Editorial

When I went back to Croatia this summer to visit family and friends, little did I think I would find myself standing in the hospital where I trained as an intern. At 1:00 _AM I took my father to the ER for an acute episode of nausea, vomiting, dizziness, chest tightness, and dyspnea. Earlier that day, he had been watching the World Cup, not moving from his chair for several hours. The ER saw him promptly and transferred him to the main hospital in town.

Hours later, I was alone in the middle of a wide, marble corridor. Memories flowed back to when I was a young nursing student and later an intern, full of life, energy, and dreams. Now the walls were yellow and darker than I remembered. They were barren, almost sad: no pictures, no art, no life. On my left, patients were taken to a room for procedures such as thoracentesis and lumbar puncture. The next door led to a balcony where cigarettes glowed like orange fireflies. Dark shapes murmured to one another as they nursed their habit. At least smoking wasn't allowed in the patient rooms.

On my right were alternating male and female patient rooms: up to 7 beds per room. They would add an eighth and potentially squeeze in a ninth bed when needed. There were no private rooms, even if you had money or status. There were no dividers or curtains between patients. With no privacy and nothing else to do, patients entertained each other. Some were young, others older. Some had fought in the last war; others were tourists who were visiting. They shared their stories. They overheard each other's plans of care during morning rounds conducted by physicians and nurses.

Each hospital bed had a little nightstand, but that was about it. If you were lucky, you got pajamas. My dad got warm flannel pajamas in the middle of the summer, but at least he got something. We left the house in a hurry and didn't bring anything. No towels? You had to bring your own. No toothpaste or a toothbrush? There was running water but no cup to drink it in. There was not even toilet paper. You had to bring your own.

Everything was nice and clean but something was missing in this former military hospital, as if the life had been drained out of it. It was once a premier facility. Maybe it was getting older or worn out by the war, or lack of maintenance. The best equipment (including new ventilators) were reportedly stolen and sent to another city.

There was no army of people serving you. No medical assistants, physicians assistants, nurse‐practitioners, or technicians. No physical therapists or occupational therapists or even a front desk where people were greeted. No case managers. The hospital population was so much younger than in the United States. There was only 1 patient on the ward who was 90 years old, as opposed to the usual 10 patients on my service in their 80s and 90s. Most patients were discharged home with their families; very few were sent to nursing homes. There was no length of stay to worry about. There were no insurance hassles, preapproval for a test or for an additional day of hospitalization.

There were no daily blood draws. They are not watching him closely enough, I worried. The ER physician apparently ruled out cardiac causes before admitting my father to the neurology service for presumed vertebrobasilar insufficiency. Was the ER physician's history, cardiac bedside exam, 2 normal EKGs an hour apart, and CXR enough to assure him there was no need for a CPK or a troponin? I was told the CPK was normal but never saw the result. They used to do troponin but had stopped because it was too expensive. I cannot imagine admitting a patient in the United States with chest tightness without ordering cardiac enzymes. Are we scared we'll miss something or afraid of litigation? There was no such fear that I could detect in Croatia.

The inpatient workup was otherwise thorough, and everyone was courteous. Nonetheless, the money was tight. If a patient needed over the‐counter medications, a family member would be asked to buy it, sometimes at significant cost. Almost every patient had a peripheral IV but there were no unnecessary IV infusions, unlike the occasional TKO IVs we see here to justify hospitalization for a little old lady who didn't have a place to go or whose insurance would otherwise refuse to pay.

My father seemed dehydrated.

Could you put some normal saline in? I asked.

He already got some, the charge nurse replied.

What did he get?

Metoclopramide infusion in 500 cc of normal saline. He is not vomiting any longer, he can eat and drink, and he doesn't need any more IVs. It is expensive. Go buy some water and juices for him, the charge nurse said.

The meals were served 3 times a day. No snacks in‐between unless friends and family brought something.

Visiting hours were 2‐4 _PM daily. Information time for families took place on Tuesday and Friday afternoons. I arrived 30 minutes early to speak with the neurologist. In less than 20 minutes the room was filled. Everyone patiently waited their turn. The time spent with the doctor was brief but was better than nothing. As hospitalists, we spend a significant amount of time on the telephone tracking down family members, talking to them, or arranging a meeting to accommodate their schedule. On the other hand, there are family members who become frustrated because they have difficulty catching the doctor. I wonder if it would be helpful for us to have a dedicated information time. It could prevent frustration, unnecessary phone calls and pages, and perhaps save us time. Given our shorter length of stay, information time only twice a week probably wouldn't be enough.

What are you doing here? Dr. T., a friend of mine, exclaimed. Come on, a doctor from America waiting for the information! Come here, you don't need to wait! Your father is already better. We did a head CT, and we'll do a cervical spine x‐ray and carotid ultrasound tomorrow. Although I was hesitant, my brother, a medical student, tried to question the current treatment.

Why are you giving him diazepam and diclofenac intramuscularly? he asked.

What do you mean why? Because this is how we do it, Dr. T. said.

You already have an IV access. Couldn't you give it to him IV? my brother persisted. Dr. T. looked at him like he had fallen off the apple cart.

I had never seen it done this way in Austria or Germany, my brother continued. Why cause unnecessary pain and complications?

What complications? said Dr. T., now impatient. We use it intramuscularly. This is how it is done. It is only 10 injections. That's nothing.

Ten injections? You can injure a nerve! my brother exclaimed.

What nerve? Not if you do it right. We've been doing it this way forever. Your dad had dizziness and vomiting, and now he is better.

My father was better. Something had worked. Was it the medications or that he had slept and was rested?

The night had sneaked up on us again. The ward was quiet. No call lights. No patient telephones. No TVs. No IV machines and their beeping. No vital signs were taken in the middle of the night. No early‐morning blood draws. No pagers. The hospital was a place to get some rest.

The following day I spoke to the on‐call physician. The head CT and labs were normal. After 4 days in the hospital, I needed to know what the weekend plans would be.

How much longer will he need to be in the hospital? I asked.

Oh, about 10 to 14 days.

Ten to 14 days? I couldn't hide my surprise. What for? I might have as well asked if pigs were falling from the sky. This is how it was done.

Documentation was scanty. No worries of audits to justify the work done. How much time was saved this way? No wonder each physician saw 20 to 30 patients or more. There were 2 forms at discharge typed into a computer by the physician: a short one containing discharge medications and follow‐up plans and a long one to be completed later. We got the short one immediately and made follow‐up appointments. But many weeks later, we are still waiting for the long one. Apparently not all the lab tests are back.

Looking back, I see that when I tried to push for more information, I was viewed as pushy. So I stopped pushing. When I asked some logical questions, I felt like I was showing off. So I stopped asking too many questions. When I asked dad to tell me what happened during the day, he did not know. He did not remember the name of the consultants or what they said. When I asked him to try harder, he refused. When I asked him to write things down, he hesitated. It would mark him as a troublemaker. He was concerned that he would be labeled as an outsider, despite having lived in Croatia his whole life. Years after the war, a person's last name could still conjure up barely concealed hatred or suspicion. My father wanted to be seen as a good and compliant patient. He felt too vulnerable to be pushing for answers. Somehow, against my better judgment, I fell into the same mode.

Coming back to my hometown curiously hampered me. I still don't understand why. Was it sadness in my heart and nostalgia? Or emotional remnants of the recent war lingering in the air? Or a more patriarchal mentality and the unwritten rules of thinking and behaving that I had forgotten about? I was both a daughter and a visitor. I grew up in Croatia, but I left 2 weeks before the fighting broke out, and my prewar memories were still pristine. I was both a native and an American physician with all the expectations of stateside care. When I was a student there, physicians were authoritative and almost never questioned.

In the end, my father received care that was professional and thorough. The hospital lacked some basic necessities. They were on a strict budget for medicines including IV solutions. On the other hand, they kept my father in for 9 days, consulted an internist, an ENT. and a urologist. They also did numerous studies, including a head CT, cervical spine x‐ray, carotid ultrasound, hearing test and vestibulogram, CXR, and abdominal ultrasound. He had only 2 blood draws: CBC and Chem 7 (one time, one stick) and thyroid tests and PSA (one time, second stick). If he had been my patient, I would have probably tried to discharge him within 2 days and have him complete the evaluation as an outpatient. They gave him 9 days of diclofenac and diazepam intramuscularly and 7 days of 500 cc of normal saline and metoclopramide IV. My father was released from the hospital several days early at his insistence and mine. He had no more nausea or vomiting, no chest pain or shortness of breath. He was calm and relaxed. He was well rested. He felt better. And he is fine today.

When I went back to Croatia this summer to visit family and friends, little did I think I would find myself standing in the hospital where I trained as an intern. At 1:00 _AM I took my father to the ER for an acute episode of nausea, vomiting, dizziness, chest tightness, and dyspnea. Earlier that day, he had been watching the World Cup, not moving from his chair for several hours. The ER saw him promptly and transferred him to the main hospital in town.

Hours later, I was alone in the middle of a wide, marble corridor. Memories flowed back to when I was a young nursing student and later an intern, full of life, energy, and dreams. Now the walls were yellow and darker than I remembered. They were barren, almost sad: no pictures, no art, no life. On my left, patients were taken to a room for procedures such as thoracentesis and lumbar puncture. The next door led to a balcony where cigarettes glowed like orange fireflies. Dark shapes murmured to one another as they nursed their habit. At least smoking wasn't allowed in the patient rooms.

On my right were alternating male and female patient rooms: up to 7 beds per room. They would add an eighth and potentially squeeze in a ninth bed when needed. There were no private rooms, even if you had money or status. There were no dividers or curtains between patients. With no privacy and nothing else to do, patients entertained each other. Some were young, others older. Some had fought in the last war; others were tourists who were visiting. They shared their stories. They overheard each other's plans of care during morning rounds conducted by physicians and nurses.

Each hospital bed had a little nightstand, but that was about it. If you were lucky, you got pajamas. My dad got warm flannel pajamas in the middle of the summer, but at least he got something. We left the house in a hurry and didn't bring anything. No towels? You had to bring your own. No toothpaste or a toothbrush? There was running water but no cup to drink it in. There was not even toilet paper. You had to bring your own.

Everything was nice and clean but something was missing in this former military hospital, as if the life had been drained out of it. It was once a premier facility. Maybe it was getting older or worn out by the war, or lack of maintenance. The best equipment (including new ventilators) were reportedly stolen and sent to another city.

There was no army of people serving you. No medical assistants, physicians assistants, nurse‐practitioners, or technicians. No physical therapists or occupational therapists or even a front desk where people were greeted. No case managers. The hospital population was so much younger than in the United States. There was only 1 patient on the ward who was 90 years old, as opposed to the usual 10 patients on my service in their 80s and 90s. Most patients were discharged home with their families; very few were sent to nursing homes. There was no length of stay to worry about. There were no insurance hassles, preapproval for a test or for an additional day of hospitalization.

There were no daily blood draws. They are not watching him closely enough, I worried. The ER physician apparently ruled out cardiac causes before admitting my father to the neurology service for presumed vertebrobasilar insufficiency. Was the ER physician's history, cardiac bedside exam, 2 normal EKGs an hour apart, and CXR enough to assure him there was no need for a CPK or a troponin? I was told the CPK was normal but never saw the result. They used to do troponin but had stopped because it was too expensive. I cannot imagine admitting a patient in the United States with chest tightness without ordering cardiac enzymes. Are we scared we'll miss something or afraid of litigation? There was no such fear that I could detect in Croatia.

The inpatient workup was otherwise thorough, and everyone was courteous. Nonetheless, the money was tight. If a patient needed over the‐counter medications, a family member would be asked to buy it, sometimes at significant cost. Almost every patient had a peripheral IV but there were no unnecessary IV infusions, unlike the occasional TKO IVs we see here to justify hospitalization for a little old lady who didn't have a place to go or whose insurance would otherwise refuse to pay.

My father seemed dehydrated.

Could you put some normal saline in? I asked.

He already got some, the charge nurse replied.

What did he get?

Metoclopramide infusion in 500 cc of normal saline. He is not vomiting any longer, he can eat and drink, and he doesn't need any more IVs. It is expensive. Go buy some water and juices for him, the charge nurse said.

The meals were served 3 times a day. No snacks in‐between unless friends and family brought something.

Visiting hours were 2‐4 _PM daily. Information time for families took place on Tuesday and Friday afternoons. I arrived 30 minutes early to speak with the neurologist. In less than 20 minutes the room was filled. Everyone patiently waited their turn. The time spent with the doctor was brief but was better than nothing. As hospitalists, we spend a significant amount of time on the telephone tracking down family members, talking to them, or arranging a meeting to accommodate their schedule. On the other hand, there are family members who become frustrated because they have difficulty catching the doctor. I wonder if it would be helpful for us to have a dedicated information time. It could prevent frustration, unnecessary phone calls and pages, and perhaps save us time. Given our shorter length of stay, information time only twice a week probably wouldn't be enough.

What are you doing here? Dr. T., a friend of mine, exclaimed. Come on, a doctor from America waiting for the information! Come here, you don't need to wait! Your father is already better. We did a head CT, and we'll do a cervical spine x‐ray and carotid ultrasound tomorrow. Although I was hesitant, my brother, a medical student, tried to question the current treatment.

Why are you giving him diazepam and diclofenac intramuscularly? he asked.

What do you mean why? Because this is how we do it, Dr. T. said.

You already have an IV access. Couldn't you give it to him IV? my brother persisted. Dr. T. looked at him like he had fallen off the apple cart.

I had never seen it done this way in Austria or Germany, my brother continued. Why cause unnecessary pain and complications?

What complications? said Dr. T., now impatient. We use it intramuscularly. This is how it is done. It is only 10 injections. That's nothing.

Ten injections? You can injure a nerve! my brother exclaimed.

What nerve? Not if you do it right. We've been doing it this way forever. Your dad had dizziness and vomiting, and now he is better.

My father was better. Something had worked. Was it the medications or that he had slept and was rested?

The night had sneaked up on us again. The ward was quiet. No call lights. No patient telephones. No TVs. No IV machines and their beeping. No vital signs were taken in the middle of the night. No early‐morning blood draws. No pagers. The hospital was a place to get some rest.

The following day I spoke to the on‐call physician. The head CT and labs were normal. After 4 days in the hospital, I needed to know what the weekend plans would be.

How much longer will he need to be in the hospital? I asked.

Oh, about 10 to 14 days.

Ten to 14 days? I couldn't hide my surprise. What for? I might have as well asked if pigs were falling from the sky. This is how it was done.

Documentation was scanty. No worries of audits to justify the work done. How much time was saved this way? No wonder each physician saw 20 to 30 patients or more. There were 2 forms at discharge typed into a computer by the physician: a short one containing discharge medications and follow‐up plans and a long one to be completed later. We got the short one immediately and made follow‐up appointments. But many weeks later, we are still waiting for the long one. Apparently not all the lab tests are back.

Looking back, I see that when I tried to push for more information, I was viewed as pushy. So I stopped pushing. When I asked some logical questions, I felt like I was showing off. So I stopped asking too many questions. When I asked dad to tell me what happened during the day, he did not know. He did not remember the name of the consultants or what they said. When I asked him to try harder, he refused. When I asked him to write things down, he hesitated. It would mark him as a troublemaker. He was concerned that he would be labeled as an outsider, despite having lived in Croatia his whole life. Years after the war, a person's last name could still conjure up barely concealed hatred or suspicion. My father wanted to be seen as a good and compliant patient. He felt too vulnerable to be pushing for answers. Somehow, against my better judgment, I fell into the same mode.

Coming back to my hometown curiously hampered me. I still don't understand why. Was it sadness in my heart and nostalgia? Or emotional remnants of the recent war lingering in the air? Or a more patriarchal mentality and the unwritten rules of thinking and behaving that I had forgotten about? I was both a daughter and a visitor. I grew up in Croatia, but I left 2 weeks before the fighting broke out, and my prewar memories were still pristine. I was both a native and an American physician with all the expectations of stateside care. When I was a student there, physicians were authoritative and almost never questioned.

In the end, my father received care that was professional and thorough. The hospital lacked some basic necessities. They were on a strict budget for medicines including IV solutions. On the other hand, they kept my father in for 9 days, consulted an internist, an ENT. and a urologist. They also did numerous studies, including a head CT, cervical spine x‐ray, carotid ultrasound, hearing test and vestibulogram, CXR, and abdominal ultrasound. He had only 2 blood draws: CBC and Chem 7 (one time, one stick) and thyroid tests and PSA (one time, second stick). If he had been my patient, I would have probably tried to discharge him within 2 days and have him complete the evaluation as an outpatient. They gave him 9 days of diclofenac and diazepam intramuscularly and 7 days of 500 cc of normal saline and metoclopramide IV. My father was released from the hospital several days early at his insistence and mine. He had no more nausea or vomiting, no chest pain or shortness of breath. He was calm and relaxed. He was well rested. He felt better. And he is fine today.

When I went back to Croatia this summer to visit family and friends, little did I think I would find myself standing in the hospital where I trained as an intern. At 1:00 _AM I took my father to the ER for an acute episode of nausea, vomiting, dizziness, chest tightness, and dyspnea. Earlier that day, he had been watching the World Cup, not moving from his chair for several hours. The ER saw him promptly and transferred him to the main hospital in town.

Hours later, I was alone in the middle of a wide, marble corridor. Memories flowed back to when I was a young nursing student and later an intern, full of life, energy, and dreams. Now the walls were yellow and darker than I remembered. They were barren, almost sad: no pictures, no art, no life. On my left, patients were taken to a room for procedures such as thoracentesis and lumbar puncture. The next door led to a balcony where cigarettes glowed like orange fireflies. Dark shapes murmured to one another as they nursed their habit. At least smoking wasn't allowed in the patient rooms.

On my right were alternating male and female patient rooms: up to 7 beds per room. They would add an eighth and potentially squeeze in a ninth bed when needed. There were no private rooms, even if you had money or status. There were no dividers or curtains between patients. With no privacy and nothing else to do, patients entertained each other. Some were young, others older. Some had fought in the last war; others were tourists who were visiting. They shared their stories. They overheard each other's plans of care during morning rounds conducted by physicians and nurses.

Each hospital bed had a little nightstand, but that was about it. If you were lucky, you got pajamas. My dad got warm flannel pajamas in the middle of the summer, but at least he got something. We left the house in a hurry and didn't bring anything. No towels? You had to bring your own. No toothpaste or a toothbrush? There was running water but no cup to drink it in. There was not even toilet paper. You had to bring your own.

Everything was nice and clean but something was missing in this former military hospital, as if the life had been drained out of it. It was once a premier facility. Maybe it was getting older or worn out by the war, or lack of maintenance. The best equipment (including new ventilators) were reportedly stolen and sent to another city.

There was no army of people serving you. No medical assistants, physicians assistants, nurse‐practitioners, or technicians. No physical therapists or occupational therapists or even a front desk where people were greeted. No case managers. The hospital population was so much younger than in the United States. There was only 1 patient on the ward who was 90 years old, as opposed to the usual 10 patients on my service in their 80s and 90s. Most patients were discharged home with their families; very few were sent to nursing homes. There was no length of stay to worry about. There were no insurance hassles, preapproval for a test or for an additional day of hospitalization.

There were no daily blood draws. They are not watching him closely enough, I worried. The ER physician apparently ruled out cardiac causes before admitting my father to the neurology service for presumed vertebrobasilar insufficiency. Was the ER physician's history, cardiac bedside exam, 2 normal EKGs an hour apart, and CXR enough to assure him there was no need for a CPK or a troponin? I was told the CPK was normal but never saw the result. They used to do troponin but had stopped because it was too expensive. I cannot imagine admitting a patient in the United States with chest tightness without ordering cardiac enzymes. Are we scared we'll miss something or afraid of litigation? There was no such fear that I could detect in Croatia.

The inpatient workup was otherwise thorough, and everyone was courteous. Nonetheless, the money was tight. If a patient needed over the‐counter medications, a family member would be asked to buy it, sometimes at significant cost. Almost every patient had a peripheral IV but there were no unnecessary IV infusions, unlike the occasional TKO IVs we see here to justify hospitalization for a little old lady who didn't have a place to go or whose insurance would otherwise refuse to pay.

My father seemed dehydrated.

Could you put some normal saline in? I asked.

He already got some, the charge nurse replied.

What did he get?

Metoclopramide infusion in 500 cc of normal saline. He is not vomiting any longer, he can eat and drink, and he doesn't need any more IVs. It is expensive. Go buy some water and juices for him, the charge nurse said.

The meals were served 3 times a day. No snacks in‐between unless friends and family brought something.

Visiting hours were 2‐4 _PM daily. Information time for families took place on Tuesday and Friday afternoons. I arrived 30 minutes early to speak with the neurologist. In less than 20 minutes the room was filled. Everyone patiently waited their turn. The time spent with the doctor was brief but was better than nothing. As hospitalists, we spend a significant amount of time on the telephone tracking down family members, talking to them, or arranging a meeting to accommodate their schedule. On the other hand, there are family members who become frustrated because they have difficulty catching the doctor. I wonder if it would be helpful for us to have a dedicated information time. It could prevent frustration, unnecessary phone calls and pages, and perhaps save us time. Given our shorter length of stay, information time only twice a week probably wouldn't be enough.

What are you doing here? Dr. T., a friend of mine, exclaimed. Come on, a doctor from America waiting for the information! Come here, you don't need to wait! Your father is already better. We did a head CT, and we'll do a cervical spine x‐ray and carotid ultrasound tomorrow. Although I was hesitant, my brother, a medical student, tried to question the current treatment.

Why are you giving him diazepam and diclofenac intramuscularly? he asked.

What do you mean why? Because this is how we do it, Dr. T. said.

You already have an IV access. Couldn't you give it to him IV? my brother persisted. Dr. T. looked at him like he had fallen off the apple cart.

I had never seen it done this way in Austria or Germany, my brother continued. Why cause unnecessary pain and complications?

What complications? said Dr. T., now impatient. We use it intramuscularly. This is how it is done. It is only 10 injections. That's nothing.

Ten injections? You can injure a nerve! my brother exclaimed.

What nerve? Not if you do it right. We've been doing it this way forever. Your dad had dizziness and vomiting, and now he is better.

My father was better. Something had worked. Was it the medications or that he had slept and was rested?

The night had sneaked up on us again. The ward was quiet. No call lights. No patient telephones. No TVs. No IV machines and their beeping. No vital signs were taken in the middle of the night. No early‐morning blood draws. No pagers. The hospital was a place to get some rest.

The following day I spoke to the on‐call physician. The head CT and labs were normal. After 4 days in the hospital, I needed to know what the weekend plans would be.

How much longer will he need to be in the hospital? I asked.

Oh, about 10 to 14 days.

Ten to 14 days? I couldn't hide my surprise. What for? I might have as well asked if pigs were falling from the sky. This is how it was done.

Documentation was scanty. No worries of audits to justify the work done. How much time was saved this way? No wonder each physician saw 20 to 30 patients or more. There were 2 forms at discharge typed into a computer by the physician: a short one containing discharge medications and follow‐up plans and a long one to be completed later. We got the short one immediately and made follow‐up appointments. But many weeks later, we are still waiting for the long one. Apparently not all the lab tests are back.

Looking back, I see that when I tried to push for more information, I was viewed as pushy. So I stopped pushing. When I asked some logical questions, I felt like I was showing off. So I stopped asking too many questions. When I asked dad to tell me what happened during the day, he did not know. He did not remember the name of the consultants or what they said. When I asked him to try harder, he refused. When I asked him to write things down, he hesitated. It would mark him as a troublemaker. He was concerned that he would be labeled as an outsider, despite having lived in Croatia his whole life. Years after the war, a person's last name could still conjure up barely concealed hatred or suspicion. My father wanted to be seen as a good and compliant patient. He felt too vulnerable to be pushing for answers. Somehow, against my better judgment, I fell into the same mode.

Coming back to my hometown curiously hampered me. I still don't understand why. Was it sadness in my heart and nostalgia? Or emotional remnants of the recent war lingering in the air? Or a more patriarchal mentality and the unwritten rules of thinking and behaving that I had forgotten about? I was both a daughter and a visitor. I grew up in Croatia, but I left 2 weeks before the fighting broke out, and my prewar memories were still pristine. I was both a native and an American physician with all the expectations of stateside care. When I was a student there, physicians were authoritative and almost never questioned.

In the end, my father received care that was professional and thorough. The hospital lacked some basic necessities. They were on a strict budget for medicines including IV solutions. On the other hand, they kept my father in for 9 days, consulted an internist, an ENT. and a urologist. They also did numerous studies, including a head CT, cervical spine x‐ray, carotid ultrasound, hearing test and vestibulogram, CXR, and abdominal ultrasound. He had only 2 blood draws: CBC and Chem 7 (one time, one stick) and thyroid tests and PSA (one time, second stick). If he had been my patient, I would have probably tried to discharge him within 2 days and have him complete the evaluation as an outpatient. They gave him 9 days of diclofenac and diazepam intramuscularly and 7 days of 500 cc of normal saline and metoclopramide IV. My father was released from the hospital several days early at his insistence and mine. He had no more nausea or vomiting, no chest pain or shortness of breath. He was calm and relaxed. He was well rested. He felt better. And he is fine today.

In 10 short years, the explosive growth in the number of hospitalists has made hospital medicine programs the cornerstone of many innovations that support the institutions they serve: expanded inpatient care, developing consultative and comanagement services, hospital capacity management, improved patient quality and safety practices, and more. Hospitalist teams have demonstrated a genuine commitment to improving the hospital system, with literature supporting that hospitalists can positively affect cost, length of stay, quality of care, and, at academic institutions, education.1 To the casual observer, these hospitalist groups and the solutions they bring may seem fairly uniform; however, to the discerning eye, nothing could be farther from the truth. Hospital medicine programs, and their innovations, are as varied as the hospitals they serve.

Although the challenges encountered in hospital systems have clear, institution‐specific elements, common themes are often encountered by clinicians that parallel those seen at other facilities. Unfortunately, widely disseminated articles from peer‐reviewed journals on hospital‐based innovations have not been available for other hospitalists to use and glean ideas from for use at their home institutionsuntil now. The Journal of Hospital Medicine is pleased to announce the creation of that opportunity.

This year, the Journal of Hospital Medicine will publish articles on and later a supplement dedicated to innovations in hospital medicine. We invite authors to submit manuscripts related to any successful innovation they initiated in their hospital. We will consider any original work that pertains to hospital medicine, including but not limited to clinical innovations, educational programs, quality and safety initiatives, and administrative or academic issues. When available and appropriate, we encourage outcomes to be reported.

To be able to publish articles on a significant number of innovations, we request manuscripts be a maximum of 1500 words with no more than 2 tables or figures and fewer than 15 references. The deadline for submissions is August 1, 2007. All submitted manuscripts will undergo both editorial review by JHM staff and peer review. Authors should consult JHM's instructions for authors2 for guidelines on manuscript submission and preparation.

In 10 short years, the explosive growth in the number of hospitalists has made hospital medicine programs the cornerstone of many innovations that support the institutions they serve: expanded inpatient care, developing consultative and comanagement services, hospital capacity management, improved patient quality and safety practices, and more. Hospitalist teams have demonstrated a genuine commitment to improving the hospital system, with literature supporting that hospitalists can positively affect cost, length of stay, quality of care, and, at academic institutions, education.1 To the casual observer, these hospitalist groups and the solutions they bring may seem fairly uniform; however, to the discerning eye, nothing could be farther from the truth. Hospital medicine programs, and their innovations, are as varied as the hospitals they serve.

Although the challenges encountered in hospital systems have clear, institution‐specific elements, common themes are often encountered by clinicians that parallel those seen at other facilities. Unfortunately, widely disseminated articles from peer‐reviewed journals on hospital‐based innovations have not been available for other hospitalists to use and glean ideas from for use at their home institutionsuntil now. The Journal of Hospital Medicine is pleased to announce the creation of that opportunity.

This year, the Journal of Hospital Medicine will publish articles on and later a supplement dedicated to innovations in hospital medicine. We invite authors to submit manuscripts related to any successful innovation they initiated in their hospital. We will consider any original work that pertains to hospital medicine, including but not limited to clinical innovations, educational programs, quality and safety initiatives, and administrative or academic issues. When available and appropriate, we encourage outcomes to be reported.

To be able to publish articles on a significant number of innovations, we request manuscripts be a maximum of 1500 words with no more than 2 tables or figures and fewer than 15 references. The deadline for submissions is August 1, 2007. All submitted manuscripts will undergo both editorial review by JHM staff and peer review. Authors should consult JHM's instructions for authors2 for guidelines on manuscript submission and preparation.

In 10 short years, the explosive growth in the number of hospitalists has made hospital medicine programs the cornerstone of many innovations that support the institutions they serve: expanded inpatient care, developing consultative and comanagement services, hospital capacity management, improved patient quality and safety practices, and more. Hospitalist teams have demonstrated a genuine commitment to improving the hospital system, with literature supporting that hospitalists can positively affect cost, length of stay, quality of care, and, at academic institutions, education.1 To the casual observer, these hospitalist groups and the solutions they bring may seem fairly uniform; however, to the discerning eye, nothing could be farther from the truth. Hospital medicine programs, and their innovations, are as varied as the hospitals they serve.

Although the challenges encountered in hospital systems have clear, institution‐specific elements, common themes are often encountered by clinicians that parallel those seen at other facilities. Unfortunately, widely disseminated articles from peer‐reviewed journals on hospital‐based innovations have not been available for other hospitalists to use and glean ideas from for use at their home institutionsuntil now. The Journal of Hospital Medicine is pleased to announce the creation of that opportunity.

This year, the Journal of Hospital Medicine will publish articles on and later a supplement dedicated to innovations in hospital medicine. We invite authors to submit manuscripts related to any successful innovation they initiated in their hospital. We will consider any original work that pertains to hospital medicine, including but not limited to clinical innovations, educational programs, quality and safety initiatives, and administrative or academic issues. When available and appropriate, we encourage outcomes to be reported.

To be able to publish articles on a significant number of innovations, we request manuscripts be a maximum of 1500 words with no more than 2 tables or figures and fewer than 15 references. The deadline for submissions is August 1, 2007. All submitted manuscripts will undergo both editorial review by JHM staff and peer review. Authors should consult JHM's instructions for authors2 for guidelines on manuscript submission and preparation.

Embracing, with strengthened spirits

Shades of Her Life

Embracing, with strengthened spirits

Shades of Her Life

Embracing, with strengthened spirits

Shades of Her Life

In this issue of the Journal of Hospital Medicine, Simon et al.1 provide the first report of pediatric hospitalist comanagement of patients undergoing spinal fusion surgery. In this retrospective cohort study, 14 of 115 patients were comanaged by a pediatric hospitalist. The primary outcomes of the study were length of stay and variability in length of stay. Prior to the initiation of hospitalist comanagement service, all patients were managed preoperatively by a spine surgery nurse and aided by medical subspecialists and other allied health professionals (nutritionists, respiratory therapists, physical therapists, social workers). After the intervention, patients with the most complex medical disease were assigned to comanagement by a pediatric hospitalist. When compared to a historical control of patients with similar medical complexity but not comanaged by hospitalists, the length of stay was reduced by 2.4 days (8.6 vs. 6.2 days). The variability in mean length of stay was also reduced.

This study follows on the heels of 3 important studies addressing the utility of hospitalists in the comanagement of surgical patients. The HOT (Hospitalist Orthopedic Team) trial was a randomized controlled trial assessing the effect of hospitalists on the management of patients undergoing elective hip and knee arthroplasty.2 There was no effect on length of stay or patient outcomes, though the comanagement model did decrease minor postoperative medical complications and improve physician and nurse satisfaction. Macpherson et al. conducted a retrospective trial where an internist joined a cardiothoracic surgery service at a tertiary‐care center.3 They found a decrease in overall mortality and resource utilization such as labs testing and consultations. There was significant reduction in the length of stay and number of x‐rays performed. The third study, by Jaffer et al.,4 showed that an outpatient, preoperative evaluation clinic staffed by hospitalists at a large tertiary‐care center provides a practical model for managing preoperative patients and may be associated with a low rate of postoperative pulmonary complications.

The study by Simon et al. in this issue of the journal has limitations. It is a retrospective cohort trial, and like all such study designs, the validity of the results is subject to confounding. Severity of patient medical disease, intraoperative complications, and advances in surgical technique are examples. While the authors did everything possible to minimize the effect of confounding, it remains a limitation of the study. The study also enrolled only 14 patients in the comanagement group, and this limited any stratification or subgroup analysis to offset known confounders. Patients assigned to the hospitalist comanagement service were by design more medically complex than other spinal fusion patients, and generalizing the results of this trial to all spinal fusion patients may not be possible.

From the study's limitations, however, comes great insight into the role of the hospitalist in surgical comanagement. It is clear from the aforementioned studies that there is a role for the hospitalist in comanagement of surgical patients. While the evidence is conflicting, there are scenarios in which comanagement improves efficiency and quality of care. Yet it is also possible that hospitalist comanagement is not ideal for all surgical patients. The HOT trial did not show benefits in length‐of‐stay reduction or patient mortality because the patients were homogenous in their complexity and pre‐ and postoperative care was protocol driven. Length of stay was limited by accessibility of rehabilitation facilities after discharge and not the efficiency of medical care in the hospital. The study in this issue of the Journal of Hospital Medicine selectively included patients with the highest complexity of medical disease, and there was a reduction in length of stay. Both trials suggest that the greatest potential benefit for augmenting efficiency and outcomes with hospitalist comanagement may be predicated on the complexity of the patients involved and the surgical system through which they will receive care.

The next step in assessing hospitalist comanagement should not be a hunt‐and‐peck exercise to stumble on the surgical procedures that show benefit from comanagement. Rather, the prudent next step is to follow the lead of Simon et al. and others3, 4 in trying to identify those surgical patients who represent the greatest medical complexity or have the most variability in their preoperative and postoperative medical care. These are the patients for whom the hospitalist can effect the greatest benefit and the services for which the hospitalist can best augment efficiency. High‐risk procedures, patients with multiple comorbitities or elevated preoperative risks, and surgical procedures without defined pre‐ and postoperative protocols would appear to be the ideal candidates for hospitalist comanagement.

As the discussion of hospital comanagement progresses, it is important to recognize comanagement as a paradigm shift. Surgical comanagement is not merely medical consultation. To be successful, the role of the hospitalist in comanaging surgical patients must be clearly defined as advancing postoperative care as much as it is in assessing preoperative risk. As a comanager, a hospitalist must actively manage preexisting and newly developed medical issues rather than just make recommendations for the surgical team.

The hospitalist must also be more than a discharge coordinator postoperatively; investing in hospitalists merely for discharge planning is a poor use of resources both from a financial and an opportunity‐cost perspective. The paradigm of comanagement is not foreign, however, and hospitalists are likely to prosper by learning from the experience of our nephrology and hepatology colleagues, who have successfully found collaborative roles in improving patient care on renal and liver transplant services. The success of these services is due to the precisely defined roles for the internist and the surgeon and because the complexity of the patient being managed warrants continuity of expert consultation.

There is great potential for the hospitalist in surgical comanagement. In less than a decade, the focus of hospital‐based medical care has shifted from staffing a shift to improving the quality of the system through which patients traverse the hospital. The lessons hospitalists have learned in quality improvement and in augmenting systems of care are perfectly suited for application to surgical services. Hospitalist comanagement is right not only because it may offer improvement in a surgical patient's medical care, but also for the augmentation of quality improvement in surgical services that have yet to reap the benefits that have defined the excellence of hospitalist medicine. The next step is to embark on the road of prudent prospective research: identifying the patients, and the procedures, that have the greatest opportunity for improvement by hospitalist comanagement. And at the end of that road will be a new home for the hospitalist, assuming the role of the quality‐advocate for all aspects of hospital care: pediatric, medical, and surgical patients.

In this issue of the Journal of Hospital Medicine, Simon et al.1 provide the first report of pediatric hospitalist comanagement of patients undergoing spinal fusion surgery. In this retrospective cohort study, 14 of 115 patients were comanaged by a pediatric hospitalist. The primary outcomes of the study were length of stay and variability in length of stay. Prior to the initiation of hospitalist comanagement service, all patients were managed preoperatively by a spine surgery nurse and aided by medical subspecialists and other allied health professionals (nutritionists, respiratory therapists, physical therapists, social workers). After the intervention, patients with the most complex medical disease were assigned to comanagement by a pediatric hospitalist. When compared to a historical control of patients with similar medical complexity but not comanaged by hospitalists, the length of stay was reduced by 2.4 days (8.6 vs. 6.2 days). The variability in mean length of stay was also reduced.

This study follows on the heels of 3 important studies addressing the utility of hospitalists in the comanagement of surgical patients. The HOT (Hospitalist Orthopedic Team) trial was a randomized controlled trial assessing the effect of hospitalists on the management of patients undergoing elective hip and knee arthroplasty.2 There was no effect on length of stay or patient outcomes, though the comanagement model did decrease minor postoperative medical complications and improve physician and nurse satisfaction. Macpherson et al. conducted a retrospective trial where an internist joined a cardiothoracic surgery service at a tertiary‐care center.3 They found a decrease in overall mortality and resource utilization such as labs testing and consultations. There was significant reduction in the length of stay and number of x‐rays performed. The third study, by Jaffer et al.,4 showed that an outpatient, preoperative evaluation clinic staffed by hospitalists at a large tertiary‐care center provides a practical model for managing preoperative patients and may be associated with a low rate of postoperative pulmonary complications.

The study by Simon et al. in this issue of the journal has limitations. It is a retrospective cohort trial, and like all such study designs, the validity of the results is subject to confounding. Severity of patient medical disease, intraoperative complications, and advances in surgical technique are examples. While the authors did everything possible to minimize the effect of confounding, it remains a limitation of the study. The study also enrolled only 14 patients in the comanagement group, and this limited any stratification or subgroup analysis to offset known confounders. Patients assigned to the hospitalist comanagement service were by design more medically complex than other spinal fusion patients, and generalizing the results of this trial to all spinal fusion patients may not be possible.

From the study's limitations, however, comes great insight into the role of the hospitalist in surgical comanagement. It is clear from the aforementioned studies that there is a role for the hospitalist in comanagement of surgical patients. While the evidence is conflicting, there are scenarios in which comanagement improves efficiency and quality of care. Yet it is also possible that hospitalist comanagement is not ideal for all surgical patients. The HOT trial did not show benefits in length‐of‐stay reduction or patient mortality because the patients were homogenous in their complexity and pre‐ and postoperative care was protocol driven. Length of stay was limited by accessibility of rehabilitation facilities after discharge and not the efficiency of medical care in the hospital. The study in this issue of the Journal of Hospital Medicine selectively included patients with the highest complexity of medical disease, and there was a reduction in length of stay. Both trials suggest that the greatest potential benefit for augmenting efficiency and outcomes with hospitalist comanagement may be predicated on the complexity of the patients involved and the surgical system through which they will receive care.

The next step in assessing hospitalist comanagement should not be a hunt‐and‐peck exercise to stumble on the surgical procedures that show benefit from comanagement. Rather, the prudent next step is to follow the lead of Simon et al. and others3, 4 in trying to identify those surgical patients who represent the greatest medical complexity or have the most variability in their preoperative and postoperative medical care. These are the patients for whom the hospitalist can effect the greatest benefit and the services for which the hospitalist can best augment efficiency. High‐risk procedures, patients with multiple comorbitities or elevated preoperative risks, and surgical procedures without defined pre‐ and postoperative protocols would appear to be the ideal candidates for hospitalist comanagement.

As the discussion of hospital comanagement progresses, it is important to recognize comanagement as a paradigm shift. Surgical comanagement is not merely medical consultation. To be successful, the role of the hospitalist in comanaging surgical patients must be clearly defined as advancing postoperative care as much as it is in assessing preoperative risk. As a comanager, a hospitalist must actively manage preexisting and newly developed medical issues rather than just make recommendations for the surgical team.

The hospitalist must also be more than a discharge coordinator postoperatively; investing in hospitalists merely for discharge planning is a poor use of resources both from a financial and an opportunity‐cost perspective. The paradigm of comanagement is not foreign, however, and hospitalists are likely to prosper by learning from the experience of our nephrology and hepatology colleagues, who have successfully found collaborative roles in improving patient care on renal and liver transplant services. The success of these services is due to the precisely defined roles for the internist and the surgeon and because the complexity of the patient being managed warrants continuity of expert consultation.

There is great potential for the hospitalist in surgical comanagement. In less than a decade, the focus of hospital‐based medical care has shifted from staffing a shift to improving the quality of the system through which patients traverse the hospital. The lessons hospitalists have learned in quality improvement and in augmenting systems of care are perfectly suited for application to surgical services. Hospitalist comanagement is right not only because it may offer improvement in a surgical patient's medical care, but also for the augmentation of quality improvement in surgical services that have yet to reap the benefits that have defined the excellence of hospitalist medicine. The next step is to embark on the road of prudent prospective research: identifying the patients, and the procedures, that have the greatest opportunity for improvement by hospitalist comanagement. And at the end of that road will be a new home for the hospitalist, assuming the role of the quality‐advocate for all aspects of hospital care: pediatric, medical, and surgical patients.

In this issue of the Journal of Hospital Medicine, Simon et al.1 provide the first report of pediatric hospitalist comanagement of patients undergoing spinal fusion surgery. In this retrospective cohort study, 14 of 115 patients were comanaged by a pediatric hospitalist. The primary outcomes of the study were length of stay and variability in length of stay. Prior to the initiation of hospitalist comanagement service, all patients were managed preoperatively by a spine surgery nurse and aided by medical subspecialists and other allied health professionals (nutritionists, respiratory therapists, physical therapists, social workers). After the intervention, patients with the most complex medical disease were assigned to comanagement by a pediatric hospitalist. When compared to a historical control of patients with similar medical complexity but not comanaged by hospitalists, the length of stay was reduced by 2.4 days (8.6 vs. 6.2 days). The variability in mean length of stay was also reduced.

This study follows on the heels of 3 important studies addressing the utility of hospitalists in the comanagement of surgical patients. The HOT (Hospitalist Orthopedic Team) trial was a randomized controlled trial assessing the effect of hospitalists on the management of patients undergoing elective hip and knee arthroplasty.2 There was no effect on length of stay or patient outcomes, though the comanagement model did decrease minor postoperative medical complications and improve physician and nurse satisfaction. Macpherson et al. conducted a retrospective trial where an internist joined a cardiothoracic surgery service at a tertiary‐care center.3 They found a decrease in overall mortality and resource utilization such as labs testing and consultations. There was significant reduction in the length of stay and number of x‐rays performed. The third study, by Jaffer et al.,4 showed that an outpatient, preoperative evaluation clinic staffed by hospitalists at a large tertiary‐care center provides a practical model for managing preoperative patients and may be associated with a low rate of postoperative pulmonary complications.

The study by Simon et al. in this issue of the journal has limitations. It is a retrospective cohort trial, and like all such study designs, the validity of the results is subject to confounding. Severity of patient medical disease, intraoperative complications, and advances in surgical technique are examples. While the authors did everything possible to minimize the effect of confounding, it remains a limitation of the study. The study also enrolled only 14 patients in the comanagement group, and this limited any stratification or subgroup analysis to offset known confounders. Patients assigned to the hospitalist comanagement service were by design more medically complex than other spinal fusion patients, and generalizing the results of this trial to all spinal fusion patients may not be possible.

From the study's limitations, however, comes great insight into the role of the hospitalist in surgical comanagement. It is clear from the aforementioned studies that there is a role for the hospitalist in comanagement of surgical patients. While the evidence is conflicting, there are scenarios in which comanagement improves efficiency and quality of care. Yet it is also possible that hospitalist comanagement is not ideal for all surgical patients. The HOT trial did not show benefits in length‐of‐stay reduction or patient mortality because the patients were homogenous in their complexity and pre‐ and postoperative care was protocol driven. Length of stay was limited by accessibility of rehabilitation facilities after discharge and not the efficiency of medical care in the hospital. The study in this issue of the Journal of Hospital Medicine selectively included patients with the highest complexity of medical disease, and there was a reduction in length of stay. Both trials suggest that the greatest potential benefit for augmenting efficiency and outcomes with hospitalist comanagement may be predicated on the complexity of the patients involved and the surgical system through which they will receive care.

The next step in assessing hospitalist comanagement should not be a hunt‐and‐peck exercise to stumble on the surgical procedures that show benefit from comanagement. Rather, the prudent next step is to follow the lead of Simon et al. and others3, 4 in trying to identify those surgical patients who represent the greatest medical complexity or have the most variability in their preoperative and postoperative medical care. These are the patients for whom the hospitalist can effect the greatest benefit and the services for which the hospitalist can best augment efficiency. High‐risk procedures, patients with multiple comorbitities or elevated preoperative risks, and surgical procedures without defined pre‐ and postoperative protocols would appear to be the ideal candidates for hospitalist comanagement.

As the discussion of hospital comanagement progresses, it is important to recognize comanagement as a paradigm shift. Surgical comanagement is not merely medical consultation. To be successful, the role of the hospitalist in comanaging surgical patients must be clearly defined as advancing postoperative care as much as it is in assessing preoperative risk. As a comanager, a hospitalist must actively manage preexisting and newly developed medical issues rather than just make recommendations for the surgical team.

The hospitalist must also be more than a discharge coordinator postoperatively; investing in hospitalists merely for discharge planning is a poor use of resources both from a financial and an opportunity‐cost perspective. The paradigm of comanagement is not foreign, however, and hospitalists are likely to prosper by learning from the experience of our nephrology and hepatology colleagues, who have successfully found collaborative roles in improving patient care on renal and liver transplant services. The success of these services is due to the precisely defined roles for the internist and the surgeon and because the complexity of the patient being managed warrants continuity of expert consultation.

There is great potential for the hospitalist in surgical comanagement. In less than a decade, the focus of hospital‐based medical care has shifted from staffing a shift to improving the quality of the system through which patients traverse the hospital. The lessons hospitalists have learned in quality improvement and in augmenting systems of care are perfectly suited for application to surgical services. Hospitalist comanagement is right not only because it may offer improvement in a surgical patient's medical care, but also for the augmentation of quality improvement in surgical services that have yet to reap the benefits that have defined the excellence of hospitalist medicine. The next step is to embark on the road of prudent prospective research: identifying the patients, and the procedures, that have the greatest opportunity for improvement by hospitalist comanagement. And at the end of that road will be a new home for the hospitalist, assuming the role of the quality‐advocate for all aspects of hospital care: pediatric, medical, and surgical patients.

One year of the Journal of Hospital Medicine is done, and we now embark on our second with this first issue of volume 2. Before moving on, I heartily thank all the authors who contributed their manuscripts to the Journal of Hospital Medicine (JHM), bravely investing in this new academic periodical. A remarkable 284 manuscripts have been submitted since we first opened the JHM Web site, 197 of them during 2006. This clearly reflects the robust demand by hospitalists and their colleagues for original research and relevant clinical reviews about our evolving specialty of hospital medicine. I probably should not be surprised that this demand exists among the 15,000‐plus hospitalists in America and the 6000‐plus members of the Society of Hospital Medicine. Regardless, I am ineffably humbled by the enthusiasm and energy of all the contributors.

Understandably, this volume of submissions, exceeding our projections by nearly 50%, required yeoman's work by our associate editors and reviewers. On page 55 we list the 203 reviewers who donated their time and acumen to assure the quality of our publication. Many reviewed more than 4 articles during the year. Our associate editors deserve particular appreciation and gratitude for their willingness to donate extraordinary amounts of time and effort to ensure the success of JHMVincent Chang from Boston Children's Hospital, Scott Flanders from the University of Michigan, Karen Hauer from the University of California, San Francisco, Jean Kutner from the University of Colorado, James Pile from Cleveland MetroHealth, and Kaveh Shojania from the University of Ottawa. Additionally, the energetic assistant editors have supported them and me with frequent reviews, article submissions, and creative ideas for improving the journal. Finally, our auspicious editorial board has proffered sage guidance, and many of its members have also submitted manuscripts and participated in reviewing articles.

Moving forward we expect continued growth, as both the submitted articles and demand for the journal are being recognized. At 7:29 a.m. on November 30, 2006, Vickie Thaw (Vice President and Publisher, John Wiley & Sons, Inc.) called me to report that the National Library of Medicine validated all our efforts. The Journal of Hospital Medicine had been selected for indexing and inclusion in the National Library of Medicine's MEDLINE (Medical Literature Analysis and Retrieval System Online). The primary component of PubMed, MEDLINE is a bibliographic database containing approximately 13 million references to journal articles on medicine, nursing, dentistry, veterinary medicine, health care systems, and preclinical sciences dating to the mid‐1960s. With this approval, hospital medicine has achieved another milestone in its evolution into a new specialty.

We now hope to respond to the robust interest in clinical materials as well as to continue publication of original research. To achieve our aim of increasing the amount of clinically relevant content for practicing hospitalists, authors are encouraged to submit to JHM case reports, clinical updates, and clinical images that convey novel or underappreciated teaching points. Teaching points may be purely clinical and may focus on clinical pearls or unusual presentations of well‐known diseases, although submission of straightforward presentations of rare diseases is discouraged. Alternatively, manuscripts may involve succinct case‐based descriptions of innovations, quality improvementrelated issues, or medical errors. Submitted case reports should be less than 800 words and should contain a maximum of 5 references and no more than 1 table or figure. Case reports should not include an abstract. Submission of the case report and review type should be avoided. Instead, we seek formal clinical updates of no more than 2000 words that present important aspects of a case along with new research findings and citations from the literature that change what has historically been the standard of delivery of care. Finally, we continue to seek cases most appropriate for the Hospital Images Dx section, edited by Paul Aronowitz. They should be submitted with that designation and have fewer than 150 words. These 3 categories are identified on our Manuscript Central website (http://mc.manuscriptcentral.com/jhm).

Again, thanks to all of you for making the launch of the Journal of Hospital Medicine an unqualified success. We look forward to your continued participation as we grow as the premier journal for the specialty of hospital medicine.

P.S. Sadly, one of our superstar associate editors, Kaveh Shojania, is stepping aside, and we sincerely express thanks for his terrific contributions. We welcome suggestions for an alternative to fulfill his responsibilities.

One year of the Journal of Hospital Medicine is done, and we now embark on our second with this first issue of volume 2. Before moving on, I heartily thank all the authors who contributed their manuscripts to the Journal of Hospital Medicine (JHM), bravely investing in this new academic periodical. A remarkable 284 manuscripts have been submitted since we first opened the JHM Web site, 197 of them during 2006. This clearly reflects the robust demand by hospitalists and their colleagues for original research and relevant clinical reviews about our evolving specialty of hospital medicine. I probably should not be surprised that this demand exists among the 15,000‐plus hospitalists in America and the 6000‐plus members of the Society of Hospital Medicine. Regardless, I am ineffably humbled by the enthusiasm and energy of all the contributors.

Understandably, this volume of submissions, exceeding our projections by nearly 50%, required yeoman's work by our associate editors and reviewers. On page 55 we list the 203 reviewers who donated their time and acumen to assure the quality of our publication. Many reviewed more than 4 articles during the year. Our associate editors deserve particular appreciation and gratitude for their willingness to donate extraordinary amounts of time and effort to ensure the success of JHMVincent Chang from Boston Children's Hospital, Scott Flanders from the University of Michigan, Karen Hauer from the University of California, San Francisco, Jean Kutner from the University of Colorado, James Pile from Cleveland MetroHealth, and Kaveh Shojania from the University of Ottawa. Additionally, the energetic assistant editors have supported them and me with frequent reviews, article submissions, and creative ideas for improving the journal. Finally, our auspicious editorial board has proffered sage guidance, and many of its members have also submitted manuscripts and participated in reviewing articles.

Moving forward we expect continued growth, as both the submitted articles and demand for the journal are being recognized. At 7:29 a.m. on November 30, 2006, Vickie Thaw (Vice President and Publisher, John Wiley & Sons, Inc.) called me to report that the National Library of Medicine validated all our efforts. The Journal of Hospital Medicine had been selected for indexing and inclusion in the National Library of Medicine's MEDLINE (Medical Literature Analysis and Retrieval System Online). The primary component of PubMed, MEDLINE is a bibliographic database containing approximately 13 million references to journal articles on medicine, nursing, dentistry, veterinary medicine, health care systems, and preclinical sciences dating to the mid‐1960s. With this approval, hospital medicine has achieved another milestone in its evolution into a new specialty.

We now hope to respond to the robust interest in clinical materials as well as to continue publication of original research. To achieve our aim of increasing the amount of clinically relevant content for practicing hospitalists, authors are encouraged to submit to JHM case reports, clinical updates, and clinical images that convey novel or underappreciated teaching points. Teaching points may be purely clinical and may focus on clinical pearls or unusual presentations of well‐known diseases, although submission of straightforward presentations of rare diseases is discouraged. Alternatively, manuscripts may involve succinct case‐based descriptions of innovations, quality improvementrelated issues, or medical errors. Submitted case reports should be less than 800 words and should contain a maximum of 5 references and no more than 1 table or figure. Case reports should not include an abstract. Submission of the case report and review type should be avoided. Instead, we seek formal clinical updates of no more than 2000 words that present important aspects of a case along with new research findings and citations from the literature that change what has historically been the standard of delivery of care. Finally, we continue to seek cases most appropriate for the Hospital Images Dx section, edited by Paul Aronowitz. They should be submitted with that designation and have fewer than 150 words. These 3 categories are identified on our Manuscript Central website (http://mc.manuscriptcentral.com/jhm).

Again, thanks to all of you for making the launch of the Journal of Hospital Medicine an unqualified success. We look forward to your continued participation as we grow as the premier journal for the specialty of hospital medicine.

P.S. Sadly, one of our superstar associate editors, Kaveh Shojania, is stepping aside, and we sincerely express thanks for his terrific contributions. We welcome suggestions for an alternative to fulfill his responsibilities.

One year of the Journal of Hospital Medicine is done, and we now embark on our second with this first issue of volume 2. Before moving on, I heartily thank all the authors who contributed their manuscripts to the Journal of Hospital Medicine (JHM), bravely investing in this new academic periodical. A remarkable 284 manuscripts have been submitted since we first opened the JHM Web site, 197 of them during 2006. This clearly reflects the robust demand by hospitalists and their colleagues for original research and relevant clinical reviews about our evolving specialty of hospital medicine. I probably should not be surprised that this demand exists among the 15,000‐plus hospitalists in America and the 6000‐plus members of the Society of Hospital Medicine. Regardless, I am ineffably humbled by the enthusiasm and energy of all the contributors.

Understandably, this volume of submissions, exceeding our projections by nearly 50%, required yeoman's work by our associate editors and reviewers. On page 55 we list the 203 reviewers who donated their time and acumen to assure the quality of our publication. Many reviewed more than 4 articles during the year. Our associate editors deserve particular appreciation and gratitude for their willingness to donate extraordinary amounts of time and effort to ensure the success of JHMVincent Chang from Boston Children's Hospital, Scott Flanders from the University of Michigan, Karen Hauer from the University of California, San Francisco, Jean Kutner from the University of Colorado, James Pile from Cleveland MetroHealth, and Kaveh Shojania from the University of Ottawa. Additionally, the energetic assistant editors have supported them and me with frequent reviews, article submissions, and creative ideas for improving the journal. Finally, our auspicious editorial board has proffered sage guidance, and many of its members have also submitted manuscripts and participated in reviewing articles.

Moving forward we expect continued growth, as both the submitted articles and demand for the journal are being recognized. At 7:29 a.m. on November 30, 2006, Vickie Thaw (Vice President and Publisher, John Wiley & Sons, Inc.) called me to report that the National Library of Medicine validated all our efforts. The Journal of Hospital Medicine had been selected for indexing and inclusion in the National Library of Medicine's MEDLINE (Medical Literature Analysis and Retrieval System Online). The primary component of PubMed, MEDLINE is a bibliographic database containing approximately 13 million references to journal articles on medicine, nursing, dentistry, veterinary medicine, health care systems, and preclinical sciences dating to the mid‐1960s. With this approval, hospital medicine has achieved another milestone in its evolution into a new specialty.

We now hope to respond to the robust interest in clinical materials as well as to continue publication of original research. To achieve our aim of increasing the amount of clinically relevant content for practicing hospitalists, authors are encouraged to submit to JHM case reports, clinical updates, and clinical images that convey novel or underappreciated teaching points. Teaching points may be purely clinical and may focus on clinical pearls or unusual presentations of well‐known diseases, although submission of straightforward presentations of rare diseases is discouraged. Alternatively, manuscripts may involve succinct case‐based descriptions of innovations, quality improvementrelated issues, or medical errors. Submitted case reports should be less than 800 words and should contain a maximum of 5 references and no more than 1 table or figure. Case reports should not include an abstract. Submission of the case report and review type should be avoided. Instead, we seek formal clinical updates of no more than 2000 words that present important aspects of a case along with new research findings and citations from the literature that change what has historically been the standard of delivery of care. Finally, we continue to seek cases most appropriate for the Hospital Images Dx section, edited by Paul Aronowitz. They should be submitted with that designation and have fewer than 150 words. These 3 categories are identified on our Manuscript Central website (http://mc.manuscriptcentral.com/jhm).

Again, thanks to all of you for making the launch of the Journal of Hospital Medicine an unqualified success. We look forward to your continued participation as we grow as the premier journal for the specialty of hospital medicine.

P.S. Sadly, one of our superstar associate editors, Kaveh Shojania, is stepping aside, and we sincerely express thanks for his terrific contributions. We welcome suggestions for an alternative to fulfill his responsibilities.

It was the second week after finishing my internal medicine residency. What a daunting experience it was to be a newly appointed attending physician. My hospital rounds were painfully slow because I would consult the Tarsacon pharmacopoeia and Uptodate prior to writing any orders or making clinical decisions. During this keystone phase of my career I had the privilege of taking care of Ms. S. It has been almost 2 years since, and I still think of her and what I learned taking care of her.

Ms. S was a woman in her eighties with end‐stage chronic obstructive pulmonary disease (COPD). She was a frequent flyer, as evidenced by the multiple discharge summaries appended to her chart. Her hospital course was predictably punctuated by frequent inpatient exacerbations of COPD, and every time I told her that she'd be discharged the next day I had to eat my own words. After much effort and pharmaceutical gymnastics she finally seemed to be improving. She went nearly 3 days without a significant exacerbation of her condition. I believed that with my medical prowess, I would be mankind's next savior. As I told her yet again that she'd be discharged the next day, she thanked me and said she hoped not to be readmitted any time soon. Making small talk I learned that she had been a nurse at the very same hospital, where she had spent close to 40 years discharging her responsibilities. We didn't know smoking was bad back theneverybody did it, she said. I commiserated and assured her that she was well on her way to recovery.

The next day as I zealously sauntered into the hospital, I thought of the fantastic job I had done managing Ms. S's COPD. I mentally patted myself on the back; after all I was a smart guy. As I went into her room, I saw to my utter horror that she was in the midst of a severe COPD exacerbation. I swung into action, barked orders to start nebulizers, gave her a huge dose of steroids, and put her on a monitor. Through the clutter of nurses starting their IVs and the beeping of monitors, she said her time had come and she was ready to die. I gently chided her, assuring her this was just another episode, no different from her previous ones. She looked frail and tired, and her eyes appeared sad and forlorn. I departed from her room to call the resident in the ICU, where I thought surely she would be better served.

The unit unsurprisingly had no beds immediately available. She would be moved as soon as the unit had a bed; meanwhile, the pulmonary physician was on his way to see her. I dashed back to her room to check on her. To my dismay she was in respiratory distress, unable to talk and using all she had just to breathe. On the table next to the bed she had scribbled on a piece of scrap paper: Let me go please, it is OK. Knowing how exhausted she was, it must have taken superhuman effort to write this. She already had advance directives and was a DNR/DNI, but now she was precipitously declining in front of my eyes. Visibly trembling, I went to the nursing station and called her sister to apprise her of the waning of Ms. S's condition. I had never been faced with a scenario like this before. Taking time to compose myself, I wrote an order to put Ms. S on a morphine drip. All the while I couldn't shake off a sense of being ineffectual. Was modern medicine powerless to help people like her? I hoped I was doing the right thing. The pulmonary physician concurred with what I was doing, giving me the validation I was seeking.

Her sister arrived expeditiously, and I filled her in on what had happened. She nodded in understanding and stated her sister had always said when her time was up, she wanted to be let go. Her next question was the one I dreaded: How long do you think she has? I was evasive, reflecting my discomfiture at being totally unprepared in such situations. It is hard to tell, maybe 24 to 48 hours, but these things are hard to predict, I answered her. Writing orders for comfort measures, I couldn't help feeling unqualified to be a doctor. This wasn't something I thought I'd have to grapple with.

Soon all of Ms. S's relatives near and far came in to see her. They spent time at her bedside, but the morphine had taken effect. She was sleeping and looked comfortable but was unable to participate in conversation.

The next day as I arrived at the hospital, there was a cloud of dread in my mind. Ms. S probably had passed away some time during the night. At the nursing station, I was informed that the predictable hadn't happened. I went into her room to find it full of her loved ones. Her sister looked haggard but calm, and Ms. S was sleeping. I asked how things were, and Ms. S's sister's eyes lit up. She woke up at 1 a.m. and spoke to us for 2 hours. We were all able to tell her how much we loved her. She asked about all the children in the family and told us how much she loved them. Thereafter she went to sleep. She woke up at 6 a.m., looked around, and said, Why the hell am I still alive? She went to sleep soon and has been sleeping ever since. Laughter broke out in the room. I laughed with them. This was all a new experience. So Ms. S had closure before she died. Her family seemed content in this sad hour.

Ms. S passed away shortly after that. Her family thanked me for making her comfortable. But initially I felt I had done nothing much. Then the realization of my role as a doctor finally hit home. Sometimes it is apposite to hold a patient's hand and let the inevitable happen rather than fret on the shortcomings of medicine. It is all right not to overintellectualize every clinical event. After all it is all about treating people, not a constellation of bodily organs. Sometimes less is more and all that is needed. I always look back on this experience every time I feel smug. Since then I have incorporated discussion about goals of care into my repertoire. Patients with multiple admissions for incurable diseases need special attention. I hope my personal growth involves approaching such patients with the empathy and compassion they need. Having such discussions also helps to prevent the frenzied panicking that usually accompanies the inevitable decline of patients with terminal illness. The increasing emphasis of medical school curricula on end‐of‐life care issues reflects these sentiments. A growing geriatric cohort with multiple and often chronic medical diagnoses makes these skills indispensable.

My personal credo has been profoundly influenced by Sir Robert Hutchison's Physician's Prayer. I first read it in medical school but revisited it shortly after my experience with Ms S. To my mind, it is still relevant and serves to keep me on an even keel when making difficult decisions.

From inability to let well alone, from too much zeal for the new and contempt for what is old, from putting knowledge before wisdom, science before art and cleverness before common sense, from treating patients as cases and from making the cure of the disease more grievous than the endurance of the same, good Lord deliver us.

Sir Robert Hutchison (1871‐1960)

Print and Online Resources

1. Oxford Textbook of Palliative Medicine.

2. Center to Advance Palliative Care: www.capc.org.

3. American Academy of Hospice and Palliative Medicine: www.abhpm.org.

4. International Association for Hospice and Palliative Care: www.hospicecare.com.

It was the second week after finishing my internal medicine residency. What a daunting experience it was to be a newly appointed attending physician. My hospital rounds were painfully slow because I would consult the Tarsacon pharmacopoeia and Uptodate prior to writing any orders or making clinical decisions. During this keystone phase of my career I had the privilege of taking care of Ms. S. It has been almost 2 years since, and I still think of her and what I learned taking care of her.

Ms. S was a woman in her eighties with end‐stage chronic obstructive pulmonary disease (COPD). She was a frequent flyer, as evidenced by the multiple discharge summaries appended to her chart. Her hospital course was predictably punctuated by frequent inpatient exacerbations of COPD, and every time I told her that she'd be discharged the next day I had to eat my own words. After much effort and pharmaceutical gymnastics she finally seemed to be improving. She went nearly 3 days without a significant exacerbation of her condition. I believed that with my medical prowess, I would be mankind's next savior. As I told her yet again that she'd be discharged the next day, she thanked me and said she hoped not to be readmitted any time soon. Making small talk I learned that she had been a nurse at the very same hospital, where she had spent close to 40 years discharging her responsibilities. We didn't know smoking was bad back theneverybody did it, she said. I commiserated and assured her that she was well on her way to recovery.

The next day as I zealously sauntered into the hospital, I thought of the fantastic job I had done managing Ms. S's COPD. I mentally patted myself on the back; after all I was a smart guy. As I went into her room, I saw to my utter horror that she was in the midst of a severe COPD exacerbation. I swung into action, barked orders to start nebulizers, gave her a huge dose of steroids, and put her on a monitor. Through the clutter of nurses starting their IVs and the beeping of monitors, she said her time had come and she was ready to die. I gently chided her, assuring her this was just another episode, no different from her previous ones. She looked frail and tired, and her eyes appeared sad and forlorn. I departed from her room to call the resident in the ICU, where I thought surely she would be better served.

The unit unsurprisingly had no beds immediately available. She would be moved as soon as the unit had a bed; meanwhile, the pulmonary physician was on his way to see her. I dashed back to her room to check on her. To my dismay she was in respiratory distress, unable to talk and using all she had just to breathe. On the table next to the bed she had scribbled on a piece of scrap paper: Let me go please, it is OK. Knowing how exhausted she was, it must have taken superhuman effort to write this. She already had advance directives and was a DNR/DNI, but now she was precipitously declining in front of my eyes. Visibly trembling, I went to the nursing station and called her sister to apprise her of the waning of Ms. S's condition. I had never been faced with a scenario like this before. Taking time to compose myself, I wrote an order to put Ms. S on a morphine drip. All the while I couldn't shake off a sense of being ineffectual. Was modern medicine powerless to help people like her? I hoped I was doing the right thing. The pulmonary physician concurred with what I was doing, giving me the validation I was seeking.

Her sister arrived expeditiously, and I filled her in on what had happened. She nodded in understanding and stated her sister had always said when her time was up, she wanted to be let go. Her next question was the one I dreaded: How long do you think she has? I was evasive, reflecting my discomfiture at being totally unprepared in such situations. It is hard to tell, maybe 24 to 48 hours, but these things are hard to predict, I answered her. Writing orders for comfort measures, I couldn't help feeling unqualified to be a doctor. This wasn't something I thought I'd have to grapple with.

Soon all of Ms. S's relatives near and far came in to see her. They spent time at her bedside, but the morphine had taken effect. She was sleeping and looked comfortable but was unable to participate in conversation.

The next day as I arrived at the hospital, there was a cloud of dread in my mind. Ms. S probably had passed away some time during the night. At the nursing station, I was informed that the predictable hadn't happened. I went into her room to find it full of her loved ones. Her sister looked haggard but calm, and Ms. S was sleeping. I asked how things were, and Ms. S's sister's eyes lit up. She woke up at 1 a.m. and spoke to us for 2 hours. We were all able to tell her how much we loved her. She asked about all the children in the family and told us how much she loved them. Thereafter she went to sleep. She woke up at 6 a.m., looked around, and said, Why the hell am I still alive? She went to sleep soon and has been sleeping ever since. Laughter broke out in the room. I laughed with them. This was all a new experience. So Ms. S had closure before she died. Her family seemed content in this sad hour.

Ms. S passed away shortly after that. Her family thanked me for making her comfortable. But initially I felt I had done nothing much. Then the realization of my role as a doctor finally hit home. Sometimes it is apposite to hold a patient's hand and let the inevitable happen rather than fret on the shortcomings of medicine. It is all right not to overintellectualize every clinical event. After all it is all about treating people, not a constellation of bodily organs. Sometimes less is more and all that is needed. I always look back on this experience every time I feel smug. Since then I have incorporated discussion about goals of care into my repertoire. Patients with multiple admissions for incurable diseases need special attention. I hope my personal growth involves approaching such patients with the empathy and compassion they need. Having such discussions also helps to prevent the frenzied panicking that usually accompanies the inevitable decline of patients with terminal illness. The increasing emphasis of medical school curricula on end‐of‐life care issues reflects these sentiments. A growing geriatric cohort with multiple and often chronic medical diagnoses makes these skills indispensable.

My personal credo has been profoundly influenced by Sir Robert Hutchison's Physician's Prayer. I first read it in medical school but revisited it shortly after my experience with Ms S. To my mind, it is still relevant and serves to keep me on an even keel when making difficult decisions.

From inability to let well alone, from too much zeal for the new and contempt for what is old, from putting knowledge before wisdom, science before art and cleverness before common sense, from treating patients as cases and from making the cure of the disease more grievous than the endurance of the same, good Lord deliver us.

Sir Robert Hutchison (1871‐1960)

Print and Online Resources

1. Oxford Textbook of Palliative Medicine.

2. Center to Advance Palliative Care: www.capc.org.

3. American Academy of Hospice and Palliative Medicine: www.abhpm.org.

4. International Association for Hospice and Palliative Care: www.hospicecare.com.

It was the second week after finishing my internal medicine residency. What a daunting experience it was to be a newly appointed attending physician. My hospital rounds were painfully slow because I would consult the Tarsacon pharmacopoeia and Uptodate prior to writing any orders or making clinical decisions. During this keystone phase of my career I had the privilege of taking care of Ms. S. It has been almost 2 years since, and I still think of her and what I learned taking care of her.

Ms. S was a woman in her eighties with end‐stage chronic obstructive pulmonary disease (COPD). She was a frequent flyer, as evidenced by the multiple discharge summaries appended to her chart. Her hospital course was predictably punctuated by frequent inpatient exacerbations of COPD, and every time I told her that she'd be discharged the next day I had to eat my own words. After much effort and pharmaceutical gymnastics she finally seemed to be improving. She went nearly 3 days without a significant exacerbation of her condition. I believed that with my medical prowess, I would be mankind's next savior. As I told her yet again that she'd be discharged the next day, she thanked me and said she hoped not to be readmitted any time soon. Making small talk I learned that she had been a nurse at the very same hospital, where she had spent close to 40 years discharging her responsibilities. We didn't know smoking was bad back theneverybody did it, she said. I commiserated and assured her that she was well on her way to recovery.

The next day as I zealously sauntered into the hospital, I thought of the fantastic job I had done managing Ms. S's COPD. I mentally patted myself on the back; after all I was a smart guy. As I went into her room, I saw to my utter horror that she was in the midst of a severe COPD exacerbation. I swung into action, barked orders to start nebulizers, gave her a huge dose of steroids, and put her on a monitor. Through the clutter of nurses starting their IVs and the beeping of monitors, she said her time had come and she was ready to die. I gently chided her, assuring her this was just another episode, no different from her previous ones. She looked frail and tired, and her eyes appeared sad and forlorn. I departed from her room to call the resident in the ICU, where I thought surely she would be better served.

The unit unsurprisingly had no beds immediately available. She would be moved as soon as the unit had a bed; meanwhile, the pulmonary physician was on his way to see her. I dashed back to her room to check on her. To my dismay she was in respiratory distress, unable to talk and using all she had just to breathe. On the table next to the bed she had scribbled on a piece of scrap paper: Let me go please, it is OK. Knowing how exhausted she was, it must have taken superhuman effort to write this. She already had advance directives and was a DNR/DNI, but now she was precipitously declining in front of my eyes. Visibly trembling, I went to the nursing station and called her sister to apprise her of the waning of Ms. S's condition. I had never been faced with a scenario like this before. Taking time to compose myself, I wrote an order to put Ms. S on a morphine drip. All the while I couldn't shake off a sense of being ineffectual. Was modern medicine powerless to help people like her? I hoped I was doing the right thing. The pulmonary physician concurred with what I was doing, giving me the validation I was seeking.

Her sister arrived expeditiously, and I filled her in on what had happened. She nodded in understanding and stated her sister had always said when her time was up, she wanted to be let go. Her next question was the one I dreaded: How long do you think she has? I was evasive, reflecting my discomfiture at being totally unprepared in such situations. It is hard to tell, maybe 24 to 48 hours, but these things are hard to predict, I answered her. Writing orders for comfort measures, I couldn't help feeling unqualified to be a doctor. This wasn't something I thought I'd have to grapple with.

Soon all of Ms. S's relatives near and far came in to see her. They spent time at her bedside, but the morphine had taken effect. She was sleeping and looked comfortable but was unable to participate in conversation.

The next day as I arrived at the hospital, there was a cloud of dread in my mind. Ms. S probably had passed away some time during the night. At the nursing station, I was informed that the predictable hadn't happened. I went into her room to find it full of her loved ones. Her sister looked haggard but calm, and Ms. S was sleeping. I asked how things were, and Ms. S's sister's eyes lit up. She woke up at 1 a.m. and spoke to us for 2 hours. We were all able to tell her how much we loved her. She asked about all the children in the family and told us how much she loved them. Thereafter she went to sleep. She woke up at 6 a.m., looked around, and said, Why the hell am I still alive? She went to sleep soon and has been sleeping ever since. Laughter broke out in the room. I laughed with them. This was all a new experience. So Ms. S had closure before she died. Her family seemed content in this sad hour.

Ms. S passed away shortly after that. Her family thanked me for making her comfortable. But initially I felt I had done nothing much. Then the realization of my role as a doctor finally hit home. Sometimes it is apposite to hold a patient's hand and let the inevitable happen rather than fret on the shortcomings of medicine. It is all right not to overintellectualize every clinical event. After all it is all about treating people, not a constellation of bodily organs. Sometimes less is more and all that is needed. I always look back on this experience every time I feel smug. Since then I have incorporated discussion about goals of care into my repertoire. Patients with multiple admissions for incurable diseases need special attention. I hope my personal growth involves approaching such patients with the empathy and compassion they need. Having such discussions also helps to prevent the frenzied panicking that usually accompanies the inevitable decline of patients with terminal illness. The increasing emphasis of medical school curricula on end‐of‐life care issues reflects these sentiments. A growing geriatric cohort with multiple and often chronic medical diagnoses makes these skills indispensable.

My personal credo has been profoundly influenced by Sir Robert Hutchison's Physician's Prayer. I first read it in medical school but revisited it shortly after my experience with Ms S. To my mind, it is still relevant and serves to keep me on an even keel when making difficult decisions.

From inability to let well alone, from too much zeal for the new and contempt for what is old, from putting knowledge before wisdom, science before art and cleverness before common sense, from treating patients as cases and from making the cure of the disease more grievous than the endurance of the same, good Lord deliver us.

Sir Robert Hutchison (1871‐1960)

Print and Online Resources

1. Oxford Textbook of Palliative Medicine.

2. Center to Advance Palliative Care: www.capc.org.

3. American Academy of Hospice and Palliative Medicine: www.abhpm.org.

4. International Association for Hospice and Palliative Care: www.hospicecare.com.

As we approach the 6th year since the Institute of Medicine's Crossing the Quality Chasm offered a new vision for the American health care system, we still have a marked mismatch between the demand for health care quality and the supply of know‐how to deliver it. What the field of quality improvement (QI) still needs is merely this: QI practitioners in every care setting, a working vocabulary, a predictive framework for the mechanisms of reliable care, and rational therapies rigorously studied.13 Fortunately, the field of QI has attracted enough empiricistsworking in the lab of the hospital and other care settingsto lurch forward. But few would argue that we still have far less insight into the delivery of quality care than into the delivery of myocardial blood flow.

For ischemic heart disease we have classes of therapies, each of which is grounded in basic and clinical science: antiplatelets, beta‐blockers, vasodilators, lipid‐lowering agents. For care delivery we have the makings of analogous therapy classes, derived and introduced rather recently in a large review, Closing the Quality Gap: A Critical Analysis of the Quality Improvement Literature.4, 5 To facilitate their review of the evidence, the authors, including 2 prominent hospitalists, developed a new taxonomy of QI strategies (see Table 1). Though their effect size, relative efficacy, and interactions are not yet clear, many of these strategies can be applied to the inpatient setting, perhaps no less rationally than a well‐constructed antianginal regimen.

Where in the pathophysiology of a hospital do these QI therapies act? A plurality target the level of the provider: provider education, provider reminders, audit‐and‐feedback of provider performance, and facilitated relay of clinical data to providers. Remaining strategies target the patient (patient education, promotion of self‐management, and patient reminders), the immediate system within which care is delivered (organizational change), and the methodology of problem solving (continuous quality improvement). Only one strategy (financial incentives, regulation, and policy) fails to act directly at the level of the patient or provider, arguably the only level at which care actually can be improved.6

The value of the Quality Gap taxonomy is still largely untapped. If QI researchers and practitioners were to adopt its language as a standard, we could ramp up the power with which we communicate, interpret, and ultimately conduct improvement initiatives. In this issue of the Journal of Hospital Medicine, Cohn and colleagues profile a quality improvement initiative that achieved an impressive new level of performance. For an inpatient metric with a baseline institutional performance of 47%and an international benchmark of 39%the investigators executed a QI initiative that appears to have raised the rate of VTE prophylaxis to 85%.7 Despite a study design that weakens validity (beforeafter without controls) and a setting that diminishes applicability (medical patients in a single academic center), the authors have made a solid contribution to the QI literature simply by using the Quality Gap taxonomy. The authors specifically name and profile at least 3 distinct classes of QI strategies: provider education, a provider reminder element (ie, decision support), and an audit‐and‐feedback layer.

Even though provider education is unlikely to be sufficient as a lone QI strategya large review showed consistent but only modest benefitsit is often necessary.8 The provider education executed by Cohn and colleagues was frequent and regular. In the beginning of each month the chief resident oriented incoming house staff about venous thromboembolism (VTE) risk factors and the need for prophylaxis. They were given decision support pocket cards. Posters on display in nurse and physician work areas highlighted VTE risk factors. The provider education element also included discussions with the division chief about the topic. As robust as it was, however, the provider education was just a single component of the larger QI effort.

The second element, decision support, included VTE risk factor pocket cards with prophylaxis options listed. Introduced initially with the provider education, the pocket cards were handed out monthly by the chief resident. It is critical to recognize this decision support layer as a distinct core QI strategyand that it may even be fundamental to the success of the other strategies. Placed into the clinical workflow as a durable item, the decision support pocket card has the power to overcome provider uncertainty at moments of medical decision making. Generally speaking, a decision support layer, whether a pocket card, computer alert, or algorithm on a preprinted order form, can function as a shared baseline. Shared baselines or protocols reduce unnecessary variation in practice, a common source of poor quality care. Any mechanism that encourages groups of providers to deliver the same recommended care to groups of similarly at‐risk patients, while allowing customization of the protocol to meet the special needs of any individual patient, will have the net effect of raising overall quality of care.

This QI initiative may have achieved its greatest performance gainsas well as its greatest loss in terms of applicability to other settingsfrom its third facet, the audit‐and‐feedback layer. As a QI strategy audit‐and‐feedback has been defined as a summary of clinical performance for health care providers or institutions, performed for a specific period of time and reported either publicly or confidentially.1 It has demonstrated small to moderate benefits, with variations in effect most likely related to the format.9 As profiled in this study, it is hard to imagine a more powerful audit‐and‐feedback arrangement. The division chief of General Internal Medicine not only performed the audits, but also directly delivered the feedback to the house staff. In a deliberate, systematic, and successful way the investigators constructively used an existing authority gradient to leverage the Hawthorne effect, a change in worker behavior triggered by knowledge of being observed. Although it contributed to the impressive new VTE prophylaxis rates, this component did diminish generalizability and sustainability. Nonacademic centers may struggle to replicate these results, a point the authors dutifully point out. But even other academic centers might struggle in the absence of an authority figure with comparable influence and dedication to VTE prophylaxis. At the study hospital itself, similar rates of improvement would not be expected in patient populations outside the purview of the division chief.

Several alternatives to the before‐after study design could have produced richer information. Simultaneous data on VTE prophylaxis rates in a nonintervention population in the same or a similar hospital could have controlled for background or secular effects. An interrupted time series design may even have been feasible and could have provided more confidence in causality and more information on effect size. For example, what would be the effect on performance, if any, with removal of the decision support pocket card at 10 or 15 months? How much would performance rebound after its reintroduction? What could we have learned had the authors chosen instead to measure performance after sequentially introducing each component?

Using the language of the Quality Gap taxonomy, what conclusions can we draw from this improvement initiative? The introduction of a portable provider reminder (the decision support pocket card), when preceded by a program of provider education and followed by high‐intensity audit‐and‐feedback within an existing provider hierarchy, may have the power to raise VTE prophylaxis rates to 85% over an 18‐month period. With the large effect size somewhat mitigating the design flaws that weaken causality, we might risk an inference that these 3 classes of QI strategies can be reasonably successful in combination. But would we introduce them in our own medical centers? Using the clarity afforded by the taxonomy, we can identify several potential limitations, all attributable to the specifics of the audit‐and‐feedback arrangement: stringent preconditions of the practice setting, guaranteed inability to spread the initiative to other patient populations within the same medical center, limited scalability to include other QI projects, and reliance on the role of a single individual. Although clopidogrel 300 mg daily in the last week of every month is one way to pursue antiplatelet activity, other schedules or alternative agents may be preferable for the vast majority of patients.

The taxonomy can be used to compare, contrast, and more fully understand other QI studies. For example, among acutely ill medical inpatients not receiving VTE prophylaxis, Kucher and colleagues found that an electronic alert nearly doubled prophylaxis rates compared to those in a control group.10 Before trying to emulate their experience, a similarly equipped hospital would do well to recognize that the electronic alert was deployed as a composite of provider education, provider reminder, and facilitated relay of clinical information strategies, increasing prophylaxis rates for high risk patients from a baseline of 85% to 88%.

On the 21st‐century side of the quality chasm there is still something to be learned from QI research that falls short of recently proposed standards.3 This may be true as long as the key question remains: what are the mechanisms of reliable and sustainable performance improvement? We have not yet reached the day where a predictive framework, the clarity of our inquiry, the rigor of our study design, and the strength of our evidence churn out coherent answers. But we do have insights from a wealth of ongoing QI activity triggered by such forces as the Institute for Healthcare Improvement's 100,000 Lives Campaign and the advent of mandatory public reporting of hospital performance measures. By adding to this primordial mix the taxonomy offered by Closing the Quality Gap and its uptake into our vernacular by reports such as the one by Cohn in this issue of the Journal of Hospital Medicine, we are acquiring the language and experience to conduct intelligent and intelligible QI research.

As we approach the 6th year since the Institute of Medicine's Crossing the Quality Chasm offered a new vision for the American health care system, we still have a marked mismatch between the demand for health care quality and the supply of know‐how to deliver it. What the field of quality improvement (QI) still needs is merely this: QI practitioners in every care setting, a working vocabulary, a predictive framework for the mechanisms of reliable care, and rational therapies rigorously studied.13 Fortunately, the field of QI has attracted enough empiricistsworking in the lab of the hospital and other care settingsto lurch forward. But few would argue that we still have far less insight into the delivery of quality care than into the delivery of myocardial blood flow.

For ischemic heart disease we have classes of therapies, each of which is grounded in basic and clinical science: antiplatelets, beta‐blockers, vasodilators, lipid‐lowering agents. For care delivery we have the makings of analogous therapy classes, derived and introduced rather recently in a large review, Closing the Quality Gap: A Critical Analysis of the Quality Improvement Literature.4, 5 To facilitate their review of the evidence, the authors, including 2 prominent hospitalists, developed a new taxonomy of QI strategies (see Table 1). Though their effect size, relative efficacy, and interactions are not yet clear, many of these strategies can be applied to the inpatient setting, perhaps no less rationally than a well‐constructed antianginal regimen.

Where in the pathophysiology of a hospital do these QI therapies act? A plurality target the level of the provider: provider education, provider reminders, audit‐and‐feedback of provider performance, and facilitated relay of clinical data to providers. Remaining strategies target the patient (patient education, promotion of self‐management, and patient reminders), the immediate system within which care is delivered (organizational change), and the methodology of problem solving (continuous quality improvement). Only one strategy (financial incentives, regulation, and policy) fails to act directly at the level of the patient or provider, arguably the only level at which care actually can be improved.6

The value of the Quality Gap taxonomy is still largely untapped. If QI researchers and practitioners were to adopt its language as a standard, we could ramp up the power with which we communicate, interpret, and ultimately conduct improvement initiatives. In this issue of the Journal of Hospital Medicine, Cohn and colleagues profile a quality improvement initiative that achieved an impressive new level of performance. For an inpatient metric with a baseline institutional performance of 47%and an international benchmark of 39%the investigators executed a QI initiative that appears to have raised the rate of VTE prophylaxis to 85%.7 Despite a study design that weakens validity (beforeafter without controls) and a setting that diminishes applicability (medical patients in a single academic center), the authors have made a solid contribution to the QI literature simply by using the Quality Gap taxonomy. The authors specifically name and profile at least 3 distinct classes of QI strategies: provider education, a provider reminder element (ie, decision support), and an audit‐and‐feedback layer.

Even though provider education is unlikely to be sufficient as a lone QI strategya large review showed consistent but only modest benefitsit is often necessary.8 The provider education executed by Cohn and colleagues was frequent and regular. In the beginning of each month the chief resident oriented incoming house staff about venous thromboembolism (VTE) risk factors and the need for prophylaxis. They were given decision support pocket cards. Posters on display in nurse and physician work areas highlighted VTE risk factors. The provider education element also included discussions with the division chief about the topic. As robust as it was, however, the provider education was just a single component of the larger QI effort.

The second element, decision support, included VTE risk factor pocket cards with prophylaxis options listed. Introduced initially with the provider education, the pocket cards were handed out monthly by the chief resident. It is critical to recognize this decision support layer as a distinct core QI strategyand that it may even be fundamental to the success of the other strategies. Placed into the clinical workflow as a durable item, the decision support pocket card has the power to overcome provider uncertainty at moments of medical decision making. Generally speaking, a decision support layer, whether a pocket card, computer alert, or algorithm on a preprinted order form, can function as a shared baseline. Shared baselines or protocols reduce unnecessary variation in practice, a common source of poor quality care. Any mechanism that encourages groups of providers to deliver the same recommended care to groups of similarly at‐risk patients, while allowing customization of the protocol to meet the special needs of any individual patient, will have the net effect of raising overall quality of care.

This QI initiative may have achieved its greatest performance gainsas well as its greatest loss in terms of applicability to other settingsfrom its third facet, the audit‐and‐feedback layer. As a QI strategy audit‐and‐feedback has been defined as a summary of clinical performance for health care providers or institutions, performed for a specific period of time and reported either publicly or confidentially.1 It has demonstrated small to moderate benefits, with variations in effect most likely related to the format.9 As profiled in this study, it is hard to imagine a more powerful audit‐and‐feedback arrangement. The division chief of General Internal Medicine not only performed the audits, but also directly delivered the feedback to the house staff. In a deliberate, systematic, and successful way the investigators constructively used an existing authority gradient to leverage the Hawthorne effect, a change in worker behavior triggered by knowledge of being observed. Although it contributed to the impressive new VTE prophylaxis rates, this component did diminish generalizability and sustainability. Nonacademic centers may struggle to replicate these results, a point the authors dutifully point out. But even other academic centers might struggle in the absence of an authority figure with comparable influence and dedication to VTE prophylaxis. At the study hospital itself, similar rates of improvement would not be expected in patient populations outside the purview of the division chief.

Several alternatives to the before‐after study design could have produced richer information. Simultaneous data on VTE prophylaxis rates in a nonintervention population in the same or a similar hospital could have controlled for background or secular effects. An interrupted time series design may even have been feasible and could have provided more confidence in causality and more information on effect size. For example, what would be the effect on performance, if any, with removal of the decision support pocket card at 10 or 15 months? How much would performance rebound after its reintroduction? What could we have learned had the authors chosen instead to measure performance after sequentially introducing each component?

Using the language of the Quality Gap taxonomy, what conclusions can we draw from this improvement initiative? The introduction of a portable provider reminder (the decision support pocket card), when preceded by a program of provider education and followed by high‐intensity audit‐and‐feedback within an existing provider hierarchy, may have the power to raise VTE prophylaxis rates to 85% over an 18‐month period. With the large effect size somewhat mitigating the design flaws that weaken causality, we might risk an inference that these 3 classes of QI strategies can be reasonably successful in combination. But would we introduce them in our own medical centers? Using the clarity afforded by the taxonomy, we can identify several potential limitations, all attributable to the specifics of the audit‐and‐feedback arrangement: stringent preconditions of the practice setting, guaranteed inability to spread the initiative to other patient populations within the same medical center, limited scalability to include other QI projects, and reliance on the role of a single individual. Although clopidogrel 300 mg daily in the last week of every month is one way to pursue antiplatelet activity, other schedules or alternative agents may be preferable for the vast majority of patients.

The taxonomy can be used to compare, contrast, and more fully understand other QI studies. For example, among acutely ill medical inpatients not receiving VTE prophylaxis, Kucher and colleagues found that an electronic alert nearly doubled prophylaxis rates compared to those in a control group.10 Before trying to emulate their experience, a similarly equipped hospital would do well to recognize that the electronic alert was deployed as a composite of provider education, provider reminder, and facilitated relay of clinical information strategies, increasing prophylaxis rates for high risk patients from a baseline of 85% to 88%.

On the 21st‐century side of the quality chasm there is still something to be learned from QI research that falls short of recently proposed standards.3 This may be true as long as the key question remains: what are the mechanisms of reliable and sustainable performance improvement? We have not yet reached the day where a predictive framework, the clarity of our inquiry, the rigor of our study design, and the strength of our evidence churn out coherent answers. But we do have insights from a wealth of ongoing QI activity triggered by such forces as the Institute for Healthcare Improvement's 100,000 Lives Campaign and the advent of mandatory public reporting of hospital performance measures. By adding to this primordial mix the taxonomy offered by Closing the Quality Gap and its uptake into our vernacular by reports such as the one by Cohn in this issue of the Journal of Hospital Medicine, we are acquiring the language and experience to conduct intelligent and intelligible QI research.

As we approach the 6th year since the Institute of Medicine's Crossing the Quality Chasm offered a new vision for the American health care system, we still have a marked mismatch between the demand for health care quality and the supply of know‐how to deliver it. What the field of quality improvement (QI) still needs is merely this: QI practitioners in every care setting, a working vocabulary, a predictive framework for the mechanisms of reliable care, and rational therapies rigorously studied.13 Fortunately, the field of QI has attracted enough empiricistsworking in the lab of the hospital and other care settingsto lurch forward. But few would argue that we still have far less insight into the delivery of quality care than into the delivery of myocardial blood flow.

For ischemic heart disease we have classes of therapies, each of which is grounded in basic and clinical science: antiplatelets, beta‐blockers, vasodilators, lipid‐lowering agents. For care delivery we have the makings of analogous therapy classes, derived and introduced rather recently in a large review, Closing the Quality Gap: A Critical Analysis of the Quality Improvement Literature.4, 5 To facilitate their review of the evidence, the authors, including 2 prominent hospitalists, developed a new taxonomy of QI strategies (see Table 1). Though their effect size, relative efficacy, and interactions are not yet clear, many of these strategies can be applied to the inpatient setting, perhaps no less rationally than a well‐constructed antianginal regimen.

Where in the pathophysiology of a hospital do these QI therapies act? A plurality target the level of the provider: provider education, provider reminders, audit‐and‐feedback of provider performance, and facilitated relay of clinical data to providers. Remaining strategies target the patient (patient education, promotion of self‐management, and patient reminders), the immediate system within which care is delivered (organizational change), and the methodology of problem solving (continuous quality improvement). Only one strategy (financial incentives, regulation, and policy) fails to act directly at the level of the patient or provider, arguably the only level at which care actually can be improved.6

The value of the Quality Gap taxonomy is still largely untapped. If QI researchers and practitioners were to adopt its language as a standard, we could ramp up the power with which we communicate, interpret, and ultimately conduct improvement initiatives. In this issue of the Journal of Hospital Medicine, Cohn and colleagues profile a quality improvement initiative that achieved an impressive new level of performance. For an inpatient metric with a baseline institutional performance of 47%and an international benchmark of 39%the investigators executed a QI initiative that appears to have raised the rate of VTE prophylaxis to 85%.7 Despite a study design that weakens validity (beforeafter without controls) and a setting that diminishes applicability (medical patients in a single academic center), the authors have made a solid contribution to the QI literature simply by using the Quality Gap taxonomy. The authors specifically name and profile at least 3 distinct classes of QI strategies: provider education, a provider reminder element (ie, decision support), and an audit‐and‐feedback layer.

Even though provider education is unlikely to be sufficient as a lone QI strategya large review showed consistent but only modest benefitsit is often necessary.8 The provider education executed by Cohn and colleagues was frequent and regular. In the beginning of each month the chief resident oriented incoming house staff about venous thromboembolism (VTE) risk factors and the need for prophylaxis. They were given decision support pocket cards. Posters on display in nurse and physician work areas highlighted VTE risk factors. The provider education element also included discussions with the division chief about the topic. As robust as it was, however, the provider education was just a single component of the larger QI effort.

The second element, decision support, included VTE risk factor pocket cards with prophylaxis options listed. Introduced initially with the provider education, the pocket cards were handed out monthly by the chief resident. It is critical to recognize this decision support layer as a distinct core QI strategyand that it may even be fundamental to the success of the other strategies. Placed into the clinical workflow as a durable item, the decision support pocket card has the power to overcome provider uncertainty at moments of medical decision making. Generally speaking, a decision support layer, whether a pocket card, computer alert, or algorithm on a preprinted order form, can function as a shared baseline. Shared baselines or protocols reduce unnecessary variation in practice, a common source of poor quality care. Any mechanism that encourages groups of providers to deliver the same recommended care to groups of similarly at‐risk patients, while allowing customization of the protocol to meet the special needs of any individual patient, will have the net effect of raising overall quality of care.

This QI initiative may have achieved its greatest performance gainsas well as its greatest loss in terms of applicability to other settingsfrom its third facet, the audit‐and‐feedback layer. As a QI strategy audit‐and‐feedback has been defined as a summary of clinical performance for health care providers or institutions, performed for a specific period of time and reported either publicly or confidentially.1 It has demonstrated small to moderate benefits, with variations in effect most likely related to the format.9 As profiled in this study, it is hard to imagine a more powerful audit‐and‐feedback arrangement. The division chief of General Internal Medicine not only performed the audits, but also directly delivered the feedback to the house staff. In a deliberate, systematic, and successful way the investigators constructively used an existing authority gradient to leverage the Hawthorne effect, a change in worker behavior triggered by knowledge of being observed. Although it contributed to the impressive new VTE prophylaxis rates, this component did diminish generalizability and sustainability. Nonacademic centers may struggle to replicate these results, a point the authors dutifully point out. But even other academic centers might struggle in the absence of an authority figure with comparable influence and dedication to VTE prophylaxis. At the study hospital itself, similar rates of improvement would not be expected in patient populations outside the purview of the division chief.

Several alternatives to the before‐after study design could have produced richer information. Simultaneous data on VTE prophylaxis rates in a nonintervention population in the same or a similar hospital could have controlled for background or secular effects. An interrupted time series design may even have been feasible and could have provided more confidence in causality and more information on effect size. For example, what would be the effect on performance, if any, with removal of the decision support pocket card at 10 or 15 months? How much would performance rebound after its reintroduction? What could we have learned had the authors chosen instead to measure performance after sequentially introducing each component?

Using the language of the Quality Gap taxonomy, what conclusions can we draw from this improvement initiative? The introduction of a portable provider reminder (the decision support pocket card), when preceded by a program of provider education and followed by high‐intensity audit‐and‐feedback within an existing provider hierarchy, may have the power to raise VTE prophylaxis rates to 85% over an 18‐month period. With the large effect size somewhat mitigating the design flaws that weaken causality, we might risk an inference that these 3 classes of QI strategies can be reasonably successful in combination. But would we introduce them in our own medical centers? Using the clarity afforded by the taxonomy, we can identify several potential limitations, all attributable to the specifics of the audit‐and‐feedback arrangement: stringent preconditions of the practice setting, guaranteed inability to spread the initiative to other patient populations within the same medical center, limited scalability to include other QI projects, and reliance on the role of a single individual. Although clopidogrel 300 mg daily in the last week of every month is one way to pursue antiplatelet activity, other schedules or alternative agents may be preferable for the vast majority of patients.

The taxonomy can be used to compare, contrast, and more fully understand other QI studies. For example, among acutely ill medical inpatients not receiving VTE prophylaxis, Kucher and colleagues found that an electronic alert nearly doubled prophylaxis rates compared to those in a control group.10 Before trying to emulate their experience, a similarly equipped hospital would do well to recognize that the electronic alert was deployed as a composite of provider education, provider reminder, and facilitated relay of clinical information strategies, increasing prophylaxis rates for high risk patients from a baseline of 85% to 88%.

On the 21st‐century side of the quality chasm there is still something to be learned from QI research that falls short of recently proposed standards.3 This may be true as long as the key question remains: what are the mechanisms of reliable and sustainable performance improvement? We have not yet reached the day where a predictive framework, the clarity of our inquiry, the rigor of our study design, and the strength of our evidence churn out coherent answers. But we do have insights from a wealth of ongoing QI activity triggered by such forces as the Institute for Healthcare Improvement's 100,000 Lives Campaign and the advent of mandatory public reporting of hospital performance measures. By adding to this primordial mix the taxonomy offered by Closing the Quality Gap and its uptake into our vernacular by reports such as the one by Cohn in this issue of the Journal of Hospital Medicine, we are acquiring the language and experience to conduct intelligent and intelligible QI research.