is attuned to changes happening now as well as issues on the horizon, and will always strive to be an even better messenger for Hospital Medicine as a professional and academic specialty.1 In that way, JHM 2.0 will be the same as JHM 1.0. I'm excited to shepherd JHM's ongoing growth and look forward to my years at the helm.

Ten years ago, leaders in Hospital Medicine saw the need for a peer‐reviewed Hospital Medicine journal, a key step in the growth of the field. However, there was no small amount of uncertainty as to whether there was room for another medical publication, or whether Hospital Medicine was ready for its own journal.

It's clear now that we should not have been worried. Our specialty has grown in size and influence, and the Journal of Hospital Medicine's growth has progressed along a similar track, linked to the success of the many leaders in our field, including the founders of the Society of Hospital Medicine: John Nelson, MD, MHM, Win Whitcomb, MD, MHM, and Bob Wachter, MD, MHM. Support from them in selecting the Founding Editor, Mark V. Williams, ensured his success in assembling an outstanding editorial team, developing JHM's editorial process, and setting this journal as the bestand not just the onlyjournal for hospitalists to publish their work. JHM serves as both a beacon and a mirror for the field of Hospital Medicine, and I am honored for the opportunity to lead this dynamic journal. I also owe special thanks to the Society of Hospital Medicine and the outstanding team at Wiley‐Blackwell, who have made my transition to this role a smooth one.

After the transition, JHM will continue to be a mirror for Hospital Medicine in that it will reflect the scholarship and innovation of hospitalists' scholarly work in research, quality improvement, education, and clinical excellence. From a practical standpoint, this means JHM will continue to do what it has done so successfully to date: provide fair, insightful, and rapid evaluation and publication of articles that are scientifically rigorous and have an impact on hospitalists and their patients. Being an effective mirror also means the journal will need to be in tune with technological advances in publication and learning. Few of us read paper journals any longer, and the move from print to digital and mobile media provides an important opportunity for this journal. Expanding the means by which we disseminate JHM's findings, highlight evidence, and promote knowledge that impacts our field is a clear direction for the journal.

At the transition from JHM 1.0 to JHM 2.0, the journal is positioned to be a beacon for the field by publishing papers that address new and rapidly evolving issues that will affect hospitalists and their patients. JHM and my editorial team eagerly seek submission of manuscripts on these issues delineated below.

Even if health care reform legislation evolves or changes after the 2012 elections, the need to improve health care value across multiple phases of care is unlikely to disappear. The medical home and accountable care organizations will prompt hospitalists to work with outpatient partners to achieve improvements; focus on readmissions and high‐utilization patients may catalyze integration even without larger changes. This evolution plays to hospitalists' traditional strengths as innovators and leaders of health system innovations while erasing the boundaries between inpatient and outpatient phases of care. How the field adapts toor even better, anticipateschanges in care delivery is a momentous opportunity.

Hospitalists will continue to be leaders in quality and safety improvement, but the need to develop innovations that are effective, scalable, and widely adoptable is growing even more acute. Stated alternately, we need to develop innovations quickly and rigorously, so that neither time nor resources are wasted. Fortunately, there is likely to be financial support for projects that link improvement and evaluation from the Center for Medicare and Medicaid Innovations (CMMI). It is a fair bet that a large number of the CMMI's target issues will be ones that hospitalists also find important, and which are ripe for inquiry.

Shifting from quality to outcomes will prompt a revisiting of how we measure our success as hospitalists. Achieving success in process benchmarks will no longer be sufficient, as our practices will increasingly be measured by our patients' experience, functional status, quality of life, and clinical events (of which measures of safety are a part)both within the walls of the hospital and afterwardrather than solely relying on whether patients appropriately received a drug or procedure during their stay. The need to improve outcomes will immediately bump up against the disappointingly small proportion of measures or evidence that apply to the typical Hospital Medicine patient. Developing these new measures, and the evidence for how to improve them, will be a key challenge for the field of Hospital Medicine. Outcome development and comparisons are a clear focus of the Patient‐Centered Outcomes Research Institute. Again, studies documenting such research will find a welcome home at JHM.

The role of information technology in how hospitalists provide care to patients, decide on best practices, communicate with physicians and patients, and manage their practices is becoming central. A huge, nationwide natural experiment is underway as health systems work to meet meaningful use criteria, and oftentimes hospitalists are central to these efforts. Disseminating best practices, implementing innovative systems, and creating workflows that meet the needs of hospitalists' patients is a key short‐term need, and one our field is uniquely positioned to address.

Finally, the practice of Hospital Medicine continues to evolve. In teaching centers, hospitalists are leading educators of medical students and residents; developing training models that reflect newer thinking about how to teach a 21^st‐century physician is a key need for the field. The importance of adaptations to work‐hour reductions for residents cannot be overstated, but attention must be paid to how hospitalists' work hours impact patient care as well. Comanagement systemswhether for medical subspecialties (ie, cancer or heart failure) or surgical specialtieshave yet to fulfill their promise, yet demand for comanagement grows. How might comanagement systems be adapted and targeted so that they become more effective?

Not being a futurist or even slightly omniscient, I am sure this list is neither exhaustive nor final. In my 15 or so years in Hospital Medicine, I know firsthand that the field is vigorous, innovative, and full of surprises. Fortunately, JHM is attuned to changes happening now as well as issues on the horizon, and will always strive to be an even better messenger for Hospital Medicine as a professional and academic specialty.1 In that way, JHM 2.0 will be the same as JHM 1.0. I'm excited to shepherd JHM's ongoing growth and look forward to my years at the helm.

Ten years ago, leaders in Hospital Medicine saw the need for a peer‐reviewed Hospital Medicine journal, a key step in the growth of the field. However, there was no small amount of uncertainty as to whether there was room for another medical publication, or whether Hospital Medicine was ready for its own journal.

It's clear now that we should not have been worried. Our specialty has grown in size and influence, and the Journal of Hospital Medicine's growth has progressed along a similar track, linked to the success of the many leaders in our field, including the founders of the Society of Hospital Medicine: John Nelson, MD, MHM, Win Whitcomb, MD, MHM, and Bob Wachter, MD, MHM. Support from them in selecting the Founding Editor, Mark V. Williams, ensured his success in assembling an outstanding editorial team, developing JHM's editorial process, and setting this journal as the bestand not just the onlyjournal for hospitalists to publish their work. JHM serves as both a beacon and a mirror for the field of Hospital Medicine, and I am honored for the opportunity to lead this dynamic journal. I also owe special thanks to the Society of Hospital Medicine and the outstanding team at Wiley‐Blackwell, who have made my transition to this role a smooth one.

After the transition, JHM will continue to be a mirror for Hospital Medicine in that it will reflect the scholarship and innovation of hospitalists' scholarly work in research, quality improvement, education, and clinical excellence. From a practical standpoint, this means JHM will continue to do what it has done so successfully to date: provide fair, insightful, and rapid evaluation and publication of articles that are scientifically rigorous and have an impact on hospitalists and their patients. Being an effective mirror also means the journal will need to be in tune with technological advances in publication and learning. Few of us read paper journals any longer, and the move from print to digital and mobile media provides an important opportunity for this journal. Expanding the means by which we disseminate JHM's findings, highlight evidence, and promote knowledge that impacts our field is a clear direction for the journal.

At the transition from JHM 1.0 to JHM 2.0, the journal is positioned to be a beacon for the field by publishing papers that address new and rapidly evolving issues that will affect hospitalists and their patients. JHM and my editorial team eagerly seek submission of manuscripts on these issues delineated below.

Even if health care reform legislation evolves or changes after the 2012 elections, the need to improve health care value across multiple phases of care is unlikely to disappear. The medical home and accountable care organizations will prompt hospitalists to work with outpatient partners to achieve improvements; focus on readmissions and high‐utilization patients may catalyze integration even without larger changes. This evolution plays to hospitalists' traditional strengths as innovators and leaders of health system innovations while erasing the boundaries between inpatient and outpatient phases of care. How the field adapts toor even better, anticipateschanges in care delivery is a momentous opportunity.

Hospitalists will continue to be leaders in quality and safety improvement, but the need to develop innovations that are effective, scalable, and widely adoptable is growing even more acute. Stated alternately, we need to develop innovations quickly and rigorously, so that neither time nor resources are wasted. Fortunately, there is likely to be financial support for projects that link improvement and evaluation from the Center for Medicare and Medicaid Innovations (CMMI). It is a fair bet that a large number of the CMMI's target issues will be ones that hospitalists also find important, and which are ripe for inquiry.

Shifting from quality to outcomes will prompt a revisiting of how we measure our success as hospitalists. Achieving success in process benchmarks will no longer be sufficient, as our practices will increasingly be measured by our patients' experience, functional status, quality of life, and clinical events (of which measures of safety are a part)both within the walls of the hospital and afterwardrather than solely relying on whether patients appropriately received a drug or procedure during their stay. The need to improve outcomes will immediately bump up against the disappointingly small proportion of measures or evidence that apply to the typical Hospital Medicine patient. Developing these new measures, and the evidence for how to improve them, will be a key challenge for the field of Hospital Medicine. Outcome development and comparisons are a clear focus of the Patient‐Centered Outcomes Research Institute. Again, studies documenting such research will find a welcome home at JHM.

The role of information technology in how hospitalists provide care to patients, decide on best practices, communicate with physicians and patients, and manage their practices is becoming central. A huge, nationwide natural experiment is underway as health systems work to meet meaningful use criteria, and oftentimes hospitalists are central to these efforts. Disseminating best practices, implementing innovative systems, and creating workflows that meet the needs of hospitalists' patients is a key short‐term need, and one our field is uniquely positioned to address.

Finally, the practice of Hospital Medicine continues to evolve. In teaching centers, hospitalists are leading educators of medical students and residents; developing training models that reflect newer thinking about how to teach a 21^st‐century physician is a key need for the field. The importance of adaptations to work‐hour reductions for residents cannot be overstated, but attention must be paid to how hospitalists' work hours impact patient care as well. Comanagement systemswhether for medical subspecialties (ie, cancer or heart failure) or surgical specialtieshave yet to fulfill their promise, yet demand for comanagement grows. How might comanagement systems be adapted and targeted so that they become more effective?

Not being a futurist or even slightly omniscient, I am sure this list is neither exhaustive nor final. In my 15 or so years in Hospital Medicine, I know firsthand that the field is vigorous, innovative, and full of surprises. Fortunately, JHM is attuned to changes happening now as well as issues on the horizon, and will always strive to be an even better messenger for Hospital Medicine as a professional and academic specialty.1 In that way, JHM 2.0 will be the same as JHM 1.0. I'm excited to shepherd JHM's ongoing growth and look forward to my years at the helm.

Ms Chen acutely worse, altered, please assist, room 522Beth, chirped my pager. Ever increasing time pressures meant that hospitalists were supervising rounds almost daily. I had sent my resident, Beth, and the rest of the team to round separately that day, to foster their independence. It looked like we would be meeting ahead of schedule.

I'd received a similar page 2 years earlier when I was a junior resident myself. From the beginning of internship, our faculty never hesitated to challenge us. I will never forget when one of the hospitalists who had just come across an unresponsive patient tapped me on the shoulder and casually asked, Hey, you wanna run a code? and will never forget my inadequacy or the specific assistance I required in those tense few minutes. He, and the ICU team that arrived, gave me every chance to lead, and supported me each time I hesitated.

In similar fashion, I had sent my intern, David, to admit a patient with suspected CHF. I received his urgent update shortly after our patient arrived on the cardiology floor: Mr Johnson dropping sats, please help, room 207. I jogged to the patient's room, where I found David, 3 nurses, 2 medical students, and in the center, Mr Johnson: lethargic, gray, cachectic, and making no effort to rise from the 40 degree incline of his hospital bed. Weak respirations fogged his non‐rebreather mask about 28 times a minute.

David offered a quick report: 74‐year‐old male, CAD, hypertension, dementia CHF exacerbation hypertensive to 190. I think he needs IV nitroglycerin and another 80 of lasix.

I was pleased to hear him commit to a diagnosis and plan, but after sitting Mr Johnson up for a quick exam, I couldn't agree. Are you sure? He sounds more junky than crackly. Neck veins are flat.

His EF is 25% and he's been here 3 times with CHF.

Well, that won't protect him from anything else. Mr Johnson slumped forward, accessory muscles firing weakly, and only half‐opened his eyes to a loud command and vigorous shake. Well, let's get the diagnosis later, what does he need, now?

Well, the lasix and the nitro

Assuming this is CHF, looking at him now, will that work fast enough to prevent intubation? David shook his head no. He's full code, right? Let's just call a code before he gets any worse. Anyone disagree? A nurse made the call, then guarded the door to turn away everyone but anesthesia and the MICU as they arrived.

So what do you think it is? David asked.

This doesn't smell like failure. He's not anxious, he's more obtunded than dyspneic. He looks hypercarbic. He doesn't have COPD?

Nah, just vomiting, then weaker, more confused, restless.

Maybe he aspirated. We'll see. So what do you want to have ready for anesthesia?

Um, meds. An IV. Chest X‐ray ready.

Good they bring the meds he's got an IV how about we pull the bed from the wall and raise it up, get some suction ready, take the headboard off? Nurses sprang into action.

If he's hypercarbic, shouldn't we bag him? David asked.

Good point, I said. David took the mask from the bag of emergency gear from the wall and started to fit it on Mr Johnson. It's a 2‐person job, if you want to hold the mask2 hands, good. A nurse began ventilations, and I added some cricoid pressure. Keeps us from inflating his stomach.

Seconds later, anesthesia arrived, and David provided a concise, organized summary. Mr Johnson was intubated and whisked without incident to the MICU, where bronchoscopy extracted several mucus plugs. He was soon extubated, and later recovered from a delirium which began with promethazine for nausea. It was the last year before the 80‐hour workweek regulations, and not once in the entire processfrom admission, to emergency on the ward, to initial MICU managementdid I or my fellow residents think to call an attending, although I'm sure we would have learned something, as I hadn't suspected a mucous plug. We weren't hiding anything. We were just taking care of our patient.

Two years later, it didn't seem odd that my junior resident called me for assistance with Ms Cheninitially. In room 522, much as I found Mr Johnson, I found Ms Chen: elderly, lethargic, gray, frail, laboring to breathe, rhythmically fogging a non‐rebreather mask 30 times a minute, only half‐opening her eyes to a vigorous shake. It was day 4 of her fifth hospitalization for bronchiectasis‐related respiratory failure within 2 months.

She just got a treatment but she still sounds awful, offered Beth. Indeed, Ms Chen's chest was gurgly and wheezy throughout. We put her on a non‐rebreather, but that hasn't helped.

I glanced at her monitor. Sat's 99%. What was she before?

96%.

So hypoxia isn't the problemwho's this? I asked, as transportation staff arrived.

Stat head CT for Chen, he replied.

I'm sorry, she can't go off the floor right now. Thanks for coming, I apologized, and sent him away. Beth, can you lay her flat or send her off the unit right now?

She's altered and I need to rule out stroke.

Let's talk about that later. I did a quick neuro exam as I spoke: Besides, she resists weak but equal; pupils and face symmetricshe's not focal. What's a more likely cause?

Metabolic? We can repeat her morning labs

Will they be different? Why is she here? What's her exam telling you?

Beth took in the scene before her, as Ms Chen struggled weakly to ventilate her lungs, and after a brief pause she had it worked out. She's hypercarbic. She needs an ABG. You think she plugged? She shook her head, and grasped Ms Chen's hand in her own. But she really hates suctioning.

Well, she's DNI, and without it, she could die. Beth agreed; we also called for noninvasive ventilation. But the team missed much of the action. The medical student missed the entire eventaside from attempting to summarize it from second‐hand reports for rounds the following day. I realized only later that her intern had been pushed to the back of the room for the critical decisions (much like the students during Mr Johnson's emergency), and headed out midway to attend a mandatory teaching sessionthe chief residents had begun taking attendance. The resident soon left for noon conference and afternoon clinic, enlisting me to write transfer orders and call the family. Finished with her other work, and under pressure to bank time against work hour limitations, which she was at risk of violating, the intern signed her pager over to me and left in the early afternoon, after sheepishly asking me if I wouldn't mind keeping an eye on our patient.

Later, a translator and I met with the Chens to comfort them and plan care for the family matriarch, having found a quiet solarium we could use, with summery views of the city and ocean in the distance to belie the grim topic of discussion.

What is your understanding of her lung problem right now?

Nay yeega jee um'jee huigor fai ho jing yeung?

What were her hopes and fears about her health?

Nay jee um'jee huigor see seung hai mai ho tai hoi?

My mind drifted during the Cantonese as I thought about how I use the unique teaching opportunities offered by wholly translated meetings. Never check the time. This body language says I am listening. I am speaking to them, not the translator. I make notes because families don't remember much after the C‐word, I would whisper to trainees while families conversed with translators. Now, as I began to discuss hospice philosophy, I felt acutely alone.

My team had missed most of a great hospital medicine experience: applying knowledge to manage a physiologic crisis; using communication skills to ease the resulting human crisis. Recently, to manage the latest set of work hour restrictions, our residency program withdrew from medicine consultation at 2 of 3 sites, and from the medicine wards at the hospital that serves most of our insured, geriatric, and oncology patients. The cost of this experiment to the overall residency experience is unknown. But cases like Ms Chen's remind me how much I missed being the primary doctor. I do not mind the new tasks I perform for my trainees. But I worry about what they are missing: sufficient responsibility for making key clinical decisions while protected by supervision on demand. I am glad my internship challenged meit prepared me for residency, moonlighting, and attending positions. Without a doubt, residency remains challenging, but it seems that the greatestor firstchallenge imposed on residents is now to beat the clock, not to become a well‐rounded, capable, independent physician.

That night, I complained to my spouse, then a psychiatry intern: We weren't giving our trainees the best preparation for a career in medicine the lengthy shift I spent managing a hypotensive crisis would be forbidden now my pre‐work hours interns were much happier than their work hours successors a 4‐year residency must be around the corner. The response I got was more bemused smile than grave concern. You don't think that's important? I asked.

Of course I do. It's just that with all this talk about the days of the giants, he said gently, you're starting to sound like a grumpy old man. We chuckled. He was right. I expect a lot from myself, my trainees, and every clinician. I'd figured I'd be worthy of the title at some point.

But at 30?

Ms Chen acutely worse, altered, please assist, room 522Beth, chirped my pager. Ever increasing time pressures meant that hospitalists were supervising rounds almost daily. I had sent my resident, Beth, and the rest of the team to round separately that day, to foster their independence. It looked like we would be meeting ahead of schedule.

I'd received a similar page 2 years earlier when I was a junior resident myself. From the beginning of internship, our faculty never hesitated to challenge us. I will never forget when one of the hospitalists who had just come across an unresponsive patient tapped me on the shoulder and casually asked, Hey, you wanna run a code? and will never forget my inadequacy or the specific assistance I required in those tense few minutes. He, and the ICU team that arrived, gave me every chance to lead, and supported me each time I hesitated.

In similar fashion, I had sent my intern, David, to admit a patient with suspected CHF. I received his urgent update shortly after our patient arrived on the cardiology floor: Mr Johnson dropping sats, please help, room 207. I jogged to the patient's room, where I found David, 3 nurses, 2 medical students, and in the center, Mr Johnson: lethargic, gray, cachectic, and making no effort to rise from the 40 degree incline of his hospital bed. Weak respirations fogged his non‐rebreather mask about 28 times a minute.

David offered a quick report: 74‐year‐old male, CAD, hypertension, dementia CHF exacerbation hypertensive to 190. I think he needs IV nitroglycerin and another 80 of lasix.

I was pleased to hear him commit to a diagnosis and plan, but after sitting Mr Johnson up for a quick exam, I couldn't agree. Are you sure? He sounds more junky than crackly. Neck veins are flat.

His EF is 25% and he's been here 3 times with CHF.

Well, that won't protect him from anything else. Mr Johnson slumped forward, accessory muscles firing weakly, and only half‐opened his eyes to a loud command and vigorous shake. Well, let's get the diagnosis later, what does he need, now?

Well, the lasix and the nitro

Assuming this is CHF, looking at him now, will that work fast enough to prevent intubation? David shook his head no. He's full code, right? Let's just call a code before he gets any worse. Anyone disagree? A nurse made the call, then guarded the door to turn away everyone but anesthesia and the MICU as they arrived.

So what do you think it is? David asked.

This doesn't smell like failure. He's not anxious, he's more obtunded than dyspneic. He looks hypercarbic. He doesn't have COPD?

Nah, just vomiting, then weaker, more confused, restless.

Maybe he aspirated. We'll see. So what do you want to have ready for anesthesia?

Um, meds. An IV. Chest X‐ray ready.

Good they bring the meds he's got an IV how about we pull the bed from the wall and raise it up, get some suction ready, take the headboard off? Nurses sprang into action.

If he's hypercarbic, shouldn't we bag him? David asked.

Good point, I said. David took the mask from the bag of emergency gear from the wall and started to fit it on Mr Johnson. It's a 2‐person job, if you want to hold the mask2 hands, good. A nurse began ventilations, and I added some cricoid pressure. Keeps us from inflating his stomach.

Seconds later, anesthesia arrived, and David provided a concise, organized summary. Mr Johnson was intubated and whisked without incident to the MICU, where bronchoscopy extracted several mucus plugs. He was soon extubated, and later recovered from a delirium which began with promethazine for nausea. It was the last year before the 80‐hour workweek regulations, and not once in the entire processfrom admission, to emergency on the ward, to initial MICU managementdid I or my fellow residents think to call an attending, although I'm sure we would have learned something, as I hadn't suspected a mucous plug. We weren't hiding anything. We were just taking care of our patient.

Two years later, it didn't seem odd that my junior resident called me for assistance with Ms Cheninitially. In room 522, much as I found Mr Johnson, I found Ms Chen: elderly, lethargic, gray, frail, laboring to breathe, rhythmically fogging a non‐rebreather mask 30 times a minute, only half‐opening her eyes to a vigorous shake. It was day 4 of her fifth hospitalization for bronchiectasis‐related respiratory failure within 2 months.

She just got a treatment but she still sounds awful, offered Beth. Indeed, Ms Chen's chest was gurgly and wheezy throughout. We put her on a non‐rebreather, but that hasn't helped.

I glanced at her monitor. Sat's 99%. What was she before?

96%.

So hypoxia isn't the problemwho's this? I asked, as transportation staff arrived.

Stat head CT for Chen, he replied.

I'm sorry, she can't go off the floor right now. Thanks for coming, I apologized, and sent him away. Beth, can you lay her flat or send her off the unit right now?

She's altered and I need to rule out stroke.

Let's talk about that later. I did a quick neuro exam as I spoke: Besides, she resists weak but equal; pupils and face symmetricshe's not focal. What's a more likely cause?

Metabolic? We can repeat her morning labs

Will they be different? Why is she here? What's her exam telling you?

Beth took in the scene before her, as Ms Chen struggled weakly to ventilate her lungs, and after a brief pause she had it worked out. She's hypercarbic. She needs an ABG. You think she plugged? She shook her head, and grasped Ms Chen's hand in her own. But she really hates suctioning.

Well, she's DNI, and without it, she could die. Beth agreed; we also called for noninvasive ventilation. But the team missed much of the action. The medical student missed the entire eventaside from attempting to summarize it from second‐hand reports for rounds the following day. I realized only later that her intern had been pushed to the back of the room for the critical decisions (much like the students during Mr Johnson's emergency), and headed out midway to attend a mandatory teaching sessionthe chief residents had begun taking attendance. The resident soon left for noon conference and afternoon clinic, enlisting me to write transfer orders and call the family. Finished with her other work, and under pressure to bank time against work hour limitations, which she was at risk of violating, the intern signed her pager over to me and left in the early afternoon, after sheepishly asking me if I wouldn't mind keeping an eye on our patient.

Later, a translator and I met with the Chens to comfort them and plan care for the family matriarch, having found a quiet solarium we could use, with summery views of the city and ocean in the distance to belie the grim topic of discussion.

What is your understanding of her lung problem right now?

Nay yeega jee um'jee huigor fai ho jing yeung?

What were her hopes and fears about her health?

Nay jee um'jee huigor see seung hai mai ho tai hoi?

My mind drifted during the Cantonese as I thought about how I use the unique teaching opportunities offered by wholly translated meetings. Never check the time. This body language says I am listening. I am speaking to them, not the translator. I make notes because families don't remember much after the C‐word, I would whisper to trainees while families conversed with translators. Now, as I began to discuss hospice philosophy, I felt acutely alone.

My team had missed most of a great hospital medicine experience: applying knowledge to manage a physiologic crisis; using communication skills to ease the resulting human crisis. Recently, to manage the latest set of work hour restrictions, our residency program withdrew from medicine consultation at 2 of 3 sites, and from the medicine wards at the hospital that serves most of our insured, geriatric, and oncology patients. The cost of this experiment to the overall residency experience is unknown. But cases like Ms Chen's remind me how much I missed being the primary doctor. I do not mind the new tasks I perform for my trainees. But I worry about what they are missing: sufficient responsibility for making key clinical decisions while protected by supervision on demand. I am glad my internship challenged meit prepared me for residency, moonlighting, and attending positions. Without a doubt, residency remains challenging, but it seems that the greatestor firstchallenge imposed on residents is now to beat the clock, not to become a well‐rounded, capable, independent physician.

That night, I complained to my spouse, then a psychiatry intern: We weren't giving our trainees the best preparation for a career in medicine the lengthy shift I spent managing a hypotensive crisis would be forbidden now my pre‐work hours interns were much happier than their work hours successors a 4‐year residency must be around the corner. The response I got was more bemused smile than grave concern. You don't think that's important? I asked.

Of course I do. It's just that with all this talk about the days of the giants, he said gently, you're starting to sound like a grumpy old man. We chuckled. He was right. I expect a lot from myself, my trainees, and every clinician. I'd figured I'd be worthy of the title at some point.

But at 30?

Ms Chen acutely worse, altered, please assist, room 522Beth, chirped my pager. Ever increasing time pressures meant that hospitalists were supervising rounds almost daily. I had sent my resident, Beth, and the rest of the team to round separately that day, to foster their independence. It looked like we would be meeting ahead of schedule.

I'd received a similar page 2 years earlier when I was a junior resident myself. From the beginning of internship, our faculty never hesitated to challenge us. I will never forget when one of the hospitalists who had just come across an unresponsive patient tapped me on the shoulder and casually asked, Hey, you wanna run a code? and will never forget my inadequacy or the specific assistance I required in those tense few minutes. He, and the ICU team that arrived, gave me every chance to lead, and supported me each time I hesitated.

In similar fashion, I had sent my intern, David, to admit a patient with suspected CHF. I received his urgent update shortly after our patient arrived on the cardiology floor: Mr Johnson dropping sats, please help, room 207. I jogged to the patient's room, where I found David, 3 nurses, 2 medical students, and in the center, Mr Johnson: lethargic, gray, cachectic, and making no effort to rise from the 40 degree incline of his hospital bed. Weak respirations fogged his non‐rebreather mask about 28 times a minute.

David offered a quick report: 74‐year‐old male, CAD, hypertension, dementia CHF exacerbation hypertensive to 190. I think he needs IV nitroglycerin and another 80 of lasix.

I was pleased to hear him commit to a diagnosis and plan, but after sitting Mr Johnson up for a quick exam, I couldn't agree. Are you sure? He sounds more junky than crackly. Neck veins are flat.

His EF is 25% and he's been here 3 times with CHF.

Well, that won't protect him from anything else. Mr Johnson slumped forward, accessory muscles firing weakly, and only half‐opened his eyes to a loud command and vigorous shake. Well, let's get the diagnosis later, what does he need, now?

Well, the lasix and the nitro

Assuming this is CHF, looking at him now, will that work fast enough to prevent intubation? David shook his head no. He's full code, right? Let's just call a code before he gets any worse. Anyone disagree? A nurse made the call, then guarded the door to turn away everyone but anesthesia and the MICU as they arrived.

So what do you think it is? David asked.

This doesn't smell like failure. He's not anxious, he's more obtunded than dyspneic. He looks hypercarbic. He doesn't have COPD?

Nah, just vomiting, then weaker, more confused, restless.

Maybe he aspirated. We'll see. So what do you want to have ready for anesthesia?

Um, meds. An IV. Chest X‐ray ready.

Good they bring the meds he's got an IV how about we pull the bed from the wall and raise it up, get some suction ready, take the headboard off? Nurses sprang into action.

If he's hypercarbic, shouldn't we bag him? David asked.

Good point, I said. David took the mask from the bag of emergency gear from the wall and started to fit it on Mr Johnson. It's a 2‐person job, if you want to hold the mask2 hands, good. A nurse began ventilations, and I added some cricoid pressure. Keeps us from inflating his stomach.

Seconds later, anesthesia arrived, and David provided a concise, organized summary. Mr Johnson was intubated and whisked without incident to the MICU, where bronchoscopy extracted several mucus plugs. He was soon extubated, and later recovered from a delirium which began with promethazine for nausea. It was the last year before the 80‐hour workweek regulations, and not once in the entire processfrom admission, to emergency on the ward, to initial MICU managementdid I or my fellow residents think to call an attending, although I'm sure we would have learned something, as I hadn't suspected a mucous plug. We weren't hiding anything. We were just taking care of our patient.

Two years later, it didn't seem odd that my junior resident called me for assistance with Ms Cheninitially. In room 522, much as I found Mr Johnson, I found Ms Chen: elderly, lethargic, gray, frail, laboring to breathe, rhythmically fogging a non‐rebreather mask 30 times a minute, only half‐opening her eyes to a vigorous shake. It was day 4 of her fifth hospitalization for bronchiectasis‐related respiratory failure within 2 months.

She just got a treatment but she still sounds awful, offered Beth. Indeed, Ms Chen's chest was gurgly and wheezy throughout. We put her on a non‐rebreather, but that hasn't helped.

I glanced at her monitor. Sat's 99%. What was she before?

96%.

So hypoxia isn't the problemwho's this? I asked, as transportation staff arrived.

Stat head CT for Chen, he replied.

I'm sorry, she can't go off the floor right now. Thanks for coming, I apologized, and sent him away. Beth, can you lay her flat or send her off the unit right now?

She's altered and I need to rule out stroke.

Let's talk about that later. I did a quick neuro exam as I spoke: Besides, she resists weak but equal; pupils and face symmetricshe's not focal. What's a more likely cause?

Metabolic? We can repeat her morning labs

Will they be different? Why is she here? What's her exam telling you?

Beth took in the scene before her, as Ms Chen struggled weakly to ventilate her lungs, and after a brief pause she had it worked out. She's hypercarbic. She needs an ABG. You think she plugged? She shook her head, and grasped Ms Chen's hand in her own. But she really hates suctioning.

Well, she's DNI, and without it, she could die. Beth agreed; we also called for noninvasive ventilation. But the team missed much of the action. The medical student missed the entire eventaside from attempting to summarize it from second‐hand reports for rounds the following day. I realized only later that her intern had been pushed to the back of the room for the critical decisions (much like the students during Mr Johnson's emergency), and headed out midway to attend a mandatory teaching sessionthe chief residents had begun taking attendance. The resident soon left for noon conference and afternoon clinic, enlisting me to write transfer orders and call the family. Finished with her other work, and under pressure to bank time against work hour limitations, which she was at risk of violating, the intern signed her pager over to me and left in the early afternoon, after sheepishly asking me if I wouldn't mind keeping an eye on our patient.

Later, a translator and I met with the Chens to comfort them and plan care for the family matriarch, having found a quiet solarium we could use, with summery views of the city and ocean in the distance to belie the grim topic of discussion.

What is your understanding of her lung problem right now?

Nay yeega jee um'jee huigor fai ho jing yeung?

What were her hopes and fears about her health?

Nay jee um'jee huigor see seung hai mai ho tai hoi?

My mind drifted during the Cantonese as I thought about how I use the unique teaching opportunities offered by wholly translated meetings. Never check the time. This body language says I am listening. I am speaking to them, not the translator. I make notes because families don't remember much after the C‐word, I would whisper to trainees while families conversed with translators. Now, as I began to discuss hospice philosophy, I felt acutely alone.

My team had missed most of a great hospital medicine experience: applying knowledge to manage a physiologic crisis; using communication skills to ease the resulting human crisis. Recently, to manage the latest set of work hour restrictions, our residency program withdrew from medicine consultation at 2 of 3 sites, and from the medicine wards at the hospital that serves most of our insured, geriatric, and oncology patients. The cost of this experiment to the overall residency experience is unknown. But cases like Ms Chen's remind me how much I missed being the primary doctor. I do not mind the new tasks I perform for my trainees. But I worry about what they are missing: sufficient responsibility for making key clinical decisions while protected by supervision on demand. I am glad my internship challenged meit prepared me for residency, moonlighting, and attending positions. Without a doubt, residency remains challenging, but it seems that the greatestor firstchallenge imposed on residents is now to beat the clock, not to become a well‐rounded, capable, independent physician.

That night, I complained to my spouse, then a psychiatry intern: We weren't giving our trainees the best preparation for a career in medicine the lengthy shift I spent managing a hypotensive crisis would be forbidden now my pre‐work hours interns were much happier than their work hours successors a 4‐year residency must be around the corner. The response I got was more bemused smile than grave concern. You don't think that's important? I asked.

Of course I do. It's just that with all this talk about the days of the giants, he said gently, you're starting to sound like a grumpy old man. We chuckled. He was right. I expect a lot from myself, my trainees, and every clinician. I'd figured I'd be worthy of the title at some point.

But at 30?

Academic hospitalists have multiple duties including direct patient care, hospital management, teaching, and scholarly productivity. We are frequently pulled in divergent directions, while attending to these responsibilities. Without a framework to manage these assorted tasks, we are at risk of subpar performance and career dissatisfaction. Alternatively, we often thrive in our roles as utility players when armed with a developed skill set. Our profession could benefit greatly from encouraging future academic hospitalists to obtain further training prior to starting as an attending. Although hospital medicine fellowship training exists, there are still relatively few programs available. A well‐crafted year spent as a chief medical resident (CMR) may be a viable alternative.

My year as CMR allowed me to develop the skills necessary for success as an academic hospitalist in a supportive setting, and has given me an advantage in accelerating my career. This experience provided me with important tools that my initial 3 years of internal medicine residency did not. Even during my final year of residency, I was focused mostly on obtaining medical knowledge, learning its clinical applications, and honing team leadership skills. My mind rarely trespassed into the broader concerns of quality improvement initiatives, educational enhancements, or hospital management issues. Although the American College of Graduate Medical Education (ACGME) core competencies are helping to better focus residents' attention to these more diverse aspects of healthcare, residents still spend the majority of their time providing direct patient care.1 Now in my fourth year as an attending academic hospitalist, I continue to appreciate how my chief experience provided the foundation for much of the work I perform today.

My motivations for becoming a CMR included a desire to spend more time teaching and learning medicine, and an interest in helping to improve the residency program itself. I did not appreciate how much of the job would be spent managing people, and evaluating systems of care within the hospital, while working closely with nurses and hospital administrators. However, the skills I learned while addressing those unexpected tasks are what continue to help me in my position as a multifaceted hospitalist today. CMRs have been described as middle managers, being pushed and pulled by the demands and requirements of the groups above, below and around them.2 Academic hospitalists who frequently wear administrative and educational hats are not dissimilar. Retrospectively, I realize how fortunate I was to be exposed to those aspects as a CMR, with many of the same responsibilities but without the full expectations of a more seasoned attending.

The most memorable interaction during my first day as junior ward attending was with a revered internist, himself a former CMR, who dryly commented, So, you're pretending now. It took me a moment to catch his play on words until he clarified, you are now a pre‐attending. The true meaning of this was elucidated over the next several weeks as I was expected to perform many of the same duties of a seasoned attending, but often had the sense that I was only pretending to be an attending and still had much to learn.

CMR positions vary in terms of clinical, educational, and administrative responsibilities. Moreover, many institutions mix inpatient and outpatient roles. My position was focused almost entirely on inpatient duties at a single hospital, which gave me an in‐depth and longitudinal view of how a hospital is managed. Like many other CMRs, much of my time was spent on educational activities, such as running morning report, preparing for chief of medicine rounds, coordinating noon teaching conferences, and spending time with the medical students. Administrative tasks included various institutional‐based meetings for student grading, educational review committees, and program scheduling. In addition, I spent 1 month as junior attending on a ward team. Many other programs' CMRs spend more time as junior attending; however, by offloading some of this ward service requirement, I feel fortunate to have had that time to use for my own scholarly activity and teaching/administrative opportunities. Perhaps unique to my CMR position, I also was involved with the daily running of the hospital by working with administrators to evaluate patient transfer requests and addressing provider work flow issues. These additional tasks provided an invaluable learning experience.

Organizing morning report, running physical diagnosis rounds, and preparing cases and speakers for Chair's Rounds allowed me to hone and expand my teaching skills in ways that 3 years of residency did not. Moreover, it put me in direct contact with an energetic, inspiring group of learners that challenged me to solidify my own medical knowledge. (Try explaining the delta‐delta equation to figure out if there are 2 metabolic processes going on, in front of a group of 20 residents, and you'll discover what I mean.) I quickly learned that the one doing the talking is the one doing the learning and changed my teaching style to better facilitate student learning. My bedside learning was further augmented by attending Masters' Rounds to which I owe my ongoing interests in physical diagnosis. Masters Rounds were given once a week by 2 master clinicians. It was only for chief residents and was directed at teaching us how to teach others the art of bedside physical diagnosis. The majority of physical exam teaching points I focus on today come from those sessions.

As chief, I felt like I had the pulse of the hospital at all times. Most of my mornings were spent on the wards floating between teams. I owe thanks to my predecessor who told me that the true sign of a good CMR was to never sit long enough in your chair to let it get warm. My office was located on the wards, between a team room and a double patient room. Aside from times when I was having confidential conversations with residents, the door was open. Nurses looking to vent, phlebotomists wanting to sit down, and attendings needing a break from their teams to get work done were common visitors. Administrative personnel were also frequent visitors, usually requesting me to disseminate new policies to the residents. Because of this, I learned to understand and better interact with the diverse group of people responsible for making a teaching hospital function. These are the same constituencies that I now sit down with on various committees to attempt to make my present hospital operate more smoothly.

Despite running morning report, attending rounds with teams, and developing plans for better patient flow, I had time for scholarly work and found easy mentorship. I was able to revive 2 projects I had started as a resident and bring them close to conclusion under the continued mentorship of my coinvestigators. Offers for career skill development were also abound, and I benefited greatly from one associate director's tutorials on preparing effective PowerPoint presentations. Another attending mentored me in student feedback skills, which have allowed me to become a much more effective educator. I was also able to model that mentorship and begin to build my own mentor relationships with my students. In fact, this mentorship has become one of the most fulfilling aspects of my job. I was fortunate to have that mentorship early on in my career, as similar mentorship becomes difficult to obtain once in an attending hospitalist position.3

In conclusion, although current internal medicine residency training provides intensive direct patient care experiences, it only allows glimpses into the other aspects of an academic hospitalist's job. Unfortunately, it does not adequately prepare one to begin this type of position with a full complement of skills. Only a minority of hospitalists pursue additional structured training directly after residency; the majority jump into hospitalist positions and opt for on‐the‐job training. While there is an early economic advantage to starting an attending position without delay, I believe that the skills learned during an additional year of dedicated training allow for a more meaningful work experience and, ultimately, a faster rise within the track of an academic hospitalist.

The tasks that residency programs and hospitals may give to CMRs provide fertile material for developing the skills necessary to become a productive academic hospitalist. I thrived on the multifaceted work of caring for a diverse group of patients, teaching different levels of learners, helping to manage various hospital systems, and better understanding the hospital as the sum of its parts. As noted above, this pre‐attending league gave me the exposure to more fully develop my academic hospitalist game in a supportive environment. A CMR year may be beneficial for residents entering any career in internal medicine; however, I believe it is most aptly suited as a stepping stone for future academic hospitalists. I strongly recommend that current residents interested in academic hospital medicine consider a CMR position, and encourage program directors to consider molding their inpatient CMR experiences to facilitate this. Moreover, unless fellowship training in hospital medicine becomes the norm, I propose that current academic hospitalists do more to closely court and usher these pretenders into our ranks.

Academic hospitalists have multiple duties including direct patient care, hospital management, teaching, and scholarly productivity. We are frequently pulled in divergent directions, while attending to these responsibilities. Without a framework to manage these assorted tasks, we are at risk of subpar performance and career dissatisfaction. Alternatively, we often thrive in our roles as utility players when armed with a developed skill set. Our profession could benefit greatly from encouraging future academic hospitalists to obtain further training prior to starting as an attending. Although hospital medicine fellowship training exists, there are still relatively few programs available. A well‐crafted year spent as a chief medical resident (CMR) may be a viable alternative.

My year as CMR allowed me to develop the skills necessary for success as an academic hospitalist in a supportive setting, and has given me an advantage in accelerating my career. This experience provided me with important tools that my initial 3 years of internal medicine residency did not. Even during my final year of residency, I was focused mostly on obtaining medical knowledge, learning its clinical applications, and honing team leadership skills. My mind rarely trespassed into the broader concerns of quality improvement initiatives, educational enhancements, or hospital management issues. Although the American College of Graduate Medical Education (ACGME) core competencies are helping to better focus residents' attention to these more diverse aspects of healthcare, residents still spend the majority of their time providing direct patient care.1 Now in my fourth year as an attending academic hospitalist, I continue to appreciate how my chief experience provided the foundation for much of the work I perform today.

My motivations for becoming a CMR included a desire to spend more time teaching and learning medicine, and an interest in helping to improve the residency program itself. I did not appreciate how much of the job would be spent managing people, and evaluating systems of care within the hospital, while working closely with nurses and hospital administrators. However, the skills I learned while addressing those unexpected tasks are what continue to help me in my position as a multifaceted hospitalist today. CMRs have been described as middle managers, being pushed and pulled by the demands and requirements of the groups above, below and around them.2 Academic hospitalists who frequently wear administrative and educational hats are not dissimilar. Retrospectively, I realize how fortunate I was to be exposed to those aspects as a CMR, with many of the same responsibilities but without the full expectations of a more seasoned attending.

The most memorable interaction during my first day as junior ward attending was with a revered internist, himself a former CMR, who dryly commented, So, you're pretending now. It took me a moment to catch his play on words until he clarified, you are now a pre‐attending. The true meaning of this was elucidated over the next several weeks as I was expected to perform many of the same duties of a seasoned attending, but often had the sense that I was only pretending to be an attending and still had much to learn.

CMR positions vary in terms of clinical, educational, and administrative responsibilities. Moreover, many institutions mix inpatient and outpatient roles. My position was focused almost entirely on inpatient duties at a single hospital, which gave me an in‐depth and longitudinal view of how a hospital is managed. Like many other CMRs, much of my time was spent on educational activities, such as running morning report, preparing for chief of medicine rounds, coordinating noon teaching conferences, and spending time with the medical students. Administrative tasks included various institutional‐based meetings for student grading, educational review committees, and program scheduling. In addition, I spent 1 month as junior attending on a ward team. Many other programs' CMRs spend more time as junior attending; however, by offloading some of this ward service requirement, I feel fortunate to have had that time to use for my own scholarly activity and teaching/administrative opportunities. Perhaps unique to my CMR position, I also was involved with the daily running of the hospital by working with administrators to evaluate patient transfer requests and addressing provider work flow issues. These additional tasks provided an invaluable learning experience.

Organizing morning report, running physical diagnosis rounds, and preparing cases and speakers for Chair's Rounds allowed me to hone and expand my teaching skills in ways that 3 years of residency did not. Moreover, it put me in direct contact with an energetic, inspiring group of learners that challenged me to solidify my own medical knowledge. (Try explaining the delta‐delta equation to figure out if there are 2 metabolic processes going on, in front of a group of 20 residents, and you'll discover what I mean.) I quickly learned that the one doing the talking is the one doing the learning and changed my teaching style to better facilitate student learning. My bedside learning was further augmented by attending Masters' Rounds to which I owe my ongoing interests in physical diagnosis. Masters Rounds were given once a week by 2 master clinicians. It was only for chief residents and was directed at teaching us how to teach others the art of bedside physical diagnosis. The majority of physical exam teaching points I focus on today come from those sessions.

As chief, I felt like I had the pulse of the hospital at all times. Most of my mornings were spent on the wards floating between teams. I owe thanks to my predecessor who told me that the true sign of a good CMR was to never sit long enough in your chair to let it get warm. My office was located on the wards, between a team room and a double patient room. Aside from times when I was having confidential conversations with residents, the door was open. Nurses looking to vent, phlebotomists wanting to sit down, and attendings needing a break from their teams to get work done were common visitors. Administrative personnel were also frequent visitors, usually requesting me to disseminate new policies to the residents. Because of this, I learned to understand and better interact with the diverse group of people responsible for making a teaching hospital function. These are the same constituencies that I now sit down with on various committees to attempt to make my present hospital operate more smoothly.

Despite running morning report, attending rounds with teams, and developing plans for better patient flow, I had time for scholarly work and found easy mentorship. I was able to revive 2 projects I had started as a resident and bring them close to conclusion under the continued mentorship of my coinvestigators. Offers for career skill development were also abound, and I benefited greatly from one associate director's tutorials on preparing effective PowerPoint presentations. Another attending mentored me in student feedback skills, which have allowed me to become a much more effective educator. I was also able to model that mentorship and begin to build my own mentor relationships with my students. In fact, this mentorship has become one of the most fulfilling aspects of my job. I was fortunate to have that mentorship early on in my career, as similar mentorship becomes difficult to obtain once in an attending hospitalist position.3

In conclusion, although current internal medicine residency training provides intensive direct patient care experiences, it only allows glimpses into the other aspects of an academic hospitalist's job. Unfortunately, it does not adequately prepare one to begin this type of position with a full complement of skills. Only a minority of hospitalists pursue additional structured training directly after residency; the majority jump into hospitalist positions and opt for on‐the‐job training. While there is an early economic advantage to starting an attending position without delay, I believe that the skills learned during an additional year of dedicated training allow for a more meaningful work experience and, ultimately, a faster rise within the track of an academic hospitalist.

The tasks that residency programs and hospitals may give to CMRs provide fertile material for developing the skills necessary to become a productive academic hospitalist. I thrived on the multifaceted work of caring for a diverse group of patients, teaching different levels of learners, helping to manage various hospital systems, and better understanding the hospital as the sum of its parts. As noted above, this pre‐attending league gave me the exposure to more fully develop my academic hospitalist game in a supportive environment. A CMR year may be beneficial for residents entering any career in internal medicine; however, I believe it is most aptly suited as a stepping stone for future academic hospitalists. I strongly recommend that current residents interested in academic hospital medicine consider a CMR position, and encourage program directors to consider molding their inpatient CMR experiences to facilitate this. Moreover, unless fellowship training in hospital medicine becomes the norm, I propose that current academic hospitalists do more to closely court and usher these pretenders into our ranks.

Academic hospitalists have multiple duties including direct patient care, hospital management, teaching, and scholarly productivity. We are frequently pulled in divergent directions, while attending to these responsibilities. Without a framework to manage these assorted tasks, we are at risk of subpar performance and career dissatisfaction. Alternatively, we often thrive in our roles as utility players when armed with a developed skill set. Our profession could benefit greatly from encouraging future academic hospitalists to obtain further training prior to starting as an attending. Although hospital medicine fellowship training exists, there are still relatively few programs available. A well‐crafted year spent as a chief medical resident (CMR) may be a viable alternative.

My year as CMR allowed me to develop the skills necessary for success as an academic hospitalist in a supportive setting, and has given me an advantage in accelerating my career. This experience provided me with important tools that my initial 3 years of internal medicine residency did not. Even during my final year of residency, I was focused mostly on obtaining medical knowledge, learning its clinical applications, and honing team leadership skills. My mind rarely trespassed into the broader concerns of quality improvement initiatives, educational enhancements, or hospital management issues. Although the American College of Graduate Medical Education (ACGME) core competencies are helping to better focus residents' attention to these more diverse aspects of healthcare, residents still spend the majority of their time providing direct patient care.1 Now in my fourth year as an attending academic hospitalist, I continue to appreciate how my chief experience provided the foundation for much of the work I perform today.

My motivations for becoming a CMR included a desire to spend more time teaching and learning medicine, and an interest in helping to improve the residency program itself. I did not appreciate how much of the job would be spent managing people, and evaluating systems of care within the hospital, while working closely with nurses and hospital administrators. However, the skills I learned while addressing those unexpected tasks are what continue to help me in my position as a multifaceted hospitalist today. CMRs have been described as middle managers, being pushed and pulled by the demands and requirements of the groups above, below and around them.2 Academic hospitalists who frequently wear administrative and educational hats are not dissimilar. Retrospectively, I realize how fortunate I was to be exposed to those aspects as a CMR, with many of the same responsibilities but without the full expectations of a more seasoned attending.

The most memorable interaction during my first day as junior ward attending was with a revered internist, himself a former CMR, who dryly commented, So, you're pretending now. It took me a moment to catch his play on words until he clarified, you are now a pre‐attending. The true meaning of this was elucidated over the next several weeks as I was expected to perform many of the same duties of a seasoned attending, but often had the sense that I was only pretending to be an attending and still had much to learn.

CMR positions vary in terms of clinical, educational, and administrative responsibilities. Moreover, many institutions mix inpatient and outpatient roles. My position was focused almost entirely on inpatient duties at a single hospital, which gave me an in‐depth and longitudinal view of how a hospital is managed. Like many other CMRs, much of my time was spent on educational activities, such as running morning report, preparing for chief of medicine rounds, coordinating noon teaching conferences, and spending time with the medical students. Administrative tasks included various institutional‐based meetings for student grading, educational review committees, and program scheduling. In addition, I spent 1 month as junior attending on a ward team. Many other programs' CMRs spend more time as junior attending; however, by offloading some of this ward service requirement, I feel fortunate to have had that time to use for my own scholarly activity and teaching/administrative opportunities. Perhaps unique to my CMR position, I also was involved with the daily running of the hospital by working with administrators to evaluate patient transfer requests and addressing provider work flow issues. These additional tasks provided an invaluable learning experience.

Organizing morning report, running physical diagnosis rounds, and preparing cases and speakers for Chair's Rounds allowed me to hone and expand my teaching skills in ways that 3 years of residency did not. Moreover, it put me in direct contact with an energetic, inspiring group of learners that challenged me to solidify my own medical knowledge. (Try explaining the delta‐delta equation to figure out if there are 2 metabolic processes going on, in front of a group of 20 residents, and you'll discover what I mean.) I quickly learned that the one doing the talking is the one doing the learning and changed my teaching style to better facilitate student learning. My bedside learning was further augmented by attending Masters' Rounds to which I owe my ongoing interests in physical diagnosis. Masters Rounds were given once a week by 2 master clinicians. It was only for chief residents and was directed at teaching us how to teach others the art of bedside physical diagnosis. The majority of physical exam teaching points I focus on today come from those sessions.

As chief, I felt like I had the pulse of the hospital at all times. Most of my mornings were spent on the wards floating between teams. I owe thanks to my predecessor who told me that the true sign of a good CMR was to never sit long enough in your chair to let it get warm. My office was located on the wards, between a team room and a double patient room. Aside from times when I was having confidential conversations with residents, the door was open. Nurses looking to vent, phlebotomists wanting to sit down, and attendings needing a break from their teams to get work done were common visitors. Administrative personnel were also frequent visitors, usually requesting me to disseminate new policies to the residents. Because of this, I learned to understand and better interact with the diverse group of people responsible for making a teaching hospital function. These are the same constituencies that I now sit down with on various committees to attempt to make my present hospital operate more smoothly.

Despite running morning report, attending rounds with teams, and developing plans for better patient flow, I had time for scholarly work and found easy mentorship. I was able to revive 2 projects I had started as a resident and bring them close to conclusion under the continued mentorship of my coinvestigators. Offers for career skill development were also abound, and I benefited greatly from one associate director's tutorials on preparing effective PowerPoint presentations. Another attending mentored me in student feedback skills, which have allowed me to become a much more effective educator. I was also able to model that mentorship and begin to build my own mentor relationships with my students. In fact, this mentorship has become one of the most fulfilling aspects of my job. I was fortunate to have that mentorship early on in my career, as similar mentorship becomes difficult to obtain once in an attending hospitalist position.3

In conclusion, although current internal medicine residency training provides intensive direct patient care experiences, it only allows glimpses into the other aspects of an academic hospitalist's job. Unfortunately, it does not adequately prepare one to begin this type of position with a full complement of skills. Only a minority of hospitalists pursue additional structured training directly after residency; the majority jump into hospitalist positions and opt for on‐the‐job training. While there is an early economic advantage to starting an attending position without delay, I believe that the skills learned during an additional year of dedicated training allow for a more meaningful work experience and, ultimately, a faster rise within the track of an academic hospitalist.

The tasks that residency programs and hospitals may give to CMRs provide fertile material for developing the skills necessary to become a productive academic hospitalist. I thrived on the multifaceted work of caring for a diverse group of patients, teaching different levels of learners, helping to manage various hospital systems, and better understanding the hospital as the sum of its parts. As noted above, this pre‐attending league gave me the exposure to more fully develop my academic hospitalist game in a supportive environment. A CMR year may be beneficial for residents entering any career in internal medicine; however, I believe it is most aptly suited as a stepping stone for future academic hospitalists. I strongly recommend that current residents interested in academic hospital medicine consider a CMR position, and encourage program directors to consider molding their inpatient CMR experiences to facilitate this. Moreover, unless fellowship training in hospital medicine becomes the norm, I propose that current academic hospitalists do more to closely court and usher these pretenders into our ranks.