Editorial

As a hospitalist of about 6 years, I enjoy hospital medicine and hope, over the course of my career, to see it develop into an increasingly respected, diverse, and influential specialty. There is abundant evidence that this is occurring, primarily through the praiseworthy efforts of the leadership and members of the Society of Hospital Medicine (SHM). Efforts to prove our value to inpatient care and align ourselves with quality improvement, as promoted early in the hospitalist movement,2 are coming to fruition. However, I would like to raise a flag of concern; and this is based on my experience working as a hospitalist in 10 community hospitals in 5 states, including positions as a locum tenens hospitalist, staff hospitalist, medical director of a hospitalist group, and full‐time teaching hospitalist for a community hospital residency program. I believe that hospitalists, particularly those working in community hospitals (approximately 80% of all hospitalists),3 are currently at a critical crossroad, with the option of either actively expanding their clinical, administrative, and quality improvement roles or allowing these roles to stagnate or atrophy. As in any career, we are, like Alice, perched on a mushroom, one side of which will make us grow taller and the other side of which will make us grow shorter. Which side are we choosing in our careers as hospitalists?

Hospitalists currently have numerous opportunities to expand their clinical, administrative, and quality improvement roles and responsibilities (Table 1), and these opportunities are in full alignment with the mission statement of SHM: to promote the highest quality of care for all hospitalized patients.4 My concern is that, for one reason or another, hospitalists in some settings are shrinking away from roles that they could or should fill, and this is a trend that I believe could affect our specialty adversely over time and that we, as an organization, should find ways to prevent. Although family medicine and traditional internal medicine physicians who work in the hospital face similar challenges, if we as hospitalists wish to qualify one day as board‐certified hospital medicine specialists, we are obligated to develop knowledge and skill sets that are truly unique to our profession.5 Holding to this goal, we cannot settle into a narrow comfort zone. I believe that the development of the hospital medicine core competencies by SHM6 was an important step in helping us define our intended reach, but even so, what are the specific growth factors or inhibitors that are influencing the expansion or shrinking of hospitalists and hospital medicine groups?

On the basis of my observations, I believe that this problem is due in large part to a misalignment of incentives. Specifically, I believe that the expansion of hospitalist roles and responsibilities is often counteraligned with the bottom‐line productivity goals of the group. That is, to maintain high productivity, a hospitalist has a tendency to minimize his or her role in ways that save time. For example, there may be a tendency to overuse subspecialty consultations, which can take away some of the burden of complex clinical decision making, or to quickly transfer patients that are sicker and require more time to a higher level of care (if available). There may also be a tendency to avoid performing inpatient procedures (a significant part of the core competencies) because of time constraints and the demands of a higher census. Excessively rapid rounding results, and this diminishes other claimed benefits of the hospitalist model of care: patient satisfaction, safety, quality, and communication. Length‐of‐stay measures also suffer as productivity exceeds the limits of efficient care. Moreover, in such a productivity‐based environment, there is certainly no incentive for hospitalists to become enthusiastically involved in hospital committees, education, or quality improvement efforts, all of which are critical to the development of hospital medicine as a unique subspecialty. In essence, the incentive to expand one's role as a hospitalist in such a setting is almost completely absent, and I believe that this puts the future influence and reach of our specialty at significant risk.

Particularly as hospitals face increasing scrutiny about their quality and safety, and especially as the costs of hospital care increase and reimbursements threaten to decline, the value of hospitalists to the hospital has become different from that of all other physicians. Their value lies not in sheer productivity but in their ability to improve the cost, quality, efficiency, and safety of inpatient care simultaneously. If hospitalists settle into or are forced into a lesser role, hospital medicine will not be worthy of consideration as a unique subspecialty. Some of the remaining roles of the shrunken hospitalist may, at some point and in some settings, shift to nonphysicians,7 with a decline in the ratio of physicians to mid‐level providers in hospital medicine programs, and the jobs of some hospitalists will be effectively eliminated. Market forces will lead to improved training of mid‐level providers, allowing hospitals to fill inpatient care needs in a more cost‐effective way.

Having worked with some very capable nurse practitioners in 4 different community hospitals, I believe that a well‐trained mid‐level provider, with appropriate physician backup, can effectively manage many of the typical general medical admissions and surgical consultations seen in a community hospital setting. I admit that this may not be the case in larger referral centers or academic medical centers.

In developing and defining this new specialty and also in training new physicians for the field, we do not want to lose this transient opportunity to define ourselves as broadly as possible, pushing beyond traditional internal medicine to new areas of inpatient care and management and managing more complex conditions than a traditional primary care physician would typically manage, conditions that have always fallen within the broad spectrum of inpatient internal medicine (Table 2). If we instead develop a tendency to admit, consult, and walk away and do not have the time or appropriate incentives to expand our roles in other important ways (noted in Table 1) because of a focus on productivity, what is our specialty destined to become?

That said, how can incentives be restructured to encourage hospitalists to expand their universe? Perhaps the simplest way of influencing the incentive structure of hospital medicine programs is more selectivity in the choice of jobs: seeking out jobs that offer us clear incentives (typically financial) to expand our universe by rewarding efforts to improve the quality, safety, and efficiency of inpatient care. According to the SHM 20052006 survey, about two‐thirds of responding hospital medicine programs reimbursed their physicians with a mix of salary and productivity/performance bonuses, with productivity being the dominant incentive (more than 80%). However, bonuses based on quality/efficiency measures were also being rewarded (about 60%), as well as bonuses for committee or project work (about 25%). Of all responding groups, that leaves about 60% of programs with no financial incentives for quality/efficiency measures. There is certainly room for progress in this area, and we can influence the process positively by requesting that such incentives be added to our contract before making a final commitment to a job or by negotiating changes to our current incentive structure at the time of contract renewal. This would be in the best interest of our individual careers as well as our specialty.

As we consider different job opportunities, we may also wish to consider the possible effect of the employment model on the incentive structure. Although it may seem logical that hospital‐employed groups would have broader goals than independent groups and thus might be more motivated to provide proper incentives, I do not believe that this is the case universally. Conversely, private groups who might be expected to focus more on productivity measures may actually offer excellent growth‐promoting incentives. In either case, careful consideration of the incentive structure is warranted when we choose to work in a given employment model.

Perhaps another way of encouraging hospitalists to expand their role would be through a program of national recognition, potentially established by SHM, that would allow individual hospitalists to formally claim specialization in a particular area of hospital medicine and benefit from such distinctions. For example, a hospitalist that was particularly proficient with inpatient procedures could submit documentation of procedures completed in a given time period and subsequently receive a formal designation as a certified procedural hospitalist or something similar. Alternatively, a hospitalist who preferred to focus on quality improvement efforts could submit information regarding his involvement with quality improvement initiatives and results and, on the basis of defined criteria, receive a formal designation as a quality improvement hospitalist. This approach could apply to any area of focus, and more than one designation could be achieved by each hospitalist. As the specialty of hospital medicine matures, these designations (similar to academic rank) could eventually correlate with salary ranges or incentive bonuses as hospitals learned to value the diverse skills of individual hospitalists.

Discouraging overconsultation of subspecialists while concurrently encouraging the broadening of our clinical skills is particularly difficult to address. The only solution to this issue that I can imagine would be to somehow align physician reimbursement more closely to the actual complexity of and time spent in managing patients with multiple comorbidities. Currently, the actual hospitalist physician reimbursement for subsequent visits of patients, with or without subspecialists involved, likely does not vary much. However, if hospitalists knew their extra effort in managing more complex conditions would be reimbursed differently (ie, billing for critical care time), they would certainly tend to broaden their practice to the benefit of their careers and the future of the specialty.

In summary, I believe that misaligned incentives are causing some hospitalists to underestimate their potential; this has the potential to adversely affect the future of the specialty of hospital medicine. I hope that this opinion will serve to generate discussion on the potential origins of and solutions to this problem and ultimately promote the future expansion of our hospital medicine universe, so that we do not find ourselves in Alice's predicament:

As a hospitalist of about 6 years, I enjoy hospital medicine and hope, over the course of my career, to see it develop into an increasingly respected, diverse, and influential specialty. There is abundant evidence that this is occurring, primarily through the praiseworthy efforts of the leadership and members of the Society of Hospital Medicine (SHM). Efforts to prove our value to inpatient care and align ourselves with quality improvement, as promoted early in the hospitalist movement,2 are coming to fruition. However, I would like to raise a flag of concern; and this is based on my experience working as a hospitalist in 10 community hospitals in 5 states, including positions as a locum tenens hospitalist, staff hospitalist, medical director of a hospitalist group, and full‐time teaching hospitalist for a community hospital residency program. I believe that hospitalists, particularly those working in community hospitals (approximately 80% of all hospitalists),3 are currently at a critical crossroad, with the option of either actively expanding their clinical, administrative, and quality improvement roles or allowing these roles to stagnate or atrophy. As in any career, we are, like Alice, perched on a mushroom, one side of which will make us grow taller and the other side of which will make us grow shorter. Which side are we choosing in our careers as hospitalists?

Hospitalists currently have numerous opportunities to expand their clinical, administrative, and quality improvement roles and responsibilities (Table 1), and these opportunities are in full alignment with the mission statement of SHM: to promote the highest quality of care for all hospitalized patients.4 My concern is that, for one reason or another, hospitalists in some settings are shrinking away from roles that they could or should fill, and this is a trend that I believe could affect our specialty adversely over time and that we, as an organization, should find ways to prevent. Although family medicine and traditional internal medicine physicians who work in the hospital face similar challenges, if we as hospitalists wish to qualify one day as board‐certified hospital medicine specialists, we are obligated to develop knowledge and skill sets that are truly unique to our profession.5 Holding to this goal, we cannot settle into a narrow comfort zone. I believe that the development of the hospital medicine core competencies by SHM6 was an important step in helping us define our intended reach, but even so, what are the specific growth factors or inhibitors that are influencing the expansion or shrinking of hospitalists and hospital medicine groups?

On the basis of my observations, I believe that this problem is due in large part to a misalignment of incentives. Specifically, I believe that the expansion of hospitalist roles and responsibilities is often counteraligned with the bottom‐line productivity goals of the group. That is, to maintain high productivity, a hospitalist has a tendency to minimize his or her role in ways that save time. For example, there may be a tendency to overuse subspecialty consultations, which can take away some of the burden of complex clinical decision making, or to quickly transfer patients that are sicker and require more time to a higher level of care (if available). There may also be a tendency to avoid performing inpatient procedures (a significant part of the core competencies) because of time constraints and the demands of a higher census. Excessively rapid rounding results, and this diminishes other claimed benefits of the hospitalist model of care: patient satisfaction, safety, quality, and communication. Length‐of‐stay measures also suffer as productivity exceeds the limits of efficient care. Moreover, in such a productivity‐based environment, there is certainly no incentive for hospitalists to become enthusiastically involved in hospital committees, education, or quality improvement efforts, all of which are critical to the development of hospital medicine as a unique subspecialty. In essence, the incentive to expand one's role as a hospitalist in such a setting is almost completely absent, and I believe that this puts the future influence and reach of our specialty at significant risk.

Particularly as hospitals face increasing scrutiny about their quality and safety, and especially as the costs of hospital care increase and reimbursements threaten to decline, the value of hospitalists to the hospital has become different from that of all other physicians. Their value lies not in sheer productivity but in their ability to improve the cost, quality, efficiency, and safety of inpatient care simultaneously. If hospitalists settle into or are forced into a lesser role, hospital medicine will not be worthy of consideration as a unique subspecialty. Some of the remaining roles of the shrunken hospitalist may, at some point and in some settings, shift to nonphysicians,7 with a decline in the ratio of physicians to mid‐level providers in hospital medicine programs, and the jobs of some hospitalists will be effectively eliminated. Market forces will lead to improved training of mid‐level providers, allowing hospitals to fill inpatient care needs in a more cost‐effective way.

Having worked with some very capable nurse practitioners in 4 different community hospitals, I believe that a well‐trained mid‐level provider, with appropriate physician backup, can effectively manage many of the typical general medical admissions and surgical consultations seen in a community hospital setting. I admit that this may not be the case in larger referral centers or academic medical centers.

In developing and defining this new specialty and also in training new physicians for the field, we do not want to lose this transient opportunity to define ourselves as broadly as possible, pushing beyond traditional internal medicine to new areas of inpatient care and management and managing more complex conditions than a traditional primary care physician would typically manage, conditions that have always fallen within the broad spectrum of inpatient internal medicine (Table 2). If we instead develop a tendency to admit, consult, and walk away and do not have the time or appropriate incentives to expand our roles in other important ways (noted in Table 1) because of a focus on productivity, what is our specialty destined to become?

That said, how can incentives be restructured to encourage hospitalists to expand their universe? Perhaps the simplest way of influencing the incentive structure of hospital medicine programs is more selectivity in the choice of jobs: seeking out jobs that offer us clear incentives (typically financial) to expand our universe by rewarding efforts to improve the quality, safety, and efficiency of inpatient care. According to the SHM 20052006 survey, about two‐thirds of responding hospital medicine programs reimbursed their physicians with a mix of salary and productivity/performance bonuses, with productivity being the dominant incentive (more than 80%). However, bonuses based on quality/efficiency measures were also being rewarded (about 60%), as well as bonuses for committee or project work (about 25%). Of all responding groups, that leaves about 60% of programs with no financial incentives for quality/efficiency measures. There is certainly room for progress in this area, and we can influence the process positively by requesting that such incentives be added to our contract before making a final commitment to a job or by negotiating changes to our current incentive structure at the time of contract renewal. This would be in the best interest of our individual careers as well as our specialty.

As we consider different job opportunities, we may also wish to consider the possible effect of the employment model on the incentive structure. Although it may seem logical that hospital‐employed groups would have broader goals than independent groups and thus might be more motivated to provide proper incentives, I do not believe that this is the case universally. Conversely, private groups who might be expected to focus more on productivity measures may actually offer excellent growth‐promoting incentives. In either case, careful consideration of the incentive structure is warranted when we choose to work in a given employment model.

Perhaps another way of encouraging hospitalists to expand their role would be through a program of national recognition, potentially established by SHM, that would allow individual hospitalists to formally claim specialization in a particular area of hospital medicine and benefit from such distinctions. For example, a hospitalist that was particularly proficient with inpatient procedures could submit documentation of procedures completed in a given time period and subsequently receive a formal designation as a certified procedural hospitalist or something similar. Alternatively, a hospitalist who preferred to focus on quality improvement efforts could submit information regarding his involvement with quality improvement initiatives and results and, on the basis of defined criteria, receive a formal designation as a quality improvement hospitalist. This approach could apply to any area of focus, and more than one designation could be achieved by each hospitalist. As the specialty of hospital medicine matures, these designations (similar to academic rank) could eventually correlate with salary ranges or incentive bonuses as hospitals learned to value the diverse skills of individual hospitalists.

Discouraging overconsultation of subspecialists while concurrently encouraging the broadening of our clinical skills is particularly difficult to address. The only solution to this issue that I can imagine would be to somehow align physician reimbursement more closely to the actual complexity of and time spent in managing patients with multiple comorbidities. Currently, the actual hospitalist physician reimbursement for subsequent visits of patients, with or without subspecialists involved, likely does not vary much. However, if hospitalists knew their extra effort in managing more complex conditions would be reimbursed differently (ie, billing for critical care time), they would certainly tend to broaden their practice to the benefit of their careers and the future of the specialty.

In summary, I believe that misaligned incentives are causing some hospitalists to underestimate their potential; this has the potential to adversely affect the future of the specialty of hospital medicine. I hope that this opinion will serve to generate discussion on the potential origins of and solutions to this problem and ultimately promote the future expansion of our hospital medicine universe, so that we do not find ourselves in Alice's predicament:

As a hospitalist of about 6 years, I enjoy hospital medicine and hope, over the course of my career, to see it develop into an increasingly respected, diverse, and influential specialty. There is abundant evidence that this is occurring, primarily through the praiseworthy efforts of the leadership and members of the Society of Hospital Medicine (SHM). Efforts to prove our value to inpatient care and align ourselves with quality improvement, as promoted early in the hospitalist movement,2 are coming to fruition. However, I would like to raise a flag of concern; and this is based on my experience working as a hospitalist in 10 community hospitals in 5 states, including positions as a locum tenens hospitalist, staff hospitalist, medical director of a hospitalist group, and full‐time teaching hospitalist for a community hospital residency program. I believe that hospitalists, particularly those working in community hospitals (approximately 80% of all hospitalists),3 are currently at a critical crossroad, with the option of either actively expanding their clinical, administrative, and quality improvement roles or allowing these roles to stagnate or atrophy. As in any career, we are, like Alice, perched on a mushroom, one side of which will make us grow taller and the other side of which will make us grow shorter. Which side are we choosing in our careers as hospitalists?

Hospitalists currently have numerous opportunities to expand their clinical, administrative, and quality improvement roles and responsibilities (Table 1), and these opportunities are in full alignment with the mission statement of SHM: to promote the highest quality of care for all hospitalized patients.4 My concern is that, for one reason or another, hospitalists in some settings are shrinking away from roles that they could or should fill, and this is a trend that I believe could affect our specialty adversely over time and that we, as an organization, should find ways to prevent. Although family medicine and traditional internal medicine physicians who work in the hospital face similar challenges, if we as hospitalists wish to qualify one day as board‐certified hospital medicine specialists, we are obligated to develop knowledge and skill sets that are truly unique to our profession.5 Holding to this goal, we cannot settle into a narrow comfort zone. I believe that the development of the hospital medicine core competencies by SHM6 was an important step in helping us define our intended reach, but even so, what are the specific growth factors or inhibitors that are influencing the expansion or shrinking of hospitalists and hospital medicine groups?

On the basis of my observations, I believe that this problem is due in large part to a misalignment of incentives. Specifically, I believe that the expansion of hospitalist roles and responsibilities is often counteraligned with the bottom‐line productivity goals of the group. That is, to maintain high productivity, a hospitalist has a tendency to minimize his or her role in ways that save time. For example, there may be a tendency to overuse subspecialty consultations, which can take away some of the burden of complex clinical decision making, or to quickly transfer patients that are sicker and require more time to a higher level of care (if available). There may also be a tendency to avoid performing inpatient procedures (a significant part of the core competencies) because of time constraints and the demands of a higher census. Excessively rapid rounding results, and this diminishes other claimed benefits of the hospitalist model of care: patient satisfaction, safety, quality, and communication. Length‐of‐stay measures also suffer as productivity exceeds the limits of efficient care. Moreover, in such a productivity‐based environment, there is certainly no incentive for hospitalists to become enthusiastically involved in hospital committees, education, or quality improvement efforts, all of which are critical to the development of hospital medicine as a unique subspecialty. In essence, the incentive to expand one's role as a hospitalist in such a setting is almost completely absent, and I believe that this puts the future influence and reach of our specialty at significant risk.

Particularly as hospitals face increasing scrutiny about their quality and safety, and especially as the costs of hospital care increase and reimbursements threaten to decline, the value of hospitalists to the hospital has become different from that of all other physicians. Their value lies not in sheer productivity but in their ability to improve the cost, quality, efficiency, and safety of inpatient care simultaneously. If hospitalists settle into or are forced into a lesser role, hospital medicine will not be worthy of consideration as a unique subspecialty. Some of the remaining roles of the shrunken hospitalist may, at some point and in some settings, shift to nonphysicians,7 with a decline in the ratio of physicians to mid‐level providers in hospital medicine programs, and the jobs of some hospitalists will be effectively eliminated. Market forces will lead to improved training of mid‐level providers, allowing hospitals to fill inpatient care needs in a more cost‐effective way.

Having worked with some very capable nurse practitioners in 4 different community hospitals, I believe that a well‐trained mid‐level provider, with appropriate physician backup, can effectively manage many of the typical general medical admissions and surgical consultations seen in a community hospital setting. I admit that this may not be the case in larger referral centers or academic medical centers.

In developing and defining this new specialty and also in training new physicians for the field, we do not want to lose this transient opportunity to define ourselves as broadly as possible, pushing beyond traditional internal medicine to new areas of inpatient care and management and managing more complex conditions than a traditional primary care physician would typically manage, conditions that have always fallen within the broad spectrum of inpatient internal medicine (Table 2). If we instead develop a tendency to admit, consult, and walk away and do not have the time or appropriate incentives to expand our roles in other important ways (noted in Table 1) because of a focus on productivity, what is our specialty destined to become?

That said, how can incentives be restructured to encourage hospitalists to expand their universe? Perhaps the simplest way of influencing the incentive structure of hospital medicine programs is more selectivity in the choice of jobs: seeking out jobs that offer us clear incentives (typically financial) to expand our universe by rewarding efforts to improve the quality, safety, and efficiency of inpatient care. According to the SHM 20052006 survey, about two‐thirds of responding hospital medicine programs reimbursed their physicians with a mix of salary and productivity/performance bonuses, with productivity being the dominant incentive (more than 80%). However, bonuses based on quality/efficiency measures were also being rewarded (about 60%), as well as bonuses for committee or project work (about 25%). Of all responding groups, that leaves about 60% of programs with no financial incentives for quality/efficiency measures. There is certainly room for progress in this area, and we can influence the process positively by requesting that such incentives be added to our contract before making a final commitment to a job or by negotiating changes to our current incentive structure at the time of contract renewal. This would be in the best interest of our individual careers as well as our specialty.

As we consider different job opportunities, we may also wish to consider the possible effect of the employment model on the incentive structure. Although it may seem logical that hospital‐employed groups would have broader goals than independent groups and thus might be more motivated to provide proper incentives, I do not believe that this is the case universally. Conversely, private groups who might be expected to focus more on productivity measures may actually offer excellent growth‐promoting incentives. In either case, careful consideration of the incentive structure is warranted when we choose to work in a given employment model.

Perhaps another way of encouraging hospitalists to expand their role would be through a program of national recognition, potentially established by SHM, that would allow individual hospitalists to formally claim specialization in a particular area of hospital medicine and benefit from such distinctions. For example, a hospitalist that was particularly proficient with inpatient procedures could submit documentation of procedures completed in a given time period and subsequently receive a formal designation as a certified procedural hospitalist or something similar. Alternatively, a hospitalist who preferred to focus on quality improvement efforts could submit information regarding his involvement with quality improvement initiatives and results and, on the basis of defined criteria, receive a formal designation as a quality improvement hospitalist. This approach could apply to any area of focus, and more than one designation could be achieved by each hospitalist. As the specialty of hospital medicine matures, these designations (similar to academic rank) could eventually correlate with salary ranges or incentive bonuses as hospitals learned to value the diverse skills of individual hospitalists.

Discouraging overconsultation of subspecialists while concurrently encouraging the broadening of our clinical skills is particularly difficult to address. The only solution to this issue that I can imagine would be to somehow align physician reimbursement more closely to the actual complexity of and time spent in managing patients with multiple comorbidities. Currently, the actual hospitalist physician reimbursement for subsequent visits of patients, with or without subspecialists involved, likely does not vary much. However, if hospitalists knew their extra effort in managing more complex conditions would be reimbursed differently (ie, billing for critical care time), they would certainly tend to broaden their practice to the benefit of their careers and the future of the specialty.

In summary, I believe that misaligned incentives are causing some hospitalists to underestimate their potential; this has the potential to adversely affect the future of the specialty of hospital medicine. I hope that this opinion will serve to generate discussion on the potential origins of and solutions to this problem and ultimately promote the future expansion of our hospital medicine universe, so that we do not find ourselves in Alice's predicament:

Accelerating the development of clinical research in academic hospitalist programs is a worthwhile goal if pursued with clarity, objectivity, and a thorough understanding of the process and its implications. In their articles, Flanders et al.1 and Wright et al.2 identify major barriers to growing academic hospitalist programs. These barriers include the need for protected time, the shortage of trained research faculty, the lack of infrastructure, and the limited availability of senior mentors. Both Flanders et al. and Wright et al. offer smart and innovative ways of addressing these issues. However, building an academic program from the ground up is more complex and challenging than it may seem at first glance. It takes time, patience, creativity, diplomacy, and the ability to recruit collaborators and advocates who are willing to share infrastructure and resources.

Although both articles add significantly to the discussion of strategies for creating an academic hospitalist program, they are unclear about the definition of academic in this context. The term academic is often misunderstood to be synonymous with research. However, research is just one component of an academic program, which also includes education, quality improvement (QI), administration, and program development. It may be helpful, therefore, to replace academic with scholarship, which can be defined as a process that involves peer review and dissemination of ideas at local, regional, and national levels. Scholarship also goes beyond research, encompassing education and other areas such as QI. Although academic programs are not necessarily involved with funded research, there is usually an expectation of peer review, through either presentations at regional and national meetings or publication. For the purposes of this discussion, the term academic hospitalist program will be defined broadly to include any program affiliated with a university that is involved in the teaching of residents and medical students and whose faculty is required to participate in a promotions process.

All members of an academic division should be expected to participate in scholarship, whether it is education, QI projects, or research. If there is a strong expectation that traditional National Institute of Health (NIH) funded research will take place, this expectation must come with sufficient resources. Without infrastructure for research and investment in research faculty, procuring NIH funds for research is not a reasonable expectation. Organizers of hospitalist programs currently within academic divisions of general internal medicine should consider ways to better integrate programs into the existing research infrastructure in their divisions. For either freestanding hospitalist programs or programs within academic divisions of general internal medicine, investments in infrastructure and faculty are needed to nurture this area of research and build an academic focus in hospital medicine. However, if obtaining NIH research funds is not the expectation and resources are not available for hospitalists or for any other division or department at that institution, then academic expectations should focus on other pursuits. Examples include participation in the education and QI initiatives.

For programs with expectations of both funded research and other scholarship, a successful program will most likely include a small core of skilled clinical researchers working closely with well‐trained clinical educators, all of whom are involved in scholarship. Both clinical educators and researchers need to be continuously developing, and to reach their full potential, all should have access to infrastructure that supports these activities, including resources such as MPH‐level project managers, research assistants, database managers, and, most importantly, appropriate mentors.

Clinician educators must be both proficient clinicians and dedicated teachers. Ideally, they should have strong familiarity with educational theory in addition to skills in hands‐on teaching. Their responsibilities include mastering the skills that students need, staying up to the minute in their areas of expertise, and serving as role models in their attitudes toward patients, colleagues, and their work.3 Many hospitalists may not have these skills when they begin, often fresh out of residency, and will need help developing them.

PROTECTED TIME

Protected time is crucial to the success of any academic program. Finding this time presents a challenge for any clinical group, but the challenge is exacerbated for hospitalists, who face tremendous pressure to serve full‐time clinical jobs with little emphasis on academic elements such as education, QI, and participation in funded research. As both Wright et al.2 and Flanders et al.1 point out, to build a group of well‐developed academic clinician educators, academic hospitalists not on track for funding need to be given adequate protected time to participate in committees, sharpen their teaching skills, develop QI projects that can be converted to scholarships, participate in research, and present at national and regional meetings.

The requirements of protected time for researchers are more challenging than those for educators. Building a newly funded research unit within a hospitalist group, as with any group, will entail hiring fellowship trained faculty with significant protected time (approximately 80%) to give them time to obtain funding such as a K award and eventually become independent investigators with RO1 grant funding. Building research units requires support from collaborators with infrastructure and mentors already in place that can be tapped during the incubation stage of the academic program. For most hospitalist programs, infrastructure and mentors will be found in their divisions of general internal medicine.

Protected time should be considered an integral element of academic hospitalist positionsnot a perkas long as the time is used responsibly and productively. As both Wright et al.2 and Flanders et al.1 correctly point out, herein lies the major challenge of creating any kind of academic program: How will the program support protected time for both educators and researchers? In most instances, significant seed money will be needed to support junior faculty over the first few years of their careers. It is noteworthy that building a federally funded hospital medicine research program will be particularly difficult in today's economy because funding levels at the NIH, Agency for Healthcare Research and Quality, Health Resources and Services Administration, and other traditional funders of clinical research either are flat or have been reduced dramatically.

To many Academic Medical Centers (AMC), it may not be immediately obvious why a strong Academic Hospitalist program is in their economic best interest. Hospitalist programs may confront consistently high levels of turnover and a shrinking supply of general internists. The associated high costs of hiring new, junior faculty include the time and effort needed to interview, credential, train, and most importantly build familiarity with the complex systems encountered in maneuvering through a hospital, especially one with widespread dissemination of electronic medical records for documentation and order entry. However, hospitalists provided with opportunities for academic development are more likely to stay on the job longer and perform at a higher level, providing convincing motivation for hospitals to invest in their academic hospitalist programs. Retaining high‐quality hospitalists may be one of the most cost‐efficient methods for an AMC to support a hospital medicine program.

STRATEGIES IN ACTION

Flanders et al.1 point to a shortage of well‐trained clinician investigators with a focus on inpatient research as a barrier to the development of academic hospitalist programming. They describe a strategy of collaboration with specialty groups. This highlights the importance of collaboration with more well‐established research units as a key ingredient to building a new academic unit. Wright et al.2 describe their mentorship program and how they created protected time for scholarship for hospitalists, including supporting mentors' time. These examples highlight another key benchmark of a viable academic program, mentoring, and the importance of ensuring that mentors have time for this essential effort.

However, it is critically important to remember that all politics is local, to quote the late Tip O'Neill, long‐time speaker of the US House of Representatives. What works in one setting may not work as well in a different contexthence the need for creativity and political acumen.

For example, although the specialty‐group collaboration described by Flanders et al.1 may be helpful in one setting, other strategic alliances may work on a larger scale and over a longer time period. Most hospital medicine groups are currently within academic divisions of general internal medicine, where infrastructure and mentoring may already exist for both research and educational scholarship. In those cases, fostering interaction between the division's hospitalists and its researchers would be a critical first step. The programming and growth developed in this way can be leveraged to support ongoing academic activities by hospitalists rather than being limited to a single project.

In the Division of General Internal Medicine at Mount Sinai, which houses the academic hospitalists, building research entailed collaboration with the well‐established Departments of Geriatrics and Health Policy, which had preexisting research infrastructure and mentors. At the same time, we developed a research fellowship program by applying jointly with the Division of General Pediatrics for federal grant support. Such diversity of collaboration enhanced our application.

LOOKING AHEAD

Putting the academic into academic hospitalist programs is the key to the future of hospital medicine. To be successful, one must consider all the issues described in light of available resources and the local and federal political landscape. As Flanders et al.1 and Wright et al.2 emphasize, collaboration will be the main component for success in the current academic landscape.

Accelerating the development of clinical research in academic hospitalist programs is a worthwhile goal if pursued with clarity, objectivity, and a thorough understanding of the process and its implications. In their articles, Flanders et al.1 and Wright et al.2 identify major barriers to growing academic hospitalist programs. These barriers include the need for protected time, the shortage of trained research faculty, the lack of infrastructure, and the limited availability of senior mentors. Both Flanders et al. and Wright et al. offer smart and innovative ways of addressing these issues. However, building an academic program from the ground up is more complex and challenging than it may seem at first glance. It takes time, patience, creativity, diplomacy, and the ability to recruit collaborators and advocates who are willing to share infrastructure and resources.

Although both articles add significantly to the discussion of strategies for creating an academic hospitalist program, they are unclear about the definition of academic in this context. The term academic is often misunderstood to be synonymous with research. However, research is just one component of an academic program, which also includes education, quality improvement (QI), administration, and program development. It may be helpful, therefore, to replace academic with scholarship, which can be defined as a process that involves peer review and dissemination of ideas at local, regional, and national levels. Scholarship also goes beyond research, encompassing education and other areas such as QI. Although academic programs are not necessarily involved with funded research, there is usually an expectation of peer review, through either presentations at regional and national meetings or publication. For the purposes of this discussion, the term academic hospitalist program will be defined broadly to include any program affiliated with a university that is involved in the teaching of residents and medical students and whose faculty is required to participate in a promotions process.

All members of an academic division should be expected to participate in scholarship, whether it is education, QI projects, or research. If there is a strong expectation that traditional National Institute of Health (NIH) funded research will take place, this expectation must come with sufficient resources. Without infrastructure for research and investment in research faculty, procuring NIH funds for research is not a reasonable expectation. Organizers of hospitalist programs currently within academic divisions of general internal medicine should consider ways to better integrate programs into the existing research infrastructure in their divisions. For either freestanding hospitalist programs or programs within academic divisions of general internal medicine, investments in infrastructure and faculty are needed to nurture this area of research and build an academic focus in hospital medicine. However, if obtaining NIH research funds is not the expectation and resources are not available for hospitalists or for any other division or department at that institution, then academic expectations should focus on other pursuits. Examples include participation in the education and QI initiatives.

For programs with expectations of both funded research and other scholarship, a successful program will most likely include a small core of skilled clinical researchers working closely with well‐trained clinical educators, all of whom are involved in scholarship. Both clinical educators and researchers need to be continuously developing, and to reach their full potential, all should have access to infrastructure that supports these activities, including resources such as MPH‐level project managers, research assistants, database managers, and, most importantly, appropriate mentors.

Clinician educators must be both proficient clinicians and dedicated teachers. Ideally, they should have strong familiarity with educational theory in addition to skills in hands‐on teaching. Their responsibilities include mastering the skills that students need, staying up to the minute in their areas of expertise, and serving as role models in their attitudes toward patients, colleagues, and their work.3 Many hospitalists may not have these skills when they begin, often fresh out of residency, and will need help developing them.

PROTECTED TIME

Protected time is crucial to the success of any academic program. Finding this time presents a challenge for any clinical group, but the challenge is exacerbated for hospitalists, who face tremendous pressure to serve full‐time clinical jobs with little emphasis on academic elements such as education, QI, and participation in funded research. As both Wright et al.2 and Flanders et al.1 point out, to build a group of well‐developed academic clinician educators, academic hospitalists not on track for funding need to be given adequate protected time to participate in committees, sharpen their teaching skills, develop QI projects that can be converted to scholarships, participate in research, and present at national and regional meetings.

The requirements of protected time for researchers are more challenging than those for educators. Building a newly funded research unit within a hospitalist group, as with any group, will entail hiring fellowship trained faculty with significant protected time (approximately 80%) to give them time to obtain funding such as a K award and eventually become independent investigators with RO1 grant funding. Building research units requires support from collaborators with infrastructure and mentors already in place that can be tapped during the incubation stage of the academic program. For most hospitalist programs, infrastructure and mentors will be found in their divisions of general internal medicine.

Protected time should be considered an integral element of academic hospitalist positionsnot a perkas long as the time is used responsibly and productively. As both Wright et al.2 and Flanders et al.1 correctly point out, herein lies the major challenge of creating any kind of academic program: How will the program support protected time for both educators and researchers? In most instances, significant seed money will be needed to support junior faculty over the first few years of their careers. It is noteworthy that building a federally funded hospital medicine research program will be particularly difficult in today's economy because funding levels at the NIH, Agency for Healthcare Research and Quality, Health Resources and Services Administration, and other traditional funders of clinical research either are flat or have been reduced dramatically.

To many Academic Medical Centers (AMC), it may not be immediately obvious why a strong Academic Hospitalist program is in their economic best interest. Hospitalist programs may confront consistently high levels of turnover and a shrinking supply of general internists. The associated high costs of hiring new, junior faculty include the time and effort needed to interview, credential, train, and most importantly build familiarity with the complex systems encountered in maneuvering through a hospital, especially one with widespread dissemination of electronic medical records for documentation and order entry. However, hospitalists provided with opportunities for academic development are more likely to stay on the job longer and perform at a higher level, providing convincing motivation for hospitals to invest in their academic hospitalist programs. Retaining high‐quality hospitalists may be one of the most cost‐efficient methods for an AMC to support a hospital medicine program.

STRATEGIES IN ACTION

Flanders et al.1 point to a shortage of well‐trained clinician investigators with a focus on inpatient research as a barrier to the development of academic hospitalist programming. They describe a strategy of collaboration with specialty groups. This highlights the importance of collaboration with more well‐established research units as a key ingredient to building a new academic unit. Wright et al.2 describe their mentorship program and how they created protected time for scholarship for hospitalists, including supporting mentors' time. These examples highlight another key benchmark of a viable academic program, mentoring, and the importance of ensuring that mentors have time for this essential effort.

However, it is critically important to remember that all politics is local, to quote the late Tip O'Neill, long‐time speaker of the US House of Representatives. What works in one setting may not work as well in a different contexthence the need for creativity and political acumen.

For example, although the specialty‐group collaboration described by Flanders et al.1 may be helpful in one setting, other strategic alliances may work on a larger scale and over a longer time period. Most hospital medicine groups are currently within academic divisions of general internal medicine, where infrastructure and mentoring may already exist for both research and educational scholarship. In those cases, fostering interaction between the division's hospitalists and its researchers would be a critical first step. The programming and growth developed in this way can be leveraged to support ongoing academic activities by hospitalists rather than being limited to a single project.

In the Division of General Internal Medicine at Mount Sinai, which houses the academic hospitalists, building research entailed collaboration with the well‐established Departments of Geriatrics and Health Policy, which had preexisting research infrastructure and mentors. At the same time, we developed a research fellowship program by applying jointly with the Division of General Pediatrics for federal grant support. Such diversity of collaboration enhanced our application.

LOOKING AHEAD

Putting the academic into academic hospitalist programs is the key to the future of hospital medicine. To be successful, one must consider all the issues described in light of available resources and the local and federal political landscape. As Flanders et al.1 and Wright et al.2 emphasize, collaboration will be the main component for success in the current academic landscape.

Accelerating the development of clinical research in academic hospitalist programs is a worthwhile goal if pursued with clarity, objectivity, and a thorough understanding of the process and its implications. In their articles, Flanders et al.1 and Wright et al.2 identify major barriers to growing academic hospitalist programs. These barriers include the need for protected time, the shortage of trained research faculty, the lack of infrastructure, and the limited availability of senior mentors. Both Flanders et al. and Wright et al. offer smart and innovative ways of addressing these issues. However, building an academic program from the ground up is more complex and challenging than it may seem at first glance. It takes time, patience, creativity, diplomacy, and the ability to recruit collaborators and advocates who are willing to share infrastructure and resources.

Although both articles add significantly to the discussion of strategies for creating an academic hospitalist program, they are unclear about the definition of academic in this context. The term academic is often misunderstood to be synonymous with research. However, research is just one component of an academic program, which also includes education, quality improvement (QI), administration, and program development. It may be helpful, therefore, to replace academic with scholarship, which can be defined as a process that involves peer review and dissemination of ideas at local, regional, and national levels. Scholarship also goes beyond research, encompassing education and other areas such as QI. Although academic programs are not necessarily involved with funded research, there is usually an expectation of peer review, through either presentations at regional and national meetings or publication. For the purposes of this discussion, the term academic hospitalist program will be defined broadly to include any program affiliated with a university that is involved in the teaching of residents and medical students and whose faculty is required to participate in a promotions process.

All members of an academic division should be expected to participate in scholarship, whether it is education, QI projects, or research. If there is a strong expectation that traditional National Institute of Health (NIH) funded research will take place, this expectation must come with sufficient resources. Without infrastructure for research and investment in research faculty, procuring NIH funds for research is not a reasonable expectation. Organizers of hospitalist programs currently within academic divisions of general internal medicine should consider ways to better integrate programs into the existing research infrastructure in their divisions. For either freestanding hospitalist programs or programs within academic divisions of general internal medicine, investments in infrastructure and faculty are needed to nurture this area of research and build an academic focus in hospital medicine. However, if obtaining NIH research funds is not the expectation and resources are not available for hospitalists or for any other division or department at that institution, then academic expectations should focus on other pursuits. Examples include participation in the education and QI initiatives.

For programs with expectations of both funded research and other scholarship, a successful program will most likely include a small core of skilled clinical researchers working closely with well‐trained clinical educators, all of whom are involved in scholarship. Both clinical educators and researchers need to be continuously developing, and to reach their full potential, all should have access to infrastructure that supports these activities, including resources such as MPH‐level project managers, research assistants, database managers, and, most importantly, appropriate mentors.

Clinician educators must be both proficient clinicians and dedicated teachers. Ideally, they should have strong familiarity with educational theory in addition to skills in hands‐on teaching. Their responsibilities include mastering the skills that students need, staying up to the minute in their areas of expertise, and serving as role models in their attitudes toward patients, colleagues, and their work.3 Many hospitalists may not have these skills when they begin, often fresh out of residency, and will need help developing them.

PROTECTED TIME

Protected time is crucial to the success of any academic program. Finding this time presents a challenge for any clinical group, but the challenge is exacerbated for hospitalists, who face tremendous pressure to serve full‐time clinical jobs with little emphasis on academic elements such as education, QI, and participation in funded research. As both Wright et al.2 and Flanders et al.1 point out, to build a group of well‐developed academic clinician educators, academic hospitalists not on track for funding need to be given adequate protected time to participate in committees, sharpen their teaching skills, develop QI projects that can be converted to scholarships, participate in research, and present at national and regional meetings.

The requirements of protected time for researchers are more challenging than those for educators. Building a newly funded research unit within a hospitalist group, as with any group, will entail hiring fellowship trained faculty with significant protected time (approximately 80%) to give them time to obtain funding such as a K award and eventually become independent investigators with RO1 grant funding. Building research units requires support from collaborators with infrastructure and mentors already in place that can be tapped during the incubation stage of the academic program. For most hospitalist programs, infrastructure and mentors will be found in their divisions of general internal medicine.

Protected time should be considered an integral element of academic hospitalist positionsnot a perkas long as the time is used responsibly and productively. As both Wright et al.2 and Flanders et al.1 correctly point out, herein lies the major challenge of creating any kind of academic program: How will the program support protected time for both educators and researchers? In most instances, significant seed money will be needed to support junior faculty over the first few years of their careers. It is noteworthy that building a federally funded hospital medicine research program will be particularly difficult in today's economy because funding levels at the NIH, Agency for Healthcare Research and Quality, Health Resources and Services Administration, and other traditional funders of clinical research either are flat or have been reduced dramatically.

To many Academic Medical Centers (AMC), it may not be immediately obvious why a strong Academic Hospitalist program is in their economic best interest. Hospitalist programs may confront consistently high levels of turnover and a shrinking supply of general internists. The associated high costs of hiring new, junior faculty include the time and effort needed to interview, credential, train, and most importantly build familiarity with the complex systems encountered in maneuvering through a hospital, especially one with widespread dissemination of electronic medical records for documentation and order entry. However, hospitalists provided with opportunities for academic development are more likely to stay on the job longer and perform at a higher level, providing convincing motivation for hospitals to invest in their academic hospitalist programs. Retaining high‐quality hospitalists may be one of the most cost‐efficient methods for an AMC to support a hospital medicine program.

STRATEGIES IN ACTION

Flanders et al.1 point to a shortage of well‐trained clinician investigators with a focus on inpatient research as a barrier to the development of academic hospitalist programming. They describe a strategy of collaboration with specialty groups. This highlights the importance of collaboration with more well‐established research units as a key ingredient to building a new academic unit. Wright et al.2 describe their mentorship program and how they created protected time for scholarship for hospitalists, including supporting mentors' time. These examples highlight another key benchmark of a viable academic program, mentoring, and the importance of ensuring that mentors have time for this essential effort.

However, it is critically important to remember that all politics is local, to quote the late Tip O'Neill, long‐time speaker of the US House of Representatives. What works in one setting may not work as well in a different contexthence the need for creativity and political acumen.

For example, although the specialty‐group collaboration described by Flanders et al.1 may be helpful in one setting, other strategic alliances may work on a larger scale and over a longer time period. Most hospital medicine groups are currently within academic divisions of general internal medicine, where infrastructure and mentoring may already exist for both research and educational scholarship. In those cases, fostering interaction between the division's hospitalists and its researchers would be a critical first step. The programming and growth developed in this way can be leveraged to support ongoing academic activities by hospitalists rather than being limited to a single project.

In the Division of General Internal Medicine at Mount Sinai, which houses the academic hospitalists, building research entailed collaboration with the well‐established Departments of Geriatrics and Health Policy, which had preexisting research infrastructure and mentors. At the same time, we developed a research fellowship program by applying jointly with the Division of General Pediatrics for federal grant support. Such diversity of collaboration enhanced our application.

LOOKING AHEAD

Putting the academic into academic hospitalist programs is the key to the future of hospital medicine. To be successful, one must consider all the issues described in light of available resources and the local and federal political landscape. As Flanders et al.1 and Wright et al.2 emphasize, collaboration will be the main component for success in the current academic landscape.

To the seasoned intensivist, discussions with family members of critically ill patients in the intensive care unit (ICU) can be very predictable. However, this does not imply that these dialogues are straightforward or simple. Each day, we spend a significant amount of time meeting with family members at different stages of their loved one's ICU stay. Some family members are satisfied with these exchanges while others leave them distraught or in emotional shambles. At times, intensivists do not always effectively communicate with family members.13 Both the team and the families come to the ICU table with different sets of perspectives, expectations, conversational skill sets, life experiences, and tolerances for stress. These differences are magnified when the ICU course turns rocky.

We thought it useful to illustrate ICU dialogues with family members as we perceive them. We focus on the potential checkpoints where miscommunication and misunderstanding may occur throughout the roller coaster ICU experience. To this end, over the past few years, our Critical Care Medicine group has been collecting thought‐provoking comments from various family conferences. Herein, we present the dynamic phases of an ICU encounter contextually inserting relevant quotes.

The specter of a loved one lying helplessly in an ICU bed, attached to imposing machines, with tubes coming out on all sides can be quite numbing and frightening. No amount of schooling or training can really prepare a person for this emotionally taxing situation. Disbelief reigns! We frequently hear, How can a person go from being fine one day to being so sick the next? or He was shoveling snow just last week! or, She was just fine after surgery, talking, walking, and eating.

Not only is the ICU a strange and scary place, but oftentimes, in the midst of our first meeting with family members of newly admitted ICU patients, we quickly realize that they are not really sure who we are or what we do. It seems to us that Critical Care Medicine as a medical specialty suffers from a lack of brand recognition. Often the family members say, You're a what? An intensivist? We've never heard of an intensivist. Do you also work in the Emergency Room? I heard someone mention critical care, is that the same as intensive care? Or sometimes we get whacked, What about getting a real doctor, like a cardiologist or a pulmonologist!

Family members immediately find different ways to let us know how much the patient means to them. They try to impress upon us the vitality and unique nature of their loved ones in the hope that this will make us all work harder. He's a real fighter and never gives up. Or He's a young and healthy 90. Or You have to take extra care of her, she's very special, she's the mother of eight children. Sometimes political or social connections are used to further incentivize or push the ICU team. He's best friends with Mr. Z who is on the Board of Trustees, or She's friends with this or that politician.

But, Google has really altered the nature of our family discussions; everyone, it seems, can now be a doctor. We used to hear I'm not a doctor, but Now, the inevitable internet search leads to I've been doing some reading on the web about this new drug and I've heard that it's a wonder drug. Why isn't my mother getting it? Or What is the APACHE III score of my sister and how are you using this value?

Just as intensivists regularly look at reams of lab data and calculate all types of organ failure and prognostication scores, family members similarly reframe the ICU discussion to a numbers game. This approach to seemingly getting our arms around the complicated big picture is used in many aspects of our lives, whether tracking our retirement portfolios or determining the odds of next week's football game. Doctor, what are her chances for improvement ‐ 50/50, 30/70 or 80/20? Even one in a million? Over time, family members even become experts at looking at the bedside monitors and devices. I've been watching the numbers, I see that the heart rate is down and you were able to decrease the oxygen on the respirator to 80%, and the blood oxygen is still over 90%, so my father must be better, right?

As the days go by, some families become more desperate. They seek good news or even any news from every person they meet. And the ICU environment certainly offers family members a myriad of people with whom to converse. Unfortunately, this frantic search for information leads them to receive conflicting and unreliable data. Frustration results, Why do we keep getting mixed messages? Or, Doctor, we like the hospital, but why can't all of you get the story straight? As family members gather together with other patients' families in the waiting room day and night, they often share their ICU stories with each other. We'll overhear someone say, What about the new antibiotic the patient in Bed 8 is getting? Shouldn't my husband be getting that too? I see everyone is gowning up, I keep hearing about that bad Staph bug going around, my father better not catch it.

Occasionally we become concerned, even perplexed, when we cannot successfully convey our message to the family despite our best intentions and efforts. Some families are just in denial; the reality of no progress and/or likely poor outcome cannot be heard, much less accepted. Doctor, I have been badgered with the truth enough. I just don't want to believe it. Or, Doctor, don't you ever have any good news to report to us? The insatiable need for prolonged and repetitive family conferences may deflect time away from the care of other patients and meeting with other families.

Unfortunately, some patients get stuck in the ICU, either not improving, or just steadily deteriorating despite aggressive care. We broach treatment limitation or end of life care with the family as we realize that further ICU care is not going to be beneficial. Sometimes this news is greeted with stunned silence. The family often pleads for their loved one to be able to stay a little bit longer in the ICU, Let's just see how he does for a few more days or over the weekend. Or, We just need to buy some more time until everything turns around. Or other approaches are used to postpone the inevitable ICU transfer. Doctor, our 50th wedding anniversary is in two weeks, so let's continue to keep him in the ICU. Or, You can't discharge my mother, she averages 14.5 alarms per hour, how can the ward ever take care of her?

And then comes the quest for the miracle, Don't you believe in miracles? Haven't you ever seen someone in this condition get better? Are you giving up? We'll never give up! Or, ignoring the express wishes of the patient, Oh, Doctor, my father did have an advanced directive, but I'm not sure whether I want to give it to you. Or, the message now gets personal What would you do if this was your mother or father?

Such questions highlight the existential dichotomy of critical care. As intensivists, we sometimes have to reconcile the family members' unrealistic view of prognosis, overly hopeful expectations, and desire for endless futile ICU care with our own understandings of prognosis, goals of care, and appropriate use of ICU beds. Where, and when should we draw the line? How do we all let go?4

This collection of comments and thoughts reflects a synthesis of many different discussions conducted under diverse conditions. Thankfully, not all of the individual elements of the scenario described above occur with each patient. Family members and intensivists commonly have amicable discourse resulting in an acceptable degree of understanding and consensus regarding the prognosis and care plan. However, on occasion, things just don't go as well as hoped for, neither in clinical outcomes nor in our discussions. While effective ICU communication strategies have been designed and studied,512 even the best of these may not prevent conflict and disagreement. Nevertheless, our challenge as critical care practitioners is to ensure that our dialogues with family members are honest and direct and that we communicate in a timely, consistent and empathetic manner.

Well, onto the next family meeting!

To the seasoned intensivist, discussions with family members of critically ill patients in the intensive care unit (ICU) can be very predictable. However, this does not imply that these dialogues are straightforward or simple. Each day, we spend a significant amount of time meeting with family members at different stages of their loved one's ICU stay. Some family members are satisfied with these exchanges while others leave them distraught or in emotional shambles. At times, intensivists do not always effectively communicate with family members.13 Both the team and the families come to the ICU table with different sets of perspectives, expectations, conversational skill sets, life experiences, and tolerances for stress. These differences are magnified when the ICU course turns rocky.

We thought it useful to illustrate ICU dialogues with family members as we perceive them. We focus on the potential checkpoints where miscommunication and misunderstanding may occur throughout the roller coaster ICU experience. To this end, over the past few years, our Critical Care Medicine group has been collecting thought‐provoking comments from various family conferences. Herein, we present the dynamic phases of an ICU encounter contextually inserting relevant quotes.

The specter of a loved one lying helplessly in an ICU bed, attached to imposing machines, with tubes coming out on all sides can be quite numbing and frightening. No amount of schooling or training can really prepare a person for this emotionally taxing situation. Disbelief reigns! We frequently hear, How can a person go from being fine one day to being so sick the next? or He was shoveling snow just last week! or, She was just fine after surgery, talking, walking, and eating.

Not only is the ICU a strange and scary place, but oftentimes, in the midst of our first meeting with family members of newly admitted ICU patients, we quickly realize that they are not really sure who we are or what we do. It seems to us that Critical Care Medicine as a medical specialty suffers from a lack of brand recognition. Often the family members say, You're a what? An intensivist? We've never heard of an intensivist. Do you also work in the Emergency Room? I heard someone mention critical care, is that the same as intensive care? Or sometimes we get whacked, What about getting a real doctor, like a cardiologist or a pulmonologist!

Family members immediately find different ways to let us know how much the patient means to them. They try to impress upon us the vitality and unique nature of their loved ones in the hope that this will make us all work harder. He's a real fighter and never gives up. Or He's a young and healthy 90. Or You have to take extra care of her, she's very special, she's the mother of eight children. Sometimes political or social connections are used to further incentivize or push the ICU team. He's best friends with Mr. Z who is on the Board of Trustees, or She's friends with this or that politician.

But, Google has really altered the nature of our family discussions; everyone, it seems, can now be a doctor. We used to hear I'm not a doctor, but Now, the inevitable internet search leads to I've been doing some reading on the web about this new drug and I've heard that it's a wonder drug. Why isn't my mother getting it? Or What is the APACHE III score of my sister and how are you using this value?

Just as intensivists regularly look at reams of lab data and calculate all types of organ failure and prognostication scores, family members similarly reframe the ICU discussion to a numbers game. This approach to seemingly getting our arms around the complicated big picture is used in many aspects of our lives, whether tracking our retirement portfolios or determining the odds of next week's football game. Doctor, what are her chances for improvement ‐ 50/50, 30/70 or 80/20? Even one in a million? Over time, family members even become experts at looking at the bedside monitors and devices. I've been watching the numbers, I see that the heart rate is down and you were able to decrease the oxygen on the respirator to 80%, and the blood oxygen is still over 90%, so my father must be better, right?

As the days go by, some families become more desperate. They seek good news or even any news from every person they meet. And the ICU environment certainly offers family members a myriad of people with whom to converse. Unfortunately, this frantic search for information leads them to receive conflicting and unreliable data. Frustration results, Why do we keep getting mixed messages? Or, Doctor, we like the hospital, but why can't all of you get the story straight? As family members gather together with other patients' families in the waiting room day and night, they often share their ICU stories with each other. We'll overhear someone say, What about the new antibiotic the patient in Bed 8 is getting? Shouldn't my husband be getting that too? I see everyone is gowning up, I keep hearing about that bad Staph bug going around, my father better not catch it.

Occasionally we become concerned, even perplexed, when we cannot successfully convey our message to the family despite our best intentions and efforts. Some families are just in denial; the reality of no progress and/or likely poor outcome cannot be heard, much less accepted. Doctor, I have been badgered with the truth enough. I just don't want to believe it. Or, Doctor, don't you ever have any good news to report to us? The insatiable need for prolonged and repetitive family conferences may deflect time away from the care of other patients and meeting with other families.

Unfortunately, some patients get stuck in the ICU, either not improving, or just steadily deteriorating despite aggressive care. We broach treatment limitation or end of life care with the family as we realize that further ICU care is not going to be beneficial. Sometimes this news is greeted with stunned silence. The family often pleads for their loved one to be able to stay a little bit longer in the ICU, Let's just see how he does for a few more days or over the weekend. Or, We just need to buy some more time until everything turns around. Or other approaches are used to postpone the inevitable ICU transfer. Doctor, our 50th wedding anniversary is in two weeks, so let's continue to keep him in the ICU. Or, You can't discharge my mother, she averages 14.5 alarms per hour, how can the ward ever take care of her?

And then comes the quest for the miracle, Don't you believe in miracles? Haven't you ever seen someone in this condition get better? Are you giving up? We'll never give up! Or, ignoring the express wishes of the patient, Oh, Doctor, my father did have an advanced directive, but I'm not sure whether I want to give it to you. Or, the message now gets personal What would you do if this was your mother or father?

Such questions highlight the existential dichotomy of critical care. As intensivists, we sometimes have to reconcile the family members' unrealistic view of prognosis, overly hopeful expectations, and desire for endless futile ICU care with our own understandings of prognosis, goals of care, and appropriate use of ICU beds. Where, and when should we draw the line? How do we all let go?4

This collection of comments and thoughts reflects a synthesis of many different discussions conducted under diverse conditions. Thankfully, not all of the individual elements of the scenario described above occur with each patient. Family members and intensivists commonly have amicable discourse resulting in an acceptable degree of understanding and consensus regarding the prognosis and care plan. However, on occasion, things just don't go as well as hoped for, neither in clinical outcomes nor in our discussions. While effective ICU communication strategies have been designed and studied,512 even the best of these may not prevent conflict and disagreement. Nevertheless, our challenge as critical care practitioners is to ensure that our dialogues with family members are honest and direct and that we communicate in a timely, consistent and empathetic manner.

Well, onto the next family meeting!

To the seasoned intensivist, discussions with family members of critically ill patients in the intensive care unit (ICU) can be very predictable. However, this does not imply that these dialogues are straightforward or simple. Each day, we spend a significant amount of time meeting with family members at different stages of their loved one's ICU stay. Some family members are satisfied with these exchanges while others leave them distraught or in emotional shambles. At times, intensivists do not always effectively communicate with family members.13 Both the team and the families come to the ICU table with different sets of perspectives, expectations, conversational skill sets, life experiences, and tolerances for stress. These differences are magnified when the ICU course turns rocky.

We thought it useful to illustrate ICU dialogues with family members as we perceive them. We focus on the potential checkpoints where miscommunication and misunderstanding may occur throughout the roller coaster ICU experience. To this end, over the past few years, our Critical Care Medicine group has been collecting thought‐provoking comments from various family conferences. Herein, we present the dynamic phases of an ICU encounter contextually inserting relevant quotes.

The specter of a loved one lying helplessly in an ICU bed, attached to imposing machines, with tubes coming out on all sides can be quite numbing and frightening. No amount of schooling or training can really prepare a person for this emotionally taxing situation. Disbelief reigns! We frequently hear, How can a person go from being fine one day to being so sick the next? or He was shoveling snow just last week! or, She was just fine after surgery, talking, walking, and eating.

Not only is the ICU a strange and scary place, but oftentimes, in the midst of our first meeting with family members of newly admitted ICU patients, we quickly realize that they are not really sure who we are or what we do. It seems to us that Critical Care Medicine as a medical specialty suffers from a lack of brand recognition. Often the family members say, You're a what? An intensivist? We've never heard of an intensivist. Do you also work in the Emergency Room? I heard someone mention critical care, is that the same as intensive care? Or sometimes we get whacked, What about getting a real doctor, like a cardiologist or a pulmonologist!

Family members immediately find different ways to let us know how much the patient means to them. They try to impress upon us the vitality and unique nature of their loved ones in the hope that this will make us all work harder. He's a real fighter and never gives up. Or He's a young and healthy 90. Or You have to take extra care of her, she's very special, she's the mother of eight children. Sometimes political or social connections are used to further incentivize or push the ICU team. He's best friends with Mr. Z who is on the Board of Trustees, or She's friends with this or that politician.

But, Google has really altered the nature of our family discussions; everyone, it seems, can now be a doctor. We used to hear I'm not a doctor, but Now, the inevitable internet search leads to I've been doing some reading on the web about this new drug and I've heard that it's a wonder drug. Why isn't my mother getting it? Or What is the APACHE III score of my sister and how are you using this value?

Just as intensivists regularly look at reams of lab data and calculate all types of organ failure and prognostication scores, family members similarly reframe the ICU discussion to a numbers game. This approach to seemingly getting our arms around the complicated big picture is used in many aspects of our lives, whether tracking our retirement portfolios or determining the odds of next week's football game. Doctor, what are her chances for improvement ‐ 50/50, 30/70 or 80/20? Even one in a million? Over time, family members even become experts at looking at the bedside monitors and devices. I've been watching the numbers, I see that the heart rate is down and you were able to decrease the oxygen on the respirator to 80%, and the blood oxygen is still over 90%, so my father must be better, right?

As the days go by, some families become more desperate. They seek good news or even any news from every person they meet. And the ICU environment certainly offers family members a myriad of people with whom to converse. Unfortunately, this frantic search for information leads them to receive conflicting and unreliable data. Frustration results, Why do we keep getting mixed messages? Or, Doctor, we like the hospital, but why can't all of you get the story straight? As family members gather together with other patients' families in the waiting room day and night, they often share their ICU stories with each other. We'll overhear someone say, What about the new antibiotic the patient in Bed 8 is getting? Shouldn't my husband be getting that too? I see everyone is gowning up, I keep hearing about that bad Staph bug going around, my father better not catch it.

Occasionally we become concerned, even perplexed, when we cannot successfully convey our message to the family despite our best intentions and efforts. Some families are just in denial; the reality of no progress and/or likely poor outcome cannot be heard, much less accepted. Doctor, I have been badgered with the truth enough. I just don't want to believe it. Or, Doctor, don't you ever have any good news to report to us? The insatiable need for prolonged and repetitive family conferences may deflect time away from the care of other patients and meeting with other families.

Unfortunately, some patients get stuck in the ICU, either not improving, or just steadily deteriorating despite aggressive care. We broach treatment limitation or end of life care with the family as we realize that further ICU care is not going to be beneficial. Sometimes this news is greeted with stunned silence. The family often pleads for their loved one to be able to stay a little bit longer in the ICU, Let's just see how he does for a few more days or over the weekend. Or, We just need to buy some more time until everything turns around. Or other approaches are used to postpone the inevitable ICU transfer. Doctor, our 50th wedding anniversary is in two weeks, so let's continue to keep him in the ICU. Or, You can't discharge my mother, she averages 14.5 alarms per hour, how can the ward ever take care of her?

And then comes the quest for the miracle, Don't you believe in miracles? Haven't you ever seen someone in this condition get better? Are you giving up? We'll never give up! Or, ignoring the express wishes of the patient, Oh, Doctor, my father did have an advanced directive, but I'm not sure whether I want to give it to you. Or, the message now gets personal What would you do if this was your mother or father?

Such questions highlight the existential dichotomy of critical care. As intensivists, we sometimes have to reconcile the family members' unrealistic view of prognosis, overly hopeful expectations, and desire for endless futile ICU care with our own understandings of prognosis, goals of care, and appropriate use of ICU beds. Where, and when should we draw the line? How do we all let go?4

This collection of comments and thoughts reflects a synthesis of many different discussions conducted under diverse conditions. Thankfully, not all of the individual elements of the scenario described above occur with each patient. Family members and intensivists commonly have amicable discourse resulting in an acceptable degree of understanding and consensus regarding the prognosis and care plan. However, on occasion, things just don't go as well as hoped for, neither in clinical outcomes nor in our discussions. While effective ICU communication strategies have been designed and studied,512 even the best of these may not prevent conflict and disagreement. Nevertheless, our challenge as critical care practitioners is to ensure that our dialogues with family members are honest and direct and that we communicate in a timely, consistent and empathetic manner.

Well, onto the next family meeting!

Specialist or generalist? The question of which physicians are best suited to treat patients with a single condition or in a particular care setting has been the subject of study and debate for decades.13 Investigators have asked whether cardiologists provide better care for patients with acute myocardial infarction1 or whether intensivists achieve superior outcomes in critical care settings.2 One implication of these studies is that a hospital or health plan armed with this knowledge would be capable of improving outcomes by directing a greater proportion of patients to the superior physician group. In fact, much of the literature reporting on the effect of hospitalists is simply a new variation on this old theme.48 Of course, to realize any potential gains, there must be an adequate number of specialists or the ability to increase the supply quickly. Neither option tends to be especially realistic. Further, these studies have a tendency to create false dilemmas because consultation and comanagement are more common than single‐handed care.

Because studies comparing the outcomes of physician groups are generally not randomized trials, minimizing the threat of selection bias (ie, patient prognosis influencing treatment assignment) is of paramount importance. For example, one can imagine how patients with a particularly poor prognosis in the setting of acute myocardial infarction (perhaps related to age or the presence of multiple comorbidities) might be preferentially directed toward a general medicine service, especially when remunerative cardiac intervention is unlikely. In such instances, comparing simple mortality rates would erroneously lead to the conclusion that patients cared for by cardiologists had better outcomes.

Multivariable modeling techniques like logistic and liner regression and more recently, propensity‐based methods, are the standard approaches used to adjust for differences in patient characteristics stemming from nonrandom assignment. When propensity methods are used, a multivariable model is created to predict the likelihood, or propensity, of a patient receiving treatment. Because it is not necessary to be parsimonious in the development of propensity models, they can include many factors and interaction terms that might be left out of a standard multivariable logistic regression. Then, the outcomes of patients with a similar treatment propensity who did receive the intervention can be compared to the outcomes of those who did not. Some have gone so far as to use the term pseudorandomized trial to describe this approach because it is often capable balancing covariates between the treated and nontreated patients. However, as sophisticated as this form of modeling may be, these techniques at best are only capable of reducing bias related to measured confounders. Residual bias from confounders that go unmeasured remains a threatand is particularly common when relying on administrative data sources.

In this issue of the Journal of Hospital Medicine, Gillum and Johnston9 apply a version of instrumental variable analysis, a technique borrowed from econometrics, to address the issue of unmeasured confounding head‐on. The approach, called group‐treatment analysis, is based on the relatively simple notion that if neurologist care is superior to that provided by generalists, all other things being equal, hospitals that admit a large proportion of their patients to neurologists should have better outcomes than those admitting a smaller proportion. This approach has theoretical advantages over propensity adjustment because it does not attempt to control for differences between treated and untreated patients at the individual hospital level, where, presumably, the problem of selection bias is more potent. Although their standard multivariable models suggested that patients admitted to a neurologist were 40% less likely to die while hospitalized than patients admitted to generalists, Gillum and Johnston found that after adjusting for the institutional rate of neurologist admission, any apparent benefit had disappeared. Similar results were observed in their analyses of length of stay and cost.

In some ways, the findings of this study are more startling for the questions they raise about the presence of residual bias in observational studies using conventional multivariable methods than for the fact that generalist care was found to be as safe as neurologist care and add to a growing body of evidence suggesting that stronger methods are required to deal with residual bias in observational studies.10

Although the results largely speak for themselves and should be reassuring given that most patients with ischemic stroke in the United States are and will continue to be cared for by generalists, a number of important questions remain unanswered. First, the focus of this study was on short‐term outcomes. Because functional status and quality of life probably matter as much or more to stroke patients than in‐hospital mortality and certainly length of stay or cost, we can only hope that it is safe to extrapolate from the authors' mortality findings. Second, this study relied on data from the late 1990s, before the widespread availability of hospitalists. How generalizable the findings would be in today's environment is uncertain. On a more practical level, the authors were unable to assess the impact of formal or informal consultation by a neurologist. If this played a significant role (a reasonable assumption, I think), this would have blurred any distinction between the 2 physician groups. For this reason one cannot draw any conclusions about a more pragmatic questionthe necessity or benefit of neurologist consultation in patients with ischemic stroke.

Looking ahead, researchers hoping to improve the outcomes of patients with acute ischemic stroke should focus on developing novel models of collaboration between hospitalists and neurologists, instead of simply trying to prove that a neurologist should take care of a patient suffering a stroke alone versus a hospitalist without help from a neurologist. We also should recognize that the use of protocols and checklists or leveraging information technology investments may provide clinical decision support that improves care more than just consulting a specialist or having them care for the patient.

Specialist or generalist? The question of which physicians are best suited to treat patients with a single condition or in a particular care setting has been the subject of study and debate for decades.13 Investigators have asked whether cardiologists provide better care for patients with acute myocardial infarction1 or whether intensivists achieve superior outcomes in critical care settings.2 One implication of these studies is that a hospital or health plan armed with this knowledge would be capable of improving outcomes by directing a greater proportion of patients to the superior physician group. In fact, much of the literature reporting on the effect of hospitalists is simply a new variation on this old theme.48 Of course, to realize any potential gains, there must be an adequate number of specialists or the ability to increase the supply quickly. Neither option tends to be especially realistic. Further, these studies have a tendency to create false dilemmas because consultation and comanagement are more common than single‐handed care.

Because studies comparing the outcomes of physician groups are generally not randomized trials, minimizing the threat of selection bias (ie, patient prognosis influencing treatment assignment) is of paramount importance. For example, one can imagine how patients with a particularly poor prognosis in the setting of acute myocardial infarction (perhaps related to age or the presence of multiple comorbidities) might be preferentially directed toward a general medicine service, especially when remunerative cardiac intervention is unlikely. In such instances, comparing simple mortality rates would erroneously lead to the conclusion that patients cared for by cardiologists had better outcomes.

Multivariable modeling techniques like logistic and liner regression and more recently, propensity‐based methods, are the standard approaches used to adjust for differences in patient characteristics stemming from nonrandom assignment. When propensity methods are used, a multivariable model is created to predict the likelihood, or propensity, of a patient receiving treatment. Because it is not necessary to be parsimonious in the development of propensity models, they can include many factors and interaction terms that might be left out of a standard multivariable logistic regression. Then, the outcomes of patients with a similar treatment propensity who did receive the intervention can be compared to the outcomes of those who did not. Some have gone so far as to use the term pseudorandomized trial to describe this approach because it is often capable balancing covariates between the treated and nontreated patients. However, as sophisticated as this form of modeling may be, these techniques at best are only capable of reducing bias related to measured confounders. Residual bias from confounders that go unmeasured remains a threatand is particularly common when relying on administrative data sources.

In this issue of the Journal of Hospital Medicine, Gillum and Johnston9 apply a version of instrumental variable analysis, a technique borrowed from econometrics, to address the issue of unmeasured confounding head‐on. The approach, called group‐treatment analysis, is based on the relatively simple notion that if neurologist care is superior to that provided by generalists, all other things being equal, hospitals that admit a large proportion of their patients to neurologists should have better outcomes than those admitting a smaller proportion. This approach has theoretical advantages over propensity adjustment because it does not attempt to control for differences between treated and untreated patients at the individual hospital level, where, presumably, the problem of selection bias is more potent. Although their standard multivariable models suggested that patients admitted to a neurologist were 40% less likely to die while hospitalized than patients admitted to generalists, Gillum and Johnston found that after adjusting for the institutional rate of neurologist admission, any apparent benefit had disappeared. Similar results were observed in their analyses of length of stay and cost.

In some ways, the findings of this study are more startling for the questions they raise about the presence of residual bias in observational studies using conventional multivariable methods than for the fact that generalist care was found to be as safe as neurologist care and add to a growing body of evidence suggesting that stronger methods are required to deal with residual bias in observational studies.10

Although the results largely speak for themselves and should be reassuring given that most patients with ischemic stroke in the United States are and will continue to be cared for by generalists, a number of important questions remain unanswered. First, the focus of this study was on short‐term outcomes. Because functional status and quality of life probably matter as much or more to stroke patients than in‐hospital mortality and certainly length of stay or cost, we can only hope that it is safe to extrapolate from the authors' mortality findings. Second, this study relied on data from the late 1990s, before the widespread availability of hospitalists. How generalizable the findings would be in today's environment is uncertain. On a more practical level, the authors were unable to assess the impact of formal or informal consultation by a neurologist. If this played a significant role (a reasonable assumption, I think), this would have blurred any distinction between the 2 physician groups. For this reason one cannot draw any conclusions about a more pragmatic questionthe necessity or benefit of neurologist consultation in patients with ischemic stroke.

Looking ahead, researchers hoping to improve the outcomes of patients with acute ischemic stroke should focus on developing novel models of collaboration between hospitalists and neurologists, instead of simply trying to prove that a neurologist should take care of a patient suffering a stroke alone versus a hospitalist without help from a neurologist. We also should recognize that the use of protocols and checklists or leveraging information technology investments may provide clinical decision support that improves care more than just consulting a specialist or having them care for the patient.

Specialist or generalist? The question of which physicians are best suited to treat patients with a single condition or in a particular care setting has been the subject of study and debate for decades.13 Investigators have asked whether cardiologists provide better care for patients with acute myocardial infarction1 or whether intensivists achieve superior outcomes in critical care settings.2 One implication of these studies is that a hospital or health plan armed with this knowledge would be capable of improving outcomes by directing a greater proportion of patients to the superior physician group. In fact, much of the literature reporting on the effect of hospitalists is simply a new variation on this old theme.48 Of course, to realize any potential gains, there must be an adequate number of specialists or the ability to increase the supply quickly. Neither option tends to be especially realistic. Further, these studies have a tendency to create false dilemmas because consultation and comanagement are more common than single‐handed care.

Because studies comparing the outcomes of physician groups are generally not randomized trials, minimizing the threat of selection bias (ie, patient prognosis influencing treatment assignment) is of paramount importance. For example, one can imagine how patients with a particularly poor prognosis in the setting of acute myocardial infarction (perhaps related to age or the presence of multiple comorbidities) might be preferentially directed toward a general medicine service, especially when remunerative cardiac intervention is unlikely. In such instances, comparing simple mortality rates would erroneously lead to the conclusion that patients cared for by cardiologists had better outcomes.

Multivariable modeling techniques like logistic and liner regression and more recently, propensity‐based methods, are the standard approaches used to adjust for differences in patient characteristics stemming from nonrandom assignment. When propensity methods are used, a multivariable model is created to predict the likelihood, or propensity, of a patient receiving treatment. Because it is not necessary to be parsimonious in the development of propensity models, they can include many factors and interaction terms that might be left out of a standard multivariable logistic regression. Then, the outcomes of patients with a similar treatment propensity who did receive the intervention can be compared to the outcomes of those who did not. Some have gone so far as to use the term pseudorandomized trial to describe this approach because it is often capable balancing covariates between the treated and nontreated patients. However, as sophisticated as this form of modeling may be, these techniques at best are only capable of reducing bias related to measured confounders. Residual bias from confounders that go unmeasured remains a threatand is particularly common when relying on administrative data sources.

In this issue of the Journal of Hospital Medicine, Gillum and Johnston9 apply a version of instrumental variable analysis, a technique borrowed from econometrics, to address the issue of unmeasured confounding head‐on. The approach, called group‐treatment analysis, is based on the relatively simple notion that if neurologist care is superior to that provided by generalists, all other things being equal, hospitals that admit a large proportion of their patients to neurologists should have better outcomes than those admitting a smaller proportion. This approach has theoretical advantages over propensity adjustment because it does not attempt to control for differences between treated and untreated patients at the individual hospital level, where, presumably, the problem of selection bias is more potent. Although their standard multivariable models suggested that patients admitted to a neurologist were 40% less likely to die while hospitalized than patients admitted to generalists, Gillum and Johnston found that after adjusting for the institutional rate of neurologist admission, any apparent benefit had disappeared. Similar results were observed in their analyses of length of stay and cost.

In some ways, the findings of this study are more startling for the questions they raise about the presence of residual bias in observational studies using conventional multivariable methods than for the fact that generalist care was found to be as safe as neurologist care and add to a growing body of evidence suggesting that stronger methods are required to deal with residual bias in observational studies.10

Although the results largely speak for themselves and should be reassuring given that most patients with ischemic stroke in the United States are and will continue to be cared for by generalists, a number of important questions remain unanswered. First, the focus of this study was on short‐term outcomes. Because functional status and quality of life probably matter as much or more to stroke patients than in‐hospital mortality and certainly length of stay or cost, we can only hope that it is safe to extrapolate from the authors' mortality findings. Second, this study relied on data from the late 1990s, before the widespread availability of hospitalists. How generalizable the findings would be in today's environment is uncertain. On a more practical level, the authors were unable to assess the impact of formal or informal consultation by a neurologist. If this played a significant role (a reasonable assumption, I think), this would have blurred any distinction between the 2 physician groups. For this reason one cannot draw any conclusions about a more pragmatic questionthe necessity or benefit of neurologist consultation in patients with ischemic stroke.

Looking ahead, researchers hoping to improve the outcomes of patients with acute ischemic stroke should focus on developing novel models of collaboration between hospitalists and neurologists, instead of simply trying to prove that a neurologist should take care of a patient suffering a stroke alone versus a hospitalist without help from a neurologist. We also should recognize that the use of protocols and checklists or leveraging information technology investments may provide clinical decision support that improves care more than just consulting a specialist or having them care for the patient.

Over the past decade, an emerging body of literature established a link between nurses' working conditions and their ability to provide safe care. Nurses who are not at their best are both prone to making errors themselves, and less able to serve as effective safety nets for their patients, intercepting errors made by physicians and others.1 Excessive nurse workloads predict an increased rate of adverse events,2, 3 and, by their own reports, nurses working shifts of >12 hours are at greatly increased risk of making medical errors.4, 5 On the basis of these and related findings, the Institute of Medicine has recommended: a) that efforts be made to assure appropriate nurse workloads and b) that nurses work no more than 12 hours per day and 60 hours per week;6 but these recommendations have not been broadly enforced.7

Two articles in the current issue of the Journal of Hospital Medicine add to our understanding of the relationship between nurse working conditions and safety, and substantiate the need to improve nurses' working conditions. In the first, Surani et al. conducted a pilot study of 20 night nurses working 12‐hour shifts in which well‐validated, objective tools revealed that ICU nurses were suffering from pathologic levels of drowsiness on the job.8 The topic is of importance as recent survey work demonstrated that nurses working >12 hours and resident‐physicians working shifts of 24 of more hours make significantly more medical errors and suffer many more occupational injuries than those working less exhausting schedules.4, 5, 912 Objective data on resident‐physicians has corroborated these findings,13, 14 but objective data measuring sleepiness in nurses has been lacking. Surani et al.'s study helps to fill this need. Further, this study suggests that hospitals should not be complacent about the safety of 12‐hour shifts, which may still be associated with dangerous levels of drowsiness‐induced impairment. Careful management of the number of consecutive night shifts,15 or further reductions in nursing work hours even beyond the 12‐hour limit endorsed by the IOM may be in orderparticularly in high‐risk critical care environmentsthough further research substantiating Surani et al.'s findings and comparing alternative scheduling options would be valuable.

The second study by Conway et al. analyzed data for acute care hospitals in California from 1993 to 2004, and found that following the passage of nurse staffing legislation in 1999 and its implementation in 2004, nurse‐patient staffing ratios increased significantly.16 Safety‐net hospitals, however, with high proportions of vulnerable patient populations, were least likely to achieve mandated ratios. As the authors point out, diverting funds to achieve mandated ratios in under‐funded safety net hospitals could potentially lead to reductions in other essential services, though whether such an eventuality might come to pass has not been adequately assessed to date.

In light of these data, where should we go from here? Public and professional concerns over the impact of fewer nurses on the delivery of care have led to the passage of legislation or adoption of regulations by many states in an attempt to ensure safe care. Examples include elimination of mandatory overtime in the following states: CT, IL, ME, MD, MN, NJ, NH, OR, RI, WA, WV, CA, MO, and TX; implementation of nurse staffing plans with input from staff nurses (WA, IL, OR, RI, TX), and mandates of specific nurse to patient ratios (CA [as discussed by Conway et al.] and FL).17 Proposed legislation regarding nurse staffing and nurse‐to‐patient ratios is currently under consideration in many additional states. Legislation broadly restricting nurse work hours has not been passed by the federal government or individual states, but some hospital systems including the Veteran's Administration now have policies prohibiting shifts of greater than 12 hours and work weeks of greater than 60 hours.18

Unfortunately, several major barriers have made the implementation of safer work hours and workloads challenging, and uncertainty about the effectiveness of implementation efforts remains. A major challenge has been the presence of a serious shortage of nurses, which is expected to peak by 2020.19 A lack of nurses will make both staffing and scheduling initiatives difficult. Over the next 10 to 15 years, policies that fund nursing education or otherwise address this shortfall will consequently be essential.

A second challenge in efforts to implement safer work schedules appears to be an absence of knowledge about the hazards of sleep deprivation, compounded by financial pressures that may lead to unsafe schedules. Some nurses oppose restriction of work hours citing that they know when they are tired, their schedule works for their personal life, and they should be allowed to work as much as they want to earn the salary they want/need. Unfortunately, it has been well‐demonstrated that chronically sleep‐deprived individuals routinely under‐estimate their level of impairment, calling into question the ability of nurses and others working extreme hours to accurately judge their abilities to perform safely.20

Clearly, education on the effects of fatigue on performance is needed, as are widespread efforts to implement safe schedules. Further study of work injuries, medical errors, and their relation to fatigue and specific work schedules is warranted, as well as studies of the impact of fatigue on sick calls and absenteeism. In many tightly staffed hospitals, overtime is used to provide coverage for sick calls, which in turn potentiates further risk of fatigue. As a profession, nurses need to take the fear factor out of saying I'm tired and advocate for adequate breaks, naps, and diet. Nurse leaders often find that offering 12‐hour shifts is required to recruit nurses, and that rotating shiftssometimes in a manner that can lead to significant circadian misalignmenthelps balance the schedule and preference for day shifts. They are also aware that a scheduled 3‐day work week is attractive to many nurses, as it allows those desiring greater income to work additional shifts through an agency at premium pay, though this may lead to further sleep deprivation. It is easy to conceive how these factors can lead to a serious conundrum.

How best to address concerns over nurse staffing remains a subject of ongoing debate. Higher nurse‐to‐patient ratios have been associated in multiple studies and a meta‐analysis with lower rates of complications and mortality.3, 21 Understanding the causal relationship between ratios and outcomes, however, has been complicated by consideration of confounding hospital variables and varying acuity of patient care between centers. The number of patients a nurse can safely care for at any one time is likely a product of the acuity of the patients, the education and experience of the nurse, and the makeup of the team available to care for the patients' needs. How well implementation of mandates regarding nurse‐patient ratios can address this complex need is unclear, and should be a focus of future research.

Leadership is essential in implementing work hour standards and staffing plans to promote a high‐quality nursing environment. Hospitals with poor operating margins, poor leadership, or poor environments of care will be unable to retain nurses to meet care requirements. Magnet hospitals, with nurse leaders who promote RN empowerment, can develop less stressful work environments with lower turnover rates and greater job satisfaction, which positively impacts quality of care. The Magnet Recognition Program, developed by the American Nurses Credentialing Center (ANCC), has recognized less than 300 hospitals in the US as providing nursing excellence (http://www.nursecredentialing.org/magnet/).

State and federal regulation may address initial safety needs, but it cannot in isolation address all of the elements that contribute to high‐quality care. While data are limited, it is possible that in financially constrained hospitals, suboptimal implementation of mandates may potentially lead to misuse of limited resources. Future research should directly assess the net effects of implementing nurse scheduling and staffing policies on mortality, hospital complication rates, and the safety of patient care processes across diverse medical centers and patient care settings. Building upon the research of Surani, Conway, and their colleagues, such research could help promote the further development of optimal care policies and the quality of patient care.

Over the past decade, an emerging body of literature established a link between nurses' working conditions and their ability to provide safe care. Nurses who are not at their best are both prone to making errors themselves, and less able to serve as effective safety nets for their patients, intercepting errors made by physicians and others.1 Excessive nurse workloads predict an increased rate of adverse events,2, 3 and, by their own reports, nurses working shifts of >12 hours are at greatly increased risk of making medical errors.4, 5 On the basis of these and related findings, the Institute of Medicine has recommended: a) that efforts be made to assure appropriate nurse workloads and b) that nurses work no more than 12 hours per day and 60 hours per week;6 but these recommendations have not been broadly enforced.7

Two articles in the current issue of the Journal of Hospital Medicine add to our understanding of the relationship between nurse working conditions and safety, and substantiate the need to improve nurses' working conditions. In the first, Surani et al. conducted a pilot study of 20 night nurses working 12‐hour shifts in which well‐validated, objective tools revealed that ICU nurses were suffering from pathologic levels of drowsiness on the job.8 The topic is of importance as recent survey work demonstrated that nurses working >12 hours and resident‐physicians working shifts of 24 of more hours make significantly more medical errors and suffer many more occupational injuries than those working less exhausting schedules.4, 5, 912 Objective data on resident‐physicians has corroborated these findings,13, 14 but objective data measuring sleepiness in nurses has been lacking. Surani et al.'s study helps to fill this need. Further, this study suggests that hospitals should not be complacent about the safety of 12‐hour shifts, which may still be associated with dangerous levels of drowsiness‐induced impairment. Careful management of the number of consecutive night shifts,15 or further reductions in nursing work hours even beyond the 12‐hour limit endorsed by the IOM may be in orderparticularly in high‐risk critical care environmentsthough further research substantiating Surani et al.'s findings and comparing alternative scheduling options would be valuable.

The second study by Conway et al. analyzed data for acute care hospitals in California from 1993 to 2004, and found that following the passage of nurse staffing legislation in 1999 and its implementation in 2004, nurse‐patient staffing ratios increased significantly.16 Safety‐net hospitals, however, with high proportions of vulnerable patient populations, were least likely to achieve mandated ratios. As the authors point out, diverting funds to achieve mandated ratios in under‐funded safety net hospitals could potentially lead to reductions in other essential services, though whether such an eventuality might come to pass has not been adequately assessed to date.

In light of these data, where should we go from here? Public and professional concerns over the impact of fewer nurses on the delivery of care have led to the passage of legislation or adoption of regulations by many states in an attempt to ensure safe care. Examples include elimination of mandatory overtime in the following states: CT, IL, ME, MD, MN, NJ, NH, OR, RI, WA, WV, CA, MO, and TX; implementation of nurse staffing plans with input from staff nurses (WA, IL, OR, RI, TX), and mandates of specific nurse to patient ratios (CA [as discussed by Conway et al.] and FL).17 Proposed legislation regarding nurse staffing and nurse‐to‐patient ratios is currently under consideration in many additional states. Legislation broadly restricting nurse work hours has not been passed by the federal government or individual states, but some hospital systems including the Veteran's Administration now have policies prohibiting shifts of greater than 12 hours and work weeks of greater than 60 hours.18

Unfortunately, several major barriers have made the implementation of safer work hours and workloads challenging, and uncertainty about the effectiveness of implementation efforts remains. A major challenge has been the presence of a serious shortage of nurses, which is expected to peak by 2020.19 A lack of nurses will make both staffing and scheduling initiatives difficult. Over the next 10 to 15 years, policies that fund nursing education or otherwise address this shortfall will consequently be essential.

A second challenge in efforts to implement safer work schedules appears to be an absence of knowledge about the hazards of sleep deprivation, compounded by financial pressures that may lead to unsafe schedules. Some nurses oppose restriction of work hours citing that they know when they are tired, their schedule works for their personal life, and they should be allowed to work as much as they want to earn the salary they want/need. Unfortunately, it has been well‐demonstrated that chronically sleep‐deprived individuals routinely under‐estimate their level of impairment, calling into question the ability of nurses and others working extreme hours to accurately judge their abilities to perform safely.20

Clearly, education on the effects of fatigue on performance is needed, as are widespread efforts to implement safe schedules. Further study of work injuries, medical errors, and their relation to fatigue and specific work schedules is warranted, as well as studies of the impact of fatigue on sick calls and absenteeism. In many tightly staffed hospitals, overtime is used to provide coverage for sick calls, which in turn potentiates further risk of fatigue. As a profession, nurses need to take the fear factor out of saying I'm tired and advocate for adequate breaks, naps, and diet. Nurse leaders often find that offering 12‐hour shifts is required to recruit nurses, and that rotating shiftssometimes in a manner that can lead to significant circadian misalignmenthelps balance the schedule and preference for day shifts. They are also aware that a scheduled 3‐day work week is attractive to many nurses, as it allows those desiring greater income to work additional shifts through an agency at premium pay, though this may lead to further sleep deprivation. It is easy to conceive how these factors can lead to a serious conundrum.

How best to address concerns over nurse staffing remains a subject of ongoing debate. Higher nurse‐to‐patient ratios have been associated in multiple studies and a meta‐analysis with lower rates of complications and mortality.3, 21 Understanding the causal relationship between ratios and outcomes, however, has been complicated by consideration of confounding hospital variables and varying acuity of patient care between centers. The number of patients a nurse can safely care for at any one time is likely a product of the acuity of the patients, the education and experience of the nurse, and the makeup of the team available to care for the patients' needs. How well implementation of mandates regarding nurse‐patient ratios can address this complex need is unclear, and should be a focus of future research.

Leadership is essential in implementing work hour standards and staffing plans to promote a high‐quality nursing environment. Hospitals with poor operating margins, poor leadership, or poor environments of care will be unable to retain nurses to meet care requirements. Magnet hospitals, with nurse leaders who promote RN empowerment, can develop less stressful work environments with lower turnover rates and greater job satisfaction, which positively impacts quality of care. The Magnet Recognition Program, developed by the American Nurses Credentialing Center (ANCC), has recognized less than 300 hospitals in the US as providing nursing excellence (http://www.nursecredentialing.org/magnet/).

State and federal regulation may address initial safety needs, but it cannot in isolation address all of the elements that contribute to high‐quality care. While data are limited, it is possible that in financially constrained hospitals, suboptimal implementation of mandates may potentially lead to misuse of limited resources. Future research should directly assess the net effects of implementing nurse scheduling and staffing policies on mortality, hospital complication rates, and the safety of patient care processes across diverse medical centers and patient care settings. Building upon the research of Surani, Conway, and their colleagues, such research could help promote the further development of optimal care policies and the quality of patient care.

Over the past decade, an emerging body of literature established a link between nurses' working conditions and their ability to provide safe care. Nurses who are not at their best are both prone to making errors themselves, and less able to serve as effective safety nets for their patients, intercepting errors made by physicians and others.1 Excessive nurse workloads predict an increased rate of adverse events,2, 3 and, by their own reports, nurses working shifts of >12 hours are at greatly increased risk of making medical errors.4, 5 On the basis of these and related findings, the Institute of Medicine has recommended: a) that efforts be made to assure appropriate nurse workloads and b) that nurses work no more than 12 hours per day and 60 hours per week;6 but these recommendations have not been broadly enforced.7

Two articles in the current issue of the Journal of Hospital Medicine add to our understanding of the relationship between nurse working conditions and safety, and substantiate the need to improve nurses' working conditions. In the first, Surani et al. conducted a pilot study of 20 night nurses working 12‐hour shifts in which well‐validated, objective tools revealed that ICU nurses were suffering from pathologic levels of drowsiness on the job.8 The topic is of importance as recent survey work demonstrated that nurses working >12 hours and resident‐physicians working shifts of 24 of more hours make significantly more medical errors and suffer many more occupational injuries than those working less exhausting schedules.4, 5, 912 Objective data on resident‐physicians has corroborated these findings,13, 14 but objective data measuring sleepiness in nurses has been lacking. Surani et al.'s study helps to fill this need. Further, this study suggests that hospitals should not be complacent about the safety of 12‐hour shifts, which may still be associated with dangerous levels of drowsiness‐induced impairment. Careful management of the number of consecutive night shifts,15 or further reductions in nursing work hours even beyond the 12‐hour limit endorsed by the IOM may be in orderparticularly in high‐risk critical care environmentsthough further research substantiating Surani et al.'s findings and comparing alternative scheduling options would be valuable.

The second study by Conway et al. analyzed data for acute care hospitals in California from 1993 to 2004, and found that following the passage of nurse staffing legislation in 1999 and its implementation in 2004, nurse‐patient staffing ratios increased significantly.16 Safety‐net hospitals, however, with high proportions of vulnerable patient populations, were least likely to achieve mandated ratios. As the authors point out, diverting funds to achieve mandated ratios in under‐funded safety net hospitals could potentially lead to reductions in other essential services, though whether such an eventuality might come to pass has not been adequately assessed to date.

In light of these data, where should we go from here? Public and professional concerns over the impact of fewer nurses on the delivery of care have led to the passage of legislation or adoption of regulations by many states in an attempt to ensure safe care. Examples include elimination of mandatory overtime in the following states: CT, IL, ME, MD, MN, NJ, NH, OR, RI, WA, WV, CA, MO, and TX; implementation of nurse staffing plans with input from staff nurses (WA, IL, OR, RI, TX), and mandates of specific nurse to patient ratios (CA [as discussed by Conway et al.] and FL).17 Proposed legislation regarding nurse staffing and nurse‐to‐patient ratios is currently under consideration in many additional states. Legislation broadly restricting nurse work hours has not been passed by the federal government or individual states, but some hospital systems including the Veteran's Administration now have policies prohibiting shifts of greater than 12 hours and work weeks of greater than 60 hours.18

Unfortunately, several major barriers have made the implementation of safer work hours and workloads challenging, and uncertainty about the effectiveness of implementation efforts remains. A major challenge has been the presence of a serious shortage of nurses, which is expected to peak by 2020.19 A lack of nurses will make both staffing and scheduling initiatives difficult. Over the next 10 to 15 years, policies that fund nursing education or otherwise address this shortfall will consequently be essential.

A second challenge in efforts to implement safer work schedules appears to be an absence of knowledge about the hazards of sleep deprivation, compounded by financial pressures that may lead to unsafe schedules. Some nurses oppose restriction of work hours citing that they know when they are tired, their schedule works for their personal life, and they should be allowed to work as much as they want to earn the salary they want/need. Unfortunately, it has been well‐demonstrated that chronically sleep‐deprived individuals routinely under‐estimate their level of impairment, calling into question the ability of nurses and others working extreme hours to accurately judge their abilities to perform safely.20

Clearly, education on the effects of fatigue on performance is needed, as are widespread efforts to implement safe schedules. Further study of work injuries, medical errors, and their relation to fatigue and specific work schedules is warranted, as well as studies of the impact of fatigue on sick calls and absenteeism. In many tightly staffed hospitals, overtime is used to provide coverage for sick calls, which in turn potentiates further risk of fatigue. As a profession, nurses need to take the fear factor out of saying I'm tired and advocate for adequate breaks, naps, and diet. Nurse leaders often find that offering 12‐hour shifts is required to recruit nurses, and that rotating shiftssometimes in a manner that can lead to significant circadian misalignmenthelps balance the schedule and preference for day shifts. They are also aware that a scheduled 3‐day work week is attractive to many nurses, as it allows those desiring greater income to work additional shifts through an agency at premium pay, though this may lead to further sleep deprivation. It is easy to conceive how these factors can lead to a serious conundrum.

How best to address concerns over nurse staffing remains a subject of ongoing debate. Higher nurse‐to‐patient ratios have been associated in multiple studies and a meta‐analysis with lower rates of complications and mortality.3, 21 Understanding the causal relationship between ratios and outcomes, however, has been complicated by consideration of confounding hospital variables and varying acuity of patient care between centers. The number of patients a nurse can safely care for at any one time is likely a product of the acuity of the patients, the education and experience of the nurse, and the makeup of the team available to care for the patients' needs. How well implementation of mandates regarding nurse‐patient ratios can address this complex need is unclear, and should be a focus of future research.

Leadership is essential in implementing work hour standards and staffing plans to promote a high‐quality nursing environment. Hospitals with poor operating margins, poor leadership, or poor environments of care will be unable to retain nurses to meet care requirements. Magnet hospitals, with nurse leaders who promote RN empowerment, can develop less stressful work environments with lower turnover rates and greater job satisfaction, which positively impacts quality of care. The Magnet Recognition Program, developed by the American Nurses Credentialing Center (ANCC), has recognized less than 300 hospitals in the US as providing nursing excellence (http://www.nursecredentialing.org/magnet/).

State and federal regulation may address initial safety needs, but it cannot in isolation address all of the elements that contribute to high‐quality care. While data are limited, it is possible that in financially constrained hospitals, suboptimal implementation of mandates may potentially lead to misuse of limited resources. Future research should directly assess the net effects of implementing nurse scheduling and staffing policies on mortality, hospital complication rates, and the safety of patient care processes across diverse medical centers and patient care settings. Building upon the research of Surani, Conway, and their colleagues, such research could help promote the further development of optimal care policies and the quality of patient care.

POSITION

The American Society of Health‐System Pharmacists (ASHP) and the Society of Hospital Medicine (SHM) believe that the rapidly emerging hospitalist model of inpatient care offers new and significant opportunities to optimize patient care through collaboration among hospitalists, hospital pharmacists (hereinafter, pharmacists), and other health care providers. The emerging model of care allows for deeper professional relationships among health care providers and promotes a shared interest in and responsibility for direct patient care, indirect patient care, and service activities. ASHP and SHM encourage hospitalists, pharmacists, and health care executives to seek out ways to foster collaboration between hospitalists and pharmacists.

The purpose of this consensus statement is to promote an understanding of the ways hospitalists and pharmacists can jointly optimize the care provided to patients in hospitals, examine opportunities for improving hospitalistpharmacist alliances that enhance patient care, suggest future directions for collaboration, and identify aspects of such collaboration that warrant further research.

BACKGROUND

Increases in health care spending and the expanding influence of managed care in the late 1980s and early 1990s resulted in calls for more efficient health care. The movement toward greater efficiency resulted in more emphasis on ambulatory care, fewer hospital admissions, shortened hospital stays, and an overall increase in the acuity of illness of hospitalized patients. The emphasis on ambulatory care increased the number and complexity of physician office visits, and the changing characteristics of office‐ and hospital‐based care placed significant demands on primary care physicians and contributed to the rise of hospital medicine.

In 1996, the term hospitalist was introduced into the health care lexicon.1 A hospitalist was defined as an inpatient physician who manages the care of hospitalized patients and facilitates the transfer of their care back to the primary care physician. The Society of Hospital Medicine has since defined a hospitalist as a physician whose primary professional focus is the general medical care of hospitalized patients and whose activities may include patient care, teaching, research, and leadership related to hospital medicine.2

The past decade has seen rapid growth of the number of hospitalists and the use of hospitalists by US hospitals.3 In 2005, 70% of hospitals with more than 200 beds used hospitalist services, and there were more than 16,000 hospitalists in practice.4 An estimated 20,000 hospitalists were practicing at more than 2600 US hospitals in 2007.5

Initially, many physicians expressed concern about the potential for hospitalists to interfere in the relationship between the patient and the primary care physician, as well as about the potential negative impact on continuity of care.6 However, subsequent studies demonstrated increasing acceptance of hospitalists by primary care physicians, with as many as 89% considering the hospitalist model to be superior to the historical model of hospital care provided by primary care physicians or by specialists working on rotations.7, 8 Numerous studies demonstrate the value of hospitalists in improving quality of care, decreasing hospital costs and length of stay, and reducing hospital readmissions.921

As early as 1921, hospital pharmacists in the American Pharmaceutical Association (now the American Pharmacists Association) had formed a committee to address their distinct concerns. During the 1930s, hospital pharmacists began to organize state organizations and to adhere to a set of minimum standards of practice. In 1942, the American Society of Hospital Pharmacists (now the American Society of Health‐System Pharmacists) was formed to establish minimum standards of pharmaceutical services in hospitals, provide interchange among pharmacists, promote new pharmaceutical techniques, and aid the medical profession in extending the economic and rational use of medications.22 As of 2005, there were approximately 50,000 pharmacists practicing in US hospitals.23

The modern mission of hospital pharmacy departments is to ensure optimal outcomes from the use of medicines.24 Although the focus of hospital pharmacy has traditionally been on the safe dispensing of medications, direct patient care by pharmacists (clinical pharmacy) has always been a component of hospital pharmacy practice. Following the rise of pharmaceutical care in the 1980s,25 these pharmacist services have expanded greatly. It has been estimated that 35%‐40% of hospital pharmacists are devoted to providing clinical services.23 A systematic review in 2006 documented improved outcomes when clinical pharmacists interacted with the health care team on patient rounds, interviewed patients, reconciled medications, and provided discharge counseling and follow‐up.26 These findings support those of other studies in which specific clinical pharmacy services were associated with improved therapeutic and economic outcomes.2731

OPPORTUNITIES FOR COLLABORATION BETWEEN PHARMACISTS AND HOSPITALISTS

Pharmacists and hospitalists have shared interests that provide strong incentives for collaboration. All health care professionals share, first, a commitment to and responsibility for providing safe and effective patient care. Physicians, pharmacists, and other health care providers have long collaborated in providing direct patient care. The emerging hospitalist model of care offers more opportunities for collaboration because pharmacists and hospitalists also share interest in and responsibility for indirect patient care and service activitiesdeveloping the institutional policies, processes, and infrastructure that support patient care.

Direct patient care activities typically performed by hospitalists include obtaining patient histories, conducting physical examinations, making diagnoses, developing treatment plans, monitoring patients' responses to therapy, performing follow‐up hospital visits, participating in family meetings, and providing discharge instructions.32 Specific clinical pharmacy services that have been associated with improved health care outcomes include providing drug information, managing medication protocols and adverse drug reactions, participating in medical rounds, gathering admission medication histories, interviewing patients, reconciling patient medications, and providing discharge counseling and follow‐up.2631

Pharmacists should be involved in the care of hospitalized patients and can collaborate with hospitalists in numerous ways, including:

• Providing consultative services that foster appropriate, evidence‐based medication selection (eg, during rounds),

• Providing drug information to physicians, nurses, and other clinicians,

• Managing medication protocols under collaborative practice agreements,

• Assisting in the development of treatment protocols,

• Monitoring therapeutic responses (including laboratory test results),

• Continuously assessing for and managing adverse drug reactions,

• Gathering medication histories,

• Reconciling medications as patients move across the continuum of hospital care, and

• Providing patient and caretaker education, including discharge counseling and follow‐up.

Both hospitalists and pharmacists have a responsibility to ensure continuity as patients move across settings of care.

In addition to their direct patient care activities, hospitalists add value through their efforts in hospital service activities, student and resident education, and research. Typical service activities include participating in quality‐improvement and safety initiatives, developing institutional guidelines and protocols for the treatment of specific diseases, serving on hospital committees (eg, the pharmacy and therapeutics [P&T] committee), and working with others to introduce new technologies to the hospital setting.33, 34

Pharmacists also participate in hospital service activities, education, and research. For example, pharmacists serve on the P&T committee and are directly involved in managing the formulary system that guides an institution's medication use. As medication experts, pharmacists contribute to the development and implementation of patient care guidelines and other medication‐use policies. Pharmacist expertise is also integral to many quality‐improvement efforts (eg, surgical infection prophylaxis) and to technology initiatives (eg, bedside medication scanning and computerized prescriber‐order‐entry systems). Pharmacist provision of in‐service education on medications and medication use is invaluable for all health care providers.

These overlapping responsibilities provide hospitalists and pharmacists with opportunities to collaborate on activities that can have a profound effect on care in the hospital. Hospitalists and pharmacists can work together to ensure that care is evidence based, cost‐effective, and adherent to national guidelines; establish an institutional culture of safety; develop and implement quality‐improvement initiatives; meet accreditation standards; and, in many cases, foster the institution's education and research initiatives. Health professional education and research offers the opportunity to improve patient care provided not just by a single hospital but by other facilities as well.

OPPORTUNITIES TO IMPROVE COLLABORATION

ASHP and SHM believe that there are opportunities for improving collaboration between hospitalists and pharmacists. Barriers to collaboration include real and perceived professional boundaries, poor integration of technology systems, inadequate pharmacist and hospitalist staffing, time constraints, inadequate funding and resources, lack of third‐party compensation for clinical pharmacy services, and the competing obligations weighing on both professions.

Real and perceived professional boundaries can be addressed by clear communication and by enhanced interdisciplinary educational opportunities for all members of the health care team.3538 ASHP and SHM believe that while hospitalists should serve as the primary leaders of hospital care teams, all health care professionals should be willing to assume a leadership role in treating patients and, when appropriate, accept leadership by other team members. Like all members of the care team, pharmacists require timely access to hospitalists for consultation, as well as access to patient information. The vital flow of information and communication among health care providers should be conducive to collaborating and improving patient outcomes. ASHP and SHM believe that properly applied, well‐integrated technologies (eg, electronic medical records and personal digital assistants with clinical decision support systems, including drug information) can enhance communication among all members of the health care team.

Hospitalists and pharmacists can work together to overcome limitations created by inadequate funding and staffing by providing evidence to health care executives of the value of clinical pharmacist positions and pharmacisthospitalist collaboration. This evidence should examine the impact of these positions and such collaboration on therapeutic, safety, humanistic, and economic outcomes. Collaboration among all members of the health care team would also be encouraged by reforming the current fee‐for‐service reimbursement practices to base payment for care delivery on overall treatment goals (eg, a payment rate based on diagnosis).

CONCLUSIONS

An interdisciplinary approach to health care that includes physicians, pharmacists, nurses, and other health care professionals will improve the quality of patient care. Hospitalists and pharmacists need to collaborate with each other and with other health care professionals to optimize outcomes in hospitalized patients. ASHP and SHM believe that hospitalistpharmacist alliances should be encouraged and that the systems and technologies that enable collaboration and the incentives for such collaboration should be enhanced.

POSITION

The American Society of Health‐System Pharmacists (ASHP) and the Society of Hospital Medicine (SHM) believe that the rapidly emerging hospitalist model of inpatient care offers new and significant opportunities to optimize patient care through collaboration among hospitalists, hospital pharmacists (hereinafter, pharmacists), and other health care providers. The emerging model of care allows for deeper professional relationships among health care providers and promotes a shared interest in and responsibility for direct patient care, indirect patient care, and service activities. ASHP and SHM encourage hospitalists, pharmacists, and health care executives to seek out ways to foster collaboration between hospitalists and pharmacists.

The purpose of this consensus statement is to promote an understanding of the ways hospitalists and pharmacists can jointly optimize the care provided to patients in hospitals, examine opportunities for improving hospitalistpharmacist alliances that enhance patient care, suggest future directions for collaboration, and identify aspects of such collaboration that warrant further research.

BACKGROUND

Increases in health care spending and the expanding influence of managed care in the late 1980s and early 1990s resulted in calls for more efficient health care. The movement toward greater efficiency resulted in more emphasis on ambulatory care, fewer hospital admissions, shortened hospital stays, and an overall increase in the acuity of illness of hospitalized patients. The emphasis on ambulatory care increased the number and complexity of physician office visits, and the changing characteristics of office‐ and hospital‐based care placed significant demands on primary care physicians and contributed to the rise of hospital medicine.

In 1996, the term hospitalist was introduced into the health care lexicon.1 A hospitalist was defined as an inpatient physician who manages the care of hospitalized patients and facilitates the transfer of their care back to the primary care physician. The Society of Hospital Medicine has since defined a hospitalist as a physician whose primary professional focus is the general medical care of hospitalized patients and whose activities may include patient care, teaching, research, and leadership related to hospital medicine.2

The past decade has seen rapid growth of the number of hospitalists and the use of hospitalists by US hospitals.3 In 2005, 70% of hospitals with more than 200 beds used hospitalist services, and there were more than 16,000 hospitalists in practice.4 An estimated 20,000 hospitalists were practicing at more than 2600 US hospitals in 2007.5

Initially, many physicians expressed concern about the potential for hospitalists to interfere in the relationship between the patient and the primary care physician, as well as about the potential negative impact on continuity of care.6 However, subsequent studies demonstrated increasing acceptance of hospitalists by primary care physicians, with as many as 89% considering the hospitalist model to be superior to the historical model of hospital care provided by primary care physicians or by specialists working on rotations.7, 8 Numerous studies demonstrate the value of hospitalists in improving quality of care, decreasing hospital costs and length of stay, and reducing hospital readmissions.921

As early as 1921, hospital pharmacists in the American Pharmaceutical Association (now the American Pharmacists Association) had formed a committee to address their distinct concerns. During the 1930s, hospital pharmacists began to organize state organizations and to adhere to a set of minimum standards of practice. In 1942, the American Society of Hospital Pharmacists (now the American Society of Health‐System Pharmacists) was formed to establish minimum standards of pharmaceutical services in hospitals, provide interchange among pharmacists, promote new pharmaceutical techniques, and aid the medical profession in extending the economic and rational use of medications.22 As of 2005, there were approximately 50,000 pharmacists practicing in US hospitals.23

The modern mission of hospital pharmacy departments is to ensure optimal outcomes from the use of medicines.24 Although the focus of hospital pharmacy has traditionally been on the safe dispensing of medications, direct patient care by pharmacists (clinical pharmacy) has always been a component of hospital pharmacy practice. Following the rise of pharmaceutical care in the 1980s,25 these pharmacist services have expanded greatly. It has been estimated that 35%‐40% of hospital pharmacists are devoted to providing clinical services.23 A systematic review in 2006 documented improved outcomes when clinical pharmacists interacted with the health care team on patient rounds, interviewed patients, reconciled medications, and provided discharge counseling and follow‐up.26 These findings support those of other studies in which specific clinical pharmacy services were associated with improved therapeutic and economic outcomes.2731

OPPORTUNITIES FOR COLLABORATION BETWEEN PHARMACISTS AND HOSPITALISTS

Pharmacists and hospitalists have shared interests that provide strong incentives for collaboration. All health care professionals share, first, a commitment to and responsibility for providing safe and effective patient care. Physicians, pharmacists, and other health care providers have long collaborated in providing direct patient care. The emerging hospitalist model of care offers more opportunities for collaboration because pharmacists and hospitalists also share interest in and responsibility for indirect patient care and service activitiesdeveloping the institutional policies, processes, and infrastructure that support patient care.

Direct patient care activities typically performed by hospitalists include obtaining patient histories, conducting physical examinations, making diagnoses, developing treatment plans, monitoring patients' responses to therapy, performing follow‐up hospital visits, participating in family meetings, and providing discharge instructions.32 Specific clinical pharmacy services that have been associated with improved health care outcomes include providing drug information, managing medication protocols and adverse drug reactions, participating in medical rounds, gathering admission medication histories, interviewing patients, reconciling patient medications, and providing discharge counseling and follow‐up.2631

Pharmacists should be involved in the care of hospitalized patients and can collaborate with hospitalists in numerous ways, including:

• Providing consultative services that foster appropriate, evidence‐based medication selection (eg, during rounds),

• Providing drug information to physicians, nurses, and other clinicians,

• Managing medication protocols under collaborative practice agreements,

• Assisting in the development of treatment protocols,

• Monitoring therapeutic responses (including laboratory test results),

• Continuously assessing for and managing adverse drug reactions,

• Gathering medication histories,

• Reconciling medications as patients move across the continuum of hospital care, and

• Providing patient and caretaker education, including discharge counseling and follow‐up.

Both hospitalists and pharmacists have a responsibility to ensure continuity as patients move across settings of care.

In addition to their direct patient care activities, hospitalists add value through their efforts in hospital service activities, student and resident education, and research. Typical service activities include participating in quality‐improvement and safety initiatives, developing institutional guidelines and protocols for the treatment of specific diseases, serving on hospital committees (eg, the pharmacy and therapeutics [P&T] committee), and working with others to introduce new technologies to the hospital setting.33, 34

Pharmacists also participate in hospital service activities, education, and research. For example, pharmacists serve on the P&T committee and are directly involved in managing the formulary system that guides an institution's medication use. As medication experts, pharmacists contribute to the development and implementation of patient care guidelines and other medication‐use policies. Pharmacist expertise is also integral to many quality‐improvement efforts (eg, surgical infection prophylaxis) and to technology initiatives (eg, bedside medication scanning and computerized prescriber‐order‐entry systems). Pharmacist provision of in‐service education on medications and medication use is invaluable for all health care providers.

These overlapping responsibilities provide hospitalists and pharmacists with opportunities to collaborate on activities that can have a profound effect on care in the hospital. Hospitalists and pharmacists can work together to ensure that care is evidence based, cost‐effective, and adherent to national guidelines; establish an institutional culture of safety; develop and implement quality‐improvement initiatives; meet accreditation standards; and, in many cases, foster the institution's education and research initiatives. Health professional education and research offers the opportunity to improve patient care provided not just by a single hospital but by other facilities as well.

OPPORTUNITIES TO IMPROVE COLLABORATION

ASHP and SHM believe that there are opportunities for improving collaboration between hospitalists and pharmacists. Barriers to collaboration include real and perceived professional boundaries, poor integration of technology systems, inadequate pharmacist and hospitalist staffing, time constraints, inadequate funding and resources, lack of third‐party compensation for clinical pharmacy services, and the competing obligations weighing on both professions.

Real and perceived professional boundaries can be addressed by clear communication and by enhanced interdisciplinary educational opportunities for all members of the health care team.3538 ASHP and SHM believe that while hospitalists should serve as the primary leaders of hospital care teams, all health care professionals should be willing to assume a leadership role in treating patients and, when appropriate, accept leadership by other team members. Like all members of the care team, pharmacists require timely access to hospitalists for consultation, as well as access to patient information. The vital flow of information and communication among health care providers should be conducive to collaborating and improving patient outcomes. ASHP and SHM believe that properly applied, well‐integrated technologies (eg, electronic medical records and personal digital assistants with clinical decision support systems, including drug information) can enhance communication among all members of the health care team.

Hospitalists and pharmacists can work together to overcome limitations created by inadequate funding and staffing by providing evidence to health care executives of the value of clinical pharmacist positions and pharmacisthospitalist collaboration. This evidence should examine the impact of these positions and such collaboration on therapeutic, safety, humanistic, and economic outcomes. Collaboration among all members of the health care team would also be encouraged by reforming the current fee‐for‐service reimbursement practices to base payment for care delivery on overall treatment goals (eg, a payment rate based on diagnosis).

CONCLUSIONS

An interdisciplinary approach to health care that includes physicians, pharmacists, nurses, and other health care professionals will improve the quality of patient care. Hospitalists and pharmacists need to collaborate with each other and with other health care professionals to optimize outcomes in hospitalized patients. ASHP and SHM believe that hospitalistpharmacist alliances should be encouraged and that the systems and technologies that enable collaboration and the incentives for such collaboration should be enhanced.

POSITION

The American Society of Health‐System Pharmacists (ASHP) and the Society of Hospital Medicine (SHM) believe that the rapidly emerging hospitalist model of inpatient care offers new and significant opportunities to optimize patient care through collaboration among hospitalists, hospital pharmacists (hereinafter, pharmacists), and other health care providers. The emerging model of care allows for deeper professional relationships among health care providers and promotes a shared interest in and responsibility for direct patient care, indirect patient care, and service activities. ASHP and SHM encourage hospitalists, pharmacists, and health care executives to seek out ways to foster collaboration between hospitalists and pharmacists.

The purpose of this consensus statement is to promote an understanding of the ways hospitalists and pharmacists can jointly optimize the care provided to patients in hospitals, examine opportunities for improving hospitalistpharmacist alliances that enhance patient care, suggest future directions for collaboration, and identify aspects of such collaboration that warrant further research.

BACKGROUND

Increases in health care spending and the expanding influence of managed care in the late 1980s and early 1990s resulted in calls for more efficient health care. The movement toward greater efficiency resulted in more emphasis on ambulatory care, fewer hospital admissions, shortened hospital stays, and an overall increase in the acuity of illness of hospitalized patients. The emphasis on ambulatory care increased the number and complexity of physician office visits, and the changing characteristics of office‐ and hospital‐based care placed significant demands on primary care physicians and contributed to the rise of hospital medicine.

In 1996, the term hospitalist was introduced into the health care lexicon.1 A hospitalist was defined as an inpatient physician who manages the care of hospitalized patients and facilitates the transfer of their care back to the primary care physician. The Society of Hospital Medicine has since defined a hospitalist as a physician whose primary professional focus is the general medical care of hospitalized patients and whose activities may include patient care, teaching, research, and leadership related to hospital medicine.2

The past decade has seen rapid growth of the number of hospitalists and the use of hospitalists by US hospitals.3 In 2005, 70% of hospitals with more than 200 beds used hospitalist services, and there were more than 16,000 hospitalists in practice.4 An estimated 20,000 hospitalists were practicing at more than 2600 US hospitals in 2007.5

Initially, many physicians expressed concern about the potential for hospitalists to interfere in the relationship between the patient and the primary care physician, as well as about the potential negative impact on continuity of care.6 However, subsequent studies demonstrated increasing acceptance of hospitalists by primary care physicians, with as many as 89% considering the hospitalist model to be superior to the historical model of hospital care provided by primary care physicians or by specialists working on rotations.7, 8 Numerous studies demonstrate the value of hospitalists in improving quality of care, decreasing hospital costs and length of stay, and reducing hospital readmissions.921

As early as 1921, hospital pharmacists in the American Pharmaceutical Association (now the American Pharmacists Association) had formed a committee to address their distinct concerns. During the 1930s, hospital pharmacists began to organize state organizations and to adhere to a set of minimum standards of practice. In 1942, the American Society of Hospital Pharmacists (now the American Society of Health‐System Pharmacists) was formed to establish minimum standards of pharmaceutical services in hospitals, provide interchange among pharmacists, promote new pharmaceutical techniques, and aid the medical profession in extending the economic and rational use of medications.22 As of 2005, there were approximately 50,000 pharmacists practicing in US hospitals.23

The modern mission of hospital pharmacy departments is to ensure optimal outcomes from the use of medicines.24 Although the focus of hospital pharmacy has traditionally been on the safe dispensing of medications, direct patient care by pharmacists (clinical pharmacy) has always been a component of hospital pharmacy practice. Following the rise of pharmaceutical care in the 1980s,25 these pharmacist services have expanded greatly. It has been estimated that 35%‐40% of hospital pharmacists are devoted to providing clinical services.23 A systematic review in 2006 documented improved outcomes when clinical pharmacists interacted with the health care team on patient rounds, interviewed patients, reconciled medications, and provided discharge counseling and follow‐up.26 These findings support those of other studies in which specific clinical pharmacy services were associated with improved therapeutic and economic outcomes.2731

OPPORTUNITIES FOR COLLABORATION BETWEEN PHARMACISTS AND HOSPITALISTS

Pharmacists and hospitalists have shared interests that provide strong incentives for collaboration. All health care professionals share, first, a commitment to and responsibility for providing safe and effective patient care. Physicians, pharmacists, and other health care providers have long collaborated in providing direct patient care. The emerging hospitalist model of care offers more opportunities for collaboration because pharmacists and hospitalists also share interest in and responsibility for indirect patient care and service activitiesdeveloping the institutional policies, processes, and infrastructure that support patient care.

Direct patient care activities typically performed by hospitalists include obtaining patient histories, conducting physical examinations, making diagnoses, developing treatment plans, monitoring patients' responses to therapy, performing follow‐up hospital visits, participating in family meetings, and providing discharge instructions.32 Specific clinical pharmacy services that have been associated with improved health care outcomes include providing drug information, managing medication protocols and adverse drug reactions, participating in medical rounds, gathering admission medication histories, interviewing patients, reconciling patient medications, and providing discharge counseling and follow‐up.2631

Pharmacists should be involved in the care of hospitalized patients and can collaborate with hospitalists in numerous ways, including:

• Providing consultative services that foster appropriate, evidence‐based medication selection (eg, during rounds),

• Providing drug information to physicians, nurses, and other clinicians,

• Managing medication protocols under collaborative practice agreements,

• Assisting in the development of treatment protocols,

• Monitoring therapeutic responses (including laboratory test results),

• Continuously assessing for and managing adverse drug reactions,

• Gathering medication histories,

• Reconciling medications as patients move across the continuum of hospital care, and

• Providing patient and caretaker education, including discharge counseling and follow‐up.

Both hospitalists and pharmacists have a responsibility to ensure continuity as patients move across settings of care.

In addition to their direct patient care activities, hospitalists add value through their efforts in hospital service activities, student and resident education, and research. Typical service activities include participating in quality‐improvement and safety initiatives, developing institutional guidelines and protocols for the treatment of specific diseases, serving on hospital committees (eg, the pharmacy and therapeutics [P&T] committee), and working with others to introduce new technologies to the hospital setting.33, 34

Pharmacists also participate in hospital service activities, education, and research. For example, pharmacists serve on the P&T committee and are directly involved in managing the formulary system that guides an institution's medication use. As medication experts, pharmacists contribute to the development and implementation of patient care guidelines and other medication‐use policies. Pharmacist expertise is also integral to many quality‐improvement efforts (eg, surgical infection prophylaxis) and to technology initiatives (eg, bedside medication scanning and computerized prescriber‐order‐entry systems). Pharmacist provision of in‐service education on medications and medication use is invaluable for all health care providers.

These overlapping responsibilities provide hospitalists and pharmacists with opportunities to collaborate on activities that can have a profound effect on care in the hospital. Hospitalists and pharmacists can work together to ensure that care is evidence based, cost‐effective, and adherent to national guidelines; establish an institutional culture of safety; develop and implement quality‐improvement initiatives; meet accreditation standards; and, in many cases, foster the institution's education and research initiatives. Health professional education and research offers the opportunity to improve patient care provided not just by a single hospital but by other facilities as well.

OPPORTUNITIES TO IMPROVE COLLABORATION

ASHP and SHM believe that there are opportunities for improving collaboration between hospitalists and pharmacists. Barriers to collaboration include real and perceived professional boundaries, poor integration of technology systems, inadequate pharmacist and hospitalist staffing, time constraints, inadequate funding and resources, lack of third‐party compensation for clinical pharmacy services, and the competing obligations weighing on both professions.

Real and perceived professional boundaries can be addressed by clear communication and by enhanced interdisciplinary educational opportunities for all members of the health care team.3538 ASHP and SHM believe that while hospitalists should serve as the primary leaders of hospital care teams, all health care professionals should be willing to assume a leadership role in treating patients and, when appropriate, accept leadership by other team members. Like all members of the care team, pharmacists require timely access to hospitalists for consultation, as well as access to patient information. The vital flow of information and communication among health care providers should be conducive to collaborating and improving patient outcomes. ASHP and SHM believe that properly applied, well‐integrated technologies (eg, electronic medical records and personal digital assistants with clinical decision support systems, including drug information) can enhance communication among all members of the health care team.

Hospitalists and pharmacists can work together to overcome limitations created by inadequate funding and staffing by providing evidence to health care executives of the value of clinical pharmacist positions and pharmacisthospitalist collaboration. This evidence should examine the impact of these positions and such collaboration on therapeutic, safety, humanistic, and economic outcomes. Collaboration among all members of the health care team would also be encouraged by reforming the current fee‐for‐service reimbursement practices to base payment for care delivery on overall treatment goals (eg, a payment rate based on diagnosis).

CONCLUSIONS

An interdisciplinary approach to health care that includes physicians, pharmacists, nurses, and other health care professionals will improve the quality of patient care. Hospitalists and pharmacists need to collaborate with each other and with other health care professionals to optimize outcomes in hospitalized patients. ASHP and SHM believe that hospitalistpharmacist alliances should be encouraged and that the systems and technologies that enable collaboration and the incentives for such collaboration should be enhanced.