Editorial

Bertha Johnson is back with pneumonia again. The ED doctor on the telephone sounded both matter‐of‐fact and mildly bored when I answered her page about another admission to the hospitalist service. I hadn't met Mrs. Johnson previously, but came to know her and Douglas, her only son, well over the next few days.

The Johnsons were facing a difficult choice. Bertha was now bedbound and quadriplegic following a 40‐year battle with multiple sclerosis and gradually mounting disability. She was cognitively intact and had a solid grasp of medical realities, but was hard of hearing and quite dysarthric. Forming even short phrases and sentences took great effort. However tenuous, this ability to speak allowed her to communicate with those she loved. She had been admitted thrice in the past year with aspiration pneumonia, as she was unable to clear her secretions reliably. Repeated bronchoscopies demonstrated an inability to protect her airway. Douglas, who was also her health care proxy, favored proceeding with the tracheostomy suggested by the pulmonary team. On a prior admission, he had been distressed when his mother refused this intervention. Now she was back with the identical problem and had been given the same recommendation by her doctors. It was particularly difficult for me to discuss these sensitive issues when I had not previously met either Bertha or her son. I spoke to her primary care physician over the phone and he agreed with the need for tracheostomy. The pulmonary team had been involved in discussions about tracheostomy in all of her hospital admissions, providing continuity of care in the process. Ultimately, it was my responsibility to help Bertha and Douglas come to a decision.

After multiple discussions between the Johnsons and me, a consensus emerged to proceed with the tracheostomy. We recognized that the procedure would increase her care needs and arranged for a stay in a skilled nursing facility to provide access to round‐the‐clock suctioning. The evening prior to the tracheostomy, the floor nurse and I reviewed the procedure to ensure that Bertha was fully prepared. What followed resulted in a drastic change of plan. Bertha emphasized that she did not want to lose her only means of communication, even if the surgery would prolong her life. She admitted that she reluctantly agreed to the procedure only to please her son and doctors, because they believed it to be in her best interest. Her fear of the prospect of death from drowning in her own secretions was much less than her fear of silence and isolation that would result from her loss of speech. I shared her misgivings with Douglas, and she admitted to him that she had only agreed to the procedure for his sake. We cancelled the surgery.

Douglas later revealed that he also had been ambivalent about the procedure for sometime, as it would necessitate a nursing home stay and the loss of the caretakers who had cared for his mother so wonderfully for many years. Bertha lived alone in her own home with the help of visiting nurses and patient care assistants Douglas paid for out‐of‐pocket. Douglas lived and worked in a city over a hundred miles away, but managed to visit several times a month to facilitate his mother's care. He had supported the procedure only because the doctors had said it was the only way to avoid future pneumonias. The idea of a tracheostomy was definitively abandoned once and for all.

The Johnsons wanted Bertha to return to her home, but hospital case managers felt this would be an unsafe plan of care as she was alone for several hours a day. She was largely immobile and unable to escape if there were a fire or other emergency. Also, the caretakers were not trained to use the suction equipment, and the visiting nurses would only be available intermittently. The home care staff felt they could no longer meet her needs and declined to resume her care. Douglas became very frustrated by the delays and protracted negotiations, enough so that he threatened to sue the institution for taking over my mother's life. The threat of litigation is usually a cry for help that reflects either miscommunication or the suffering of a conflicted family.

As their hospitalist, I hoped to advocate for both the patient and Douglas while coordinating the overall care plan. I had always received consistent responses from the Johnsons, but other staff members noted that Douglas had expressed shifting views on the best site of care for his mother. At Bertha's request, I convened a meeting with her, Douglas, the social worker, case manager, visiting and staff nurses, the palliative care nurse, and floor manager. Prior to this, I met with all involved health care providers to ensure we understood each other's abilities and limitations regarding Bertha's care. As I entered the room for the family meeting, I knew it was ultimately the patient's choice whether she wanted to return home or notas long as she understood the risks involved.

During the meeting, all the team members explained the dilemmas they faced in planning for a safe disposition. Douglas's response illuminated his devotion and love for his ailing mother. He had known all along that it would be less expensive and burdensome for him for Bertha to be placed in a facility. However, he feared nursing home admission represented giving up and failing to fulfill my duty to my mother. Tears ran down the face of this otherwise well composed, immaculately dressed, articulate man in his late forties. He had assumed the responsibility for his mother's care while still a child and had carried this self‐imposed moral burden his entire life. This meeting was his first opportunity to voice explicitly to the medical team his immense love and concern for his dear mother.

I gently probed to clarify Bertha's values and goals. On a brief, prior nursing home stay, Bertha had found the experience to be scary and unfamiliar. However, as her functional abilities continued to decline, her feelings had changed. She now felt lonely and anxious at home when her caretakers were absent. She actually wanted to go to a nursing home, where there would always be company and support available! She had not told Douglas this because she knew he cared for her deeply and she didn't want to hurt his feelings; he seemed committed to caring for her the same way he had for so many years.

In short, Douglas knew it would be easier for him if his mother were in a nursing facility, but assumed she wanted to stay in her home. Oddly, Bertha was only remaining at home because she believed that was what her son wished. A few days later, Bertha was transferred to a nursing home near several relatives who would visit her regularly. Douglas was again selfless in not seeking to move her closer to him. He didn't want to uproot her more than was unavoidable.

Day‐to‐day practice reveals many examples of love and dedication, but I have never seen such blinding and unquestioning commitment as exemplified by this mother‐son duo. From them, I learned the importance of attentive and active listening. Our polite patients may only subtly hint at matters of the deepest import. If we cannot truly hear their unspoken emotions, we risk harming them and misinterpreting their words and actions. Some healthcare providers had seen Douglas as aggressive and demanding with his threat of a lawsuit, whereas Bertha had been described as unrealistic or in denial. These views distorted a much more complex reality. Time and attention to careful communication between the healthcare providers, the patient, and her son bore fruit in this case. The procedure that was really needed was the family meeting and not the tracheostomy! An undesired and invasive procedure was avoided, goals of care were clarified, quality of life maximized, a safe discharge arranged, and a new mutual understanding achieved. I was humbled, and reminded of the importance of team‐based care and the need to approach each patient and family member in a receptive, nonjudgmental, and open manner. Douglas and Bertha Johnson were linked with a profound and abiding bond that would only be severed at death.

Bertha Johnson is back with pneumonia again. The ED doctor on the telephone sounded both matter‐of‐fact and mildly bored when I answered her page about another admission to the hospitalist service. I hadn't met Mrs. Johnson previously, but came to know her and Douglas, her only son, well over the next few days.

The Johnsons were facing a difficult choice. Bertha was now bedbound and quadriplegic following a 40‐year battle with multiple sclerosis and gradually mounting disability. She was cognitively intact and had a solid grasp of medical realities, but was hard of hearing and quite dysarthric. Forming even short phrases and sentences took great effort. However tenuous, this ability to speak allowed her to communicate with those she loved. She had been admitted thrice in the past year with aspiration pneumonia, as she was unable to clear her secretions reliably. Repeated bronchoscopies demonstrated an inability to protect her airway. Douglas, who was also her health care proxy, favored proceeding with the tracheostomy suggested by the pulmonary team. On a prior admission, he had been distressed when his mother refused this intervention. Now she was back with the identical problem and had been given the same recommendation by her doctors. It was particularly difficult for me to discuss these sensitive issues when I had not previously met either Bertha or her son. I spoke to her primary care physician over the phone and he agreed with the need for tracheostomy. The pulmonary team had been involved in discussions about tracheostomy in all of her hospital admissions, providing continuity of care in the process. Ultimately, it was my responsibility to help Bertha and Douglas come to a decision.

After multiple discussions between the Johnsons and me, a consensus emerged to proceed with the tracheostomy. We recognized that the procedure would increase her care needs and arranged for a stay in a skilled nursing facility to provide access to round‐the‐clock suctioning. The evening prior to the tracheostomy, the floor nurse and I reviewed the procedure to ensure that Bertha was fully prepared. What followed resulted in a drastic change of plan. Bertha emphasized that she did not want to lose her only means of communication, even if the surgery would prolong her life. She admitted that she reluctantly agreed to the procedure only to please her son and doctors, because they believed it to be in her best interest. Her fear of the prospect of death from drowning in her own secretions was much less than her fear of silence and isolation that would result from her loss of speech. I shared her misgivings with Douglas, and she admitted to him that she had only agreed to the procedure for his sake. We cancelled the surgery.

Douglas later revealed that he also had been ambivalent about the procedure for sometime, as it would necessitate a nursing home stay and the loss of the caretakers who had cared for his mother so wonderfully for many years. Bertha lived alone in her own home with the help of visiting nurses and patient care assistants Douglas paid for out‐of‐pocket. Douglas lived and worked in a city over a hundred miles away, but managed to visit several times a month to facilitate his mother's care. He had supported the procedure only because the doctors had said it was the only way to avoid future pneumonias. The idea of a tracheostomy was definitively abandoned once and for all.

The Johnsons wanted Bertha to return to her home, but hospital case managers felt this would be an unsafe plan of care as she was alone for several hours a day. She was largely immobile and unable to escape if there were a fire or other emergency. Also, the caretakers were not trained to use the suction equipment, and the visiting nurses would only be available intermittently. The home care staff felt they could no longer meet her needs and declined to resume her care. Douglas became very frustrated by the delays and protracted negotiations, enough so that he threatened to sue the institution for taking over my mother's life. The threat of litigation is usually a cry for help that reflects either miscommunication or the suffering of a conflicted family.

As their hospitalist, I hoped to advocate for both the patient and Douglas while coordinating the overall care plan. I had always received consistent responses from the Johnsons, but other staff members noted that Douglas had expressed shifting views on the best site of care for his mother. At Bertha's request, I convened a meeting with her, Douglas, the social worker, case manager, visiting and staff nurses, the palliative care nurse, and floor manager. Prior to this, I met with all involved health care providers to ensure we understood each other's abilities and limitations regarding Bertha's care. As I entered the room for the family meeting, I knew it was ultimately the patient's choice whether she wanted to return home or notas long as she understood the risks involved.

During the meeting, all the team members explained the dilemmas they faced in planning for a safe disposition. Douglas's response illuminated his devotion and love for his ailing mother. He had known all along that it would be less expensive and burdensome for him for Bertha to be placed in a facility. However, he feared nursing home admission represented giving up and failing to fulfill my duty to my mother. Tears ran down the face of this otherwise well composed, immaculately dressed, articulate man in his late forties. He had assumed the responsibility for his mother's care while still a child and had carried this self‐imposed moral burden his entire life. This meeting was his first opportunity to voice explicitly to the medical team his immense love and concern for his dear mother.

I gently probed to clarify Bertha's values and goals. On a brief, prior nursing home stay, Bertha had found the experience to be scary and unfamiliar. However, as her functional abilities continued to decline, her feelings had changed. She now felt lonely and anxious at home when her caretakers were absent. She actually wanted to go to a nursing home, where there would always be company and support available! She had not told Douglas this because she knew he cared for her deeply and she didn't want to hurt his feelings; he seemed committed to caring for her the same way he had for so many years.

In short, Douglas knew it would be easier for him if his mother were in a nursing facility, but assumed she wanted to stay in her home. Oddly, Bertha was only remaining at home because she believed that was what her son wished. A few days later, Bertha was transferred to a nursing home near several relatives who would visit her regularly. Douglas was again selfless in not seeking to move her closer to him. He didn't want to uproot her more than was unavoidable.

Day‐to‐day practice reveals many examples of love and dedication, but I have never seen such blinding and unquestioning commitment as exemplified by this mother‐son duo. From them, I learned the importance of attentive and active listening. Our polite patients may only subtly hint at matters of the deepest import. If we cannot truly hear their unspoken emotions, we risk harming them and misinterpreting their words and actions. Some healthcare providers had seen Douglas as aggressive and demanding with his threat of a lawsuit, whereas Bertha had been described as unrealistic or in denial. These views distorted a much more complex reality. Time and attention to careful communication between the healthcare providers, the patient, and her son bore fruit in this case. The procedure that was really needed was the family meeting and not the tracheostomy! An undesired and invasive procedure was avoided, goals of care were clarified, quality of life maximized, a safe discharge arranged, and a new mutual understanding achieved. I was humbled, and reminded of the importance of team‐based care and the need to approach each patient and family member in a receptive, nonjudgmental, and open manner. Douglas and Bertha Johnson were linked with a profound and abiding bond that would only be severed at death.

Bertha Johnson is back with pneumonia again. The ED doctor on the telephone sounded both matter‐of‐fact and mildly bored when I answered her page about another admission to the hospitalist service. I hadn't met Mrs. Johnson previously, but came to know her and Douglas, her only son, well over the next few days.

The Johnsons were facing a difficult choice. Bertha was now bedbound and quadriplegic following a 40‐year battle with multiple sclerosis and gradually mounting disability. She was cognitively intact and had a solid grasp of medical realities, but was hard of hearing and quite dysarthric. Forming even short phrases and sentences took great effort. However tenuous, this ability to speak allowed her to communicate with those she loved. She had been admitted thrice in the past year with aspiration pneumonia, as she was unable to clear her secretions reliably. Repeated bronchoscopies demonstrated an inability to protect her airway. Douglas, who was also her health care proxy, favored proceeding with the tracheostomy suggested by the pulmonary team. On a prior admission, he had been distressed when his mother refused this intervention. Now she was back with the identical problem and had been given the same recommendation by her doctors. It was particularly difficult for me to discuss these sensitive issues when I had not previously met either Bertha or her son. I spoke to her primary care physician over the phone and he agreed with the need for tracheostomy. The pulmonary team had been involved in discussions about tracheostomy in all of her hospital admissions, providing continuity of care in the process. Ultimately, it was my responsibility to help Bertha and Douglas come to a decision.

After multiple discussions between the Johnsons and me, a consensus emerged to proceed with the tracheostomy. We recognized that the procedure would increase her care needs and arranged for a stay in a skilled nursing facility to provide access to round‐the‐clock suctioning. The evening prior to the tracheostomy, the floor nurse and I reviewed the procedure to ensure that Bertha was fully prepared. What followed resulted in a drastic change of plan. Bertha emphasized that she did not want to lose her only means of communication, even if the surgery would prolong her life. She admitted that she reluctantly agreed to the procedure only to please her son and doctors, because they believed it to be in her best interest. Her fear of the prospect of death from drowning in her own secretions was much less than her fear of silence and isolation that would result from her loss of speech. I shared her misgivings with Douglas, and she admitted to him that she had only agreed to the procedure for his sake. We cancelled the surgery.

Douglas later revealed that he also had been ambivalent about the procedure for sometime, as it would necessitate a nursing home stay and the loss of the caretakers who had cared for his mother so wonderfully for many years. Bertha lived alone in her own home with the help of visiting nurses and patient care assistants Douglas paid for out‐of‐pocket. Douglas lived and worked in a city over a hundred miles away, but managed to visit several times a month to facilitate his mother's care. He had supported the procedure only because the doctors had said it was the only way to avoid future pneumonias. The idea of a tracheostomy was definitively abandoned once and for all.

The Johnsons wanted Bertha to return to her home, but hospital case managers felt this would be an unsafe plan of care as she was alone for several hours a day. She was largely immobile and unable to escape if there were a fire or other emergency. Also, the caretakers were not trained to use the suction equipment, and the visiting nurses would only be available intermittently. The home care staff felt they could no longer meet her needs and declined to resume her care. Douglas became very frustrated by the delays and protracted negotiations, enough so that he threatened to sue the institution for taking over my mother's life. The threat of litigation is usually a cry for help that reflects either miscommunication or the suffering of a conflicted family.

As their hospitalist, I hoped to advocate for both the patient and Douglas while coordinating the overall care plan. I had always received consistent responses from the Johnsons, but other staff members noted that Douglas had expressed shifting views on the best site of care for his mother. At Bertha's request, I convened a meeting with her, Douglas, the social worker, case manager, visiting and staff nurses, the palliative care nurse, and floor manager. Prior to this, I met with all involved health care providers to ensure we understood each other's abilities and limitations regarding Bertha's care. As I entered the room for the family meeting, I knew it was ultimately the patient's choice whether she wanted to return home or notas long as she understood the risks involved.

During the meeting, all the team members explained the dilemmas they faced in planning for a safe disposition. Douglas's response illuminated his devotion and love for his ailing mother. He had known all along that it would be less expensive and burdensome for him for Bertha to be placed in a facility. However, he feared nursing home admission represented giving up and failing to fulfill my duty to my mother. Tears ran down the face of this otherwise well composed, immaculately dressed, articulate man in his late forties. He had assumed the responsibility for his mother's care while still a child and had carried this self‐imposed moral burden his entire life. This meeting was his first opportunity to voice explicitly to the medical team his immense love and concern for his dear mother.

I gently probed to clarify Bertha's values and goals. On a brief, prior nursing home stay, Bertha had found the experience to be scary and unfamiliar. However, as her functional abilities continued to decline, her feelings had changed. She now felt lonely and anxious at home when her caretakers were absent. She actually wanted to go to a nursing home, where there would always be company and support available! She had not told Douglas this because she knew he cared for her deeply and she didn't want to hurt his feelings; he seemed committed to caring for her the same way he had for so many years.

In short, Douglas knew it would be easier for him if his mother were in a nursing facility, but assumed she wanted to stay in her home. Oddly, Bertha was only remaining at home because she believed that was what her son wished. A few days later, Bertha was transferred to a nursing home near several relatives who would visit her regularly. Douglas was again selfless in not seeking to move her closer to him. He didn't want to uproot her more than was unavoidable.

Day‐to‐day practice reveals many examples of love and dedication, but I have never seen such blinding and unquestioning commitment as exemplified by this mother‐son duo. From them, I learned the importance of attentive and active listening. Our polite patients may only subtly hint at matters of the deepest import. If we cannot truly hear their unspoken emotions, we risk harming them and misinterpreting their words and actions. Some healthcare providers had seen Douglas as aggressive and demanding with his threat of a lawsuit, whereas Bertha had been described as unrealistic or in denial. These views distorted a much more complex reality. Time and attention to careful communication between the healthcare providers, the patient, and her son bore fruit in this case. The procedure that was really needed was the family meeting and not the tracheostomy! An undesired and invasive procedure was avoided, goals of care were clarified, quality of life maximized, a safe discharge arranged, and a new mutual understanding achieved. I was humbled, and reminded of the importance of team‐based care and the need to approach each patient and family member in a receptive, nonjudgmental, and open manner. Douglas and Bertha Johnson were linked with a profound and abiding bond that would only be severed at death.

In the last decade, natural disasters such as the Indonesian tsunami of 2004, Hurricane Katrina in 2004, and the Pakistani earthquake of 2005 have brought attention to the importance of diverse but complementary medical professional roles in humanitarian medical aid.14 Natural disasters that cause significant physical trauma to large populations often necessitate initial multidisciplinary responder teams comprised of surgeons, anesthesiologists, emergency medicine physicians, surgical technologists, nurses, psychiatrists, and public health specialists. Their roles are to manage life‐threatening injuries, provide immediate triage, help affected individuals deal with intense psychological shock, and address critical population‐based needs such as water, food, and sanitation. Meanwhile, general medical, pediatric, rehabilitative, and long‐term psychiatric services often constitute a secondary tier of disaster response, providing postsurgical care, managing acute medical illnesses, mitigating psychological trauma, rehabilitating injuries, and providing vaccinations to at‐risk individuals. Hospitalists can play an important role in postcatastrophe recovery services as experts in acute care, stewards of care transitions, and drivers of systems improvement.

The earthquake that occurred January 12, 2010 in Haiti is a dramatic illustration of the importance of a multidisciplinary approach to disaster relief. The 7.0‐magnitude earthquake near Port‐au‐Prince ravaged an already crippled health care system, severely damaging the country's primary academic medical center, and killed the entire class of second‐year nursing students. The death toll has been estimated to be nearly one‐quarter of a million people.5 Victims awaiting surgery, recovering from surgery, or in need of other immediate medical attention quickly inundated any existing health facilities. The following stories describe the authors' respective experiences in Haiti after the earthquake.

JC: I arrived 4 days after the earthquake to a hospital outside of Port‐au‐Prince, spared from destruction, but filled with hundreds of patients with crush injuries and severe fractures. On rounds with the surgical team, I observed that venous thromboembolism (VTE) prophylaxis had not yet been initiated, and I was concerned that patients might die from pulmonary embolism. In the overwhelming urgency of providing life‐saving surgery to as many patients as possible, this simple measure had been overlooked. After discussion with our team and our Haitian medical colleagues, we initiated subcutaneous heparin on all eligible patients and made arrangements to receive further shipments of heparin to accommodate the influx of patients.

A nearby school and church had been annexed into makeshift extensions of the hospital wards. The volume and pace of incoming injuries was such that as soon as a patient was taken to surgery, another patient would often take his or her place in the bed. The rapid movement of patients to and from x‐ray, surgery, and postsurgical care created challenges around effective and accurate communication among multiple care providers. We decided that nonsurgical personnel would triage newly arriving patients and round on patients daily. Each nonsurgical physician was responsible for staffing a particular location. This zone‐defense approach ensured that the surgeons maximized their time in the operating rooms. We also instituted a basic system of portable medical records kept with each patient at all times, allowing personnel to easily and quickly assess care given to date, and to write notes and orders.

Presurgical and postsurgical wound infections became a common event, with the risk of ensuing sepsis. Antibiotic use was dependent on the preferences of individual surgeons and also on the available supply. As a result, antimicrobial treatments were highly variable and sometimes inadequate. The internists on the team proposed standard antibiotic guidelines for open fractures, for contaminated wounds, and for postoperative wounds; these regimens were approved and implemented by Haitian staff and the rest of the team.

Internists recognized the first complications of rhabdomyolysis from crush injuries and delays in receiving medical attention. Malaise, oliguria, and volume overload were often the only clues we had for severe renal failure. We had a functional lab capable of checking complete blood counts, urinalysis and creatinine, but we had a limited supply of serum potassium assays. We only used the latter in confirmed cases of rhabdomyolysis, and on several occasions we diagnosed severe hyperkalemia. Using bedside automated electrical defibrillation devices for monitoring, we sustained these patients on calcium gluconate until they could be transferred to an external dialysis unit run by Mdecins Sans Frontires in Port‐au‐Prince.6 As the number of rhabdomyolysis cases increased, we instigated creatinine rounds on patients arriving with large crush injuries, and we evaluated urine output daily until patients were clinically stable from this threat. We also helped the Haitian staff treat the omnipresent problem of pain and advised renal dosing of medications in renal failure and elderly patients.

GH: The situation 3 months after the earthquake was medically less dire but highlights the evolving importance of generalists in the aftermath of the quake.710 For many Haitian patients, the earthquake had become a universal point of reference for their symptomatology. Anorexia, amenorrhea, headaches, epigastric pain, even fungating soft tissue masses, were all reported to be depi tranbleman t a (since the earthquake) and were often somatic manifestations of a psychologically devastating event. At a hospital in Carrefour, I cared for patients presenting with dramatic sequelae of chronic diseases that had been undertreated due to the destruction of the Haitian medical infrastructurehypertensive coma, diabetic ketoacidosis, cerebral malaria, decompensated liver disease, and severe chronic anemia (including a patient with a hemoglobin of 3 mg/dL). I encountered many patients with infections exacerbated by excessive crowding in tent communities, such as typhoid and tuberculosis. At this particular hospital, priorities appropriately placed on surgical and postsurgical care required the team to devise creative solutions for the care and placement of medical patients, such as restructuring the emergency department and creating a rehabilitation tent on the hospital grounds. While few Haitian internists were present, a number of Haitian obstetricians were on site and helped manage medical conditions within the scope of their experience, such as hypertension, abdominal pain, and genitourinary infections. The expatriate orthopedic surgeons on site sought the consultative skills of hospitalists for preoperative management, postoperative complications, and comorbid conditions.

This hospital was largely sustained by rotating teams of volunteers, which underscored the importance of establishing a flexible system that would accommodate the turnover of personnel and fluctuating levels of professional expertise. The team used a tiered model for acute care delivery designating responsibilities based on the number of nurses, physicians, and other providers available. We collaborated with Haitian physicians to establish a routine of handoff rounds. Finally, we created and centralized documentation such as clinical protocols, contact numbers, and helpful tips for our successors.

Hospitalists have valuable skills to offer in medical responses to natural catastrophes.5 Our fluency with acute care environments becomes a pluripotent asset in disaster relief. Our experiences in assessing acuity are vital in assisting with inpatient triage. Our familiarity with the comanagement model facilitates partnership with other disciplines to optimize the distribution of skill sets without neglecting the overall well‐being of patients. Our clinical expertise in treating the vulnerable elderly, VTE, renal failure, pain management, postoperative infections, sepsis, and many other conditions can bolster medical relief efforts, even when the foremost need is surgical. The hospitalist's core competencies in healthcare systems11 can support recovery initiatives in medical facilities, particularly in the domains of drug safety, resource allocation, information management, team‐based methods, and care transitions. Our respective experiences also suggest the potential value of hospitalists in domestic, in addition to international, disaster response initiatives. Since large‐scale calamities may result in the hospitalization of overwhelming numbers of victims,12 hospitalists may be well‐positioned to assist our emergency medicine and public health colleagues, who currently (and fittingly) lead domestic efforts in disaster relief.

Tragedies like the earthquake in Haiti serve as a sobering reminder that a comprehensive multidisciplinary approach is required as medical disaster relief shifts from a life‐saving focus to one of life‐preserving care.13, 14 Hospitalists can play a vital role in these restorative efforts.

In the last decade, natural disasters such as the Indonesian tsunami of 2004, Hurricane Katrina in 2004, and the Pakistani earthquake of 2005 have brought attention to the importance of diverse but complementary medical professional roles in humanitarian medical aid.14 Natural disasters that cause significant physical trauma to large populations often necessitate initial multidisciplinary responder teams comprised of surgeons, anesthesiologists, emergency medicine physicians, surgical technologists, nurses, psychiatrists, and public health specialists. Their roles are to manage life‐threatening injuries, provide immediate triage, help affected individuals deal with intense psychological shock, and address critical population‐based needs such as water, food, and sanitation. Meanwhile, general medical, pediatric, rehabilitative, and long‐term psychiatric services often constitute a secondary tier of disaster response, providing postsurgical care, managing acute medical illnesses, mitigating psychological trauma, rehabilitating injuries, and providing vaccinations to at‐risk individuals. Hospitalists can play an important role in postcatastrophe recovery services as experts in acute care, stewards of care transitions, and drivers of systems improvement.

The earthquake that occurred January 12, 2010 in Haiti is a dramatic illustration of the importance of a multidisciplinary approach to disaster relief. The 7.0‐magnitude earthquake near Port‐au‐Prince ravaged an already crippled health care system, severely damaging the country's primary academic medical center, and killed the entire class of second‐year nursing students. The death toll has been estimated to be nearly one‐quarter of a million people.5 Victims awaiting surgery, recovering from surgery, or in need of other immediate medical attention quickly inundated any existing health facilities. The following stories describe the authors' respective experiences in Haiti after the earthquake.

JC: I arrived 4 days after the earthquake to a hospital outside of Port‐au‐Prince, spared from destruction, but filled with hundreds of patients with crush injuries and severe fractures. On rounds with the surgical team, I observed that venous thromboembolism (VTE) prophylaxis had not yet been initiated, and I was concerned that patients might die from pulmonary embolism. In the overwhelming urgency of providing life‐saving surgery to as many patients as possible, this simple measure had been overlooked. After discussion with our team and our Haitian medical colleagues, we initiated subcutaneous heparin on all eligible patients and made arrangements to receive further shipments of heparin to accommodate the influx of patients.

A nearby school and church had been annexed into makeshift extensions of the hospital wards. The volume and pace of incoming injuries was such that as soon as a patient was taken to surgery, another patient would often take his or her place in the bed. The rapid movement of patients to and from x‐ray, surgery, and postsurgical care created challenges around effective and accurate communication among multiple care providers. We decided that nonsurgical personnel would triage newly arriving patients and round on patients daily. Each nonsurgical physician was responsible for staffing a particular location. This zone‐defense approach ensured that the surgeons maximized their time in the operating rooms. We also instituted a basic system of portable medical records kept with each patient at all times, allowing personnel to easily and quickly assess care given to date, and to write notes and orders.

Presurgical and postsurgical wound infections became a common event, with the risk of ensuing sepsis. Antibiotic use was dependent on the preferences of individual surgeons and also on the available supply. As a result, antimicrobial treatments were highly variable and sometimes inadequate. The internists on the team proposed standard antibiotic guidelines for open fractures, for contaminated wounds, and for postoperative wounds; these regimens were approved and implemented by Haitian staff and the rest of the team.

Internists recognized the first complications of rhabdomyolysis from crush injuries and delays in receiving medical attention. Malaise, oliguria, and volume overload were often the only clues we had for severe renal failure. We had a functional lab capable of checking complete blood counts, urinalysis and creatinine, but we had a limited supply of serum potassium assays. We only used the latter in confirmed cases of rhabdomyolysis, and on several occasions we diagnosed severe hyperkalemia. Using bedside automated electrical defibrillation devices for monitoring, we sustained these patients on calcium gluconate until they could be transferred to an external dialysis unit run by Mdecins Sans Frontires in Port‐au‐Prince.6 As the number of rhabdomyolysis cases increased, we instigated creatinine rounds on patients arriving with large crush injuries, and we evaluated urine output daily until patients were clinically stable from this threat. We also helped the Haitian staff treat the omnipresent problem of pain and advised renal dosing of medications in renal failure and elderly patients.

GH: The situation 3 months after the earthquake was medically less dire but highlights the evolving importance of generalists in the aftermath of the quake.710 For many Haitian patients, the earthquake had become a universal point of reference for their symptomatology. Anorexia, amenorrhea, headaches, epigastric pain, even fungating soft tissue masses, were all reported to be depi tranbleman t a (since the earthquake) and were often somatic manifestations of a psychologically devastating event. At a hospital in Carrefour, I cared for patients presenting with dramatic sequelae of chronic diseases that had been undertreated due to the destruction of the Haitian medical infrastructurehypertensive coma, diabetic ketoacidosis, cerebral malaria, decompensated liver disease, and severe chronic anemia (including a patient with a hemoglobin of 3 mg/dL). I encountered many patients with infections exacerbated by excessive crowding in tent communities, such as typhoid and tuberculosis. At this particular hospital, priorities appropriately placed on surgical and postsurgical care required the team to devise creative solutions for the care and placement of medical patients, such as restructuring the emergency department and creating a rehabilitation tent on the hospital grounds. While few Haitian internists were present, a number of Haitian obstetricians were on site and helped manage medical conditions within the scope of their experience, such as hypertension, abdominal pain, and genitourinary infections. The expatriate orthopedic surgeons on site sought the consultative skills of hospitalists for preoperative management, postoperative complications, and comorbid conditions.

This hospital was largely sustained by rotating teams of volunteers, which underscored the importance of establishing a flexible system that would accommodate the turnover of personnel and fluctuating levels of professional expertise. The team used a tiered model for acute care delivery designating responsibilities based on the number of nurses, physicians, and other providers available. We collaborated with Haitian physicians to establish a routine of handoff rounds. Finally, we created and centralized documentation such as clinical protocols, contact numbers, and helpful tips for our successors.

Hospitalists have valuable skills to offer in medical responses to natural catastrophes.5 Our fluency with acute care environments becomes a pluripotent asset in disaster relief. Our experiences in assessing acuity are vital in assisting with inpatient triage. Our familiarity with the comanagement model facilitates partnership with other disciplines to optimize the distribution of skill sets without neglecting the overall well‐being of patients. Our clinical expertise in treating the vulnerable elderly, VTE, renal failure, pain management, postoperative infections, sepsis, and many other conditions can bolster medical relief efforts, even when the foremost need is surgical. The hospitalist's core competencies in healthcare systems11 can support recovery initiatives in medical facilities, particularly in the domains of drug safety, resource allocation, information management, team‐based methods, and care transitions. Our respective experiences also suggest the potential value of hospitalists in domestic, in addition to international, disaster response initiatives. Since large‐scale calamities may result in the hospitalization of overwhelming numbers of victims,12 hospitalists may be well‐positioned to assist our emergency medicine and public health colleagues, who currently (and fittingly) lead domestic efforts in disaster relief.

Tragedies like the earthquake in Haiti serve as a sobering reminder that a comprehensive multidisciplinary approach is required as medical disaster relief shifts from a life‐saving focus to one of life‐preserving care.13, 14 Hospitalists can play a vital role in these restorative efforts.

In the last decade, natural disasters such as the Indonesian tsunami of 2004, Hurricane Katrina in 2004, and the Pakistani earthquake of 2005 have brought attention to the importance of diverse but complementary medical professional roles in humanitarian medical aid.14 Natural disasters that cause significant physical trauma to large populations often necessitate initial multidisciplinary responder teams comprised of surgeons, anesthesiologists, emergency medicine physicians, surgical technologists, nurses, psychiatrists, and public health specialists. Their roles are to manage life‐threatening injuries, provide immediate triage, help affected individuals deal with intense psychological shock, and address critical population‐based needs such as water, food, and sanitation. Meanwhile, general medical, pediatric, rehabilitative, and long‐term psychiatric services often constitute a secondary tier of disaster response, providing postsurgical care, managing acute medical illnesses, mitigating psychological trauma, rehabilitating injuries, and providing vaccinations to at‐risk individuals. Hospitalists can play an important role in postcatastrophe recovery services as experts in acute care, stewards of care transitions, and drivers of systems improvement.

The earthquake that occurred January 12, 2010 in Haiti is a dramatic illustration of the importance of a multidisciplinary approach to disaster relief. The 7.0‐magnitude earthquake near Port‐au‐Prince ravaged an already crippled health care system, severely damaging the country's primary academic medical center, and killed the entire class of second‐year nursing students. The death toll has been estimated to be nearly one‐quarter of a million people.5 Victims awaiting surgery, recovering from surgery, or in need of other immediate medical attention quickly inundated any existing health facilities. The following stories describe the authors' respective experiences in Haiti after the earthquake.

JC: I arrived 4 days after the earthquake to a hospital outside of Port‐au‐Prince, spared from destruction, but filled with hundreds of patients with crush injuries and severe fractures. On rounds with the surgical team, I observed that venous thromboembolism (VTE) prophylaxis had not yet been initiated, and I was concerned that patients might die from pulmonary embolism. In the overwhelming urgency of providing life‐saving surgery to as many patients as possible, this simple measure had been overlooked. After discussion with our team and our Haitian medical colleagues, we initiated subcutaneous heparin on all eligible patients and made arrangements to receive further shipments of heparin to accommodate the influx of patients.

A nearby school and church had been annexed into makeshift extensions of the hospital wards. The volume and pace of incoming injuries was such that as soon as a patient was taken to surgery, another patient would often take his or her place in the bed. The rapid movement of patients to and from x‐ray, surgery, and postsurgical care created challenges around effective and accurate communication among multiple care providers. We decided that nonsurgical personnel would triage newly arriving patients and round on patients daily. Each nonsurgical physician was responsible for staffing a particular location. This zone‐defense approach ensured that the surgeons maximized their time in the operating rooms. We also instituted a basic system of portable medical records kept with each patient at all times, allowing personnel to easily and quickly assess care given to date, and to write notes and orders.

Presurgical and postsurgical wound infections became a common event, with the risk of ensuing sepsis. Antibiotic use was dependent on the preferences of individual surgeons and also on the available supply. As a result, antimicrobial treatments were highly variable and sometimes inadequate. The internists on the team proposed standard antibiotic guidelines for open fractures, for contaminated wounds, and for postoperative wounds; these regimens were approved and implemented by Haitian staff and the rest of the team.

Internists recognized the first complications of rhabdomyolysis from crush injuries and delays in receiving medical attention. Malaise, oliguria, and volume overload were often the only clues we had for severe renal failure. We had a functional lab capable of checking complete blood counts, urinalysis and creatinine, but we had a limited supply of serum potassium assays. We only used the latter in confirmed cases of rhabdomyolysis, and on several occasions we diagnosed severe hyperkalemia. Using bedside automated electrical defibrillation devices for monitoring, we sustained these patients on calcium gluconate until they could be transferred to an external dialysis unit run by Mdecins Sans Frontires in Port‐au‐Prince.6 As the number of rhabdomyolysis cases increased, we instigated creatinine rounds on patients arriving with large crush injuries, and we evaluated urine output daily until patients were clinically stable from this threat. We also helped the Haitian staff treat the omnipresent problem of pain and advised renal dosing of medications in renal failure and elderly patients.

GH: The situation 3 months after the earthquake was medically less dire but highlights the evolving importance of generalists in the aftermath of the quake.710 For many Haitian patients, the earthquake had become a universal point of reference for their symptomatology. Anorexia, amenorrhea, headaches, epigastric pain, even fungating soft tissue masses, were all reported to be depi tranbleman t a (since the earthquake) and were often somatic manifestations of a psychologically devastating event. At a hospital in Carrefour, I cared for patients presenting with dramatic sequelae of chronic diseases that had been undertreated due to the destruction of the Haitian medical infrastructurehypertensive coma, diabetic ketoacidosis, cerebral malaria, decompensated liver disease, and severe chronic anemia (including a patient with a hemoglobin of 3 mg/dL). I encountered many patients with infections exacerbated by excessive crowding in tent communities, such as typhoid and tuberculosis. At this particular hospital, priorities appropriately placed on surgical and postsurgical care required the team to devise creative solutions for the care and placement of medical patients, such as restructuring the emergency department and creating a rehabilitation tent on the hospital grounds. While few Haitian internists were present, a number of Haitian obstetricians were on site and helped manage medical conditions within the scope of their experience, such as hypertension, abdominal pain, and genitourinary infections. The expatriate orthopedic surgeons on site sought the consultative skills of hospitalists for preoperative management, postoperative complications, and comorbid conditions.

This hospital was largely sustained by rotating teams of volunteers, which underscored the importance of establishing a flexible system that would accommodate the turnover of personnel and fluctuating levels of professional expertise. The team used a tiered model for acute care delivery designating responsibilities based on the number of nurses, physicians, and other providers available. We collaborated with Haitian physicians to establish a routine of handoff rounds. Finally, we created and centralized documentation such as clinical protocols, contact numbers, and helpful tips for our successors.

Hospitalists have valuable skills to offer in medical responses to natural catastrophes.5 Our fluency with acute care environments becomes a pluripotent asset in disaster relief. Our experiences in assessing acuity are vital in assisting with inpatient triage. Our familiarity with the comanagement model facilitates partnership with other disciplines to optimize the distribution of skill sets without neglecting the overall well‐being of patients. Our clinical expertise in treating the vulnerable elderly, VTE, renal failure, pain management, postoperative infections, sepsis, and many other conditions can bolster medical relief efforts, even when the foremost need is surgical. The hospitalist's core competencies in healthcare systems11 can support recovery initiatives in medical facilities, particularly in the domains of drug safety, resource allocation, information management, team‐based methods, and care transitions. Our respective experiences also suggest the potential value of hospitalists in domestic, in addition to international, disaster response initiatives. Since large‐scale calamities may result in the hospitalization of overwhelming numbers of victims,12 hospitalists may be well‐positioned to assist our emergency medicine and public health colleagues, who currently (and fittingly) lead domestic efforts in disaster relief.

Tragedies like the earthquake in Haiti serve as a sobering reminder that a comprehensive multidisciplinary approach is required as medical disaster relief shifts from a life‐saving focus to one of life‐preserving care.13, 14 Hospitalists can play a vital role in these restorative efforts.

Hospital readmissions pose a major problem both to the patient and the fiscal stability of our health care system.1 Many interventions have attempted to tackle this problem. Interventions exist that utilize transition coaches working intensively with hospitalized patients or nurses performing postdischarge home visits or phoning patients.2, 3 Although beneficial, these strategies are costly and require additional, highly trained personnel. Consequently, they have been difficult to sustain financially in a fee‐for‐service environment, and difficult to generalize at other locales. Recent policies to decrease hospital payments for readmissions will incentivize hospitals to implement discharge programs.4 However, all hospital systems will still want to do this in the most efficient manner possible.

One important way to maximize benefits and minimize costs is to target the most intensive, expensive interventions to the highest risk patients who are most likely to be rehospitalized. By targeting the highest risk patients, we could significantly reduce costs. However, models predicting rehospitalization have had limited accuracy, even for condition‐specific models such as heart failure. Two studies in this issue work to better identify high‐risk patients. Mudge and colleagues5 prospectively examined risk factors for recurrent readmissions in an Australian hospital and found that chronic disease, depression, and underweight were independent risk factors for repeat readmission. Allaudeen6 examined risk factors for readmission to their own institution among general medicine patients. In a retrospective analysis of administrative data, they found that several variables predicted hospital readmission, including black race, insurance coverage through Medicaid, prescription of steroids or narcotics, and diagnoses of heart failure, renal disease, cancer, anemia, and weight loss.

These studies raise two questions that are critical if we are to develop better predictive modeling of who will benefit most from intensive interventions to reduce readmissions. First, what are the risk factors for preventable hospitalizations? People with multiple readmissions seem an obvious target on which to focus. However, it may be that these individuals are just very sick with multiple comorbidities, and many of their readmissions may not be preventable. Rich and colleagues reported that a multidisciplinary discharge intervention reduced readmissions for heart failure by 56%.7 What is often forgotten is that in their pilot study they were not able to reduce admissions for the most severely ill, and their final study population excluded the sickest patients. By targeting moderate‐risk patients, they were able to reduce readmissions significantly.8 In the studies by Mudge et al.5 and Allaudeen,6 the fact that chronic diseases predicted rehospitalization is only moderately helpful. It is possible, perhaps likely, that many of the readmissions for heart failure were preventable while many of the readmissions for cancer were not. The challenge for researchers is to develop methods for classifying admissions/readmissions as preventable.9 Using a defined set of diagnostic categories to classify readmissions (eg, ambulatory care sensitive conditions) may misclassify many cases.10 Determining preventable hospitalizations through detailed chart review is expensive and may have limited interobserver reliability. Nevertheless, physician review and classification may be necessary for future research to advance the field.

Second, what predictor variables are causally related to preventable hospitalizations (and presumably actionable), and which are merely markers of true causal factors and therefore harder to interpret and more difficult to act upon? In addition to chronic disease, Mudge et al.5 found that depression and low body mass index were independent risk factors for readmission. These conditions often go hand in hand. Patients who are burdened with chronic disease may be depressed and not eat. Conversely, patients who are depressed may not eat and allow their chronic disease to worsen. But it seems that depression is the more likely of the two to be causal. Depression is an important predictor of medication nonadherence and worsening illness.11, 12 Screening hospitalized patients for depression could provide valuable information on which patients may need treatment or more rigorous postdischarge follow‐up. In contrast, being underweight may not truly cause readmissions, but could be a marker of frailty and difficulty in meeting activities of daily living.

Similarly, Allaudeen6 found that black race, Medicaid use, steroid use, and narcotic use were independently associated with hospital readmission (in addition to chronic diseases and weight loss). Can being on steroids or narcotics cause readmissions? Does enrollment in Medicaid or being of black race cause one to be readmitted? While these may be markers which are statistically significant, they are unlikely to be true causes of rehospitalization. It is more likely that these variables are markers for true causal factors, such as financial barriers to medications or access barriers to primary care. Many other studies have used administrative databases to examine variables linked to readmission. We need to drill deeper to determine what is actually causing readmissions. Did the patient misinterpret how to take their steroid taper or were they so sick that they needed to return to the hospital? Perhaps they decided to wait on taking the steroids until they spoke with their primary care physician. This deeper level of understanding cannot be ascertained through third party administrative data sets. Primary data collection is needed to correctly determine who to target and the specific foci of interventions.

Future research on risk factors for readmissions (and interventions to decrease readmissions) should begin with a theoretical framework that addresses the patient, the hospital, and the receiving outpatient primary care physician or specialist, and the interfaces between each pair that could lead to preventable readmissions (see Figure 1).

Figure 1

With every potential variable affecting readmission, we need to systematically evaluate whether they are causal and preventable. When a variable is both causal and modifiable, we can then develop interventions to target these variables. We designed Table 1 as a framework to consider when moving forward in creating and implementing interventions.

To advance this area, we need to be stringent about how we perform research and interpret findings. Studies that examine risk factors for readmission to a single hospital may be biased; for example, in the study by Allaudeen,6 it is possible that patients with Medicaid may have been equally likely to be readmitted to any hospital but more likely to be readmitted to the hospital that was the sole source of admission data. Even if findings from a single site are valid, they may not be generalizable. Ideally, studies of risk factors (and interventions to reduce readmissions) should be conducted in multiple sites that can track all hospitalizations and examine differences in risk factors for rehospitalization across hospitals. We have learned a tremendous amount over the last few years about risk markers for all‐cause readmission, and interventions to improve safety and quality of transitions in care. To advance further, multicenter studies are needed that focus on plausible causal variables of preventable readmissions and risk factors beyond the walls of the hospital (eg, access and quality of outpatient care for newly discharged patients). Only then will we better understand which patients can have their readmissions prevented and how to improve upon current strategies to improve outcomes.

Hospital readmissions pose a major problem both to the patient and the fiscal stability of our health care system.1 Many interventions have attempted to tackle this problem. Interventions exist that utilize transition coaches working intensively with hospitalized patients or nurses performing postdischarge home visits or phoning patients.2, 3 Although beneficial, these strategies are costly and require additional, highly trained personnel. Consequently, they have been difficult to sustain financially in a fee‐for‐service environment, and difficult to generalize at other locales. Recent policies to decrease hospital payments for readmissions will incentivize hospitals to implement discharge programs.4 However, all hospital systems will still want to do this in the most efficient manner possible.

One important way to maximize benefits and minimize costs is to target the most intensive, expensive interventions to the highest risk patients who are most likely to be rehospitalized. By targeting the highest risk patients, we could significantly reduce costs. However, models predicting rehospitalization have had limited accuracy, even for condition‐specific models such as heart failure. Two studies in this issue work to better identify high‐risk patients. Mudge and colleagues5 prospectively examined risk factors for recurrent readmissions in an Australian hospital and found that chronic disease, depression, and underweight were independent risk factors for repeat readmission. Allaudeen6 examined risk factors for readmission to their own institution among general medicine patients. In a retrospective analysis of administrative data, they found that several variables predicted hospital readmission, including black race, insurance coverage through Medicaid, prescription of steroids or narcotics, and diagnoses of heart failure, renal disease, cancer, anemia, and weight loss.

These studies raise two questions that are critical if we are to develop better predictive modeling of who will benefit most from intensive interventions to reduce readmissions. First, what are the risk factors for preventable hospitalizations? People with multiple readmissions seem an obvious target on which to focus. However, it may be that these individuals are just very sick with multiple comorbidities, and many of their readmissions may not be preventable. Rich and colleagues reported that a multidisciplinary discharge intervention reduced readmissions for heart failure by 56%.7 What is often forgotten is that in their pilot study they were not able to reduce admissions for the most severely ill, and their final study population excluded the sickest patients. By targeting moderate‐risk patients, they were able to reduce readmissions significantly.8 In the studies by Mudge et al.5 and Allaudeen,6 the fact that chronic diseases predicted rehospitalization is only moderately helpful. It is possible, perhaps likely, that many of the readmissions for heart failure were preventable while many of the readmissions for cancer were not. The challenge for researchers is to develop methods for classifying admissions/readmissions as preventable.9 Using a defined set of diagnostic categories to classify readmissions (eg, ambulatory care sensitive conditions) may misclassify many cases.10 Determining preventable hospitalizations through detailed chart review is expensive and may have limited interobserver reliability. Nevertheless, physician review and classification may be necessary for future research to advance the field.

Second, what predictor variables are causally related to preventable hospitalizations (and presumably actionable), and which are merely markers of true causal factors and therefore harder to interpret and more difficult to act upon? In addition to chronic disease, Mudge et al.5 found that depression and low body mass index were independent risk factors for readmission. These conditions often go hand in hand. Patients who are burdened with chronic disease may be depressed and not eat. Conversely, patients who are depressed may not eat and allow their chronic disease to worsen. But it seems that depression is the more likely of the two to be causal. Depression is an important predictor of medication nonadherence and worsening illness.11, 12 Screening hospitalized patients for depression could provide valuable information on which patients may need treatment or more rigorous postdischarge follow‐up. In contrast, being underweight may not truly cause readmissions, but could be a marker of frailty and difficulty in meeting activities of daily living.

Similarly, Allaudeen6 found that black race, Medicaid use, steroid use, and narcotic use were independently associated with hospital readmission (in addition to chronic diseases and weight loss). Can being on steroids or narcotics cause readmissions? Does enrollment in Medicaid or being of black race cause one to be readmitted? While these may be markers which are statistically significant, they are unlikely to be true causes of rehospitalization. It is more likely that these variables are markers for true causal factors, such as financial barriers to medications or access barriers to primary care. Many other studies have used administrative databases to examine variables linked to readmission. We need to drill deeper to determine what is actually causing readmissions. Did the patient misinterpret how to take their steroid taper or were they so sick that they needed to return to the hospital? Perhaps they decided to wait on taking the steroids until they spoke with their primary care physician. This deeper level of understanding cannot be ascertained through third party administrative data sets. Primary data collection is needed to correctly determine who to target and the specific foci of interventions.

Future research on risk factors for readmissions (and interventions to decrease readmissions) should begin with a theoretical framework that addresses the patient, the hospital, and the receiving outpatient primary care physician or specialist, and the interfaces between each pair that could lead to preventable readmissions (see Figure 1).

Figure 1

With every potential variable affecting readmission, we need to systematically evaluate whether they are causal and preventable. When a variable is both causal and modifiable, we can then develop interventions to target these variables. We designed Table 1 as a framework to consider when moving forward in creating and implementing interventions.

To advance this area, we need to be stringent about how we perform research and interpret findings. Studies that examine risk factors for readmission to a single hospital may be biased; for example, in the study by Allaudeen,6 it is possible that patients with Medicaid may have been equally likely to be readmitted to any hospital but more likely to be readmitted to the hospital that was the sole source of admission data. Even if findings from a single site are valid, they may not be generalizable. Ideally, studies of risk factors (and interventions to reduce readmissions) should be conducted in multiple sites that can track all hospitalizations and examine differences in risk factors for rehospitalization across hospitals. We have learned a tremendous amount over the last few years about risk markers for all‐cause readmission, and interventions to improve safety and quality of transitions in care. To advance further, multicenter studies are needed that focus on plausible causal variables of preventable readmissions and risk factors beyond the walls of the hospital (eg, access and quality of outpatient care for newly discharged patients). Only then will we better understand which patients can have their readmissions prevented and how to improve upon current strategies to improve outcomes.

Hospital readmissions pose a major problem both to the patient and the fiscal stability of our health care system.1 Many interventions have attempted to tackle this problem. Interventions exist that utilize transition coaches working intensively with hospitalized patients or nurses performing postdischarge home visits or phoning patients.2, 3 Although beneficial, these strategies are costly and require additional, highly trained personnel. Consequently, they have been difficult to sustain financially in a fee‐for‐service environment, and difficult to generalize at other locales. Recent policies to decrease hospital payments for readmissions will incentivize hospitals to implement discharge programs.4 However, all hospital systems will still want to do this in the most efficient manner possible.

One important way to maximize benefits and minimize costs is to target the most intensive, expensive interventions to the highest risk patients who are most likely to be rehospitalized. By targeting the highest risk patients, we could significantly reduce costs. However, models predicting rehospitalization have had limited accuracy, even for condition‐specific models such as heart failure. Two studies in this issue work to better identify high‐risk patients. Mudge and colleagues5 prospectively examined risk factors for recurrent readmissions in an Australian hospital and found that chronic disease, depression, and underweight were independent risk factors for repeat readmission. Allaudeen6 examined risk factors for readmission to their own institution among general medicine patients. In a retrospective analysis of administrative data, they found that several variables predicted hospital readmission, including black race, insurance coverage through Medicaid, prescription of steroids or narcotics, and diagnoses of heart failure, renal disease, cancer, anemia, and weight loss.

These studies raise two questions that are critical if we are to develop better predictive modeling of who will benefit most from intensive interventions to reduce readmissions. First, what are the risk factors for preventable hospitalizations? People with multiple readmissions seem an obvious target on which to focus. However, it may be that these individuals are just very sick with multiple comorbidities, and many of their readmissions may not be preventable. Rich and colleagues reported that a multidisciplinary discharge intervention reduced readmissions for heart failure by 56%.7 What is often forgotten is that in their pilot study they were not able to reduce admissions for the most severely ill, and their final study population excluded the sickest patients. By targeting moderate‐risk patients, they were able to reduce readmissions significantly.8 In the studies by Mudge et al.5 and Allaudeen,6 the fact that chronic diseases predicted rehospitalization is only moderately helpful. It is possible, perhaps likely, that many of the readmissions for heart failure were preventable while many of the readmissions for cancer were not. The challenge for researchers is to develop methods for classifying admissions/readmissions as preventable.9 Using a defined set of diagnostic categories to classify readmissions (eg, ambulatory care sensitive conditions) may misclassify many cases.10 Determining preventable hospitalizations through detailed chart review is expensive and may have limited interobserver reliability. Nevertheless, physician review and classification may be necessary for future research to advance the field.

Second, what predictor variables are causally related to preventable hospitalizations (and presumably actionable), and which are merely markers of true causal factors and therefore harder to interpret and more difficult to act upon? In addition to chronic disease, Mudge et al.5 found that depression and low body mass index were independent risk factors for readmission. These conditions often go hand in hand. Patients who are burdened with chronic disease may be depressed and not eat. Conversely, patients who are depressed may not eat and allow their chronic disease to worsen. But it seems that depression is the more likely of the two to be causal. Depression is an important predictor of medication nonadherence and worsening illness.11, 12 Screening hospitalized patients for depression could provide valuable information on which patients may need treatment or more rigorous postdischarge follow‐up. In contrast, being underweight may not truly cause readmissions, but could be a marker of frailty and difficulty in meeting activities of daily living.

Similarly, Allaudeen6 found that black race, Medicaid use, steroid use, and narcotic use were independently associated with hospital readmission (in addition to chronic diseases and weight loss). Can being on steroids or narcotics cause readmissions? Does enrollment in Medicaid or being of black race cause one to be readmitted? While these may be markers which are statistically significant, they are unlikely to be true causes of rehospitalization. It is more likely that these variables are markers for true causal factors, such as financial barriers to medications or access barriers to primary care. Many other studies have used administrative databases to examine variables linked to readmission. We need to drill deeper to determine what is actually causing readmissions. Did the patient misinterpret how to take their steroid taper or were they so sick that they needed to return to the hospital? Perhaps they decided to wait on taking the steroids until they spoke with their primary care physician. This deeper level of understanding cannot be ascertained through third party administrative data sets. Primary data collection is needed to correctly determine who to target and the specific foci of interventions.

Future research on risk factors for readmissions (and interventions to decrease readmissions) should begin with a theoretical framework that addresses the patient, the hospital, and the receiving outpatient primary care physician or specialist, and the interfaces between each pair that could lead to preventable readmissions (see Figure 1).

Figure 1

With every potential variable affecting readmission, we need to systematically evaluate whether they are causal and preventable. When a variable is both causal and modifiable, we can then develop interventions to target these variables. We designed Table 1 as a framework to consider when moving forward in creating and implementing interventions.

To advance this area, we need to be stringent about how we perform research and interpret findings. Studies that examine risk factors for readmission to a single hospital may be biased; for example, in the study by Allaudeen,6 it is possible that patients with Medicaid may have been equally likely to be readmitted to any hospital but more likely to be readmitted to the hospital that was the sole source of admission data. Even if findings from a single site are valid, they may not be generalizable. Ideally, studies of risk factors (and interventions to reduce readmissions) should be conducted in multiple sites that can track all hospitalizations and examine differences in risk factors for rehospitalization across hospitals. We have learned a tremendous amount over the last few years about risk markers for all‐cause readmission, and interventions to improve safety and quality of transitions in care. To advance further, multicenter studies are needed that focus on plausible causal variables of preventable readmissions and risk factors beyond the walls of the hospital (eg, access and quality of outpatient care for newly discharged patients). Only then will we better understand which patients can have their readmissions prevented and how to improve upon current strategies to improve outcomes.

The word housestaff came from an era when you moved into the hospital (house) for your internship (staff). In those days, call every other night meant you missed half the learning opportunities. In those days, supervision was as remote as it could get. My, have things changed.

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented duty hour standards that called for restricting resident duty hours to no more than 80 hours per week, and no more than 24 continuous hours with an additional 6 hours for transfer of care.1 The expectation was that limiting work hours would have positive effects on outcomes, such as resident fatigue, the educational experience, and patient safety. A recent systematic review commissioned by the ACGME reviewed three decades worth of research on duty hours and patient safety. It reviewed laboratory studies of resident performance on clinical simulations, and tests of cognitive and fine motor skills under conditions of sleep deprivation. The results of these studies imply that limiting residents' duty hours should have positive effects on patient safety. However, that assumption has not been borne out. Paradoxically, examination of studies of alternative duty hour schedules, as well as the follow‐up studies on the impact of the New York duty hour rules and ACGME duty hour regulations have documented few measurable effects on patient safety.2 Thus, the simplistic view that fewer hours worked equals better patient care deserves a second‐look. In fact, a cause‐and‐effect relationship between resident fatigue and medical errors has yet to be proven.

The hospitalist movement was in full swing by 2003 and had already transformed the care of hospitalized patients. The early studies of hospitalists focused on cost and comparing outcomes with those of other providers. As many studies showed the economic benefit of hospitalists, residency programs began redesigning their inpatient services with hospitalists at the helm. Institutions sponsoring graduate medical education programs saw hospitalists as a necessary resource to enable and maintain compliance with duty hour reform. Some institutions created hospitalist‐only services with no housestaff (nonteaching services). Others created hospitalist teaching services that used indirect supervision at night from a hospitalist on‐call from home, while others had on‐site hospitalists at night that provided direct supervision of housestaff. It is clear that hospitalists are a versatile and valuable resource.

In this issue of the Journal of Hospital Medicine, Khanna and colleagues3 describe a retrospective medical record review at a large, urban academic hospital that evaluates the potential association between night admissions by night‐shiftbased hospitalists and a resident night float system, and hospitalization‐relevant outcomes. The outcomes included length of stay, hospital charges, Intensive Care Unit (ICU) transfers, Emergency Department visits within 30 days of discharge, 30‐day readmission rates, and poor outcomes within the first 24 hours of admission. Their results showed that night or weekend admission was not associated with worse hospitalization‐relevant outcomes. The extension of on‐site faculty supervision to nights, as well as awards for nursing excellence, likely had a strong positive impact on these outcomes. In some cases, night or weekend admission was associated with better outcomes, particularly in terms of ICU transfer during hospitalization and hospital charges. Maybe off‐hours care is not so off after all.

I am not sure where we are going, but the duty hour standards have been revised again. The new duty hour standards limit continuous duty hours for 1st‐year residents to 16, and all others to 24. Upper‐level residents can stay an additional 4 hours for transfer of care.4 Functionally, this proposed standard eliminates overnight call for 1st‐year residents. Although I would never advocate returning to the days of yore where autonomy and independence were the rule, I mourn the loss of extended shifts for 1st‐year residents. The loss of the extended shift will come at the expense of overnight call in many programs. I worry about the loss of some unique teaching moments for all residents, and the increased number of transitions in a patients' care. The hospital is a different place at night. It is less chaotic with fewer visitors, and there are less interruptions in patient care. There is time for teaching and learning because the work intensity is lower. The bedside teaching among senior and junior residents, during an acute patient episode in the middle of the night, is an experience that many of us would recount as an invaluable part of our training. It is also a time when on‐site faculty supervision and nurse staffing ratios are typically reduced. In other words, the entire system of care is different at night. This dichotomy in day versus night medicine has spurred research into whether patient outcomes differed between the two. Various investigators have looked at the differences in care, and there is some data to support that patient care outcomes are worse at night than during the day.58

The results from Khanna and colleagues3 are welcome news, since graduate medical education is undergoing a paradigm shift with further reductions in duty hours. Hospital‐based medicine is a 24‐hour operation, 7 days a week. We don't get to pick when patients are admitted or need care. In fact, this study demonstrates that 58% of the admissions came after 7 _PM. It turns out that this pattern of admissions is not atypical.9 In light of the new standards, programs are left deciding where to deploy their 1st‐year resident resources. There are essentially two types of models to provide patient care off‐hours in the absence of an extended shift option: night float and night medicine. Night float implies that a trainee, usually a resident, comes from a different site or rotation to provide nocturnal care of a group of patients. That resident may do one isolated night of coverage or several nights in a row. The resident may perform cross‐cover functions, admit patients, or do both. Night medicine refers to having teams of housestaff at night along with an educational program as part of a rotation. The latter implies that trainees will get the full educational experience whether working days or nights. If one designs a model of care that puts 1st‐year residents where the volume is, they would come in late and leave early in the morning the next day. Both create more handoffs in patient care, which critics of these models have said lead to worse patient outcomes. This research challenges such earlier work and should make us all feel more comfortable that care at night does not need to be different if the proper systems are in place to manage it.

The graduate medical education community needs to take a step back and ask: Where are we going? As a long‐standing program director, I don't know anymore. As training has become competency‐based, and milestones are being developed for each level of training, we need to ask if reducing hours further is in the best interests of graduate medical education and, ultimately, the general public. I have long been interested in work intensity as a contributor to resident fatigue, burnout, and errors. A systematic review of resident workload and work activity looked at 21 studies examining resident time allocation and suggests that at least one‐third of resident time is spent on activities of limited educational value. Eight of the nine studies evaluating the impact of resident workload on patient care showed a negative impact on outcomes, including length of stay, mortality, patient satisfaction, medication errors, and lab utilization.10 If we are going to further restrict duty hours, then we need to transform the learning environment in a similar fashion. It does not seem logical to restrict duty hours further without a major redesign of the learning environment. I fear that all we have done is create more work compression because the system of care will be further strained in its weakest areas.

Hospitalists are uniquely poised to mitigate some of these concerns by being available for direct and indirect supervision, as well as being highly skilled at working in our complex systems. They are experts in systems‐based practice. The extension of direct faculty supervision to nights may be a major factor in eliminating the variances in care between nights and days. Not every program or institution will have the ability to employ night hospitalists, let alone have them in a supervisory and teaching role. Those that do can take great comfort in this research. Those that don't must challenge themselves to think about how to get there.

We all share the collective goal of producing the next generation of well‐trained physicians who will practice safe and effective care. As we begin to embrace competency‐based training, the prism through which we view patient safety must extend beyond duty hours and include learning environment reform. While the Khanna et al.3 study supports that off‐hours care is no longer off, we need to be careful that we don't drift too far towards shift work as the fundamental structure of medical training. In the beginning, residents lived in the hospital, thus the term. As we move through these stormy seas, we don't want to trade patient safety for transient trainees. There is a middle ground here that will be informed by future research. There is something to be said for living in your house.

The word housestaff came from an era when you moved into the hospital (house) for your internship (staff). In those days, call every other night meant you missed half the learning opportunities. In those days, supervision was as remote as it could get. My, have things changed.

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented duty hour standards that called for restricting resident duty hours to no more than 80 hours per week, and no more than 24 continuous hours with an additional 6 hours for transfer of care.1 The expectation was that limiting work hours would have positive effects on outcomes, such as resident fatigue, the educational experience, and patient safety. A recent systematic review commissioned by the ACGME reviewed three decades worth of research on duty hours and patient safety. It reviewed laboratory studies of resident performance on clinical simulations, and tests of cognitive and fine motor skills under conditions of sleep deprivation. The results of these studies imply that limiting residents' duty hours should have positive effects on patient safety. However, that assumption has not been borne out. Paradoxically, examination of studies of alternative duty hour schedules, as well as the follow‐up studies on the impact of the New York duty hour rules and ACGME duty hour regulations have documented few measurable effects on patient safety.2 Thus, the simplistic view that fewer hours worked equals better patient care deserves a second‐look. In fact, a cause‐and‐effect relationship between resident fatigue and medical errors has yet to be proven.

The hospitalist movement was in full swing by 2003 and had already transformed the care of hospitalized patients. The early studies of hospitalists focused on cost and comparing outcomes with those of other providers. As many studies showed the economic benefit of hospitalists, residency programs began redesigning their inpatient services with hospitalists at the helm. Institutions sponsoring graduate medical education programs saw hospitalists as a necessary resource to enable and maintain compliance with duty hour reform. Some institutions created hospitalist‐only services with no housestaff (nonteaching services). Others created hospitalist teaching services that used indirect supervision at night from a hospitalist on‐call from home, while others had on‐site hospitalists at night that provided direct supervision of housestaff. It is clear that hospitalists are a versatile and valuable resource.

In this issue of the Journal of Hospital Medicine, Khanna and colleagues3 describe a retrospective medical record review at a large, urban academic hospital that evaluates the potential association between night admissions by night‐shiftbased hospitalists and a resident night float system, and hospitalization‐relevant outcomes. The outcomes included length of stay, hospital charges, Intensive Care Unit (ICU) transfers, Emergency Department visits within 30 days of discharge, 30‐day readmission rates, and poor outcomes within the first 24 hours of admission. Their results showed that night or weekend admission was not associated with worse hospitalization‐relevant outcomes. The extension of on‐site faculty supervision to nights, as well as awards for nursing excellence, likely had a strong positive impact on these outcomes. In some cases, night or weekend admission was associated with better outcomes, particularly in terms of ICU transfer during hospitalization and hospital charges. Maybe off‐hours care is not so off after all.

I am not sure where we are going, but the duty hour standards have been revised again. The new duty hour standards limit continuous duty hours for 1st‐year residents to 16, and all others to 24. Upper‐level residents can stay an additional 4 hours for transfer of care.4 Functionally, this proposed standard eliminates overnight call for 1st‐year residents. Although I would never advocate returning to the days of yore where autonomy and independence were the rule, I mourn the loss of extended shifts for 1st‐year residents. The loss of the extended shift will come at the expense of overnight call in many programs. I worry about the loss of some unique teaching moments for all residents, and the increased number of transitions in a patients' care. The hospital is a different place at night. It is less chaotic with fewer visitors, and there are less interruptions in patient care. There is time for teaching and learning because the work intensity is lower. The bedside teaching among senior and junior residents, during an acute patient episode in the middle of the night, is an experience that many of us would recount as an invaluable part of our training. It is also a time when on‐site faculty supervision and nurse staffing ratios are typically reduced. In other words, the entire system of care is different at night. This dichotomy in day versus night medicine has spurred research into whether patient outcomes differed between the two. Various investigators have looked at the differences in care, and there is some data to support that patient care outcomes are worse at night than during the day.58

The results from Khanna and colleagues3 are welcome news, since graduate medical education is undergoing a paradigm shift with further reductions in duty hours. Hospital‐based medicine is a 24‐hour operation, 7 days a week. We don't get to pick when patients are admitted or need care. In fact, this study demonstrates that 58% of the admissions came after 7 _PM. It turns out that this pattern of admissions is not atypical.9 In light of the new standards, programs are left deciding where to deploy their 1st‐year resident resources. There are essentially two types of models to provide patient care off‐hours in the absence of an extended shift option: night float and night medicine. Night float implies that a trainee, usually a resident, comes from a different site or rotation to provide nocturnal care of a group of patients. That resident may do one isolated night of coverage or several nights in a row. The resident may perform cross‐cover functions, admit patients, or do both. Night medicine refers to having teams of housestaff at night along with an educational program as part of a rotation. The latter implies that trainees will get the full educational experience whether working days or nights. If one designs a model of care that puts 1st‐year residents where the volume is, they would come in late and leave early in the morning the next day. Both create more handoffs in patient care, which critics of these models have said lead to worse patient outcomes. This research challenges such earlier work and should make us all feel more comfortable that care at night does not need to be different if the proper systems are in place to manage it.

The graduate medical education community needs to take a step back and ask: Where are we going? As a long‐standing program director, I don't know anymore. As training has become competency‐based, and milestones are being developed for each level of training, we need to ask if reducing hours further is in the best interests of graduate medical education and, ultimately, the general public. I have long been interested in work intensity as a contributor to resident fatigue, burnout, and errors. A systematic review of resident workload and work activity looked at 21 studies examining resident time allocation and suggests that at least one‐third of resident time is spent on activities of limited educational value. Eight of the nine studies evaluating the impact of resident workload on patient care showed a negative impact on outcomes, including length of stay, mortality, patient satisfaction, medication errors, and lab utilization.10 If we are going to further restrict duty hours, then we need to transform the learning environment in a similar fashion. It does not seem logical to restrict duty hours further without a major redesign of the learning environment. I fear that all we have done is create more work compression because the system of care will be further strained in its weakest areas.

Hospitalists are uniquely poised to mitigate some of these concerns by being available for direct and indirect supervision, as well as being highly skilled at working in our complex systems. They are experts in systems‐based practice. The extension of direct faculty supervision to nights may be a major factor in eliminating the variances in care between nights and days. Not every program or institution will have the ability to employ night hospitalists, let alone have them in a supervisory and teaching role. Those that do can take great comfort in this research. Those that don't must challenge themselves to think about how to get there.

We all share the collective goal of producing the next generation of well‐trained physicians who will practice safe and effective care. As we begin to embrace competency‐based training, the prism through which we view patient safety must extend beyond duty hours and include learning environment reform. While the Khanna et al.3 study supports that off‐hours care is no longer off, we need to be careful that we don't drift too far towards shift work as the fundamental structure of medical training. In the beginning, residents lived in the hospital, thus the term. As we move through these stormy seas, we don't want to trade patient safety for transient trainees. There is a middle ground here that will be informed by future research. There is something to be said for living in your house.

The word housestaff came from an era when you moved into the hospital (house) for your internship (staff). In those days, call every other night meant you missed half the learning opportunities. In those days, supervision was as remote as it could get. My, have things changed.

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented duty hour standards that called for restricting resident duty hours to no more than 80 hours per week, and no more than 24 continuous hours with an additional 6 hours for transfer of care.1 The expectation was that limiting work hours would have positive effects on outcomes, such as resident fatigue, the educational experience, and patient safety. A recent systematic review commissioned by the ACGME reviewed three decades worth of research on duty hours and patient safety. It reviewed laboratory studies of resident performance on clinical simulations, and tests of cognitive and fine motor skills under conditions of sleep deprivation. The results of these studies imply that limiting residents' duty hours should have positive effects on patient safety. However, that assumption has not been borne out. Paradoxically, examination of studies of alternative duty hour schedules, as well as the follow‐up studies on the impact of the New York duty hour rules and ACGME duty hour regulations have documented few measurable effects on patient safety.2 Thus, the simplistic view that fewer hours worked equals better patient care deserves a second‐look. In fact, a cause‐and‐effect relationship between resident fatigue and medical errors has yet to be proven.

The hospitalist movement was in full swing by 2003 and had already transformed the care of hospitalized patients. The early studies of hospitalists focused on cost and comparing outcomes with those of other providers. As many studies showed the economic benefit of hospitalists, residency programs began redesigning their inpatient services with hospitalists at the helm. Institutions sponsoring graduate medical education programs saw hospitalists as a necessary resource to enable and maintain compliance with duty hour reform. Some institutions created hospitalist‐only services with no housestaff (nonteaching services). Others created hospitalist teaching services that used indirect supervision at night from a hospitalist on‐call from home, while others had on‐site hospitalists at night that provided direct supervision of housestaff. It is clear that hospitalists are a versatile and valuable resource.

In this issue of the Journal of Hospital Medicine, Khanna and colleagues3 describe a retrospective medical record review at a large, urban academic hospital that evaluates the potential association between night admissions by night‐shiftbased hospitalists and a resident night float system, and hospitalization‐relevant outcomes. The outcomes included length of stay, hospital charges, Intensive Care Unit (ICU) transfers, Emergency Department visits within 30 days of discharge, 30‐day readmission rates, and poor outcomes within the first 24 hours of admission. Their results showed that night or weekend admission was not associated with worse hospitalization‐relevant outcomes. The extension of on‐site faculty supervision to nights, as well as awards for nursing excellence, likely had a strong positive impact on these outcomes. In some cases, night or weekend admission was associated with better outcomes, particularly in terms of ICU transfer during hospitalization and hospital charges. Maybe off‐hours care is not so off after all.

I am not sure where we are going, but the duty hour standards have been revised again. The new duty hour standards limit continuous duty hours for 1st‐year residents to 16, and all others to 24. Upper‐level residents can stay an additional 4 hours for transfer of care.4 Functionally, this proposed standard eliminates overnight call for 1st‐year residents. Although I would never advocate returning to the days of yore where autonomy and independence were the rule, I mourn the loss of extended shifts for 1st‐year residents. The loss of the extended shift will come at the expense of overnight call in many programs. I worry about the loss of some unique teaching moments for all residents, and the increased number of transitions in a patients' care. The hospital is a different place at night. It is less chaotic with fewer visitors, and there are less interruptions in patient care. There is time for teaching and learning because the work intensity is lower. The bedside teaching among senior and junior residents, during an acute patient episode in the middle of the night, is an experience that many of us would recount as an invaluable part of our training. It is also a time when on‐site faculty supervision and nurse staffing ratios are typically reduced. In other words, the entire system of care is different at night. This dichotomy in day versus night medicine has spurred research into whether patient outcomes differed between the two. Various investigators have looked at the differences in care, and there is some data to support that patient care outcomes are worse at night than during the day.58

The results from Khanna and colleagues3 are welcome news, since graduate medical education is undergoing a paradigm shift with further reductions in duty hours. Hospital‐based medicine is a 24‐hour operation, 7 days a week. We don't get to pick when patients are admitted or need care. In fact, this study demonstrates that 58% of the admissions came after 7 _PM. It turns out that this pattern of admissions is not atypical.9 In light of the new standards, programs are left deciding where to deploy their 1st‐year resident resources. There are essentially two types of models to provide patient care off‐hours in the absence of an extended shift option: night float and night medicine. Night float implies that a trainee, usually a resident, comes from a different site or rotation to provide nocturnal care of a group of patients. That resident may do one isolated night of coverage or several nights in a row. The resident may perform cross‐cover functions, admit patients, or do both. Night medicine refers to having teams of housestaff at night along with an educational program as part of a rotation. The latter implies that trainees will get the full educational experience whether working days or nights. If one designs a model of care that puts 1st‐year residents where the volume is, they would come in late and leave early in the morning the next day. Both create more handoffs in patient care, which critics of these models have said lead to worse patient outcomes. This research challenges such earlier work and should make us all feel more comfortable that care at night does not need to be different if the proper systems are in place to manage it.

The graduate medical education community needs to take a step back and ask: Where are we going? As a long‐standing program director, I don't know anymore. As training has become competency‐based, and milestones are being developed for each level of training, we need to ask if reducing hours further is in the best interests of graduate medical education and, ultimately, the general public. I have long been interested in work intensity as a contributor to resident fatigue, burnout, and errors. A systematic review of resident workload and work activity looked at 21 studies examining resident time allocation and suggests that at least one‐third of resident time is spent on activities of limited educational value. Eight of the nine studies evaluating the impact of resident workload on patient care showed a negative impact on outcomes, including length of stay, mortality, patient satisfaction, medication errors, and lab utilization.10 If we are going to further restrict duty hours, then we need to transform the learning environment in a similar fashion. It does not seem logical to restrict duty hours further without a major redesign of the learning environment. I fear that all we have done is create more work compression because the system of care will be further strained in its weakest areas.

Hospitalists are uniquely poised to mitigate some of these concerns by being available for direct and indirect supervision, as well as being highly skilled at working in our complex systems. They are experts in systems‐based practice. The extension of direct faculty supervision to nights may be a major factor in eliminating the variances in care between nights and days. Not every program or institution will have the ability to employ night hospitalists, let alone have them in a supervisory and teaching role. Those that do can take great comfort in this research. Those that don't must challenge themselves to think about how to get there.

We all share the collective goal of producing the next generation of well‐trained physicians who will practice safe and effective care. As we begin to embrace competency‐based training, the prism through which we view patient safety must extend beyond duty hours and include learning environment reform. While the Khanna et al.3 study supports that off‐hours care is no longer off, we need to be careful that we don't drift too far towards shift work as the fundamental structure of medical training. In the beginning, residents lived in the hospital, thus the term. As we move through these stormy seas, we don't want to trade patient safety for transient trainees. There is a middle ground here that will be informed by future research. There is something to be said for living in your house.

This issue of the Journal of Hospital Medicine features an important contribution concerning the current state of academic hospital medicine. The survey of 57 hospitalists revealed what many of us already suspected: the state of mentorship in academic hospitalist groups is unsatisfactory.1

While the conclusion is alarming, it is also not surprising. Over the past decade academic medical centers enthusiastically hired hospitalists to improve efficiency for inpatient services and to lessen the effect of Accreditation Council for Graduate Medical Education (ACGME) regulations on duty hours and patient caps. Few departments of internal medicine, however, hired academic hospitalists with the intent of creating academic divisions. Thus many institutions appear to view hospitalists primarily as hospital employees ignoring their potential academic contributions, and as a result it should not be a surprise that many hospitalist groups lack the mentorship infrastructure of other divisions within a typical Department of Medicine. Compounding the hospital employee problem, the new field of academic hospital medicine has emerged only in the last decade, a time frame that has resulted in very few hospitalists qualified to serve as senior mentors.

We cannot easily remove these limitations: the past is the past, and over time, hospital medicine will mature and develop more senior mentors. But what should we do until that maturation occurs? We believe that the academic work of hospitalists, both in education and research (Quality and Patient Safety) are important endeavors too valuable to be left to chance. With 30,000 hospitalists delivering care, it is critical that research in the optimal delivery of this care be performed, targeting systems improvements to enact anticipated outcomes in quality and patient safety. The physicians who are regularly and intimately involved in this system of inpatient care delivery, the hospitalists, are best suited for identifying the unique features of the inpatient care system needing improvement. Mentorship is essential in ensuring the advancement of both areas, and the sustainability of hospital medicine in medical academe. The article by Harrison et al.1 both establishes the depth of these issues and provides important insights into potential solutions for closing this mentorship gap while the field matures.

Utilizing Other Mentors

No measure of systems change will make young hospitalists immediately experienced, such that they have the sophistication to be senior mentors for younger hospitalists. But we can compensate for this temporary gap in mentorship experience. First, in the next 5 to 10 years, young academic hospitalists need explicit direction from those within Departments of Medicine who do have this mentorship experience, even if these mentors do not work in hospital medicine. Mentors within General Internal Medicine or the subspecialties can still provide the guidance and support to ensure that academic hospitalists are engaging in the appropriate endeavors toward promotion and intellectual growth. Second, academic hospitalists have to seek out mentorship from afar through their participation in the organizations primarily devoted to the academic welfare of hospitalists: The Society of Hospital Medicine (SHM) and the Society of General Internal Medicine (SGIM). Both organizations sponsor mentorship programs, and regular attendance at regional and/or national meetings (followed by email correspondence) can greatly improve an academic hospitalist's career trajectory. Finally, midlevel and senior‐level hospitalists have to learn mentorship skills; mere experience in the field does not ensure acquisition of the necessary mentorship skills, anymore than experience in medicine ensures teaching skills. Mentorship is its own skill set, and receiving appropriate training via the SHM or SGIM national meetings or the Academic Hospitalist Academy (referenced below) is critical.

Defining Academic Expectations for Hospitalists

Harrison et al.1 note that academic hospitalists felt there was a lack of respect for the scholarly work that hospitalists do as part of their job, raising the proposition that the mentorship dearth for academic hospitalists might result from currently available mentors not knowing what to say. Even if mentors were plentiful today, we still must ask the question, What would the mentor advise the young hospitalist to do? The academic hospitalist offers extraordinary value to the Department, but in a way that is different from the standard R0RO‐1 Grant paradigm. Even if hospitalists acquire extramural funding, it will likely come from sources different from the National Institutes of Health (NIH): Agency for Healthcare Research and Quality (AHRQ), foundations (eg, The Robert Wood Johnson Foundation or The John A. Hartford Foundation), intramural hospital‐originating funding, etc. And while extramural funding may be a measure of a hospitalist's contribution to the Department, it should not be the only measure of the hospitalist's career development. There are 2 ways to get rich: acquire more money, or spend less money. Academic hospitalists, unlike other specialties in Medicine, are likely to fall into the latter category, by offering decreased hospital costs (ie, decreased length of stay, decreased never events, etc.). Further, hospitalists may save in opportunity costs: the hospitalist staffing a ward service is less costly than a subspecialist who could be performing procedures, or a basic science researcher who could be acquiring grants. The problem today is that there is no way to quantify this decreased loss, and having this sort of metric will greatly enable mentors to provide hospitalists with ways of showing value to the department outside of the standard NIH grant paradigm. The Quality Portfolio developed by the SGIM and the forthcoming Benchmarks for Academic Hospitalists Promotion white paper (as developed by the SHM's Academic Practice and Promotion Committee) will greatly improve the substance of mentorship for academic hospitalists.2 Leaders of academic hospital medicine must learn to educate chairs of medicine and medical school deans as to the value‐added services intrinsic in the integration of hospitalists into the academic environment.

Having an Academic Plan

Mentorship is a 2‐way relationship: the mentor has responsibilities, but so too, does the mentee. As we wait for the hospitalist field to further develop, new academic hospitalists must become proactive in seeking guidance in career development. The Academic Hospitalist Academy, cosponsored by SHM, SGIM, and ACLGIM, is an example of this type of training.3 As a part of this course, participants learn of the rules and the opportunities for success in academic hospital medicine. Success for academic hospitalist groups will likely follow from understanding what success looks like. The Academy provides an excellent program for distributing that knowledge.

Research Training in Hospital Medicine

Many traditionalists would insist that Hospital Medicine could evoke the same training paradigm as other subspecialties in medicine (ie, fellowships). Unfortunately there are not a sufficient number of GME‐funded positions to handle the number of hospitalists required to advance the mission of academic hospital medicine. Moreover, fellowship training for every academic hospitalist would be unlikely to produce the desired results of improving the delivery of inpatient care. The academic agenda for the hospitalist depends on understanding the hospital system, and then executing improvements that lead to safer, more efficient and effective care. In this way, the academic hospitalist academic training is much more akin to a Master of Business Administration (MBA) than it is to a Bachelor of Science (BS) degree: namely, via job immersion, the hospitalist develops a greater systems understanding that should inform his or her academic career. Thus, a fellowship right out of residency may not have the same urgency for the hospitalist as it does for the subspecialist. Nevertheless, those hospitalists seeking an academic scholarly career will experience major benefits from fellowship training. Academic hospitalists need not focus only on the few existing hospitalist fellowships; they can obtain the necessary training in research skills via a general medicine fellowship, of which there are many. For this cohort of hospitalists, we strongly encourage training in a general medicine, health services, or outcomes research fellowship, with an emphasis on research techniques as they apply to the measurement of quality, patient safety, and/or clinical education.

With respect to academic hospitalists, it is likely that nothing is as important as the question of mentorship. Even the hardest working hospitalist can lose their way without guidance and a roadmap; the mentor is central to both. But the lost opportunity is not borne by the individual physician alone; the academic department loses too. Because the hospitalist's value depends on sufficient familiarity with a specific system prior to leveraging improvements, the department accrues maximal benefits in efficiency and effectiveness only if it can maintain retention for at least 2 years.4 The turnover carries major costs; recruitment costs money, and every new hospitalist engenders major start‐up costs. Faculty members who become completely integrated into the department have higher retention rates than those who consider themselves outside the main stream. Mentorship will greatly increase the probability that hospitalists will progress and feel the importance to the department.

Academic hospital medicine must strive over the next 5 to 10 years to become totally integrated in the academic culture of every institution. This task will take great leadership both at the local level and at a national level. We agree with the authors that the SHM and the SGIM can both provide important assistance to young hospital medicine groups. We applaud the authors of this article for making explicit this next major challenge for the field.

This issue of the Journal of Hospital Medicine features an important contribution concerning the current state of academic hospital medicine. The survey of 57 hospitalists revealed what many of us already suspected: the state of mentorship in academic hospitalist groups is unsatisfactory.1

While the conclusion is alarming, it is also not surprising. Over the past decade academic medical centers enthusiastically hired hospitalists to improve efficiency for inpatient services and to lessen the effect of Accreditation Council for Graduate Medical Education (ACGME) regulations on duty hours and patient caps. Few departments of internal medicine, however, hired academic hospitalists with the intent of creating academic divisions. Thus many institutions appear to view hospitalists primarily as hospital employees ignoring their potential academic contributions, and as a result it should not be a surprise that many hospitalist groups lack the mentorship infrastructure of other divisions within a typical Department of Medicine. Compounding the hospital employee problem, the new field of academic hospital medicine has emerged only in the last decade, a time frame that has resulted in very few hospitalists qualified to serve as senior mentors.

We cannot easily remove these limitations: the past is the past, and over time, hospital medicine will mature and develop more senior mentors. But what should we do until that maturation occurs? We believe that the academic work of hospitalists, both in education and research (Quality and Patient Safety) are important endeavors too valuable to be left to chance. With 30,000 hospitalists delivering care, it is critical that research in the optimal delivery of this care be performed, targeting systems improvements to enact anticipated outcomes in quality and patient safety. The physicians who are regularly and intimately involved in this system of inpatient care delivery, the hospitalists, are best suited for identifying the unique features of the inpatient care system needing improvement. Mentorship is essential in ensuring the advancement of both areas, and the sustainability of hospital medicine in medical academe. The article by Harrison et al.1 both establishes the depth of these issues and provides important insights into potential solutions for closing this mentorship gap while the field matures.

Utilizing Other Mentors

No measure of systems change will make young hospitalists immediately experienced, such that they have the sophistication to be senior mentors for younger hospitalists. But we can compensate for this temporary gap in mentorship experience. First, in the next 5 to 10 years, young academic hospitalists need explicit direction from those within Departments of Medicine who do have this mentorship experience, even if these mentors do not work in hospital medicine. Mentors within General Internal Medicine or the subspecialties can still provide the guidance and support to ensure that academic hospitalists are engaging in the appropriate endeavors toward promotion and intellectual growth. Second, academic hospitalists have to seek out mentorship from afar through their participation in the organizations primarily devoted to the academic welfare of hospitalists: The Society of Hospital Medicine (SHM) and the Society of General Internal Medicine (SGIM). Both organizations sponsor mentorship programs, and regular attendance at regional and/or national meetings (followed by email correspondence) can greatly improve an academic hospitalist's career trajectory. Finally, midlevel and senior‐level hospitalists have to learn mentorship skills; mere experience in the field does not ensure acquisition of the necessary mentorship skills, anymore than experience in medicine ensures teaching skills. Mentorship is its own skill set, and receiving appropriate training via the SHM or SGIM national meetings or the Academic Hospitalist Academy (referenced below) is critical.

Defining Academic Expectations for Hospitalists

Harrison et al.1 note that academic hospitalists felt there was a lack of respect for the scholarly work that hospitalists do as part of their job, raising the proposition that the mentorship dearth for academic hospitalists might result from currently available mentors not knowing what to say. Even if mentors were plentiful today, we still must ask the question, What would the mentor advise the young hospitalist to do? The academic hospitalist offers extraordinary value to the Department, but in a way that is different from the standard R0RO‐1 Grant paradigm. Even if hospitalists acquire extramural funding, it will likely come from sources different from the National Institutes of Health (NIH): Agency for Healthcare Research and Quality (AHRQ), foundations (eg, The Robert Wood Johnson Foundation or The John A. Hartford Foundation), intramural hospital‐originating funding, etc. And while extramural funding may be a measure of a hospitalist's contribution to the Department, it should not be the only measure of the hospitalist's career development. There are 2 ways to get rich: acquire more money, or spend less money. Academic hospitalists, unlike other specialties in Medicine, are likely to fall into the latter category, by offering decreased hospital costs (ie, decreased length of stay, decreased never events, etc.). Further, hospitalists may save in opportunity costs: the hospitalist staffing a ward service is less costly than a subspecialist who could be performing procedures, or a basic science researcher who could be acquiring grants. The problem today is that there is no way to quantify this decreased loss, and having this sort of metric will greatly enable mentors to provide hospitalists with ways of showing value to the department outside of the standard NIH grant paradigm. The Quality Portfolio developed by the SGIM and the forthcoming Benchmarks for Academic Hospitalists Promotion white paper (as developed by the SHM's Academic Practice and Promotion Committee) will greatly improve the substance of mentorship for academic hospitalists.2 Leaders of academic hospital medicine must learn to educate chairs of medicine and medical school deans as to the value‐added services intrinsic in the integration of hospitalists into the academic environment.

Having an Academic Plan

Mentorship is a 2‐way relationship: the mentor has responsibilities, but so too, does the mentee. As we wait for the hospitalist field to further develop, new academic hospitalists must become proactive in seeking guidance in career development. The Academic Hospitalist Academy, cosponsored by SHM, SGIM, and ACLGIM, is an example of this type of training.3 As a part of this course, participants learn of the rules and the opportunities for success in academic hospital medicine. Success for academic hospitalist groups will likely follow from understanding what success looks like. The Academy provides an excellent program for distributing that knowledge.

Research Training in Hospital Medicine

Many traditionalists would insist that Hospital Medicine could evoke the same training paradigm as other subspecialties in medicine (ie, fellowships). Unfortunately there are not a sufficient number of GME‐funded positions to handle the number of hospitalists required to advance the mission of academic hospital medicine. Moreover, fellowship training for every academic hospitalist would be unlikely to produce the desired results of improving the delivery of inpatient care. The academic agenda for the hospitalist depends on understanding the hospital system, and then executing improvements that lead to safer, more efficient and effective care. In this way, the academic hospitalist academic training is much more akin to a Master of Business Administration (MBA) than it is to a Bachelor of Science (BS) degree: namely, via job immersion, the hospitalist develops a greater systems understanding that should inform his or her academic career. Thus, a fellowship right out of residency may not have the same urgency for the hospitalist as it does for the subspecialist. Nevertheless, those hospitalists seeking an academic scholarly career will experience major benefits from fellowship training. Academic hospitalists need not focus only on the few existing hospitalist fellowships; they can obtain the necessary training in research skills via a general medicine fellowship, of which there are many. For this cohort of hospitalists, we strongly encourage training in a general medicine, health services, or outcomes research fellowship, with an emphasis on research techniques as they apply to the measurement of quality, patient safety, and/or clinical education.

With respect to academic hospitalists, it is likely that nothing is as important as the question of mentorship. Even the hardest working hospitalist can lose their way without guidance and a roadmap; the mentor is central to both. But the lost opportunity is not borne by the individual physician alone; the academic department loses too. Because the hospitalist's value depends on sufficient familiarity with a specific system prior to leveraging improvements, the department accrues maximal benefits in efficiency and effectiveness only if it can maintain retention for at least 2 years.4 The turnover carries major costs; recruitment costs money, and every new hospitalist engenders major start‐up costs. Faculty members who become completely integrated into the department have higher retention rates than those who consider themselves outside the main stream. Mentorship will greatly increase the probability that hospitalists will progress and feel the importance to the department.

Academic hospital medicine must strive over the next 5 to 10 years to become totally integrated in the academic culture of every institution. This task will take great leadership both at the local level and at a national level. We agree with the authors that the SHM and the SGIM can both provide important assistance to young hospital medicine groups. We applaud the authors of this article for making explicit this next major challenge for the field.

This issue of the Journal of Hospital Medicine features an important contribution concerning the current state of academic hospital medicine. The survey of 57 hospitalists revealed what many of us already suspected: the state of mentorship in academic hospitalist groups is unsatisfactory.1

While the conclusion is alarming, it is also not surprising. Over the past decade academic medical centers enthusiastically hired hospitalists to improve efficiency for inpatient services and to lessen the effect of Accreditation Council for Graduate Medical Education (ACGME) regulations on duty hours and patient caps. Few departments of internal medicine, however, hired academic hospitalists with the intent of creating academic divisions. Thus many institutions appear to view hospitalists primarily as hospital employees ignoring their potential academic contributions, and as a result it should not be a surprise that many hospitalist groups lack the mentorship infrastructure of other divisions within a typical Department of Medicine. Compounding the hospital employee problem, the new field of academic hospital medicine has emerged only in the last decade, a time frame that has resulted in very few hospitalists qualified to serve as senior mentors.

We cannot easily remove these limitations: the past is the past, and over time, hospital medicine will mature and develop more senior mentors. But what should we do until that maturation occurs? We believe that the academic work of hospitalists, both in education and research (Quality and Patient Safety) are important endeavors too valuable to be left to chance. With 30,000 hospitalists delivering care, it is critical that research in the optimal delivery of this care be performed, targeting systems improvements to enact anticipated outcomes in quality and patient safety. The physicians who are regularly and intimately involved in this system of inpatient care delivery, the hospitalists, are best suited for identifying the unique features of the inpatient care system needing improvement. Mentorship is essential in ensuring the advancement of both areas, and the sustainability of hospital medicine in medical academe. The article by Harrison et al.1 both establishes the depth of these issues and provides important insights into potential solutions for closing this mentorship gap while the field matures.

Utilizing Other Mentors

No measure of systems change will make young hospitalists immediately experienced, such that they have the sophistication to be senior mentors for younger hospitalists. But we can compensate for this temporary gap in mentorship experience. First, in the next 5 to 10 years, young academic hospitalists need explicit direction from those within Departments of Medicine who do have this mentorship experience, even if these mentors do not work in hospital medicine. Mentors within General Internal Medicine or the subspecialties can still provide the guidance and support to ensure that academic hospitalists are engaging in the appropriate endeavors toward promotion and intellectual growth. Second, academic hospitalists have to seek out mentorship from afar through their participation in the organizations primarily devoted to the academic welfare of hospitalists: The Society of Hospital Medicine (SHM) and the Society of General Internal Medicine (SGIM). Both organizations sponsor mentorship programs, and regular attendance at regional and/or national meetings (followed by email correspondence) can greatly improve an academic hospitalist's career trajectory. Finally, midlevel and senior‐level hospitalists have to learn mentorship skills; mere experience in the field does not ensure acquisition of the necessary mentorship skills, anymore than experience in medicine ensures teaching skills. Mentorship is its own skill set, and receiving appropriate training via the SHM or SGIM national meetings or the Academic Hospitalist Academy (referenced below) is critical.

Defining Academic Expectations for Hospitalists

Harrison et al.1 note that academic hospitalists felt there was a lack of respect for the scholarly work that hospitalists do as part of their job, raising the proposition that the mentorship dearth for academic hospitalists might result from currently available mentors not knowing what to say. Even if mentors were plentiful today, we still must ask the question, What would the mentor advise the young hospitalist to do? The academic hospitalist offers extraordinary value to the Department, but in a way that is different from the standard R0RO‐1 Grant paradigm. Even if hospitalists acquire extramural funding, it will likely come from sources different from the National Institutes of Health (NIH): Agency for Healthcare Research and Quality (AHRQ), foundations (eg, The Robert Wood Johnson Foundation or The John A. Hartford Foundation), intramural hospital‐originating funding, etc. And while extramural funding may be a measure of a hospitalist's contribution to the Department, it should not be the only measure of the hospitalist's career development. There are 2 ways to get rich: acquire more money, or spend less money. Academic hospitalists, unlike other specialties in Medicine, are likely to fall into the latter category, by offering decreased hospital costs (ie, decreased length of stay, decreased never events, etc.). Further, hospitalists may save in opportunity costs: the hospitalist staffing a ward service is less costly than a subspecialist who could be performing procedures, or a basic science researcher who could be acquiring grants. The problem today is that there is no way to quantify this decreased loss, and having this sort of metric will greatly enable mentors to provide hospitalists with ways of showing value to the department outside of the standard NIH grant paradigm. The Quality Portfolio developed by the SGIM and the forthcoming Benchmarks for Academic Hospitalists Promotion white paper (as developed by the SHM's Academic Practice and Promotion Committee) will greatly improve the substance of mentorship for academic hospitalists.2 Leaders of academic hospital medicine must learn to educate chairs of medicine and medical school deans as to the value‐added services intrinsic in the integration of hospitalists into the academic environment.

Having an Academic Plan

Mentorship is a 2‐way relationship: the mentor has responsibilities, but so too, does the mentee. As we wait for the hospitalist field to further develop, new academic hospitalists must become proactive in seeking guidance in career development. The Academic Hospitalist Academy, cosponsored by SHM, SGIM, and ACLGIM, is an example of this type of training.3 As a part of this course, participants learn of the rules and the opportunities for success in academic hospital medicine. Success for academic hospitalist groups will likely follow from understanding what success looks like. The Academy provides an excellent program for distributing that knowledge.

Research Training in Hospital Medicine

Many traditionalists would insist that Hospital Medicine could evoke the same training paradigm as other subspecialties in medicine (ie, fellowships). Unfortunately there are not a sufficient number of GME‐funded positions to handle the number of hospitalists required to advance the mission of academic hospital medicine. Moreover, fellowship training for every academic hospitalist would be unlikely to produce the desired results of improving the delivery of inpatient care. The academic agenda for the hospitalist depends on understanding the hospital system, and then executing improvements that lead to safer, more efficient and effective care. In this way, the academic hospitalist academic training is much more akin to a Master of Business Administration (MBA) than it is to a Bachelor of Science (BS) degree: namely, via job immersion, the hospitalist develops a greater systems understanding that should inform his or her academic career. Thus, a fellowship right out of residency may not have the same urgency for the hospitalist as it does for the subspecialist. Nevertheless, those hospitalists seeking an academic scholarly career will experience major benefits from fellowship training. Academic hospitalists need not focus only on the few existing hospitalist fellowships; they can obtain the necessary training in research skills via a general medicine fellowship, of which there are many. For this cohort of hospitalists, we strongly encourage training in a general medicine, health services, or outcomes research fellowship, with an emphasis on research techniques as they apply to the measurement of quality, patient safety, and/or clinical education.

With respect to academic hospitalists, it is likely that nothing is as important as the question of mentorship. Even the hardest working hospitalist can lose their way without guidance and a roadmap; the mentor is central to both. But the lost opportunity is not borne by the individual physician alone; the academic department loses too. Because the hospitalist's value depends on sufficient familiarity with a specific system prior to leveraging improvements, the department accrues maximal benefits in efficiency and effectiveness only if it can maintain retention for at least 2 years.4 The turnover carries major costs; recruitment costs money, and every new hospitalist engenders major start‐up costs. Faculty members who become completely integrated into the department have higher retention rates than those who consider themselves outside the main stream. Mentorship will greatly increase the probability that hospitalists will progress and feel the importance to the department.

Academic hospital medicine must strive over the next 5 to 10 years to become totally integrated in the academic culture of every institution. This task will take great leadership both at the local level and at a national level. We agree with the authors that the SHM and the SGIM can both provide important assistance to young hospital medicine groups. We applaud the authors of this article for making explicit this next major challenge for the field.

During their junior medicine rotation, our students are asked to post to Blackboard (an online student forum) an anonymous essay about an issue of professionalism or ethics, either inspiring or troubling. In many ways, these vignettes are like postcards, written by visitors describing foreign cultures and norms. They represent a way for the students to debrief, but also provide an opportunity for us, as faculty, to reflect upon the way we practice and teach medicine. Many postingslike postcards from exotic or historic placesare inspiring stories of residents and faculty extending themselves for their patients. Unfortunately, unlike typical postcards, there are also essays that are troubling or provoking and challenge us to consider how we could improve the professional and ethical environment on our teams.

In order to begin a learning process with our faculty and housestaff, we have presented a number of these anonymous essays at both faculty and housestaff Department of Medicine conferences as well as our monthly hospital Ethics conference. The goal of these conferences was to gather as a moral community to reflect on our students' experience and consider ways in which our day to day practice as attendings could be informed by what they tell us. In addition, the junior medicine site directors have a session each quarter with their junior students to review some of the most significant issues brought up by their essays.

Practically, these vignettes and conferences serve three main purposes:

• 1

  Raising Awareness: Many professional issues noted by our students occur under the radar. Attendings are often unaware of the issues of professionalism and/or ethics confronting our students and housestaff.

• 2

  Exploring Attitudes: Some attending may underemphasize the importance of specific issues of professionalism and/or ethics. Open discussions at faculty or resident conferences create opportunities for individuals to reflect upon their own reactions and for the group to create a norm.

• 3

  Sharing Skills: It is difficult to learn the practice of professionalism and ethics from a book. Skill in this area is gained primarily by experience. Conferences provide an excellent forum for seasoned physicians to share wisdom with less experienced physicians. In addition, important teaching points can be made: Students should not deliver bad news alone. Errors should be disclosed.

Following are 3 of the essays we presented, along with brief commentaries. At the end, we provide practical suggestions for individual attendings to improve the professional climate on their teams.

The Hospital Didn't Wait

Code. On 12, the surgical wards floor. Elise sprinted to the stairwell, dashed up to 12, and ran to the corner room as fast as she could. She could see the room before she got there. Instinctively, she started reviewing the steps she had memorized so many months ago. But when she finally arrived at the patient's bathroom, her thought process came to a jolting halt as she came upon the gruesome scene.

The 76‐year‐old patient had hanged himself with the cinching rope from his garment bag, and now dangled suspended from a high towel rack against the wall. Nurses from the floor started to file in, and without losing a beat Elise barked commands. Together they brought the man's body down to the floor, laid him on his back, and stripped off his hospital gown. Elise was in charge; deliberately but forcefully, she ordered a nurse to retrieve a defibrillator, and had another resident check for a pulse. There was none. Anesthesiology was here. Quickly and expertly, they shoved a plastic tube down his throat and began ventilation. The nurse placed on the electrodes between chest compressions then called to clear the body. Airway stepped back. The chest pumper stepped back. The body lurched forward as the defibrillator issued a long beep and discharged. Still no pulse. The cycle repeated.

Finally, Elise called a stop. Time of death, 19:37. By now there were about 20 people crammed in the patient room, all of whom had a separate role during the code. Some stayed behind, while the rest left to return to their interrupted work. The medical student didn't know what to think as he returned to the team room. His jaw was sorehad he been clenching it the whole time?and as he brought his hand up to rub his face, he saw that his knuckles were bloody. Somehow he had scraped them during the code. As he logged back into the computer to finish off his evening notes, he knew that he wouldn't have time to reflect until hours later when he returned home. Codes happened all the time. There was still work to be done in the hospital, and the hospital didn't wait.

The room had already been assigned to a patient waiting in the Emergency Department downstairs. That patient would be here in a few minutes. The hospital didn't wait.

When we presented this case in our conferences, there was universal agreement that such a traumatic event merits, even demands, team debriefing and processing. But in the real life aftermath of this traumatic event, the take‐home message for the medical student was that the hospital didn't wait for such discussions. We know this is not unique to our institution. In a study of 32 medical students who were asked to reflect on their most memorable patient death,1 debriefing sessions were rare and many students felt inadequately supported. While experienced clinicians may be accustomed to seeing patients die, students are new to the culture of the hospital, and have not had the chance to develop the defense mechanisms necessary to cope with this sort of experience. Angoff2 writes, As medical educators, we ought to ask our students how they are coping with long hours, fatigue, illness, suffering, and death. We ought to model and commend compassion and react to the deep feelings of our students in the same way we would teach them to react to the deep feelings of their patients.

I Told a Man Today That He Had Brain Cancer

The resident, intern, and I were huddled together in our team room when the report came back on the computer. New 3.5 2.3 1.7 cm contrast‐enhancing lesion seen anterior to genu of corpus callosum. Concerning for metastatic focus vs. lymphoma. Advise follow‐up. It wasn't unexpected but we had nevertheless been hoping for better.

The three of us went into his room and I was waiting to see how my resident would deliver the bad news, but she didn't. She simply said that we were continuing to do imaging studies and that a neurology team would be in touch. There were probably several reasons why she didn't tell him: not enough time, not her responsibility, or maybe she was just uncomfortable with it. Whatever the case, we left the room with my patient still oblivious to the awful mass now tangled in his head.

If my resident was taking a pass on this conversation, I knew it fell to me he needed to hear it from his primary team. I came back after rounds alone, sat down next to his bed, and told him that his MRI results had come back, and that I had unfortunate news.

I told him that the images showed that his lung cancer had spread to his brain.

I paused to give him a chance to let it sink in. He turned away and looked up at the ceiling.

Where is it? How big is it?

What now?

Reflecting on this case, our audiences were disturbed that a student would attempt this difficult conversation alone, while recognizing that the student clearly felt a sense of responsibility and desire to help his patient by sharing important information. We talked about how students may erroneously pick up a message that the team member who has spent the most time with a patient is the most obvious choice to have difficult conversations. We also noted that, unfortunately, sometimes students are directly asked by their team to shoulder this responsibility on their own. In this painful account, there is no mention of preparation, supervision, or support for the student before or after the encounter. The student perceived (rightly or wrongly) that the team leaders lacked comfort or skill to deliver the bad news, and stepped in. It is possible that the attending lacked the skill and ability to model an interaction, but more likely the deficit was in awareness and attitude. It is unlikely the attending knew that the student had this conversation alone. One of the major reasons we present these vignettes is to make attendings and housestaff more aware of issues that occur under their radar so that they can take preventative action. However, once the resident or attending found out that the student had this conversation alone, the student should be pulled aside for a 1:1 discussion. At the end of the day, the student should know that it was inappropriate to attempt this conversation alone

Rosenbaum3 reviewed a number of strategies to teach the skill of delivering bad news, from lecture and small group discussions to role play and standardized patients. When asked, students cited role‐modeling as the best way to learn how to deliver bad news.4 Observation of a veteran clinician provides a firm foundation for learning; but that is not enough. Unfortunately, we know from the literature (and our student vignettes suggest) that students and residents are unprepared to carry out these conversations properly, either because of misguided attitudes, lack of experience, or inadequate training.57 We conceptualize engaging in difficult conversations as a procedure, demanding a skill set. Mere observation of an expert executing this procedure is only a beginning. With any other skill, from successful completion of a lumbar puncture to initiating cardiopulmonary resuscitation (CPR), a student would never conclude that knowing the patient the best sufficiently credentials the student to undertake these procedures. We maintain that a difficult conversationbe it breaking bad news, discussing end‐of‐life care preferences, code status discussions, or prognosisis a clinical intervention, like any other procedure in medicine. If performed with skill and caution, it can bring about a stronger therapeutic relationship and increased support for the patient; if performed clumsily, it can lead to unintended adverse outcomes, including misunderstanding, mistrust, anxiety, and anger.

A Decimal Point Got Misplaced

On palliative care, I had a 90 year‐old man with end stage lung CA that presented to the ED with increasing SOB. The resident decided that giving him some morphine would be a good solution but was worried that too much would push him over the edge. He was thin; his O2 sats weren't that good After some discussion it was decided that 2.5 mg should be the starting amount. Unfortunately, when the note was written a decimal point got misplaced and he got 25 mg as a first dose. He ended up very sedated for most of the day but his breathing was ok.

The mistake was not discussed with the patient or the patient's family. While it did not cause any lasting harm, I wondered if telling the patient/patient's family that an error had been made would have been more ethically sound.

When we presented this case in our conferences, there was little controversy about whether the error should have been disclosed. The discussion did provide reinforcement for doing a simple but difficult task. Our analysis is that the nondiscussion of this error reflects a deficit in attitude and possibly skill. The team was aware of the error, but the resident and attending did not take the opportunity to disclose an error. They should have. We do not know whether the attending or resident felt unprepared to discuss this or were simply unimpressed with the adverse event. We do get the sense that the student did not feel comfortable raising the issue with the team. As such, it was a missed opportunity to seek help from any number of hospital resources and find encouragement to take on difficult encounters.

Much has been written about apologies.810 Disclosing errors and apologizing is the ethical standard, and many of our institutions have made it policy. Yet in the moment, it is embarrassing, anxiety provoking, and our concern about litigation looms large. Learning to do the right thing begins, perhaps with lectures and standardized patients, but only when students see it modeled by our housestaff and faculty, does it take root for good.

Our housestaff are quite good at managing medical issues, but they may still need help in creating the appropriate environment for professional learning and growth. This is 1 of the most important contributions an attending can make. We have emphasized that faculty have an important role to play in the area of professional development, reinforcing the rudimentary information preclinical students are presented with in the classroom and processing experiences residents are exposed to on a regular basis. If the hospital doesn't wait, then it is the attending physician's job to create the space and time for trainees to think about what is happening and ask if it could have been done better.

A number of seasoned clinical teachers have written about ways to improve teaching on the wards.11 Below, we will add to that discussion by considering practical ways to enhance learning about professionalism and ethics (see Table 1). Note should be made that while we focus on specific behaviors and activities, underlying all is the importance of availability, presence, and intention. Like all good teaching, these activities require planning and effort.

Creating an Open Climate

The medical team, of which the attending, residents, and students are all a part, should not only be a unit that provides excellent medical care to its patients, but should also create a culture of continuous learning and improvement. As such, it is important to create a safe atmosphere where teachers are invested in the growth of their learners and learners feel free to question the prevailing logic and practice, including issues of professionalism and ethics. As Malcolm Gladwell12 describes in Outliers, Korean Air jets were crashing because subordinates were afraid to question their superiors. Once that culture changed, Korean Air safety improved dramatically. Similarly, breaking down some of the hierarchical barriers should improve the culture of a medical team. We typically make an effort to get to know our students and residents on a more personal basis: where they are from, who is in their family, what was their major, what are their interests outside of medicine, and what has been surprising to them in their training so far. Whether we set aside time when we first meet or e‐mail our questions before the first day, we aim for this to be 1 of the first team activities. We also share our own stories, making clear that the attending is part of the team, and not just an evaluating supervisor.

Vignette 1 describes the student's trauma of witnessing a code and the inability to process the event with anyone afterward. Failed resuscitation attempts are the most dramatic examples, but even expected deaths, nonfatal adverse events, and conflict between patients and providers may be traumatic for new trainees inexperienced with the reality of medicine. Attendings should be aware of these potentially traumatic events and make time to check in with the team members about how they are dealing with their emotions. Taking time on attending rounds, for example, allows the attending to not only model reflective practice and self‐care, but also elevates team support to a place traditionally reserved for discussions about diagnosis and treatment.

Supervision and Modeling

Vignettes 2 and 3 center around challenging communication tasks that require special training, including instruction, modeling, feedback, and practice. Unfortunately, as some of our student accounts document, many teaching opportunities are missed. As attendings, our duties include being aware of these opportunities, and being prepared to model competent patientor familydoctor interactions. Emphasizing the importance of the doctor‐patient relationship is in fact one of the key skills of an effective attending role model.13

When opportunities arise for any potentially difficult conversation, we make every effort to identify the issue, prebrief with the team about how to conduct the discussion, and either offer to model the conversation or be present to observe and provide feedback and debriefing afterwards. For example, by asking about all DNR discussions had with our patients, we gain insight into the skill level of our housestaff. As important, the housestaff understand that we believe that these conversations are vital to review during formal rounds, with the same attention we give to chest pain and electrocardiograms (ECGs).

Two key skills that develop with experience are the ability to know the limits of one's knowledge and to know when to ask for help. We try to be open about naming those limits and thinking about the other members of the larger healthcare team that may provide insight, skill, and expertise. We are used to doing this with medical questions (eg, asking the gastroenterology consult team to locate a source of bleeding). Asking our risk management, patient‐relations, or ethics services to assist with a difficult communication task or conflict with a family is no different, and often something the housestaff may not readily do.

We are grateful to our students and their postcards for the snapshots of our local medical culture. While we are gratified to read of excellent role modeling, we are also disappointed to read of situations which have left our students confused, demoralized and cynical. But if these exercises are to reach their full potential, they should tell us about where we would like to go, in addition to where we have been. We believe that our conferences have stimulated our faculty and housestaff to reflect on the professionalism lessons they are teaching. Reading the student postings has definitely affected our approach to teaching professionalism. They reinforce what every parent and educator knows: when it comes to teaching professionalism, communication and ethics, what matters most is the behavior of the teacher. Our words mean little if our actions do not live out what we espouse.

During their junior medicine rotation, our students are asked to post to Blackboard (an online student forum) an anonymous essay about an issue of professionalism or ethics, either inspiring or troubling. In many ways, these vignettes are like postcards, written by visitors describing foreign cultures and norms. They represent a way for the students to debrief, but also provide an opportunity for us, as faculty, to reflect upon the way we practice and teach medicine. Many postingslike postcards from exotic or historic placesare inspiring stories of residents and faculty extending themselves for their patients. Unfortunately, unlike typical postcards, there are also essays that are troubling or provoking and challenge us to consider how we could improve the professional and ethical environment on our teams.

In order to begin a learning process with our faculty and housestaff, we have presented a number of these anonymous essays at both faculty and housestaff Department of Medicine conferences as well as our monthly hospital Ethics conference. The goal of these conferences was to gather as a moral community to reflect on our students' experience and consider ways in which our day to day practice as attendings could be informed by what they tell us. In addition, the junior medicine site directors have a session each quarter with their junior students to review some of the most significant issues brought up by their essays.

Practically, these vignettes and conferences serve three main purposes:

• 1

  Raising Awareness: Many professional issues noted by our students occur under the radar. Attendings are often unaware of the issues of professionalism and/or ethics confronting our students and housestaff.

• 2

  Exploring Attitudes: Some attending may underemphasize the importance of specific issues of professionalism and/or ethics. Open discussions at faculty or resident conferences create opportunities for individuals to reflect upon their own reactions and for the group to create a norm.

• 3

  Sharing Skills: It is difficult to learn the practice of professionalism and ethics from a book. Skill in this area is gained primarily by experience. Conferences provide an excellent forum for seasoned physicians to share wisdom with less experienced physicians. In addition, important teaching points can be made: Students should not deliver bad news alone. Errors should be disclosed.

Following are 3 of the essays we presented, along with brief commentaries. At the end, we provide practical suggestions for individual attendings to improve the professional climate on their teams.

The Hospital Didn't Wait

Code. On 12, the surgical wards floor. Elise sprinted to the stairwell, dashed up to 12, and ran to the corner room as fast as she could. She could see the room before she got there. Instinctively, she started reviewing the steps she had memorized so many months ago. But when she finally arrived at the patient's bathroom, her thought process came to a jolting halt as she came upon the gruesome scene.

The 76‐year‐old patient had hanged himself with the cinching rope from his garment bag, and now dangled suspended from a high towel rack against the wall. Nurses from the floor started to file in, and without losing a beat Elise barked commands. Together they brought the man's body down to the floor, laid him on his back, and stripped off his hospital gown. Elise was in charge; deliberately but forcefully, she ordered a nurse to retrieve a defibrillator, and had another resident check for a pulse. There was none. Anesthesiology was here. Quickly and expertly, they shoved a plastic tube down his throat and began ventilation. The nurse placed on the electrodes between chest compressions then called to clear the body. Airway stepped back. The chest pumper stepped back. The body lurched forward as the defibrillator issued a long beep and discharged. Still no pulse. The cycle repeated.

Finally, Elise called a stop. Time of death, 19:37. By now there were about 20 people crammed in the patient room, all of whom had a separate role during the code. Some stayed behind, while the rest left to return to their interrupted work. The medical student didn't know what to think as he returned to the team room. His jaw was sorehad he been clenching it the whole time?and as he brought his hand up to rub his face, he saw that his knuckles were bloody. Somehow he had scraped them during the code. As he logged back into the computer to finish off his evening notes, he knew that he wouldn't have time to reflect until hours later when he returned home. Codes happened all the time. There was still work to be done in the hospital, and the hospital didn't wait.

The room had already been assigned to a patient waiting in the Emergency Department downstairs. That patient would be here in a few minutes. The hospital didn't wait.

When we presented this case in our conferences, there was universal agreement that such a traumatic event merits, even demands, team debriefing and processing. But in the real life aftermath of this traumatic event, the take‐home message for the medical student was that the hospital didn't wait for such discussions. We know this is not unique to our institution. In a study of 32 medical students who were asked to reflect on their most memorable patient death,1 debriefing sessions were rare and many students felt inadequately supported. While experienced clinicians may be accustomed to seeing patients die, students are new to the culture of the hospital, and have not had the chance to develop the defense mechanisms necessary to cope with this sort of experience. Angoff2 writes, As medical educators, we ought to ask our students how they are coping with long hours, fatigue, illness, suffering, and death. We ought to model and commend compassion and react to the deep feelings of our students in the same way we would teach them to react to the deep feelings of their patients.

I Told a Man Today That He Had Brain Cancer

The resident, intern, and I were huddled together in our team room when the report came back on the computer. New 3.5 2.3 1.7 cm contrast‐enhancing lesion seen anterior to genu of corpus callosum. Concerning for metastatic focus vs. lymphoma. Advise follow‐up. It wasn't unexpected but we had nevertheless been hoping for better.

The three of us went into his room and I was waiting to see how my resident would deliver the bad news, but she didn't. She simply said that we were continuing to do imaging studies and that a neurology team would be in touch. There were probably several reasons why she didn't tell him: not enough time, not her responsibility, or maybe she was just uncomfortable with it. Whatever the case, we left the room with my patient still oblivious to the awful mass now tangled in his head.

If my resident was taking a pass on this conversation, I knew it fell to me he needed to hear it from his primary team. I came back after rounds alone, sat down next to his bed, and told him that his MRI results had come back, and that I had unfortunate news.

I told him that the images showed that his lung cancer had spread to his brain.

I paused to give him a chance to let it sink in. He turned away and looked up at the ceiling.

Where is it? How big is it?

What now?

Reflecting on this case, our audiences were disturbed that a student would attempt this difficult conversation alone, while recognizing that the student clearly felt a sense of responsibility and desire to help his patient by sharing important information. We talked about how students may erroneously pick up a message that the team member who has spent the most time with a patient is the most obvious choice to have difficult conversations. We also noted that, unfortunately, sometimes students are directly asked by their team to shoulder this responsibility on their own. In this painful account, there is no mention of preparation, supervision, or support for the student before or after the encounter. The student perceived (rightly or wrongly) that the team leaders lacked comfort or skill to deliver the bad news, and stepped in. It is possible that the attending lacked the skill and ability to model an interaction, but more likely the deficit was in awareness and attitude. It is unlikely the attending knew that the student had this conversation alone. One of the major reasons we present these vignettes is to make attendings and housestaff more aware of issues that occur under their radar so that they can take preventative action. However, once the resident or attending found out that the student had this conversation alone, the student should be pulled aside for a 1:1 discussion. At the end of the day, the student should know that it was inappropriate to attempt this conversation alone

Rosenbaum3 reviewed a number of strategies to teach the skill of delivering bad news, from lecture and small group discussions to role play and standardized patients. When asked, students cited role‐modeling as the best way to learn how to deliver bad news.4 Observation of a veteran clinician provides a firm foundation for learning; but that is not enough. Unfortunately, we know from the literature (and our student vignettes suggest) that students and residents are unprepared to carry out these conversations properly, either because of misguided attitudes, lack of experience, or inadequate training.57 We conceptualize engaging in difficult conversations as a procedure, demanding a skill set. Mere observation of an expert executing this procedure is only a beginning. With any other skill, from successful completion of a lumbar puncture to initiating cardiopulmonary resuscitation (CPR), a student would never conclude that knowing the patient the best sufficiently credentials the student to undertake these procedures. We maintain that a difficult conversationbe it breaking bad news, discussing end‐of‐life care preferences, code status discussions, or prognosisis a clinical intervention, like any other procedure in medicine. If performed with skill and caution, it can bring about a stronger therapeutic relationship and increased support for the patient; if performed clumsily, it can lead to unintended adverse outcomes, including misunderstanding, mistrust, anxiety, and anger.

A Decimal Point Got Misplaced

On palliative care, I had a 90 year‐old man with end stage lung CA that presented to the ED with increasing SOB. The resident decided that giving him some morphine would be a good solution but was worried that too much would push him over the edge. He was thin; his O2 sats weren't that good After some discussion it was decided that 2.5 mg should be the starting amount. Unfortunately, when the note was written a decimal point got misplaced and he got 25 mg as a first dose. He ended up very sedated for most of the day but his breathing was ok.

The mistake was not discussed with the patient or the patient's family. While it did not cause any lasting harm, I wondered if telling the patient/patient's family that an error had been made would have been more ethically sound.

When we presented this case in our conferences, there was little controversy about whether the error should have been disclosed. The discussion did provide reinforcement for doing a simple but difficult task. Our analysis is that the nondiscussion of this error reflects a deficit in attitude and possibly skill. The team was aware of the error, but the resident and attending did not take the opportunity to disclose an error. They should have. We do not know whether the attending or resident felt unprepared to discuss this or were simply unimpressed with the adverse event. We do get the sense that the student did not feel comfortable raising the issue with the team. As such, it was a missed opportunity to seek help from any number of hospital resources and find encouragement to take on difficult encounters.

Much has been written about apologies.810 Disclosing errors and apologizing is the ethical standard, and many of our institutions have made it policy. Yet in the moment, it is embarrassing, anxiety provoking, and our concern about litigation looms large. Learning to do the right thing begins, perhaps with lectures and standardized patients, but only when students see it modeled by our housestaff and faculty, does it take root for good.

Our housestaff are quite good at managing medical issues, but they may still need help in creating the appropriate environment for professional learning and growth. This is 1 of the most important contributions an attending can make. We have emphasized that faculty have an important role to play in the area of professional development, reinforcing the rudimentary information preclinical students are presented with in the classroom and processing experiences residents are exposed to on a regular basis. If the hospital doesn't wait, then it is the attending physician's job to create the space and time for trainees to think about what is happening and ask if it could have been done better.

A number of seasoned clinical teachers have written about ways to improve teaching on the wards.11 Below, we will add to that discussion by considering practical ways to enhance learning about professionalism and ethics (see Table 1). Note should be made that while we focus on specific behaviors and activities, underlying all is the importance of availability, presence, and intention. Like all good teaching, these activities require planning and effort.

Creating an Open Climate

The medical team, of which the attending, residents, and students are all a part, should not only be a unit that provides excellent medical care to its patients, but should also create a culture of continuous learning and improvement. As such, it is important to create a safe atmosphere where teachers are invested in the growth of their learners and learners feel free to question the prevailing logic and practice, including issues of professionalism and ethics. As Malcolm Gladwell12 describes in Outliers, Korean Air jets were crashing because subordinates were afraid to question their superiors. Once that culture changed, Korean Air safety improved dramatically. Similarly, breaking down some of the hierarchical barriers should improve the culture of a medical team. We typically make an effort to get to know our students and residents on a more personal basis: where they are from, who is in their family, what was their major, what are their interests outside of medicine, and what has been surprising to them in their training so far. Whether we set aside time when we first meet or e‐mail our questions before the first day, we aim for this to be 1 of the first team activities. We also share our own stories, making clear that the attending is part of the team, and not just an evaluating supervisor.

Vignette 1 describes the student's trauma of witnessing a code and the inability to process the event with anyone afterward. Failed resuscitation attempts are the most dramatic examples, but even expected deaths, nonfatal adverse events, and conflict between patients and providers may be traumatic for new trainees inexperienced with the reality of medicine. Attendings should be aware of these potentially traumatic events and make time to check in with the team members about how they are dealing with their emotions. Taking time on attending rounds, for example, allows the attending to not only model reflective practice and self‐care, but also elevates team support to a place traditionally reserved for discussions about diagnosis and treatment.

Supervision and Modeling

Vignettes 2 and 3 center around challenging communication tasks that require special training, including instruction, modeling, feedback, and practice. Unfortunately, as some of our student accounts document, many teaching opportunities are missed. As attendings, our duties include being aware of these opportunities, and being prepared to model competent patientor familydoctor interactions. Emphasizing the importance of the doctor‐patient relationship is in fact one of the key skills of an effective attending role model.13

When opportunities arise for any potentially difficult conversation, we make every effort to identify the issue, prebrief with the team about how to conduct the discussion, and either offer to model the conversation or be present to observe and provide feedback and debriefing afterwards. For example, by asking about all DNR discussions had with our patients, we gain insight into the skill level of our housestaff. As important, the housestaff understand that we believe that these conversations are vital to review during formal rounds, with the same attention we give to chest pain and electrocardiograms (ECGs).

Two key skills that develop with experience are the ability to know the limits of one's knowledge and to know when to ask for help. We try to be open about naming those limits and thinking about the other members of the larger healthcare team that may provide insight, skill, and expertise. We are used to doing this with medical questions (eg, asking the gastroenterology consult team to locate a source of bleeding). Asking our risk management, patient‐relations, or ethics services to assist with a difficult communication task or conflict with a family is no different, and often something the housestaff may not readily do.

We are grateful to our students and their postcards for the snapshots of our local medical culture. While we are gratified to read of excellent role modeling, we are also disappointed to read of situations which have left our students confused, demoralized and cynical. But if these exercises are to reach their full potential, they should tell us about where we would like to go, in addition to where we have been. We believe that our conferences have stimulated our faculty and housestaff to reflect on the professionalism lessons they are teaching. Reading the student postings has definitely affected our approach to teaching professionalism. They reinforce what every parent and educator knows: when it comes to teaching professionalism, communication and ethics, what matters most is the behavior of the teacher. Our words mean little if our actions do not live out what we espouse.

During their junior medicine rotation, our students are asked to post to Blackboard (an online student forum) an anonymous essay about an issue of professionalism or ethics, either inspiring or troubling. In many ways, these vignettes are like postcards, written by visitors describing foreign cultures and norms. They represent a way for the students to debrief, but also provide an opportunity for us, as faculty, to reflect upon the way we practice and teach medicine. Many postingslike postcards from exotic or historic placesare inspiring stories of residents and faculty extending themselves for their patients. Unfortunately, unlike typical postcards, there are also essays that are troubling or provoking and challenge us to consider how we could improve the professional and ethical environment on our teams.

In order to begin a learning process with our faculty and housestaff, we have presented a number of these anonymous essays at both faculty and housestaff Department of Medicine conferences as well as our monthly hospital Ethics conference. The goal of these conferences was to gather as a moral community to reflect on our students' experience and consider ways in which our day to day practice as attendings could be informed by what they tell us. In addition, the junior medicine site directors have a session each quarter with their junior students to review some of the most significant issues brought up by their essays.

Practically, these vignettes and conferences serve three main purposes:

• 1

  Raising Awareness: Many professional issues noted by our students occur under the radar. Attendings are often unaware of the issues of professionalism and/or ethics confronting our students and housestaff.

• 2

  Exploring Attitudes: Some attending may underemphasize the importance of specific issues of professionalism and/or ethics. Open discussions at faculty or resident conferences create opportunities for individuals to reflect upon their own reactions and for the group to create a norm.

• 3

  Sharing Skills: It is difficult to learn the practice of professionalism and ethics from a book. Skill in this area is gained primarily by experience. Conferences provide an excellent forum for seasoned physicians to share wisdom with less experienced physicians. In addition, important teaching points can be made: Students should not deliver bad news alone. Errors should be disclosed.

Following are 3 of the essays we presented, along with brief commentaries. At the end, we provide practical suggestions for individual attendings to improve the professional climate on their teams.

The Hospital Didn't Wait

Code. On 12, the surgical wards floor. Elise sprinted to the stairwell, dashed up to 12, and ran to the corner room as fast as she could. She could see the room before she got there. Instinctively, she started reviewing the steps she had memorized so many months ago. But when she finally arrived at the patient's bathroom, her thought process came to a jolting halt as she came upon the gruesome scene.

The 76‐year‐old patient had hanged himself with the cinching rope from his garment bag, and now dangled suspended from a high towel rack against the wall. Nurses from the floor started to file in, and without losing a beat Elise barked commands. Together they brought the man's body down to the floor, laid him on his back, and stripped off his hospital gown. Elise was in charge; deliberately but forcefully, she ordered a nurse to retrieve a defibrillator, and had another resident check for a pulse. There was none. Anesthesiology was here. Quickly and expertly, they shoved a plastic tube down his throat and began ventilation. The nurse placed on the electrodes between chest compressions then called to clear the body. Airway stepped back. The chest pumper stepped back. The body lurched forward as the defibrillator issued a long beep and discharged. Still no pulse. The cycle repeated.

Finally, Elise called a stop. Time of death, 19:37. By now there were about 20 people crammed in the patient room, all of whom had a separate role during the code. Some stayed behind, while the rest left to return to their interrupted work. The medical student didn't know what to think as he returned to the team room. His jaw was sorehad he been clenching it the whole time?and as he brought his hand up to rub his face, he saw that his knuckles were bloody. Somehow he had scraped them during the code. As he logged back into the computer to finish off his evening notes, he knew that he wouldn't have time to reflect until hours later when he returned home. Codes happened all the time. There was still work to be done in the hospital, and the hospital didn't wait.

The room had already been assigned to a patient waiting in the Emergency Department downstairs. That patient would be here in a few minutes. The hospital didn't wait.

When we presented this case in our conferences, there was universal agreement that such a traumatic event merits, even demands, team debriefing and processing. But in the real life aftermath of this traumatic event, the take‐home message for the medical student was that the hospital didn't wait for such discussions. We know this is not unique to our institution. In a study of 32 medical students who were asked to reflect on their most memorable patient death,1 debriefing sessions were rare and many students felt inadequately supported. While experienced clinicians may be accustomed to seeing patients die, students are new to the culture of the hospital, and have not had the chance to develop the defense mechanisms necessary to cope with this sort of experience. Angoff2 writes, As medical educators, we ought to ask our students how they are coping with long hours, fatigue, illness, suffering, and death. We ought to model and commend compassion and react to the deep feelings of our students in the same way we would teach them to react to the deep feelings of their patients.

I Told a Man Today That He Had Brain Cancer

The resident, intern, and I were huddled together in our team room when the report came back on the computer. New 3.5 2.3 1.7 cm contrast‐enhancing lesion seen anterior to genu of corpus callosum. Concerning for metastatic focus vs. lymphoma. Advise follow‐up. It wasn't unexpected but we had nevertheless been hoping for better.

The three of us went into his room and I was waiting to see how my resident would deliver the bad news, but she didn't. She simply said that we were continuing to do imaging studies and that a neurology team would be in touch. There were probably several reasons why she didn't tell him: not enough time, not her responsibility, or maybe she was just uncomfortable with it. Whatever the case, we left the room with my patient still oblivious to the awful mass now tangled in his head.

If my resident was taking a pass on this conversation, I knew it fell to me he needed to hear it from his primary team. I came back after rounds alone, sat down next to his bed, and told him that his MRI results had come back, and that I had unfortunate news.

I told him that the images showed that his lung cancer had spread to his brain.

I paused to give him a chance to let it sink in. He turned away and looked up at the ceiling.

Where is it? How big is it?

What now?

Reflecting on this case, our audiences were disturbed that a student would attempt this difficult conversation alone, while recognizing that the student clearly felt a sense of responsibility and desire to help his patient by sharing important information. We talked about how students may erroneously pick up a message that the team member who has spent the most time with a patient is the most obvious choice to have difficult conversations. We also noted that, unfortunately, sometimes students are directly asked by their team to shoulder this responsibility on their own. In this painful account, there is no mention of preparation, supervision, or support for the student before or after the encounter. The student perceived (rightly or wrongly) that the team leaders lacked comfort or skill to deliver the bad news, and stepped in. It is possible that the attending lacked the skill and ability to model an interaction, but more likely the deficit was in awareness and attitude. It is unlikely the attending knew that the student had this conversation alone. One of the major reasons we present these vignettes is to make attendings and housestaff more aware of issues that occur under their radar so that they can take preventative action. However, once the resident or attending found out that the student had this conversation alone, the student should be pulled aside for a 1:1 discussion. At the end of the day, the student should know that it was inappropriate to attempt this conversation alone

Rosenbaum3 reviewed a number of strategies to teach the skill of delivering bad news, from lecture and small group discussions to role play and standardized patients. When asked, students cited role‐modeling as the best way to learn how to deliver bad news.4 Observation of a veteran clinician provides a firm foundation for learning; but that is not enough. Unfortunately, we know from the literature (and our student vignettes suggest) that students and residents are unprepared to carry out these conversations properly, either because of misguided attitudes, lack of experience, or inadequate training.57 We conceptualize engaging in difficult conversations as a procedure, demanding a skill set. Mere observation of an expert executing this procedure is only a beginning. With any other skill, from successful completion of a lumbar puncture to initiating cardiopulmonary resuscitation (CPR), a student would never conclude that knowing the patient the best sufficiently credentials the student to undertake these procedures. We maintain that a difficult conversationbe it breaking bad news, discussing end‐of‐life care preferences, code status discussions, or prognosisis a clinical intervention, like any other procedure in medicine. If performed with skill and caution, it can bring about a stronger therapeutic relationship and increased support for the patient; if performed clumsily, it can lead to unintended adverse outcomes, including misunderstanding, mistrust, anxiety, and anger.

A Decimal Point Got Misplaced

On palliative care, I had a 90 year‐old man with end stage lung CA that presented to the ED with increasing SOB. The resident decided that giving him some morphine would be a good solution but was worried that too much would push him over the edge. He was thin; his O2 sats weren't that good After some discussion it was decided that 2.5 mg should be the starting amount. Unfortunately, when the note was written a decimal point got misplaced and he got 25 mg as a first dose. He ended up very sedated for most of the day but his breathing was ok.

The mistake was not discussed with the patient or the patient's family. While it did not cause any lasting harm, I wondered if telling the patient/patient's family that an error had been made would have been more ethically sound.

When we presented this case in our conferences, there was little controversy about whether the error should have been disclosed. The discussion did provide reinforcement for doing a simple but difficult task. Our analysis is that the nondiscussion of this error reflects a deficit in attitude and possibly skill. The team was aware of the error, but the resident and attending did not take the opportunity to disclose an error. They should have. We do not know whether the attending or resident felt unprepared to discuss this or were simply unimpressed with the adverse event. We do get the sense that the student did not feel comfortable raising the issue with the team. As such, it was a missed opportunity to seek help from any number of hospital resources and find encouragement to take on difficult encounters.

Much has been written about apologies.810 Disclosing errors and apologizing is the ethical standard, and many of our institutions have made it policy. Yet in the moment, it is embarrassing, anxiety provoking, and our concern about litigation looms large. Learning to do the right thing begins, perhaps with lectures and standardized patients, but only when students see it modeled by our housestaff and faculty, does it take root for good.

Our housestaff are quite good at managing medical issues, but they may still need help in creating the appropriate environment for professional learning and growth. This is 1 of the most important contributions an attending can make. We have emphasized that faculty have an important role to play in the area of professional development, reinforcing the rudimentary information preclinical students are presented with in the classroom and processing experiences residents are exposed to on a regular basis. If the hospital doesn't wait, then it is the attending physician's job to create the space and time for trainees to think about what is happening and ask if it could have been done better.

A number of seasoned clinical teachers have written about ways to improve teaching on the wards.11 Below, we will add to that discussion by considering practical ways to enhance learning about professionalism and ethics (see Table 1). Note should be made that while we focus on specific behaviors and activities, underlying all is the importance of availability, presence, and intention. Like all good teaching, these activities require planning and effort.

Creating an Open Climate

The medical team, of which the attending, residents, and students are all a part, should not only be a unit that provides excellent medical care to its patients, but should also create a culture of continuous learning and improvement. As such, it is important to create a safe atmosphere where teachers are invested in the growth of their learners and learners feel free to question the prevailing logic and practice, including issues of professionalism and ethics. As Malcolm Gladwell12 describes in Outliers, Korean Air jets were crashing because subordinates were afraid to question their superiors. Once that culture changed, Korean Air safety improved dramatically. Similarly, breaking down some of the hierarchical barriers should improve the culture of a medical team. We typically make an effort to get to know our students and residents on a more personal basis: where they are from, who is in their family, what was their major, what are their interests outside of medicine, and what has been surprising to them in their training so far. Whether we set aside time when we first meet or e‐mail our questions before the first day, we aim for this to be 1 of the first team activities. We also share our own stories, making clear that the attending is part of the team, and not just an evaluating supervisor.

Vignette 1 describes the student's trauma of witnessing a code and the inability to process the event with anyone afterward. Failed resuscitation attempts are the most dramatic examples, but even expected deaths, nonfatal adverse events, and conflict between patients and providers may be traumatic for new trainees inexperienced with the reality of medicine. Attendings should be aware of these potentially traumatic events and make time to check in with the team members about how they are dealing with their emotions. Taking time on attending rounds, for example, allows the attending to not only model reflective practice and self‐care, but also elevates team support to a place traditionally reserved for discussions about diagnosis and treatment.

Supervision and Modeling

Vignettes 2 and 3 center around challenging communication tasks that require special training, including instruction, modeling, feedback, and practice. Unfortunately, as some of our student accounts document, many teaching opportunities are missed. As attendings, our duties include being aware of these opportunities, and being prepared to model competent patientor familydoctor interactions. Emphasizing the importance of the doctor‐patient relationship is in fact one of the key skills of an effective attending role model.13

When opportunities arise for any potentially difficult conversation, we make every effort to identify the issue, prebrief with the team about how to conduct the discussion, and either offer to model the conversation or be present to observe and provide feedback and debriefing afterwards. For example, by asking about all DNR discussions had with our patients, we gain insight into the skill level of our housestaff. As important, the housestaff understand that we believe that these conversations are vital to review during formal rounds, with the same attention we give to chest pain and electrocardiograms (ECGs).

Two key skills that develop with experience are the ability to know the limits of one's knowledge and to know when to ask for help. We try to be open about naming those limits and thinking about the other members of the larger healthcare team that may provide insight, skill, and expertise. We are used to doing this with medical questions (eg, asking the gastroenterology consult team to locate a source of bleeding). Asking our risk management, patient‐relations, or ethics services to assist with a difficult communication task or conflict with a family is no different, and often something the housestaff may not readily do.

We are grateful to our students and their postcards for the snapshots of our local medical culture. While we are gratified to read of excellent role modeling, we are also disappointed to read of situations which have left our students confused, demoralized and cynical. But if these exercises are to reach their full potential, they should tell us about where we would like to go, in addition to where we have been. We believe that our conferences have stimulated our faculty and housestaff to reflect on the professionalism lessons they are teaching. Reading the student postings has definitely affected our approach to teaching professionalism. They reinforce what every parent and educator knows: when it comes to teaching professionalism, communication and ethics, what matters most is the behavior of the teacher. Our words mean little if our actions do not live out what we espouse.

Hyperglycemia that develops acutely due to illness is associated with poor patient outcomes in hospitalized inpatients, especially those critically ill in the intensive care unit (ICU).18 In fact, those without a prior diagnosis of diabetes and therefore newly found to have hyperglycemia have worse outcomes than those who have a prior diagnosis of diabetes.1, 2, 4, 68 Many mechanisms have been put forward to explain the adverse outcomes related to hyperglycemia, including the release of counter‐regulatory hormones, increased lipolysis with free fatty acid release, the release of inflammatory cytokines and growth factors, increased reactive oxygen species with oxidative stress and altered immunoglobulin, and neutrophil phagocytic function.911

The practical importance of this was brought home by Furnary et al.12, 13 who showed that glycemic control using 3 days of intensive intravenous (IV) insulin therapy of diabetic patients undergoing cardiac surgical procedures was able to reduce significantly the risk of deep sternal wound infections and mortality and to bring these adverse outcomes to the same levels as those of nondiabetic patients. However, the benefits of intensive insulin therapy are not limited to those with diabetes and extend to those with critical illness‐induced hyperglycemia. In a landmark, randomized, prospective study from Belgium, van den Berghe et al.14 showed that the use of an intensive IV insulin protocol designed to maintain serum blood glucose 80 mg/dL to 110 mg/dL significantly decreased morbidity and mortality following admission to the surgical ICU (SICU). Of note, only 13% of the individuals in the study had a previously known diagnosis of diabetes, showing that hyperglycemia was common following SICU admission and glycemic control was beneficial regardless of diabetes status.14

These impressive benefits1214 led to the call for improved glycemic control in the hospital with glucose targets similar to those used in the Belgian study.15 The development of protocols for such treatment proceeded rapidly.16, 17 A meta‐analysis that reviewed 14 trials through May 1, 2006 of patients in SICUs showed a 31% reduction in mortality with intensive therapy, albeit at the expense of a substantially increased risk of hypoglycemia.18 Our own studies19 using 1 day of continuous insulin infusion followed by subcutaneous basal/bolus insulin for all hyperglycemic patients following coronary artery bypass surgery showed results similar to those of Furnary et al.12, 13

Subsequently, 3 large, multicenter studies of patients in medical ICU (MICU) and SICUs, the VISEP, NICE‐SUGAR, and GLUCONTROL studies, failed to show the benefit of intensive insulin therapy on mortality and all had very high rates of hypoglycemia.2022 The VISEP20 study was stopped prematurely because of excessive hypoglycemia in the intensive treatment arm and the GLUCONTROL study was stopped prematurely because of multiple protocol violations.22 The NICE‐SUGAR study actually showed an increased mortality in the intensively treated group21 but the target range for their control group was 140 mg/dL to 180 mg/dL rather than 180 mg/dL to 215 mg/dL and this likely accounted for the better mortality in their control group compared to other studies. Van den Berghe et al.,23 in a design similar to their earlier one in the SICU, found that intensive insulin therapy in the MICU resulted in significant reductions in new onset renal injury, MICU and hospital length of stay, and an improved ability to wean off mechanical ventilation; however, no improvement in mortality was found except for those whose MICU stay was >3 days duration. In a post hoc analysis of their combined SICU and MICU studies, van den Berghe et al.23 found that a glucose target of 110 mg/dL to 150 mg/dL accounted for about 75% of the mortality benefit with a low risk of hypoglycemia.24 A recent meta‐analysis that included data on 13,567 patients from 26 trials, including the NICE‐SUGAR study, concluded that although overall there was no mortality benefit from intensive insulin therapy there was benefit in the SICU but not in the MICU or mixed ICU units.25

As a result of these later studies, new recommendations from the American Association of Clinical Endocrinologists and the American Diabetes Association state that for optimal risk/benefit, the overall goal of inpatient treatment for most patients should be 140 mg/dL to 180 mg/dL, although a range of 110 mg/dL to 140 mg/dL may be appropriate for some patients.26 Stressed in this Consensus Statement is the need for experienced practitioners and systems to provide optimal implementation of protocols so as to provide adequate glycemic control without an undue amount of hypoglycemia. We have found that active individual patient management by experienced nurse practitioners who can modify existing protocols as needed provides better glycemic control with less hypoglycemia than nursing personnel adhering to a protocol without taking into account the myriad of factors affecting patients daily.16

Although hypoglycemia is certainly to be avoided and has been associated with increased mortality,6, 27 Kosiborod et al.7 showed that mortality in hyperglycemic patients following an acute myocardial infarction was not related to insulin‐induced hypoglycemia but to hypoglycemia unassociated with insulin use. In the latter case, the hypoglycemia is generally attributable to shock, sepsis, malnutrition, liver failure, renal failure, or multiorgan failure.

One of the potential hurdles to achievement of glycemic control in the critically ill is the labor‐intensive changes in patient care policies necessary to attain these goals. Particular concern lies in the ability of inpatient care providers to develop and implement successful insulin protocols. Intravenous insulin administration is effective and appropriate in the ICU and some non‐ICU settings, but administration of insulin subcutaneously is less nursing intensive and a more familiar hyperglycemia treatment option. However, glycemic control with subcutaneous insulin is only achieved using basal/bolus regimens and not with simple sliding‐scale regimens that omit basal insulin and attempt to treat rather than prevent hyperglycemia.28

In this issue of the Journal of Hospital Medicine, 3 articles deal with some of the practical aspects of inpatient hyperglycemia management. In ICU patients on continuous IV insulin infusions, Newton et al.29 demonstrated improved glycemic control without an increase in hypoglycemia when using a computer‐guided insulin algorithm using a hand‐held device (Glucommander) compared to a paper algorithm. A previous publication in JHM showed that when continuous insulin infusions were used on the regular hospital floors outside of the ICU, Smiley et al.30 found that 67% of patients achieved the targeted goal of <150 mg/dL by day 2. Wesorick et al.31 found that simply educating floor nurses as well as physicians and using standardized insulin protocols resulted in improved glycemic control and less hypoglycemia on inpatient services outside of the ICU. In the third paper, Ramos et al. found that those with glycosylated hemoglobin (HbA1c) levels >6.0%, a prior history of diabetes, or chronic steroid use did better with basal insulin than with no basal insulin when converting from insulin infusions.32 In contrast to their using only 40% of the stable insulin infusion rate for their basal dose, we found that 80% worked better.33 We also learned the hard way that overlap of the infusion by 2 hours to 4 hours after giving the basal insulin subcutaneous dose is just not carried out by the treating team because of timing and practical considerations. We now just give a dose of rapid acting insulin equal to 10% of the basal insulin dose at the time of the injection of the basal dose; this allows for the immediate cessation of the infusion without loss of glycemic control (Table 1).

Intensive insulin treatment in the ICU clearly results in better outcomes when compared to letting glucose levels remain greater than 200 mg/dL. A glucose target range of 140 mg/dL to 180 mg/dL provides improved mortality and morbidity with a low risk of hypoglycemia and is suitable for most hospitals. A more aggressive target range of 110 mg/dL to 140 mg/dL provides further improvement but increases the risk of hypoglycemia and would only be appropriate for those institutions with considerable experience with such therapy and demonstrated low rates of hypoglycemia. Work is still needed on devising the ideal treatment algorithm, regimens for conversion from IV to subcutaneous insulin, and discharge planning. However, the most important part of patient care we have found is the insertion of an intelligent and experienced brain between the patient and the insulin protocol.

Hyperglycemia that develops acutely due to illness is associated with poor patient outcomes in hospitalized inpatients, especially those critically ill in the intensive care unit (ICU).18 In fact, those without a prior diagnosis of diabetes and therefore newly found to have hyperglycemia have worse outcomes than those who have a prior diagnosis of diabetes.1, 2, 4, 68 Many mechanisms have been put forward to explain the adverse outcomes related to hyperglycemia, including the release of counter‐regulatory hormones, increased lipolysis with free fatty acid release, the release of inflammatory cytokines and growth factors, increased reactive oxygen species with oxidative stress and altered immunoglobulin, and neutrophil phagocytic function.911

The practical importance of this was brought home by Furnary et al.12, 13 who showed that glycemic control using 3 days of intensive intravenous (IV) insulin therapy of diabetic patients undergoing cardiac surgical procedures was able to reduce significantly the risk of deep sternal wound infections and mortality and to bring these adverse outcomes to the same levels as those of nondiabetic patients. However, the benefits of intensive insulin therapy are not limited to those with diabetes and extend to those with critical illness‐induced hyperglycemia. In a landmark, randomized, prospective study from Belgium, van den Berghe et al.14 showed that the use of an intensive IV insulin protocol designed to maintain serum blood glucose 80 mg/dL to 110 mg/dL significantly decreased morbidity and mortality following admission to the surgical ICU (SICU). Of note, only 13% of the individuals in the study had a previously known diagnosis of diabetes, showing that hyperglycemia was common following SICU admission and glycemic control was beneficial regardless of diabetes status.14

These impressive benefits1214 led to the call for improved glycemic control in the hospital with glucose targets similar to those used in the Belgian study.15 The development of protocols for such treatment proceeded rapidly.16, 17 A meta‐analysis that reviewed 14 trials through May 1, 2006 of patients in SICUs showed a 31% reduction in mortality with intensive therapy, albeit at the expense of a substantially increased risk of hypoglycemia.18 Our own studies19 using 1 day of continuous insulin infusion followed by subcutaneous basal/bolus insulin for all hyperglycemic patients following coronary artery bypass surgery showed results similar to those of Furnary et al.12, 13

Subsequently, 3 large, multicenter studies of patients in medical ICU (MICU) and SICUs, the VISEP, NICE‐SUGAR, and GLUCONTROL studies, failed to show the benefit of intensive insulin therapy on mortality and all had very high rates of hypoglycemia.2022 The VISEP20 study was stopped prematurely because of excessive hypoglycemia in the intensive treatment arm and the GLUCONTROL study was stopped prematurely because of multiple protocol violations.22 The NICE‐SUGAR study actually showed an increased mortality in the intensively treated group21 but the target range for their control group was 140 mg/dL to 180 mg/dL rather than 180 mg/dL to 215 mg/dL and this likely accounted for the better mortality in their control group compared to other studies. Van den Berghe et al.,23 in a design similar to their earlier one in the SICU, found that intensive insulin therapy in the MICU resulted in significant reductions in new onset renal injury, MICU and hospital length of stay, and an improved ability to wean off mechanical ventilation; however, no improvement in mortality was found except for those whose MICU stay was >3 days duration. In a post hoc analysis of their combined SICU and MICU studies, van den Berghe et al.23 found that a glucose target of 110 mg/dL to 150 mg/dL accounted for about 75% of the mortality benefit with a low risk of hypoglycemia.24 A recent meta‐analysis that included data on 13,567 patients from 26 trials, including the NICE‐SUGAR study, concluded that although overall there was no mortality benefit from intensive insulin therapy there was benefit in the SICU but not in the MICU or mixed ICU units.25

As a result of these later studies, new recommendations from the American Association of Clinical Endocrinologists and the American Diabetes Association state that for optimal risk/benefit, the overall goal of inpatient treatment for most patients should be 140 mg/dL to 180 mg/dL, although a range of 110 mg/dL to 140 mg/dL may be appropriate for some patients.26 Stressed in this Consensus Statement is the need for experienced practitioners and systems to provide optimal implementation of protocols so as to provide adequate glycemic control without an undue amount of hypoglycemia. We have found that active individual patient management by experienced nurse practitioners who can modify existing protocols as needed provides better glycemic control with less hypoglycemia than nursing personnel adhering to a protocol without taking into account the myriad of factors affecting patients daily.16

Although hypoglycemia is certainly to be avoided and has been associated with increased mortality,6, 27 Kosiborod et al.7 showed that mortality in hyperglycemic patients following an acute myocardial infarction was not related to insulin‐induced hypoglycemia but to hypoglycemia unassociated with insulin use. In the latter case, the hypoglycemia is generally attributable to shock, sepsis, malnutrition, liver failure, renal failure, or multiorgan failure.

One of the potential hurdles to achievement of glycemic control in the critically ill is the labor‐intensive changes in patient care policies necessary to attain these goals. Particular concern lies in the ability of inpatient care providers to develop and implement successful insulin protocols. Intravenous insulin administration is effective and appropriate in the ICU and some non‐ICU settings, but administration of insulin subcutaneously is less nursing intensive and a more familiar hyperglycemia treatment option. However, glycemic control with subcutaneous insulin is only achieved using basal/bolus regimens and not with simple sliding‐scale regimens that omit basal insulin and attempt to treat rather than prevent hyperglycemia.28

In this issue of the Journal of Hospital Medicine, 3 articles deal with some of the practical aspects of inpatient hyperglycemia management. In ICU patients on continuous IV insulin infusions, Newton et al.29 demonstrated improved glycemic control without an increase in hypoglycemia when using a computer‐guided insulin algorithm using a hand‐held device (Glucommander) compared to a paper algorithm. A previous publication in JHM showed that when continuous insulin infusions were used on the regular hospital floors outside of the ICU, Smiley et al.30 found that 67% of patients achieved the targeted goal of <150 mg/dL by day 2. Wesorick et al.31 found that simply educating floor nurses as well as physicians and using standardized insulin protocols resulted in improved glycemic control and less hypoglycemia on inpatient services outside of the ICU. In the third paper, Ramos et al. found that those with glycosylated hemoglobin (HbA1c) levels >6.0%, a prior history of diabetes, or chronic steroid use did better with basal insulin than with no basal insulin when converting from insulin infusions.32 In contrast to their using only 40% of the stable insulin infusion rate for their basal dose, we found that 80% worked better.33 We also learned the hard way that overlap of the infusion by 2 hours to 4 hours after giving the basal insulin subcutaneous dose is just not carried out by the treating team because of timing and practical considerations. We now just give a dose of rapid acting insulin equal to 10% of the basal insulin dose at the time of the injection of the basal dose; this allows for the immediate cessation of the infusion without loss of glycemic control (Table 1).

Intensive insulin treatment in the ICU clearly results in better outcomes when compared to letting glucose levels remain greater than 200 mg/dL. A glucose target range of 140 mg/dL to 180 mg/dL provides improved mortality and morbidity with a low risk of hypoglycemia and is suitable for most hospitals. A more aggressive target range of 110 mg/dL to 140 mg/dL provides further improvement but increases the risk of hypoglycemia and would only be appropriate for those institutions with considerable experience with such therapy and demonstrated low rates of hypoglycemia. Work is still needed on devising the ideal treatment algorithm, regimens for conversion from IV to subcutaneous insulin, and discharge planning. However, the most important part of patient care we have found is the insertion of an intelligent and experienced brain between the patient and the insulin protocol.

Hyperglycemia that develops acutely due to illness is associated with poor patient outcomes in hospitalized inpatients, especially those critically ill in the intensive care unit (ICU).18 In fact, those without a prior diagnosis of diabetes and therefore newly found to have hyperglycemia have worse outcomes than those who have a prior diagnosis of diabetes.1, 2, 4, 68 Many mechanisms have been put forward to explain the adverse outcomes related to hyperglycemia, including the release of counter‐regulatory hormones, increased lipolysis with free fatty acid release, the release of inflammatory cytokines and growth factors, increased reactive oxygen species with oxidative stress and altered immunoglobulin, and neutrophil phagocytic function.911

The practical importance of this was brought home by Furnary et al.12, 13 who showed that glycemic control using 3 days of intensive intravenous (IV) insulin therapy of diabetic patients undergoing cardiac surgical procedures was able to reduce significantly the risk of deep sternal wound infections and mortality and to bring these adverse outcomes to the same levels as those of nondiabetic patients. However, the benefits of intensive insulin therapy are not limited to those with diabetes and extend to those with critical illness‐induced hyperglycemia. In a landmark, randomized, prospective study from Belgium, van den Berghe et al.14 showed that the use of an intensive IV insulin protocol designed to maintain serum blood glucose 80 mg/dL to 110 mg/dL significantly decreased morbidity and mortality following admission to the surgical ICU (SICU). Of note, only 13% of the individuals in the study had a previously known diagnosis of diabetes, showing that hyperglycemia was common following SICU admission and glycemic control was beneficial regardless of diabetes status.14

These impressive benefits1214 led to the call for improved glycemic control in the hospital with glucose targets similar to those used in the Belgian study.15 The development of protocols for such treatment proceeded rapidly.16, 17 A meta‐analysis that reviewed 14 trials through May 1, 2006 of patients in SICUs showed a 31% reduction in mortality with intensive therapy, albeit at the expense of a substantially increased risk of hypoglycemia.18 Our own studies19 using 1 day of continuous insulin infusion followed by subcutaneous basal/bolus insulin for all hyperglycemic patients following coronary artery bypass surgery showed results similar to those of Furnary et al.12, 13

Subsequently, 3 large, multicenter studies of patients in medical ICU (MICU) and SICUs, the VISEP, NICE‐SUGAR, and GLUCONTROL studies, failed to show the benefit of intensive insulin therapy on mortality and all had very high rates of hypoglycemia.2022 The VISEP20 study was stopped prematurely because of excessive hypoglycemia in the intensive treatment arm and the GLUCONTROL study was stopped prematurely because of multiple protocol violations.22 The NICE‐SUGAR study actually showed an increased mortality in the intensively treated group21 but the target range for their control group was 140 mg/dL to 180 mg/dL rather than 180 mg/dL to 215 mg/dL and this likely accounted for the better mortality in their control group compared to other studies. Van den Berghe et al.,23 in a design similar to their earlier one in the SICU, found that intensive insulin therapy in the MICU resulted in significant reductions in new onset renal injury, MICU and hospital length of stay, and an improved ability to wean off mechanical ventilation; however, no improvement in mortality was found except for those whose MICU stay was >3 days duration. In a post hoc analysis of their combined SICU and MICU studies, van den Berghe et al.23 found that a glucose target of 110 mg/dL to 150 mg/dL accounted for about 75% of the mortality benefit with a low risk of hypoglycemia.24 A recent meta‐analysis that included data on 13,567 patients from 26 trials, including the NICE‐SUGAR study, concluded that although overall there was no mortality benefit from intensive insulin therapy there was benefit in the SICU but not in the MICU or mixed ICU units.25

As a result of these later studies, new recommendations from the American Association of Clinical Endocrinologists and the American Diabetes Association state that for optimal risk/benefit, the overall goal of inpatient treatment for most patients should be 140 mg/dL to 180 mg/dL, although a range of 110 mg/dL to 140 mg/dL may be appropriate for some patients.26 Stressed in this Consensus Statement is the need for experienced practitioners and systems to provide optimal implementation of protocols so as to provide adequate glycemic control without an undue amount of hypoglycemia. We have found that active individual patient management by experienced nurse practitioners who can modify existing protocols as needed provides better glycemic control with less hypoglycemia than nursing personnel adhering to a protocol without taking into account the myriad of factors affecting patients daily.16

Although hypoglycemia is certainly to be avoided and has been associated with increased mortality,6, 27 Kosiborod et al.7 showed that mortality in hyperglycemic patients following an acute myocardial infarction was not related to insulin‐induced hypoglycemia but to hypoglycemia unassociated with insulin use. In the latter case, the hypoglycemia is generally attributable to shock, sepsis, malnutrition, liver failure, renal failure, or multiorgan failure.

One of the potential hurdles to achievement of glycemic control in the critically ill is the labor‐intensive changes in patient care policies necessary to attain these goals. Particular concern lies in the ability of inpatient care providers to develop and implement successful insulin protocols. Intravenous insulin administration is effective and appropriate in the ICU and some non‐ICU settings, but administration of insulin subcutaneously is less nursing intensive and a more familiar hyperglycemia treatment option. However, glycemic control with subcutaneous insulin is only achieved using basal/bolus regimens and not with simple sliding‐scale regimens that omit basal insulin and attempt to treat rather than prevent hyperglycemia.28

In this issue of the Journal of Hospital Medicine, 3 articles deal with some of the practical aspects of inpatient hyperglycemia management. In ICU patients on continuous IV insulin infusions, Newton et al.29 demonstrated improved glycemic control without an increase in hypoglycemia when using a computer‐guided insulin algorithm using a hand‐held device (Glucommander) compared to a paper algorithm. A previous publication in JHM showed that when continuous insulin infusions were used on the regular hospital floors outside of the ICU, Smiley et al.30 found that 67% of patients achieved the targeted goal of <150 mg/dL by day 2. Wesorick et al.31 found that simply educating floor nurses as well as physicians and using standardized insulin protocols resulted in improved glycemic control and less hypoglycemia on inpatient services outside of the ICU. In the third paper, Ramos et al. found that those with glycosylated hemoglobin (HbA1c) levels >6.0%, a prior history of diabetes, or chronic steroid use did better with basal insulin than with no basal insulin when converting from insulin infusions.32 In contrast to their using only 40% of the stable insulin infusion rate for their basal dose, we found that 80% worked better.33 We also learned the hard way that overlap of the infusion by 2 hours to 4 hours after giving the basal insulin subcutaneous dose is just not carried out by the treating team because of timing and practical considerations. We now just give a dose of rapid acting insulin equal to 10% of the basal insulin dose at the time of the injection of the basal dose; this allows for the immediate cessation of the infusion without loss of glycemic control (Table 1).

Intensive insulin treatment in the ICU clearly results in better outcomes when compared to letting glucose levels remain greater than 200 mg/dL. A glucose target range of 140 mg/dL to 180 mg/dL provides improved mortality and morbidity with a low risk of hypoglycemia and is suitable for most hospitals. A more aggressive target range of 110 mg/dL to 140 mg/dL provides further improvement but increases the risk of hypoglycemia and would only be appropriate for those institutions with considerable experience with such therapy and demonstrated low rates of hypoglycemia. Work is still needed on devising the ideal treatment algorithm, regimens for conversion from IV to subcutaneous insulin, and discharge planning. However, the most important part of patient care we have found is the insertion of an intelligent and experienced brain between the patient and the insulin protocol.