Editorial

On my first day as a nervous, third‐year medical student, a nurse offered to orient me to the pediatric ICU. I expected a litany of facts to memorize. Instead, she pointed at each room in turn and described the tragedies they had hosted.

Room 1: a little girl just died of meningitis there. Room 2: that boy's liver transplant failed, and he had a massive stroke. The father sat holding the jaundiced hand of his unresponsive son, whose stapled abdomen held back tense ascites. His wife died of cancer 2 months ago. Now he has no one. Room 3: teen with cystic fibrosis; she'll be OK. Room 4 I will never forget. A teenager died of leukemia there and refused all painkillers. He wanted to be lucid for his family, and they huddled on his bed and sang Amazing Grace until he died. Most beautiful thing I have seen.

I had thought, Beautiful? How can you even come to work?

Five years later, I remembered that conversation as if it had just happened. I was the senior resident in the medical ICU, it was 3 AM, and I was gathering my thoughts amid the whooshes, beeps, and flickering monitors of the sleeping unit. I was preparing to go tell Betsy that Joe, her 31‐year‐old husband, needed prone ventilation. Joe lay dying from, of all things, chickenpox. He was receiving 12 infusions, including 4 pressors, sedatives, antibiotics, acyclovir, full‐strength bicarbonate, his 26th amp of calcium, and liter number‐who‐knows‐what of saline. He sprouted 2 IVs, 2 central lines, a Foley catheter, endotracheal and orogastric tubes, an arterial line, and an array of monitor leads. His blood pressure would plummetfrom a systolic of 80whenever we interrupted his bicarb drip to spike a new bag, so we knew moving him might kill him. Every nurse raced to finish tasks on other patients, preparing to help.

Joe's admission began, like several of his earlier ones, with a chief complaint of Crohn's flare. This time, however, he had a new rash, and although John's ward team suspected medications were to blame, they soon started him on acyclovir. In days, hepatitis, acute renal failure, and pneumonia prompted his ICU transfer. He required intubation hours later. His course since had been like watching a pedestrian struck by a truck in slow motion: a sudden, jolting, irreversible crueltydrawn out over hours. Anasarca had folded his blistering ears in half and forced us to revise his endotracheal tube taping 3 times so it would not incise his cheeks. He had unremitting hypotension. His transaminases climbed above 6000 and his creatinine to 6; his arterial pH dropped to 7.03, and his platelets fell to 16,000. His partial pressure of oxygen sank below 60 mm Hg despite paralysis, every conceivable ventilator adjustment, and 100% oxygen. Crossing that terrible threshold felt like drifting below hull‐crush depth in a submarine. I waited for the walls and windows of the ICU to groan with the strain as disaster neared.

My intern followed me to the waiting room where Betsy slept. She hadn't left the hospital in days. I knelt beside her cot and woke her, and she supported her pregnant abdomen with her hand as she rolled to face me. We smiled. Then she remembered where she was.

Is something wrong? she asked.

No, he's about the same. But the other things we tried didn't help. We need to do what I mentioned beforeturn him over so he can use his lungs better. She nodded. We're very careful, but he has so many IV lines right now. If he loses one, he could get much worse. So I wanted to make sure you spent some time with him now, just in case.

Her eyes teared. He could die?

Just a small chance. But possible.

And if it works, he might get better?

I paused. He's very sick.

There are other things you can do?

We have to really hope this works.

This isn't supposed to happen. I don't know if I can raise 2 children without Joe. I can't be a widow at 29. I sensed I could have talked hersleep deprived and stunnedback into sleep, into a conviction her nightmare would pass by morning. Instead I squeezed her hand and listened.

We need to do this, OK? You'll have 10 minutes to talk. Remember how his blood pressure rose when they cleaned him? He's still in there. I believe he can hear you. So you tell him to keep fighting.

Betsy wiped her eyes and searched for her shoes. As we walked briskly back to the unit, I composed myself and told my intern, I'll be 29 in 3 weeks.

Me too. What day?

May 28th.

Same as mine, he said.

It took 25 minutes to prone Joe with every nurse assisting, but the maneuver went well. His oxygenation improved, but his relentless decline resumed within hours. The following afternoon, Betsy held Joe's hand and told him it was OK for him to go, and that she would look after their children. Joe's blood pressure eventually dwindled to nothing, leaving only sinus tachycardia on the monitor and the rhythmic puffs of the ventilator. Then, within 2 weeks, the resident team managed a series of unexpected tragedies: we lost young mothers to acetaminophen overdose and lung cancer, and cared for 2 young adults with septic shock and a perimenopausal woman for whom the cost of pneumonia was her first and probably only pregnancy.

Five years before, when I first stepped into an ICU, I imagined the residents held a dozen lives in their hands and faced critical illness at all hoursalone. By the time Joe died of disseminated varicella, I realized the truth was far from that vision. Joe's nurse had worked in the ICU as long as I'd been alive, and expert respiratory therapists guided his mechanical ventilation. I had coresidents and consultantseven a rabbi when I guided a family meeting on declaring CPR not indicated. Our institution's overnight attending assisted me throughout the night, and the primary attending drove in at 2 AM to supervise nitric oxide therapy. At no point did I ever care for Joe alone.

Instead, the challenge lay in facing the winning smiles of our patient Joe and his 10 month‐old son Jacob waving from a recent photo taped by the head of his bed and a young wife refusing to leave her increasingly unrecognizable husband as his body failed, despite her conspicuous 7‐month pregnancy. And it lay in the surprising futility of all our interventions. Perhaps most of all, the challenge was in the persistence of the sights and sounds and smells of that night and many others. I've seen the expression a pathologist makes on learning his daughter has anaplastic thyroid cancer. I've heard the sound a daughter makes when her mother has a ventricular free‐wall rupture while welcoming us into her room. I've smelled a teenager who had burned to the bone while conscious yet pinned in his car. I've felt the crackle of subcutaneous emphysema after chest tubes for malignant pleural effusions that was so severe the patient could not open his eyes or close his hands. And the papery skin and tremulous handshake of a man after my news of his wife's prognosis promised their 64th year of marriage would be the last.

Far from alone, I spend much of my time in the company of these ghosts, as must many health care workers. How we make our peace with them is up to us. With tears? Humor? Alcohol? Sometimes it is by numb indifference; you might wonder from most of the businesslike discussions physicians hold if these ghosts even existed. Or, we can make our peace with words. I am grateful for a chance to speak with Betsy some days after Joe died to assure her that although we did ask Joe to fight, in the end no effort could have saved him. I am grateful she later wrote us to celebrate the healthy birth of their second son, Joshua. She assured me Joe would live on for her in their sons and live on for them through her memories. Her strength helped me welcome Joe's ghost, and many others, into my life.

After 5 years of clinical medicine, I finally understood the lesson I received from the pediatric ICU nurse. Our ghost stories help us grieve, and they celebrate healing, or if there was no healing, then release. At the very least, great tragedy reminds us of the great meaning of our calling.

On my first day as a nervous, third‐year medical student, a nurse offered to orient me to the pediatric ICU. I expected a litany of facts to memorize. Instead, she pointed at each room in turn and described the tragedies they had hosted.

Room 1: a little girl just died of meningitis there. Room 2: that boy's liver transplant failed, and he had a massive stroke. The father sat holding the jaundiced hand of his unresponsive son, whose stapled abdomen held back tense ascites. His wife died of cancer 2 months ago. Now he has no one. Room 3: teen with cystic fibrosis; she'll be OK. Room 4 I will never forget. A teenager died of leukemia there and refused all painkillers. He wanted to be lucid for his family, and they huddled on his bed and sang Amazing Grace until he died. Most beautiful thing I have seen.

I had thought, Beautiful? How can you even come to work?

Five years later, I remembered that conversation as if it had just happened. I was the senior resident in the medical ICU, it was 3 AM, and I was gathering my thoughts amid the whooshes, beeps, and flickering monitors of the sleeping unit. I was preparing to go tell Betsy that Joe, her 31‐year‐old husband, needed prone ventilation. Joe lay dying from, of all things, chickenpox. He was receiving 12 infusions, including 4 pressors, sedatives, antibiotics, acyclovir, full‐strength bicarbonate, his 26th amp of calcium, and liter number‐who‐knows‐what of saline. He sprouted 2 IVs, 2 central lines, a Foley catheter, endotracheal and orogastric tubes, an arterial line, and an array of monitor leads. His blood pressure would plummetfrom a systolic of 80whenever we interrupted his bicarb drip to spike a new bag, so we knew moving him might kill him. Every nurse raced to finish tasks on other patients, preparing to help.

Joe's admission began, like several of his earlier ones, with a chief complaint of Crohn's flare. This time, however, he had a new rash, and although John's ward team suspected medications were to blame, they soon started him on acyclovir. In days, hepatitis, acute renal failure, and pneumonia prompted his ICU transfer. He required intubation hours later. His course since had been like watching a pedestrian struck by a truck in slow motion: a sudden, jolting, irreversible crueltydrawn out over hours. Anasarca had folded his blistering ears in half and forced us to revise his endotracheal tube taping 3 times so it would not incise his cheeks. He had unremitting hypotension. His transaminases climbed above 6000 and his creatinine to 6; his arterial pH dropped to 7.03, and his platelets fell to 16,000. His partial pressure of oxygen sank below 60 mm Hg despite paralysis, every conceivable ventilator adjustment, and 100% oxygen. Crossing that terrible threshold felt like drifting below hull‐crush depth in a submarine. I waited for the walls and windows of the ICU to groan with the strain as disaster neared.

My intern followed me to the waiting room where Betsy slept. She hadn't left the hospital in days. I knelt beside her cot and woke her, and she supported her pregnant abdomen with her hand as she rolled to face me. We smiled. Then she remembered where she was.

Is something wrong? she asked.

No, he's about the same. But the other things we tried didn't help. We need to do what I mentioned beforeturn him over so he can use his lungs better. She nodded. We're very careful, but he has so many IV lines right now. If he loses one, he could get much worse. So I wanted to make sure you spent some time with him now, just in case.

Her eyes teared. He could die?

Just a small chance. But possible.

And if it works, he might get better?

I paused. He's very sick.

There are other things you can do?

We have to really hope this works.

This isn't supposed to happen. I don't know if I can raise 2 children without Joe. I can't be a widow at 29. I sensed I could have talked hersleep deprived and stunnedback into sleep, into a conviction her nightmare would pass by morning. Instead I squeezed her hand and listened.

We need to do this, OK? You'll have 10 minutes to talk. Remember how his blood pressure rose when they cleaned him? He's still in there. I believe he can hear you. So you tell him to keep fighting.

Betsy wiped her eyes and searched for her shoes. As we walked briskly back to the unit, I composed myself and told my intern, I'll be 29 in 3 weeks.

Me too. What day?

May 28th.

Same as mine, he said.

It took 25 minutes to prone Joe with every nurse assisting, but the maneuver went well. His oxygenation improved, but his relentless decline resumed within hours. The following afternoon, Betsy held Joe's hand and told him it was OK for him to go, and that she would look after their children. Joe's blood pressure eventually dwindled to nothing, leaving only sinus tachycardia on the monitor and the rhythmic puffs of the ventilator. Then, within 2 weeks, the resident team managed a series of unexpected tragedies: we lost young mothers to acetaminophen overdose and lung cancer, and cared for 2 young adults with septic shock and a perimenopausal woman for whom the cost of pneumonia was her first and probably only pregnancy.

Five years before, when I first stepped into an ICU, I imagined the residents held a dozen lives in their hands and faced critical illness at all hoursalone. By the time Joe died of disseminated varicella, I realized the truth was far from that vision. Joe's nurse had worked in the ICU as long as I'd been alive, and expert respiratory therapists guided his mechanical ventilation. I had coresidents and consultantseven a rabbi when I guided a family meeting on declaring CPR not indicated. Our institution's overnight attending assisted me throughout the night, and the primary attending drove in at 2 AM to supervise nitric oxide therapy. At no point did I ever care for Joe alone.

Instead, the challenge lay in facing the winning smiles of our patient Joe and his 10 month‐old son Jacob waving from a recent photo taped by the head of his bed and a young wife refusing to leave her increasingly unrecognizable husband as his body failed, despite her conspicuous 7‐month pregnancy. And it lay in the surprising futility of all our interventions. Perhaps most of all, the challenge was in the persistence of the sights and sounds and smells of that night and many others. I've seen the expression a pathologist makes on learning his daughter has anaplastic thyroid cancer. I've heard the sound a daughter makes when her mother has a ventricular free‐wall rupture while welcoming us into her room. I've smelled a teenager who had burned to the bone while conscious yet pinned in his car. I've felt the crackle of subcutaneous emphysema after chest tubes for malignant pleural effusions that was so severe the patient could not open his eyes or close his hands. And the papery skin and tremulous handshake of a man after my news of his wife's prognosis promised their 64th year of marriage would be the last.

Far from alone, I spend much of my time in the company of these ghosts, as must many health care workers. How we make our peace with them is up to us. With tears? Humor? Alcohol? Sometimes it is by numb indifference; you might wonder from most of the businesslike discussions physicians hold if these ghosts even existed. Or, we can make our peace with words. I am grateful for a chance to speak with Betsy some days after Joe died to assure her that although we did ask Joe to fight, in the end no effort could have saved him. I am grateful she later wrote us to celebrate the healthy birth of their second son, Joshua. She assured me Joe would live on for her in their sons and live on for them through her memories. Her strength helped me welcome Joe's ghost, and many others, into my life.

After 5 years of clinical medicine, I finally understood the lesson I received from the pediatric ICU nurse. Our ghost stories help us grieve, and they celebrate healing, or if there was no healing, then release. At the very least, great tragedy reminds us of the great meaning of our calling.

On my first day as a nervous, third‐year medical student, a nurse offered to orient me to the pediatric ICU. I expected a litany of facts to memorize. Instead, she pointed at each room in turn and described the tragedies they had hosted.

Room 1: a little girl just died of meningitis there. Room 2: that boy's liver transplant failed, and he had a massive stroke. The father sat holding the jaundiced hand of his unresponsive son, whose stapled abdomen held back tense ascites. His wife died of cancer 2 months ago. Now he has no one. Room 3: teen with cystic fibrosis; she'll be OK. Room 4 I will never forget. A teenager died of leukemia there and refused all painkillers. He wanted to be lucid for his family, and they huddled on his bed and sang Amazing Grace until he died. Most beautiful thing I have seen.

I had thought, Beautiful? How can you even come to work?

Five years later, I remembered that conversation as if it had just happened. I was the senior resident in the medical ICU, it was 3 AM, and I was gathering my thoughts amid the whooshes, beeps, and flickering monitors of the sleeping unit. I was preparing to go tell Betsy that Joe, her 31‐year‐old husband, needed prone ventilation. Joe lay dying from, of all things, chickenpox. He was receiving 12 infusions, including 4 pressors, sedatives, antibiotics, acyclovir, full‐strength bicarbonate, his 26th amp of calcium, and liter number‐who‐knows‐what of saline. He sprouted 2 IVs, 2 central lines, a Foley catheter, endotracheal and orogastric tubes, an arterial line, and an array of monitor leads. His blood pressure would plummetfrom a systolic of 80whenever we interrupted his bicarb drip to spike a new bag, so we knew moving him might kill him. Every nurse raced to finish tasks on other patients, preparing to help.

Joe's admission began, like several of his earlier ones, with a chief complaint of Crohn's flare. This time, however, he had a new rash, and although John's ward team suspected medications were to blame, they soon started him on acyclovir. In days, hepatitis, acute renal failure, and pneumonia prompted his ICU transfer. He required intubation hours later. His course since had been like watching a pedestrian struck by a truck in slow motion: a sudden, jolting, irreversible crueltydrawn out over hours. Anasarca had folded his blistering ears in half and forced us to revise his endotracheal tube taping 3 times so it would not incise his cheeks. He had unremitting hypotension. His transaminases climbed above 6000 and his creatinine to 6; his arterial pH dropped to 7.03, and his platelets fell to 16,000. His partial pressure of oxygen sank below 60 mm Hg despite paralysis, every conceivable ventilator adjustment, and 100% oxygen. Crossing that terrible threshold felt like drifting below hull‐crush depth in a submarine. I waited for the walls and windows of the ICU to groan with the strain as disaster neared.

My intern followed me to the waiting room where Betsy slept. She hadn't left the hospital in days. I knelt beside her cot and woke her, and she supported her pregnant abdomen with her hand as she rolled to face me. We smiled. Then she remembered where she was.

Is something wrong? she asked.

No, he's about the same. But the other things we tried didn't help. We need to do what I mentioned beforeturn him over so he can use his lungs better. She nodded. We're very careful, but he has so many IV lines right now. If he loses one, he could get much worse. So I wanted to make sure you spent some time with him now, just in case.

Her eyes teared. He could die?

Just a small chance. But possible.

And if it works, he might get better?

I paused. He's very sick.

There are other things you can do?

We have to really hope this works.

This isn't supposed to happen. I don't know if I can raise 2 children without Joe. I can't be a widow at 29. I sensed I could have talked hersleep deprived and stunnedback into sleep, into a conviction her nightmare would pass by morning. Instead I squeezed her hand and listened.

We need to do this, OK? You'll have 10 minutes to talk. Remember how his blood pressure rose when they cleaned him? He's still in there. I believe he can hear you. So you tell him to keep fighting.

Betsy wiped her eyes and searched for her shoes. As we walked briskly back to the unit, I composed myself and told my intern, I'll be 29 in 3 weeks.

Me too. What day?

May 28th.

Same as mine, he said.

It took 25 minutes to prone Joe with every nurse assisting, but the maneuver went well. His oxygenation improved, but his relentless decline resumed within hours. The following afternoon, Betsy held Joe's hand and told him it was OK for him to go, and that she would look after their children. Joe's blood pressure eventually dwindled to nothing, leaving only sinus tachycardia on the monitor and the rhythmic puffs of the ventilator. Then, within 2 weeks, the resident team managed a series of unexpected tragedies: we lost young mothers to acetaminophen overdose and lung cancer, and cared for 2 young adults with septic shock and a perimenopausal woman for whom the cost of pneumonia was her first and probably only pregnancy.

Five years before, when I first stepped into an ICU, I imagined the residents held a dozen lives in their hands and faced critical illness at all hoursalone. By the time Joe died of disseminated varicella, I realized the truth was far from that vision. Joe's nurse had worked in the ICU as long as I'd been alive, and expert respiratory therapists guided his mechanical ventilation. I had coresidents and consultantseven a rabbi when I guided a family meeting on declaring CPR not indicated. Our institution's overnight attending assisted me throughout the night, and the primary attending drove in at 2 AM to supervise nitric oxide therapy. At no point did I ever care for Joe alone.

Instead, the challenge lay in facing the winning smiles of our patient Joe and his 10 month‐old son Jacob waving from a recent photo taped by the head of his bed and a young wife refusing to leave her increasingly unrecognizable husband as his body failed, despite her conspicuous 7‐month pregnancy. And it lay in the surprising futility of all our interventions. Perhaps most of all, the challenge was in the persistence of the sights and sounds and smells of that night and many others. I've seen the expression a pathologist makes on learning his daughter has anaplastic thyroid cancer. I've heard the sound a daughter makes when her mother has a ventricular free‐wall rupture while welcoming us into her room. I've smelled a teenager who had burned to the bone while conscious yet pinned in his car. I've felt the crackle of subcutaneous emphysema after chest tubes for malignant pleural effusions that was so severe the patient could not open his eyes or close his hands. And the papery skin and tremulous handshake of a man after my news of his wife's prognosis promised their 64th year of marriage would be the last.

Far from alone, I spend much of my time in the company of these ghosts, as must many health care workers. How we make our peace with them is up to us. With tears? Humor? Alcohol? Sometimes it is by numb indifference; you might wonder from most of the businesslike discussions physicians hold if these ghosts even existed. Or, we can make our peace with words. I am grateful for a chance to speak with Betsy some days after Joe died to assure her that although we did ask Joe to fight, in the end no effort could have saved him. I am grateful she later wrote us to celebrate the healthy birth of their second son, Joshua. She assured me Joe would live on for her in their sons and live on for them through her memories. Her strength helped me welcome Joe's ghost, and many others, into my life.

After 5 years of clinical medicine, I finally understood the lesson I received from the pediatric ICU nurse. Our ghost stories help us grieve, and they celebrate healing, or if there was no healing, then release. At the very least, great tragedy reminds us of the great meaning of our calling.

Of the many skills a hospitalist nurtures and develops, seeing and processing visual images is paramount. From the moment we enter the hospital each day, we look at patient faces, trying to fathom their levels of pain, of illness, and of response to therapy. We look at their rashes, facial droops, surgical wounds, and neck vein elevation. When we are done visually scrutinizing our patients, we inspect their rhythm strips or electrocardiograms and then move on to their X‐rays and advanced imaging.

Although we are, in a sense, slaves to the images before us, we also enjoy medicine for the challenge that these images providethere is always something novel to see. For the experienced clinician, a deep sense of satisfaction perfuses our limbic system with the quick recognition of the delta wave of Wolf‐Parkinson‐White on an EKG or the first vesicle of a zoster outbreak in a patient with initially unexplained cutaneous pain. What we recognize easily tends to come from having seen something beforefor better or worse, we depend on pattern recognition.

Unfortunately, we are all busier than we like and receive more journals than we have time to read. To make JHM even more germane and stimulating, we are initiating Hospital Images Dx. The main goal of Hospital Images Dx will be to show interesting images that a hospitalist might encounter, both the common and the obscure. Images, whether subtle or awe‐inspiring, should generally be able to speak the proverbial thousand words. To supplement those thousand words spoken by the submitted image, accompanying text will be limited to 250 words. The text should give a brief clinical summary of the patient's problem, relevant adjunct data, and 1 or 2 succinct teaching points related to the image. Our goal, simply stated, is for the reader to walk away after reading Hospital Images Dx with an image and a couple of key teaching points stored away for a rainy day.

We anticipate a substantial number of exciting submissions to Hospital Images Dx. Health care providers clearly get excited about the things they see as well as about the recordsthe imagesthat document both mundane and unusual encounters with a patient or a patient's data. We hope to tap into this enthusiasm and to teach a few things along the way. The editors look forward to receiving your Hospital Images Dx submission soon!

Of the many skills a hospitalist nurtures and develops, seeing and processing visual images is paramount. From the moment we enter the hospital each day, we look at patient faces, trying to fathom their levels of pain, of illness, and of response to therapy. We look at their rashes, facial droops, surgical wounds, and neck vein elevation. When we are done visually scrutinizing our patients, we inspect their rhythm strips or electrocardiograms and then move on to their X‐rays and advanced imaging.

Although we are, in a sense, slaves to the images before us, we also enjoy medicine for the challenge that these images providethere is always something novel to see. For the experienced clinician, a deep sense of satisfaction perfuses our limbic system with the quick recognition of the delta wave of Wolf‐Parkinson‐White on an EKG or the first vesicle of a zoster outbreak in a patient with initially unexplained cutaneous pain. What we recognize easily tends to come from having seen something beforefor better or worse, we depend on pattern recognition.

Unfortunately, we are all busier than we like and receive more journals than we have time to read. To make JHM even more germane and stimulating, we are initiating Hospital Images Dx. The main goal of Hospital Images Dx will be to show interesting images that a hospitalist might encounter, both the common and the obscure. Images, whether subtle or awe‐inspiring, should generally be able to speak the proverbial thousand words. To supplement those thousand words spoken by the submitted image, accompanying text will be limited to 250 words. The text should give a brief clinical summary of the patient's problem, relevant adjunct data, and 1 or 2 succinct teaching points related to the image. Our goal, simply stated, is for the reader to walk away after reading Hospital Images Dx with an image and a couple of key teaching points stored away for a rainy day.

We anticipate a substantial number of exciting submissions to Hospital Images Dx. Health care providers clearly get excited about the things they see as well as about the recordsthe imagesthat document both mundane and unusual encounters with a patient or a patient's data. We hope to tap into this enthusiasm and to teach a few things along the way. The editors look forward to receiving your Hospital Images Dx submission soon!

Of the many skills a hospitalist nurtures and develops, seeing and processing visual images is paramount. From the moment we enter the hospital each day, we look at patient faces, trying to fathom their levels of pain, of illness, and of response to therapy. We look at their rashes, facial droops, surgical wounds, and neck vein elevation. When we are done visually scrutinizing our patients, we inspect their rhythm strips or electrocardiograms and then move on to their X‐rays and advanced imaging.

Although we are, in a sense, slaves to the images before us, we also enjoy medicine for the challenge that these images providethere is always something novel to see. For the experienced clinician, a deep sense of satisfaction perfuses our limbic system with the quick recognition of the delta wave of Wolf‐Parkinson‐White on an EKG or the first vesicle of a zoster outbreak in a patient with initially unexplained cutaneous pain. What we recognize easily tends to come from having seen something beforefor better or worse, we depend on pattern recognition.

Unfortunately, we are all busier than we like and receive more journals than we have time to read. To make JHM even more germane and stimulating, we are initiating Hospital Images Dx. The main goal of Hospital Images Dx will be to show interesting images that a hospitalist might encounter, both the common and the obscure. Images, whether subtle or awe‐inspiring, should generally be able to speak the proverbial thousand words. To supplement those thousand words spoken by the submitted image, accompanying text will be limited to 250 words. The text should give a brief clinical summary of the patient's problem, relevant adjunct data, and 1 or 2 succinct teaching points related to the image. Our goal, simply stated, is for the reader to walk away after reading Hospital Images Dx with an image and a couple of key teaching points stored away for a rainy day.

We anticipate a substantial number of exciting submissions to Hospital Images Dx. Health care providers clearly get excited about the things they see as well as about the recordsthe imagesthat document both mundane and unusual encounters with a patient or a patient's data. We hope to tap into this enthusiasm and to teach a few things along the way. The editors look forward to receiving your Hospital Images Dx submission soon!

In addition to marking my initial transition from student to physician, the commencement address by the medical informatics pioneer, Larry Weed, is my most enduring memory of medical school graduation. A provocative thinker in the field of decision support and structured medical records, Weed was credited by my teachers with developing the organized SOAP note. During his address he depressingly equated all the knowledge we had digested during the preceding mentally strenuous 4 years to shoveling a mountain of manure with a teaspoon. Although I agreed that some of the information I learned seemed to lack relevance (still don't know why I needed to learn the details of the Krebs cycle), as I began caring for patients as an intern, I found that much of it mattered. As I launched into residency training, I also discovered that lifelong learning would be a perpetual component of my medical career.

Despite becoming a passionate advocate of practicing evidence‐based medicine (EBM), I also recognized the impossibility of keeping up with the medical literature, given the relentless arrival of journals in the mail. Learning all the evidence is impossible, so we must develop information management skills and allow others to help us in identifying, reviewing, and summarizing salient and valid clinical information.1 One of my vital goals as editor of the Journal of Hospital Medicine is to ensure we provide our readers with useful clinical information that is concise, easily digested, and usable.

To that end we are introducing Patient‐Oriented Evidence that Matters, or POEMs. As described on the InfoPOEMs website (www.infopoems.com), POEMs have to meet three criteria:

• They address a question that we face as clinicians.

• They measure outcomes that we and our patients care about: symptoms, morbidity, quality of life, and mortality.

• They have the potential to change the way we practice.

We are not the first journal to do this and join the company of the British Medical Journal and the Cleveland Clinic Journal of Medicine.2, 3 Staff physicians at InfoPOEMs screen more than 100 peer‐reviewed medical journals for relevant articles that practicing physicians can use at the point of care, the patient. A trained physician poet then summarizes selected articles in a standardized manner into a POEM. A POEM begins with a clinical question and then provides a bottom line answer from a recently published journal article. This is followed by a structured abstract that includes the study design and setting, followed by a synopsis of the article.

We will start with at least 2 POEMs per issue focused on clinical topics relevant to hospitalists. Soon, an experienced academic hospitalist and knowledgeable expert in EBM, Dr. Jennifer Kleinbart, will be writing POEMs for hospitalists. We look forward to your opinions about whether we should increase this content. Let me know.

In addition to marking my initial transition from student to physician, the commencement address by the medical informatics pioneer, Larry Weed, is my most enduring memory of medical school graduation. A provocative thinker in the field of decision support and structured medical records, Weed was credited by my teachers with developing the organized SOAP note. During his address he depressingly equated all the knowledge we had digested during the preceding mentally strenuous 4 years to shoveling a mountain of manure with a teaspoon. Although I agreed that some of the information I learned seemed to lack relevance (still don't know why I needed to learn the details of the Krebs cycle), as I began caring for patients as an intern, I found that much of it mattered. As I launched into residency training, I also discovered that lifelong learning would be a perpetual component of my medical career.

Despite becoming a passionate advocate of practicing evidence‐based medicine (EBM), I also recognized the impossibility of keeping up with the medical literature, given the relentless arrival of journals in the mail. Learning all the evidence is impossible, so we must develop information management skills and allow others to help us in identifying, reviewing, and summarizing salient and valid clinical information.1 One of my vital goals as editor of the Journal of Hospital Medicine is to ensure we provide our readers with useful clinical information that is concise, easily digested, and usable.

To that end we are introducing Patient‐Oriented Evidence that Matters, or POEMs. As described on the InfoPOEMs website (www.infopoems.com), POEMs have to meet three criteria:

• They address a question that we face as clinicians.

• They measure outcomes that we and our patients care about: symptoms, morbidity, quality of life, and mortality.

• They have the potential to change the way we practice.

We are not the first journal to do this and join the company of the British Medical Journal and the Cleveland Clinic Journal of Medicine.2, 3 Staff physicians at InfoPOEMs screen more than 100 peer‐reviewed medical journals for relevant articles that practicing physicians can use at the point of care, the patient. A trained physician poet then summarizes selected articles in a standardized manner into a POEM. A POEM begins with a clinical question and then provides a bottom line answer from a recently published journal article. This is followed by a structured abstract that includes the study design and setting, followed by a synopsis of the article.

We will start with at least 2 POEMs per issue focused on clinical topics relevant to hospitalists. Soon, an experienced academic hospitalist and knowledgeable expert in EBM, Dr. Jennifer Kleinbart, will be writing POEMs for hospitalists. We look forward to your opinions about whether we should increase this content. Let me know.

In addition to marking my initial transition from student to physician, the commencement address by the medical informatics pioneer, Larry Weed, is my most enduring memory of medical school graduation. A provocative thinker in the field of decision support and structured medical records, Weed was credited by my teachers with developing the organized SOAP note. During his address he depressingly equated all the knowledge we had digested during the preceding mentally strenuous 4 years to shoveling a mountain of manure with a teaspoon. Although I agreed that some of the information I learned seemed to lack relevance (still don't know why I needed to learn the details of the Krebs cycle), as I began caring for patients as an intern, I found that much of it mattered. As I launched into residency training, I also discovered that lifelong learning would be a perpetual component of my medical career.

Despite becoming a passionate advocate of practicing evidence‐based medicine (EBM), I also recognized the impossibility of keeping up with the medical literature, given the relentless arrival of journals in the mail. Learning all the evidence is impossible, so we must develop information management skills and allow others to help us in identifying, reviewing, and summarizing salient and valid clinical information.1 One of my vital goals as editor of the Journal of Hospital Medicine is to ensure we provide our readers with useful clinical information that is concise, easily digested, and usable.

To that end we are introducing Patient‐Oriented Evidence that Matters, or POEMs. As described on the InfoPOEMs website (www.infopoems.com), POEMs have to meet three criteria:

• They address a question that we face as clinicians.

• They measure outcomes that we and our patients care about: symptoms, morbidity, quality of life, and mortality.

• They have the potential to change the way we practice.

We are not the first journal to do this and join the company of the British Medical Journal and the Cleveland Clinic Journal of Medicine.2, 3 Staff physicians at InfoPOEMs screen more than 100 peer‐reviewed medical journals for relevant articles that practicing physicians can use at the point of care, the patient. A trained physician poet then summarizes selected articles in a standardized manner into a POEM. A POEM begins with a clinical question and then provides a bottom line answer from a recently published journal article. This is followed by a structured abstract that includes the study design and setting, followed by a synopsis of the article.

We will start with at least 2 POEMs per issue focused on clinical topics relevant to hospitalists. Soon, an experienced academic hospitalist and knowledgeable expert in EBM, Dr. Jennifer Kleinbart, will be writing POEMs for hospitalists. We look forward to your opinions about whether we should increase this content. Let me know.

I was a newly appointed head of a department of medicine. Supervising the care of 44 patients and instructing interns and residents was a new and thrilling experience. Some patients presented complex problems, which satisfied my detective instincts and provided a stimulating intellectual challenge. Many others were less intellectually demanding, but I loved the personal interaction, the ability to change things for the better, and the endless variability.

It amazes me to reflect on how uncritical I was at the time, adopting and following common clinical practices with little questioning. It never really crossed my mind that medicine could be practiced in a different and better way. When I managed after some months to set aside one day a week to continue basic research, I was overjoyed. On that day, I became a scientist, putting each assumption to rigorous testing. At the hospital however, I was much more self‐assured and complacent. It was during a break between experiments at the research institute that I slumped wearily into an armchair in the library and picked up a shabby copy of the Green Journal. Being too tired for anything serious, I started reading what looked like a fairy tale. It was titled In a stew, by Michael LaCombe, whom I knew to be a gifted medical writer.1 Soon I found myself immersed in the story. The princess is seriously sick, and all the court doctors are baffled. She already has had 4 CT scans, 3 MRIs, and dozens of other tests. All the tests were fine, but the princess remains very sick, and the king is terribly worried. Then, somebody remembers an old, forgotten clinician who has been relegated to a small dusty den somewhere in the basement. For his services to be rendered, all he demands is that someone find him his stethoscope and that he be allowed to have a pupil. Using observation, knowledge, and wisdom (but no further tests), he elegantly elicits the relevant history and makes the correct diagnosis, which has eluded all the sophisticated court doctors armed with their batteries of high‐tech tests but with little regard for old‐fashioned clinical methods.

This was good fun, but though I enjoyed it very much, I had no idea that it would remain in my mind and shape my thinking, my practice, and my teaching. Nevertheless, I gradually found myself during rounds reflecting on this story with the patient who had had 2 CT scans done before anyone bothered to listen to him or examine him and with the patient who had been studied for months before a simple fact that should have been noted at once was finally revealed, which led to a single test that was diagnostic and to the patient's recovery.2 Then there was the patient who underwent a procedure, which looked innocent enough, but resulted in an adverse event that cascaded into months of life‐threatening illness.3 Was the procedure really necessary?

One night, a couple of years later, I woke up and instead of going back to sleep, sat in the silent living room, suddenly thinking of our departmental routine and realizing somehow that many things we physicians do may be seriously flawed: taking a superficial history and performing a perfunctory exam; having a light finger on the trigger of test ordering even if imaging and tests may mean little out of the clinical context and often beget more unnecessary testing; skipping significant information only because it is not immediately available but has to be found at another hospital or clinic or by calling the primary physician; disregarding the ubiquitous and influential emotional aspect or the patient's perspective and health literacy, which are essential for shared decisions; and the repeated underuse4 of highly effective medications and especially of proven preventive measures that are not pharmacological and hence not vigorously promoted by the large pharmaceutical companies.

The seed for this heresy was sown by the fable, and it colored my clinical life with a vein of skepticism and self‐criticism. Slowly it also grew into a long‐term commitment to teaching about and research on avoidable pitfalls in patient care.5

Thus, Lacombe's little piece often comes back to me, teaching me that a fairy tale can sometimes be more powerful than a randomized controlled study of 10,000 patients.

I was a newly appointed head of a department of medicine. Supervising the care of 44 patients and instructing interns and residents was a new and thrilling experience. Some patients presented complex problems, which satisfied my detective instincts and provided a stimulating intellectual challenge. Many others were less intellectually demanding, but I loved the personal interaction, the ability to change things for the better, and the endless variability.

It amazes me to reflect on how uncritical I was at the time, adopting and following common clinical practices with little questioning. It never really crossed my mind that medicine could be practiced in a different and better way. When I managed after some months to set aside one day a week to continue basic research, I was overjoyed. On that day, I became a scientist, putting each assumption to rigorous testing. At the hospital however, I was much more self‐assured and complacent. It was during a break between experiments at the research institute that I slumped wearily into an armchair in the library and picked up a shabby copy of the Green Journal. Being too tired for anything serious, I started reading what looked like a fairy tale. It was titled In a stew, by Michael LaCombe, whom I knew to be a gifted medical writer.1 Soon I found myself immersed in the story. The princess is seriously sick, and all the court doctors are baffled. She already has had 4 CT scans, 3 MRIs, and dozens of other tests. All the tests were fine, but the princess remains very sick, and the king is terribly worried. Then, somebody remembers an old, forgotten clinician who has been relegated to a small dusty den somewhere in the basement. For his services to be rendered, all he demands is that someone find him his stethoscope and that he be allowed to have a pupil. Using observation, knowledge, and wisdom (but no further tests), he elegantly elicits the relevant history and makes the correct diagnosis, which has eluded all the sophisticated court doctors armed with their batteries of high‐tech tests but with little regard for old‐fashioned clinical methods.

This was good fun, but though I enjoyed it very much, I had no idea that it would remain in my mind and shape my thinking, my practice, and my teaching. Nevertheless, I gradually found myself during rounds reflecting on this story with the patient who had had 2 CT scans done before anyone bothered to listen to him or examine him and with the patient who had been studied for months before a simple fact that should have been noted at once was finally revealed, which led to a single test that was diagnostic and to the patient's recovery.2 Then there was the patient who underwent a procedure, which looked innocent enough, but resulted in an adverse event that cascaded into months of life‐threatening illness.3 Was the procedure really necessary?

One night, a couple of years later, I woke up and instead of going back to sleep, sat in the silent living room, suddenly thinking of our departmental routine and realizing somehow that many things we physicians do may be seriously flawed: taking a superficial history and performing a perfunctory exam; having a light finger on the trigger of test ordering even if imaging and tests may mean little out of the clinical context and often beget more unnecessary testing; skipping significant information only because it is not immediately available but has to be found at another hospital or clinic or by calling the primary physician; disregarding the ubiquitous and influential emotional aspect or the patient's perspective and health literacy, which are essential for shared decisions; and the repeated underuse4 of highly effective medications and especially of proven preventive measures that are not pharmacological and hence not vigorously promoted by the large pharmaceutical companies.

The seed for this heresy was sown by the fable, and it colored my clinical life with a vein of skepticism and self‐criticism. Slowly it also grew into a long‐term commitment to teaching about and research on avoidable pitfalls in patient care.5

Thus, Lacombe's little piece often comes back to me, teaching me that a fairy tale can sometimes be more powerful than a randomized controlled study of 10,000 patients.

I was a newly appointed head of a department of medicine. Supervising the care of 44 patients and instructing interns and residents was a new and thrilling experience. Some patients presented complex problems, which satisfied my detective instincts and provided a stimulating intellectual challenge. Many others were less intellectually demanding, but I loved the personal interaction, the ability to change things for the better, and the endless variability.

It amazes me to reflect on how uncritical I was at the time, adopting and following common clinical practices with little questioning. It never really crossed my mind that medicine could be practiced in a different and better way. When I managed after some months to set aside one day a week to continue basic research, I was overjoyed. On that day, I became a scientist, putting each assumption to rigorous testing. At the hospital however, I was much more self‐assured and complacent. It was during a break between experiments at the research institute that I slumped wearily into an armchair in the library and picked up a shabby copy of the Green Journal. Being too tired for anything serious, I started reading what looked like a fairy tale. It was titled In a stew, by Michael LaCombe, whom I knew to be a gifted medical writer.1 Soon I found myself immersed in the story. The princess is seriously sick, and all the court doctors are baffled. She already has had 4 CT scans, 3 MRIs, and dozens of other tests. All the tests were fine, but the princess remains very sick, and the king is terribly worried. Then, somebody remembers an old, forgotten clinician who has been relegated to a small dusty den somewhere in the basement. For his services to be rendered, all he demands is that someone find him his stethoscope and that he be allowed to have a pupil. Using observation, knowledge, and wisdom (but no further tests), he elegantly elicits the relevant history and makes the correct diagnosis, which has eluded all the sophisticated court doctors armed with their batteries of high‐tech tests but with little regard for old‐fashioned clinical methods.

This was good fun, but though I enjoyed it very much, I had no idea that it would remain in my mind and shape my thinking, my practice, and my teaching. Nevertheless, I gradually found myself during rounds reflecting on this story with the patient who had had 2 CT scans done before anyone bothered to listen to him or examine him and with the patient who had been studied for months before a simple fact that should have been noted at once was finally revealed, which led to a single test that was diagnostic and to the patient's recovery.2 Then there was the patient who underwent a procedure, which looked innocent enough, but resulted in an adverse event that cascaded into months of life‐threatening illness.3 Was the procedure really necessary?

One night, a couple of years later, I woke up and instead of going back to sleep, sat in the silent living room, suddenly thinking of our departmental routine and realizing somehow that many things we physicians do may be seriously flawed: taking a superficial history and performing a perfunctory exam; having a light finger on the trigger of test ordering even if imaging and tests may mean little out of the clinical context and often beget more unnecessary testing; skipping significant information only because it is not immediately available but has to be found at another hospital or clinic or by calling the primary physician; disregarding the ubiquitous and influential emotional aspect or the patient's perspective and health literacy, which are essential for shared decisions; and the repeated underuse4 of highly effective medications and especially of proven preventive measures that are not pharmacological and hence not vigorously promoted by the large pharmaceutical companies.

The seed for this heresy was sown by the fable, and it colored my clinical life with a vein of skepticism and self‐criticism. Slowly it also grew into a long‐term commitment to teaching about and research on avoidable pitfalls in patient care.5

Thus, Lacombe's little piece often comes back to me, teaching me that a fairy tale can sometimes be more powerful than a randomized controlled study of 10,000 patients.

Self‐check‐in kiosks started to appear in airports in the late 1990s, and within a few years, they seem to have become ubiquitous in the airline industry. Today, almost 70% of business travelers use them, and other sectors of the travel industry are beginning to experiment with the technology.1 Compared to this innovation in the airline industry, adoption of computerized physician order entry (CPOE) in U.S. hospitals, first pioneered in the early 1970s,2, 3 has taken a much more leisurely pace. Despite numerous studies documenting its benefits,47 promotion by prominent national patient safety advocacy groups such as LeapFrog,8 and numerous guides on best adoption practices.912 fewer than 10% of U.S. hospitals have fully adopted this technology.13 Moreover, as Lindenauer et al.14 pointed out, most hospitals that have successfully implemented CPOE are academic medical centers that rely on house staff to enter orders. With notable exceptions,3 adoption of CPOE in community hospitals where attending physicians write most orders remains anemic.

Although an increasing number of scholarly articles has documented the reasons for this slow rate of adoption even in hospitals that have the resources to invest in this technology, much of that research is based on expert opinion and case studies.11, 1519 In this context, Lindenauer et al.14 should be commended for using empirical evidence to delineate the predictors of adoption. Lindenauer et al. found that physicians who trained in hospitals with CPOE were more likely to be frequent users of CPOE in their new environment. Although the analysis did not account for possible confounding such as employment status of the physician, this result does confirm the conventional wisdom that physicians‐in‐training are more malleable and that residency is an important opportunity to expose physicians to safety technologies. If this finding is borne out by further research, it would bode well for the adoption of CPOE, as many physicians are trained in academic institutions, which are more likely to have CPOE,20 and almost all physicians spend part of their training in a VA hospital, which has uniformly adopted CPOE. Similarly, Lindenauer et al. found that physicians who use computers for personal purposes are more likely to be frequent users of CPOE. Given the increasingly ubiquitous use of computers in all spheres of life, time is on the side of increasing acceptance of CPOE.

However, a closer examination of the data presented by Lindenauer et al. raises several concerns. First, the substantial number of infrequent users across all demographic subgroups and clinical disciplines, even among users who were exposed to CPOE during training or those who used computers regularly for personal purposes, highlights the absence of shortcuts to the universal acceptance of CPOE. Second, whereas 63% of surveyed physicians believed that CPOE would reduce the incidence of medication errors and 71% believed that CPOE would prevent aspects of care from slipping through the cracks, only 42% of the surveyed physicians were frequent users of CPOE. This implies that even when physicians believe in the safety and quality benefits of CPOE, that belief alone may not be sufficient to convince all of them to adopt this technology wholeheartedly; other factors such as speed, ease of use, and training are likely important prerequisites. Third, although 66% of orders placed in person at the 2 study hospitals were entered through CPOE, acceptance of this technology, as measured by Lindenauer et al, was moderate at both institutions. This suggests that even when organizations have reached the 70% threshold set by Leapfrog as the proportion of orders placed in CPOE that qualifies as full implementation, they may continue to face resistance to full acceptance of the technology.

Compared to their academic counterparts, community hospitals face additional hurdles as they implement CPOE. Not only does their smaller size make it difficult to achieve economies of scale, they are also at a disadvantage because of the relationship the community hospital has with its physicians. Unlike physicians‐in‐training in academic medical centers, physicians in community hospitals function as largely autonomous agents over whom the hospital administration has little control. Although these physicians and their hospitals share the common goals of patient safety and quality, the financial incentives for the adoption of CPOE are often misaligned. For example, a recent cost benefit analysis21 showed the enormous potential for hospitals to cut costs if physicians fully adopt a CPOE system with rich decision support features. However, those savings typically accrue to the hospital, not to the physicians who use the system. Assuming the typical learning curve that accompanies the use of any new technology, physicians in community hospitals may have little incentive to invest the time to learn to use the system efficiently.

So what can be done to overcome these seemingly formidable barriers to full adoption of CPOE? Emerging research, which has so far largely focused on CPOE implementation at academic hospitals, suggests there is no silver bullet. Instead, it has taught us how the complex interplay among vendor capability, organizational behavior, clinician work flow, and implementation strategy determines the success or failure of adoption.11, 17, 18, 22 Although physician characteristics will play a role in determining whether an individual adopts this technology, local factors such as the presence of champions, governance model for the project, support for staff throughout the process, and relationship between administration and physicians are likely important determinants of success at both academic and community hospitals. In addition, organizations that embark on CPOE implementation need to understand the enormity of the task at hand and must devote not only sufficient financial but also human capital over time.11, 18 In the words of a chief medical information officer, Implementing CPOE should not be thought of as an event, but a long‐term commitment.

Beyond following proposed best practices for the implementation of CPOE, community hospitals may need to adopt additional strategies to address their unique challenges. Given the misalignment of incentives for physicians' use of CPOE, leadership in community hospitals must be particularly skilled at articulating the benefits of CPOE to physicians. These benefits include not only decreased professional liability from improved patient safety and better quality of care, but also fewer pharmacy callbacks, remote access, and rapid ordering through order sets. Hospitals may also want to elicit support from physicians early by empowering them to create order sets for their disciplines. Mechanisms for hospitals and physicians to engage in mutual cost‐sharing arrangements may provide addition opportunities for hospitals to entice physicians to adopt the technology. Finally, and of particular interest to the readership of this journal, as hospitalists become more prevalent and take care of an increasing proportion of hospitalized patients,23 they are often ideal candidates to lead the implementation of CPOE in community hospitals. Because hospitalists spend most of their time in the hospital, they are often in the best position to get fully trained on CPOE, to define their own order sets, and to redesign care processes in order to take full advantage of CPOE capabilities. In addition, as many hospitalists are directly employed or supported by the hospital, their goals for quality, safety, and efficiency are usually better aligned with those of the hospital.

The stakes involved in implementing CPOE are high. Hospitals invest enormous sums of money in these systems, and many will not have the financial or political capital to attempt a second implementation after an initial failure. In addition, as recent research has pointed out,24 inappropriate implementation strategies may lead to delays in essential care and direct patient harm. In many ways, the complex task of implementing CPOE is not unlike other endeavors in patient care, where optimal outcomes require sound knowledge and reliable processes and where disaster can strike for lack of attention to detail or common sense. If Hippocrates were alive today, he might have this to say about CPOE implementation: Life is short, the art long, opportunity fleeting, experience treacherous, judgment difficult.

Self‐check‐in kiosks started to appear in airports in the late 1990s, and within a few years, they seem to have become ubiquitous in the airline industry. Today, almost 70% of business travelers use them, and other sectors of the travel industry are beginning to experiment with the technology.1 Compared to this innovation in the airline industry, adoption of computerized physician order entry (CPOE) in U.S. hospitals, first pioneered in the early 1970s,2, 3 has taken a much more leisurely pace. Despite numerous studies documenting its benefits,47 promotion by prominent national patient safety advocacy groups such as LeapFrog,8 and numerous guides on best adoption practices.912 fewer than 10% of U.S. hospitals have fully adopted this technology.13 Moreover, as Lindenauer et al.14 pointed out, most hospitals that have successfully implemented CPOE are academic medical centers that rely on house staff to enter orders. With notable exceptions,3 adoption of CPOE in community hospitals where attending physicians write most orders remains anemic.

Although an increasing number of scholarly articles has documented the reasons for this slow rate of adoption even in hospitals that have the resources to invest in this technology, much of that research is based on expert opinion and case studies.11, 1519 In this context, Lindenauer et al.14 should be commended for using empirical evidence to delineate the predictors of adoption. Lindenauer et al. found that physicians who trained in hospitals with CPOE were more likely to be frequent users of CPOE in their new environment. Although the analysis did not account for possible confounding such as employment status of the physician, this result does confirm the conventional wisdom that physicians‐in‐training are more malleable and that residency is an important opportunity to expose physicians to safety technologies. If this finding is borne out by further research, it would bode well for the adoption of CPOE, as many physicians are trained in academic institutions, which are more likely to have CPOE,20 and almost all physicians spend part of their training in a VA hospital, which has uniformly adopted CPOE. Similarly, Lindenauer et al. found that physicians who use computers for personal purposes are more likely to be frequent users of CPOE. Given the increasingly ubiquitous use of computers in all spheres of life, time is on the side of increasing acceptance of CPOE.

However, a closer examination of the data presented by Lindenauer et al. raises several concerns. First, the substantial number of infrequent users across all demographic subgroups and clinical disciplines, even among users who were exposed to CPOE during training or those who used computers regularly for personal purposes, highlights the absence of shortcuts to the universal acceptance of CPOE. Second, whereas 63% of surveyed physicians believed that CPOE would reduce the incidence of medication errors and 71% believed that CPOE would prevent aspects of care from slipping through the cracks, only 42% of the surveyed physicians were frequent users of CPOE. This implies that even when physicians believe in the safety and quality benefits of CPOE, that belief alone may not be sufficient to convince all of them to adopt this technology wholeheartedly; other factors such as speed, ease of use, and training are likely important prerequisites. Third, although 66% of orders placed in person at the 2 study hospitals were entered through CPOE, acceptance of this technology, as measured by Lindenauer et al, was moderate at both institutions. This suggests that even when organizations have reached the 70% threshold set by Leapfrog as the proportion of orders placed in CPOE that qualifies as full implementation, they may continue to face resistance to full acceptance of the technology.

Compared to their academic counterparts, community hospitals face additional hurdles as they implement CPOE. Not only does their smaller size make it difficult to achieve economies of scale, they are also at a disadvantage because of the relationship the community hospital has with its physicians. Unlike physicians‐in‐training in academic medical centers, physicians in community hospitals function as largely autonomous agents over whom the hospital administration has little control. Although these physicians and their hospitals share the common goals of patient safety and quality, the financial incentives for the adoption of CPOE are often misaligned. For example, a recent cost benefit analysis21 showed the enormous potential for hospitals to cut costs if physicians fully adopt a CPOE system with rich decision support features. However, those savings typically accrue to the hospital, not to the physicians who use the system. Assuming the typical learning curve that accompanies the use of any new technology, physicians in community hospitals may have little incentive to invest the time to learn to use the system efficiently.

So what can be done to overcome these seemingly formidable barriers to full adoption of CPOE? Emerging research, which has so far largely focused on CPOE implementation at academic hospitals, suggests there is no silver bullet. Instead, it has taught us how the complex interplay among vendor capability, organizational behavior, clinician work flow, and implementation strategy determines the success or failure of adoption.11, 17, 18, 22 Although physician characteristics will play a role in determining whether an individual adopts this technology, local factors such as the presence of champions, governance model for the project, support for staff throughout the process, and relationship between administration and physicians are likely important determinants of success at both academic and community hospitals. In addition, organizations that embark on CPOE implementation need to understand the enormity of the task at hand and must devote not only sufficient financial but also human capital over time.11, 18 In the words of a chief medical information officer, Implementing CPOE should not be thought of as an event, but a long‐term commitment.

Beyond following proposed best practices for the implementation of CPOE, community hospitals may need to adopt additional strategies to address their unique challenges. Given the misalignment of incentives for physicians' use of CPOE, leadership in community hospitals must be particularly skilled at articulating the benefits of CPOE to physicians. These benefits include not only decreased professional liability from improved patient safety and better quality of care, but also fewer pharmacy callbacks, remote access, and rapid ordering through order sets. Hospitals may also want to elicit support from physicians early by empowering them to create order sets for their disciplines. Mechanisms for hospitals and physicians to engage in mutual cost‐sharing arrangements may provide addition opportunities for hospitals to entice physicians to adopt the technology. Finally, and of particular interest to the readership of this journal, as hospitalists become more prevalent and take care of an increasing proportion of hospitalized patients,23 they are often ideal candidates to lead the implementation of CPOE in community hospitals. Because hospitalists spend most of their time in the hospital, they are often in the best position to get fully trained on CPOE, to define their own order sets, and to redesign care processes in order to take full advantage of CPOE capabilities. In addition, as many hospitalists are directly employed or supported by the hospital, their goals for quality, safety, and efficiency are usually better aligned with those of the hospital.

The stakes involved in implementing CPOE are high. Hospitals invest enormous sums of money in these systems, and many will not have the financial or political capital to attempt a second implementation after an initial failure. In addition, as recent research has pointed out,24 inappropriate implementation strategies may lead to delays in essential care and direct patient harm. In many ways, the complex task of implementing CPOE is not unlike other endeavors in patient care, where optimal outcomes require sound knowledge and reliable processes and where disaster can strike for lack of attention to detail or common sense. If Hippocrates were alive today, he might have this to say about CPOE implementation: Life is short, the art long, opportunity fleeting, experience treacherous, judgment difficult.

Self‐check‐in kiosks started to appear in airports in the late 1990s, and within a few years, they seem to have become ubiquitous in the airline industry. Today, almost 70% of business travelers use them, and other sectors of the travel industry are beginning to experiment with the technology.1 Compared to this innovation in the airline industry, adoption of computerized physician order entry (CPOE) in U.S. hospitals, first pioneered in the early 1970s,2, 3 has taken a much more leisurely pace. Despite numerous studies documenting its benefits,47 promotion by prominent national patient safety advocacy groups such as LeapFrog,8 and numerous guides on best adoption practices.912 fewer than 10% of U.S. hospitals have fully adopted this technology.13 Moreover, as Lindenauer et al.14 pointed out, most hospitals that have successfully implemented CPOE are academic medical centers that rely on house staff to enter orders. With notable exceptions,3 adoption of CPOE in community hospitals where attending physicians write most orders remains anemic.

Although an increasing number of scholarly articles has documented the reasons for this slow rate of adoption even in hospitals that have the resources to invest in this technology, much of that research is based on expert opinion and case studies.11, 1519 In this context, Lindenauer et al.14 should be commended for using empirical evidence to delineate the predictors of adoption. Lindenauer et al. found that physicians who trained in hospitals with CPOE were more likely to be frequent users of CPOE in their new environment. Although the analysis did not account for possible confounding such as employment status of the physician, this result does confirm the conventional wisdom that physicians‐in‐training are more malleable and that residency is an important opportunity to expose physicians to safety technologies. If this finding is borne out by further research, it would bode well for the adoption of CPOE, as many physicians are trained in academic institutions, which are more likely to have CPOE,20 and almost all physicians spend part of their training in a VA hospital, which has uniformly adopted CPOE. Similarly, Lindenauer et al. found that physicians who use computers for personal purposes are more likely to be frequent users of CPOE. Given the increasingly ubiquitous use of computers in all spheres of life, time is on the side of increasing acceptance of CPOE.

However, a closer examination of the data presented by Lindenauer et al. raises several concerns. First, the substantial number of infrequent users across all demographic subgroups and clinical disciplines, even among users who were exposed to CPOE during training or those who used computers regularly for personal purposes, highlights the absence of shortcuts to the universal acceptance of CPOE. Second, whereas 63% of surveyed physicians believed that CPOE would reduce the incidence of medication errors and 71% believed that CPOE would prevent aspects of care from slipping through the cracks, only 42% of the surveyed physicians were frequent users of CPOE. This implies that even when physicians believe in the safety and quality benefits of CPOE, that belief alone may not be sufficient to convince all of them to adopt this technology wholeheartedly; other factors such as speed, ease of use, and training are likely important prerequisites. Third, although 66% of orders placed in person at the 2 study hospitals were entered through CPOE, acceptance of this technology, as measured by Lindenauer et al, was moderate at both institutions. This suggests that even when organizations have reached the 70% threshold set by Leapfrog as the proportion of orders placed in CPOE that qualifies as full implementation, they may continue to face resistance to full acceptance of the technology.

Compared to their academic counterparts, community hospitals face additional hurdles as they implement CPOE. Not only does their smaller size make it difficult to achieve economies of scale, they are also at a disadvantage because of the relationship the community hospital has with its physicians. Unlike physicians‐in‐training in academic medical centers, physicians in community hospitals function as largely autonomous agents over whom the hospital administration has little control. Although these physicians and their hospitals share the common goals of patient safety and quality, the financial incentives for the adoption of CPOE are often misaligned. For example, a recent cost benefit analysis21 showed the enormous potential for hospitals to cut costs if physicians fully adopt a CPOE system with rich decision support features. However, those savings typically accrue to the hospital, not to the physicians who use the system. Assuming the typical learning curve that accompanies the use of any new technology, physicians in community hospitals may have little incentive to invest the time to learn to use the system efficiently.

So what can be done to overcome these seemingly formidable barriers to full adoption of CPOE? Emerging research, which has so far largely focused on CPOE implementation at academic hospitals, suggests there is no silver bullet. Instead, it has taught us how the complex interplay among vendor capability, organizational behavior, clinician work flow, and implementation strategy determines the success or failure of adoption.11, 17, 18, 22 Although physician characteristics will play a role in determining whether an individual adopts this technology, local factors such as the presence of champions, governance model for the project, support for staff throughout the process, and relationship between administration and physicians are likely important determinants of success at both academic and community hospitals. In addition, organizations that embark on CPOE implementation need to understand the enormity of the task at hand and must devote not only sufficient financial but also human capital over time.11, 18 In the words of a chief medical information officer, Implementing CPOE should not be thought of as an event, but a long‐term commitment.

Beyond following proposed best practices for the implementation of CPOE, community hospitals may need to adopt additional strategies to address their unique challenges. Given the misalignment of incentives for physicians' use of CPOE, leadership in community hospitals must be particularly skilled at articulating the benefits of CPOE to physicians. These benefits include not only decreased professional liability from improved patient safety and better quality of care, but also fewer pharmacy callbacks, remote access, and rapid ordering through order sets. Hospitals may also want to elicit support from physicians early by empowering them to create order sets for their disciplines. Mechanisms for hospitals and physicians to engage in mutual cost‐sharing arrangements may provide addition opportunities for hospitals to entice physicians to adopt the technology. Finally, and of particular interest to the readership of this journal, as hospitalists become more prevalent and take care of an increasing proportion of hospitalized patients,23 they are often ideal candidates to lead the implementation of CPOE in community hospitals. Because hospitalists spend most of their time in the hospital, they are often in the best position to get fully trained on CPOE, to define their own order sets, and to redesign care processes in order to take full advantage of CPOE capabilities. In addition, as many hospitalists are directly employed or supported by the hospital, their goals for quality, safety, and efficiency are usually better aligned with those of the hospital.

The stakes involved in implementing CPOE are high. Hospitals invest enormous sums of money in these systems, and many will not have the financial or political capital to attempt a second implementation after an initial failure. In addition, as recent research has pointed out,24 inappropriate implementation strategies may lead to delays in essential care and direct patient harm. In many ways, the complex task of implementing CPOE is not unlike other endeavors in patient care, where optimal outcomes require sound knowledge and reliable processes and where disaster can strike for lack of attention to detail or common sense. If Hippocrates were alive today, he might have this to say about CPOE implementation: Life is short, the art long, opportunity fleeting, experience treacherous, judgment difficult.

This issue of the Journal of Hospital Medicine contains the inaugural article in a planned series addressing key palliative care topics relevant for the practice, teaching, and study of hospital medicine. As was noted by Diane Meier in her article Palliative Care in Hospitals1 and in Steve Pantilat's accompanying editorial, Palliative Care and Hospitalists: A Partnership for Hope,2 hospitalists are well positioned to increase access to palliative care for all hospitalized patients. Achieving this goal will require that hospitalists attain at least basic competence in the components of high‐quality, comprehensive palliative care (assessment and treatment of pain and other symptom distress, communication about goals of care, and provision of practical and psychosocial support, care coordination, continuity, and bereavement services). Palliative care is becoming more prominent in medical school and residency curricula, palliative care fellowship opportunities are proliferating, a number of palliative care resources are available on the Internet, and motivated hospital‐based providers may attain palliative care education via a variety of educational programs and faculty development courses (see Table 1 in the Meier article).1 Some hospital medicine programs have specifically targeted faculty development in palliative care competencies.4

Recognizing the salience of palliative care for the practice of hospital medicine, the Society of Hospital Medicine (SHM) created the Palliative Care Task Force specifically to raise awareness of the importance of palliative care to hospital medicine and charged it with developing relevant palliative care educational materials. The Palliative Care Task Force has selected the Journal of Hospital Medicine as a means of disseminating palliative care content through a series of peer‐reviewed articles on palliative care topics relevant to hospital medicine. The articles will address practical matters relevant to care at the bedside in addition to policy issues. The article in this issue, Discussing Resuscitation Preferences: Challenges and Rewards,3 addresses the common barriers to and provides practical advice for conducting these frequent, but often difficult, conversations. Planned topics, addressing some of the key domains of palliative care clinical practice, include: pain management, symptom control, communicating bad news, caring for the clinical care provider, and importance of a multidisciplinary team approach to end‐of‐life care. Each of these articles will specifically address the relevance and implications of these topics for the practice of hospital medicine.

The Journal of Hospital Medicine looks forward to reviewing these articles from the Palliative Care Task Force and invites additional submissions relevant to the practice, teaching, or study of palliative care in the hospital setting.

This issue of the Journal of Hospital Medicine contains the inaugural article in a planned series addressing key palliative care topics relevant for the practice, teaching, and study of hospital medicine. As was noted by Diane Meier in her article Palliative Care in Hospitals1 and in Steve Pantilat's accompanying editorial, Palliative Care and Hospitalists: A Partnership for Hope,2 hospitalists are well positioned to increase access to palliative care for all hospitalized patients. Achieving this goal will require that hospitalists attain at least basic competence in the components of high‐quality, comprehensive palliative care (assessment and treatment of pain and other symptom distress, communication about goals of care, and provision of practical and psychosocial support, care coordination, continuity, and bereavement services). Palliative care is becoming more prominent in medical school and residency curricula, palliative care fellowship opportunities are proliferating, a number of palliative care resources are available on the Internet, and motivated hospital‐based providers may attain palliative care education via a variety of educational programs and faculty development courses (see Table 1 in the Meier article).1 Some hospital medicine programs have specifically targeted faculty development in palliative care competencies.4

Recognizing the salience of palliative care for the practice of hospital medicine, the Society of Hospital Medicine (SHM) created the Palliative Care Task Force specifically to raise awareness of the importance of palliative care to hospital medicine and charged it with developing relevant palliative care educational materials. The Palliative Care Task Force has selected the Journal of Hospital Medicine as a means of disseminating palliative care content through a series of peer‐reviewed articles on palliative care topics relevant to hospital medicine. The articles will address practical matters relevant to care at the bedside in addition to policy issues. The article in this issue, Discussing Resuscitation Preferences: Challenges and Rewards,3 addresses the common barriers to and provides practical advice for conducting these frequent, but often difficult, conversations. Planned topics, addressing some of the key domains of palliative care clinical practice, include: pain management, symptom control, communicating bad news, caring for the clinical care provider, and importance of a multidisciplinary team approach to end‐of‐life care. Each of these articles will specifically address the relevance and implications of these topics for the practice of hospital medicine.

The Journal of Hospital Medicine looks forward to reviewing these articles from the Palliative Care Task Force and invites additional submissions relevant to the practice, teaching, or study of palliative care in the hospital setting.

This issue of the Journal of Hospital Medicine contains the inaugural article in a planned series addressing key palliative care topics relevant for the practice, teaching, and study of hospital medicine. As was noted by Diane Meier in her article Palliative Care in Hospitals1 and in Steve Pantilat's accompanying editorial, Palliative Care and Hospitalists: A Partnership for Hope,2 hospitalists are well positioned to increase access to palliative care for all hospitalized patients. Achieving this goal will require that hospitalists attain at least basic competence in the components of high‐quality, comprehensive palliative care (assessment and treatment of pain and other symptom distress, communication about goals of care, and provision of practical and psychosocial support, care coordination, continuity, and bereavement services). Palliative care is becoming more prominent in medical school and residency curricula, palliative care fellowship opportunities are proliferating, a number of palliative care resources are available on the Internet, and motivated hospital‐based providers may attain palliative care education via a variety of educational programs and faculty development courses (see Table 1 in the Meier article).1 Some hospital medicine programs have specifically targeted faculty development in palliative care competencies.4

Recognizing the salience of palliative care for the practice of hospital medicine, the Society of Hospital Medicine (SHM) created the Palliative Care Task Force specifically to raise awareness of the importance of palliative care to hospital medicine and charged it with developing relevant palliative care educational materials. The Palliative Care Task Force has selected the Journal of Hospital Medicine as a means of disseminating palliative care content through a series of peer‐reviewed articles on palliative care topics relevant to hospital medicine. The articles will address practical matters relevant to care at the bedside in addition to policy issues. The article in this issue, Discussing Resuscitation Preferences: Challenges and Rewards,3 addresses the common barriers to and provides practical advice for conducting these frequent, but often difficult, conversations. Planned topics, addressing some of the key domains of palliative care clinical practice, include: pain management, symptom control, communicating bad news, caring for the clinical care provider, and importance of a multidisciplinary team approach to end‐of‐life care. Each of these articles will specifically address the relevance and implications of these topics for the practice of hospital medicine.

The Journal of Hospital Medicine looks forward to reviewing these articles from the Palliative Care Task Force and invites additional submissions relevant to the practice, teaching, or study of palliative care in the hospital setting.

It was dusk, and I stared glumly at cold rain falling onto steaming rooftop vents outside the clouded window of my husband's hospital room. I was feeling more than a little sorry for myself. Out there, it was a Friday night full of the promise of weekend diversions. In here, it was much like the night before, and the night before thata waiting game.

Waiting to see if Doug would live or die. Waiting to see if he could overcome the terrible malaise that gripped his body and come home. Waiting to see if he would ever be able to move his arms and legs again.

Turning from the window, I found Doug awake. He had only been off the ventilator for a short time and wasn't able to talk. I had just come from work, having been away from him since late morning. It seemed as though there should be plenty of things to tell him, but patter about the office and traffic did not belong in this room, and he'd already heard endlessly that his family and friends were pulling hard for him.

So I held his hand and leaned on the side rail of his bed, getting my face as close to his as I could. We locked eyes and smiled, and words flowed silently between us, just as they had so many times over our 25 years of marriage. God, how I'd missed that!

The nurses had dimmed the lights in the ICU for the night, and though it was far from dark, the room had a nicer ambience than usual. Straightening up, I searched the channels on Doug's TV for something more suitable than CNN. Suddenly, there were Jake and Elwood sauntering into Aretha Franklin's eatery on their mission from God. Hey, Doug. I said, It's The Blues Brothers. Moments later, Aretha was belting out R‐E‐S‐P‐E‐C‐T, and I was gyrating. Doug was doing the only thing he could, swinging his head from side to side in time to the music.

It was just a tiny moment, a vignette unnoticed by anyone but us two in the life of that ICU. But it is the sweetest memory I have of that time. Just days before his death at age 55, the spark that was us had flamed briefly to life.

It was dusk, and I stared glumly at cold rain falling onto steaming rooftop vents outside the clouded window of my husband's hospital room. I was feeling more than a little sorry for myself. Out there, it was a Friday night full of the promise of weekend diversions. In here, it was much like the night before, and the night before thata waiting game.

Waiting to see if Doug would live or die. Waiting to see if he could overcome the terrible malaise that gripped his body and come home. Waiting to see if he would ever be able to move his arms and legs again.

Turning from the window, I found Doug awake. He had only been off the ventilator for a short time and wasn't able to talk. I had just come from work, having been away from him since late morning. It seemed as though there should be plenty of things to tell him, but patter about the office and traffic did not belong in this room, and he'd already heard endlessly that his family and friends were pulling hard for him.

So I held his hand and leaned on the side rail of his bed, getting my face as close to his as I could. We locked eyes and smiled, and words flowed silently between us, just as they had so many times over our 25 years of marriage. God, how I'd missed that!

The nurses had dimmed the lights in the ICU for the night, and though it was far from dark, the room had a nicer ambience than usual. Straightening up, I searched the channels on Doug's TV for something more suitable than CNN. Suddenly, there were Jake and Elwood sauntering into Aretha Franklin's eatery on their mission from God. Hey, Doug. I said, It's The Blues Brothers. Moments later, Aretha was belting out R‐E‐S‐P‐E‐C‐T, and I was gyrating. Doug was doing the only thing he could, swinging his head from side to side in time to the music.

It was just a tiny moment, a vignette unnoticed by anyone but us two in the life of that ICU. But it is the sweetest memory I have of that time. Just days before his death at age 55, the spark that was us had flamed briefly to life.

It was dusk, and I stared glumly at cold rain falling onto steaming rooftop vents outside the clouded window of my husband's hospital room. I was feeling more than a little sorry for myself. Out there, it was a Friday night full of the promise of weekend diversions. In here, it was much like the night before, and the night before thata waiting game.

Waiting to see if Doug would live or die. Waiting to see if he could overcome the terrible malaise that gripped his body and come home. Waiting to see if he would ever be able to move his arms and legs again.

Turning from the window, I found Doug awake. He had only been off the ventilator for a short time and wasn't able to talk. I had just come from work, having been away from him since late morning. It seemed as though there should be plenty of things to tell him, but patter about the office and traffic did not belong in this room, and he'd already heard endlessly that his family and friends were pulling hard for him.

So I held his hand and leaned on the side rail of his bed, getting my face as close to his as I could. We locked eyes and smiled, and words flowed silently between us, just as they had so many times over our 25 years of marriage. God, how I'd missed that!

The nurses had dimmed the lights in the ICU for the night, and though it was far from dark, the room had a nicer ambience than usual. Straightening up, I searched the channels on Doug's TV for something more suitable than CNN. Suddenly, there were Jake and Elwood sauntering into Aretha Franklin's eatery on their mission from God. Hey, Doug. I said, It's The Blues Brothers. Moments later, Aretha was belting out R‐E‐S‐P‐E‐C‐T, and I was gyrating. Doug was doing the only thing he could, swinging his head from side to side in time to the music.

It was just a tiny moment, a vignette unnoticed by anyone but us two in the life of that ICU. But it is the sweetest memory I have of that time. Just days before his death at age 55, the spark that was us had flamed briefly to life.

My dad was a hero. I suppose it's natural that I feel that way, growing up as I did in a small rural town where my father was the only doctor. Once, he was called to attend to a farmer who had climbed down from his combine, stating flatly that he was going to die. After this pronouncement, the farmer sat on the ground, where over the next hour he proceeded to do just that.

With the benefit of my own 30‐year career in medicine, it's easy to opine that this farmer probably had a pulmonary embolism from a lower extremity deep vein thrombosis (hours spent on the seat of a tractor are the rural equivalent of a long plane ride). I'm sure he was experiencing the feeling of impending doom that can signal such an event. What's harder to conjecture is how my father was able to quickly assess the situation, know his limitations, and still have the guts to carry on. There was no dialing 911, no starting of IVs, and no CPR once the chain of events started. Even if the doomed patient had been taken to the hospital, he would likely have died en route. If not, the personnel, equipment, and therapeutics there would not have been much more than those available in the wheat field. My father had all the tools he needed right there at the scene to bring comfort to that poor individual in the final moments of his life. He also had the courage to use them. What a hero!

Other events and memories of my father flash through my mind as I remember those times. Dozens of antibiotics rendered for cold virusesbut what a placebo effect from that big shot in the butt! Tonsillectomies performed right in the office, with a nurse‐anesthetist coming in once a week to render sedation. (That is until one of a set of twins transiently quit breathing, after which all surgeries were moved to the hospital!) A shot of adrenaline, given unsuccessfully, via the intracardiac route to a high school football player who suddenly collapsed on the 30‐yard line while the usually boisterous Friday‐night crowd watched in stunned horror. Countless hours waiting in the car for my dad to make house calls or finish rounds at the local hospital.

There, in that place and at that time, my dad was it. He embodied medical science, such as it was, in our little community. His black bag and bow tie helped complete the image. He did what he could, limited as it may have been, and he loved every minute of it. Sure, he sometimes complained. It was tough when a patient showed up at the back door and interrupted dinner. He didn't much like it when then‐president LBJ tried to socialize medicine with the Medicare Act. Most of all, he hated it when my mother insisted he take a job with regular hours at a VA hospital after he had two heart attacks and a bout with colon cancer. Mostly though, I remember a happy, self‐actualized guy, especially when he was at work.

My dad died when I was a freshman in medical school, so exactly what he thought about those times I really don't know. I do know, however, how much I loved him and how much I wanted to be just like him.

In medical school and later during my residency, I had other heroes. Appropriately, for someone who ended up an internist and hospitalist, most were master diagnosticians. There was J. Willis Hurst, the renowned cardiologist, who I once saw diagnose cardiac sarcoid solely on the basis of a 12‐lead electrocardiogram. And there was Jay Sanford, author of that little book on antibiotics known as the bugs and drugs book, tucked to this day into my lab coat pocket, who I once heard tell of going to war‐torn Vietnam to collect water samples in order to make the diagnosis of babesiosis. Finally, there was Walter McDonald, then chief of medicine at the Portland VA hospital, later executive vice‐president of the American College of Physicians, who, to a third‐year medical student like I was then, seemed omniscient about each case relayed to him at morning report. They all seemed so confident and clever; so dedicated, diligent, and proud. I wanted to be just like them.

Now, as a vice‐president for medical affairs, given the task of improving quality at a large teaching hospital, I herd cats. I recite from memory the embarrassing statistics on medical errors revealed by the Institute of Medicine in 1999. I plead for standardization and strive to eliminate variability in hospital practice. From the evidence, I extract guidelines and implement them via standard order sets. But frequently I look back and wonder.

Would the practice of medicine, where the goal is standardization and lack of variability, appeal to my older heroes? How would the practices of exceeding benchmarks, following pathways, and complying with indicators play to the icons of my past? Would they be satisfied to practice in today's health care environment? Or would they perish the thought if asked to standardize their orders and comply with best‐practice norms? After all, there was nothing normal about these guys! Sure they knew the literature and would be the first to insist that practice be evidenced based, but for them, that was never enough. What made them so attractive was their ability to go beyond what any of us able to read the journals could achieve. These men (and, sadly, most, but not all, were men) treasured autonomy, yearned for diagnostic brilliance, and doggedly pursued therapeutic breakthroughs. They set the standards that mere mortals like me aspired to achieve. They were heroes.

So we must be careful not to stifle genius while promoting compliance. We must not push the standardization of health care to a point where an individual's ability to rise above the pack is limited. We should remember that with decreased variability comes the risk of denying innovation. For keep in mind that improved methods like those of hospital medicine exist because those before us sought a better way. They were able to try, and sometimes fail, to use their intuition and individual street smarts and to take risks for the greater good. To use a tired phrase, they were able to think outside the box. In the name of quality, we must not further limit the confines of that box. We must assure that however much we strive to elevate the norm, we do not restrict those few who set the curve. We must allow for heroes.

I believe our profession can produce those who will carry the banner forward. I already have some new heroesDon Berwick, Peter Pronovost, and Bob Wachter. These individuals have demonstrated the ability to combine the patient‐centered care practiced by my father with the evidenced‐based knowledge and intuitive genius of my academic mentors. They are then able to apply this admixture of competencies to the problems facing health care today such as the deficiencies in patient safety and the inefficiencies of delivery.

New heroes will attract another generation of the best and the brightest, and the cycle will repeat. With careful foresight we can assure that this will happen. To do otherwise is unthinkable. We must have heroes.

My dad was a hero. I suppose it's natural that I feel that way, growing up as I did in a small rural town where my father was the only doctor. Once, he was called to attend to a farmer who had climbed down from his combine, stating flatly that he was going to die. After this pronouncement, the farmer sat on the ground, where over the next hour he proceeded to do just that.

With the benefit of my own 30‐year career in medicine, it's easy to opine that this farmer probably had a pulmonary embolism from a lower extremity deep vein thrombosis (hours spent on the seat of a tractor are the rural equivalent of a long plane ride). I'm sure he was experiencing the feeling of impending doom that can signal such an event. What's harder to conjecture is how my father was able to quickly assess the situation, know his limitations, and still have the guts to carry on. There was no dialing 911, no starting of IVs, and no CPR once the chain of events started. Even if the doomed patient had been taken to the hospital, he would likely have died en route. If not, the personnel, equipment, and therapeutics there would not have been much more than those available in the wheat field. My father had all the tools he needed right there at the scene to bring comfort to that poor individual in the final moments of his life. He also had the courage to use them. What a hero!

Other events and memories of my father flash through my mind as I remember those times. Dozens of antibiotics rendered for cold virusesbut what a placebo effect from that big shot in the butt! Tonsillectomies performed right in the office, with a nurse‐anesthetist coming in once a week to render sedation. (That is until one of a set of twins transiently quit breathing, after which all surgeries were moved to the hospital!) A shot of adrenaline, given unsuccessfully, via the intracardiac route to a high school football player who suddenly collapsed on the 30‐yard line while the usually boisterous Friday‐night crowd watched in stunned horror. Countless hours waiting in the car for my dad to make house calls or finish rounds at the local hospital.

There, in that place and at that time, my dad was it. He embodied medical science, such as it was, in our little community. His black bag and bow tie helped complete the image. He did what he could, limited as it may have been, and he loved every minute of it. Sure, he sometimes complained. It was tough when a patient showed up at the back door and interrupted dinner. He didn't much like it when then‐president LBJ tried to socialize medicine with the Medicare Act. Most of all, he hated it when my mother insisted he take a job with regular hours at a VA hospital after he had two heart attacks and a bout with colon cancer. Mostly though, I remember a happy, self‐actualized guy, especially when he was at work.

My dad died when I was a freshman in medical school, so exactly what he thought about those times I really don't know. I do know, however, how much I loved him and how much I wanted to be just like him.

In medical school and later during my residency, I had other heroes. Appropriately, for someone who ended up an internist and hospitalist, most were master diagnosticians. There was J. Willis Hurst, the renowned cardiologist, who I once saw diagnose cardiac sarcoid solely on the basis of a 12‐lead electrocardiogram. And there was Jay Sanford, author of that little book on antibiotics known as the bugs and drugs book, tucked to this day into my lab coat pocket, who I once heard tell of going to war‐torn Vietnam to collect water samples in order to make the diagnosis of babesiosis. Finally, there was Walter McDonald, then chief of medicine at the Portland VA hospital, later executive vice‐president of the American College of Physicians, who, to a third‐year medical student like I was then, seemed omniscient about each case relayed to him at morning report. They all seemed so confident and clever; so dedicated, diligent, and proud. I wanted to be just like them.

Now, as a vice‐president for medical affairs, given the task of improving quality at a large teaching hospital, I herd cats. I recite from memory the embarrassing statistics on medical errors revealed by the Institute of Medicine in 1999. I plead for standardization and strive to eliminate variability in hospital practice. From the evidence, I extract guidelines and implement them via standard order sets. But frequently I look back and wonder.

Would the practice of medicine, where the goal is standardization and lack of variability, appeal to my older heroes? How would the practices of exceeding benchmarks, following pathways, and complying with indicators play to the icons of my past? Would they be satisfied to practice in today's health care environment? Or would they perish the thought if asked to standardize their orders and comply with best‐practice norms? After all, there was nothing normal about these guys! Sure they knew the literature and would be the first to insist that practice be evidenced based, but for them, that was never enough. What made them so attractive was their ability to go beyond what any of us able to read the journals could achieve. These men (and, sadly, most, but not all, were men) treasured autonomy, yearned for diagnostic brilliance, and doggedly pursued therapeutic breakthroughs. They set the standards that mere mortals like me aspired to achieve. They were heroes.

So we must be careful not to stifle genius while promoting compliance. We must not push the standardization of health care to a point where an individual's ability to rise above the pack is limited. We should remember that with decreased variability comes the risk of denying innovation. For keep in mind that improved methods like those of hospital medicine exist because those before us sought a better way. They were able to try, and sometimes fail, to use their intuition and individual street smarts and to take risks for the greater good. To use a tired phrase, they were able to think outside the box. In the name of quality, we must not further limit the confines of that box. We must assure that however much we strive to elevate the norm, we do not restrict those few who set the curve. We must allow for heroes.

I believe our profession can produce those who will carry the banner forward. I already have some new heroesDon Berwick, Peter Pronovost, and Bob Wachter. These individuals have demonstrated the ability to combine the patient‐centered care practiced by my father with the evidenced‐based knowledge and intuitive genius of my academic mentors. They are then able to apply this admixture of competencies to the problems facing health care today such as the deficiencies in patient safety and the inefficiencies of delivery.

New heroes will attract another generation of the best and the brightest, and the cycle will repeat. With careful foresight we can assure that this will happen. To do otherwise is unthinkable. We must have heroes.

My dad was a hero. I suppose it's natural that I feel that way, growing up as I did in a small rural town where my father was the only doctor. Once, he was called to attend to a farmer who had climbed down from his combine, stating flatly that he was going to die. After this pronouncement, the farmer sat on the ground, where over the next hour he proceeded to do just that.

With the benefit of my own 30‐year career in medicine, it's easy to opine that this farmer probably had a pulmonary embolism from a lower extremity deep vein thrombosis (hours spent on the seat of a tractor are the rural equivalent of a long plane ride). I'm sure he was experiencing the feeling of impending doom that can signal such an event. What's harder to conjecture is how my father was able to quickly assess the situation, know his limitations, and still have the guts to carry on. There was no dialing 911, no starting of IVs, and no CPR once the chain of events started. Even if the doomed patient had been taken to the hospital, he would likely have died en route. If not, the personnel, equipment, and therapeutics there would not have been much more than those available in the wheat field. My father had all the tools he needed right there at the scene to bring comfort to that poor individual in the final moments of his life. He also had the courage to use them. What a hero!

Other events and memories of my father flash through my mind as I remember those times. Dozens of antibiotics rendered for cold virusesbut what a placebo effect from that big shot in the butt! Tonsillectomies performed right in the office, with a nurse‐anesthetist coming in once a week to render sedation. (That is until one of a set of twins transiently quit breathing, after which all surgeries were moved to the hospital!) A shot of adrenaline, given unsuccessfully, via the intracardiac route to a high school football player who suddenly collapsed on the 30‐yard line while the usually boisterous Friday‐night crowd watched in stunned horror. Countless hours waiting in the car for my dad to make house calls or finish rounds at the local hospital.

There, in that place and at that time, my dad was it. He embodied medical science, such as it was, in our little community. His black bag and bow tie helped complete the image. He did what he could, limited as it may have been, and he loved every minute of it. Sure, he sometimes complained. It was tough when a patient showed up at the back door and interrupted dinner. He didn't much like it when then‐president LBJ tried to socialize medicine with the Medicare Act. Most of all, he hated it when my mother insisted he take a job with regular hours at a VA hospital after he had two heart attacks and a bout with colon cancer. Mostly though, I remember a happy, self‐actualized guy, especially when he was at work.

My dad died when I was a freshman in medical school, so exactly what he thought about those times I really don't know. I do know, however, how much I loved him and how much I wanted to be just like him.

In medical school and later during my residency, I had other heroes. Appropriately, for someone who ended up an internist and hospitalist, most were master diagnosticians. There was J. Willis Hurst, the renowned cardiologist, who I once saw diagnose cardiac sarcoid solely on the basis of a 12‐lead electrocardiogram. And there was Jay Sanford, author of that little book on antibiotics known as the bugs and drugs book, tucked to this day into my lab coat pocket, who I once heard tell of going to war‐torn Vietnam to collect water samples in order to make the diagnosis of babesiosis. Finally, there was Walter McDonald, then chief of medicine at the Portland VA hospital, later executive vice‐president of the American College of Physicians, who, to a third‐year medical student like I was then, seemed omniscient about each case relayed to him at morning report. They all seemed so confident and clever; so dedicated, diligent, and proud. I wanted to be just like them.

Now, as a vice‐president for medical affairs, given the task of improving quality at a large teaching hospital, I herd cats. I recite from memory the embarrassing statistics on medical errors revealed by the Institute of Medicine in 1999. I plead for standardization and strive to eliminate variability in hospital practice. From the evidence, I extract guidelines and implement them via standard order sets. But frequently I look back and wonder.

Would the practice of medicine, where the goal is standardization and lack of variability, appeal to my older heroes? How would the practices of exceeding benchmarks, following pathways, and complying with indicators play to the icons of my past? Would they be satisfied to practice in today's health care environment? Or would they perish the thought if asked to standardize their orders and comply with best‐practice norms? After all, there was nothing normal about these guys! Sure they knew the literature and would be the first to insist that practice be evidenced based, but for them, that was never enough. What made them so attractive was their ability to go beyond what any of us able to read the journals could achieve. These men (and, sadly, most, but not all, were men) treasured autonomy, yearned for diagnostic brilliance, and doggedly pursued therapeutic breakthroughs. They set the standards that mere mortals like me aspired to achieve. They were heroes.

So we must be careful not to stifle genius while promoting compliance. We must not push the standardization of health care to a point where an individual's ability to rise above the pack is limited. We should remember that with decreased variability comes the risk of denying innovation. For keep in mind that improved methods like those of hospital medicine exist because those before us sought a better way. They were able to try, and sometimes fail, to use their intuition and individual street smarts and to take risks for the greater good. To use a tired phrase, they were able to think outside the box. In the name of quality, we must not further limit the confines of that box. We must assure that however much we strive to elevate the norm, we do not restrict those few who set the curve. We must allow for heroes.

I believe our profession can produce those who will carry the banner forward. I already have some new heroesDon Berwick, Peter Pronovost, and Bob Wachter. These individuals have demonstrated the ability to combine the patient‐centered care practiced by my father with the evidenced‐based knowledge and intuitive genius of my academic mentors. They are then able to apply this admixture of competencies to the problems facing health care today such as the deficiencies in patient safety and the inefficiencies of delivery.

New heroes will attract another generation of the best and the brightest, and the cycle will repeat. With careful foresight we can assure that this will happen. To do otherwise is unthinkable. We must have heroes.