Editorial

You hold in your hands the inaugural issue of the Journal of Hospital Medicine (JHM). Our goal is for JHM to become the premier forum for peer‐reviewed research articles and evidence‐based reviews in the specialty of hospital medicine.

Yes, the specialty of hospital medicine. This official publication of the Society of Hospital Medicine signifies another step forward in the evolution of this specialty. With the publication of JHM the Society of Hospital Medicine continues its pivotal educational and leadership role in shaping the practice of hospital medicine. The Society is dedicated to promoting the highest‐quality care for all hospitalized patients and excellence in hospital medicine through education, advocacy, and research. As part of the Society's effort to improve care and standards, it is providing JHM to all members as part of their membership. We hope that our readership will grow to include individuals involved in all aspects of hospital care.

Packed with the results of new studies and state‐of‐the‐art reviews, JHM is not aimed solely at academicians and voracious readers of the medical literature. Rather, we hope that it fills a practical need to promote lifelong learning in both hospitalists and their hospital colleagues. For example, in this issue, national experts in palliative care and geriatrics summarize the pertinent literature and the important role of such care for hospitalized patients. JHM will also serve as a key venue for hospital medicine researchers to disseminate their findings and for educators to share their knowledge and techniques.

Why bother to create yet another journal? Given the stacks of journals that adorn many of our desks (and some of our chairs and windowsills), do we really need another to get lost among the mail that inundates us? We believe the field of hospital medicine involves a growing body of knowledge deserving of a journal focused solely on it. Hospital medicine evolved from efforts to fill a need identified by overstretched primary care physicians in the late 1980s. Physicians like the cofounders of SHM, John Nelson in Florida and Win Whitcomb in Massachusetts, began careers in a field that today numbers more than 12,000 physicians. Labeled with the moniker hospitalist given us by Bob Wachter and Lee Goldman,1 we now make up the fastest‐growing medical specialty in the United States.2 Yet, until now, no journal was devoted solely to this specialty.

The Journal of Hospital Medicine aims to provide physicians and other health care professionals with continuing insight into the basic and clinical sciences to support informed clinical decision making in the hospital. As hospitalists increasingly take an active role in the successful delivery of bench research discoveries to the bedside and become vigorous participants in the translational and clinical research sought by the National Institutes of Health,3 JHM will disseminate their findings. In addition, we hope to foster balanced debates on medical issues and health care trends that affect hospital medicine and patient care. Nonclinical aspects of hospital medicine also will be featured, including public health and the political, philosophic, ethical, legal, environmental, economic, historical, and cultural issues surrounding hospital care. We especially want to encourage submissions that evaluate projects involving the entire hospital care team: physicians and our colleagues in the hospitalnurses, pharmacists, administrators, physical and occupational therapists, social workers, and case managers.

Two articles (see pages 48 and 57) highlight this inaugural issue. One describes the development of The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (a supplement to this issue), and the other demonstrates how this document can be applied to curriculum development.4, 5 This milestone in the evolution of hospital medicine provides an initial structural framework to guide medical educators in developing curricula that incorporate these competencies into the training and evaluation of students, clinicians‐in‐training, and practicing hospitalists.4 The president and CEO of the American Board of Internal Medicine (ABIM), Christine Cassel, offers her perspective on this landmark document.6 Its timeliness is reflected by the current efforts of the American College of Physicians, the ABIM, and others to redesign the training and the certification requirements of internists. As this supplement demonstrates, the Society of Hospital Medicine will be intimately involved in this process.

After this auspicious start, subsequent issues will include articles in the following categories. Original research articles will report results of randomized controlled trials, evaluations of diagnostic tests, prospective cohort studies, casecontrol studies, and high‐quality observational studies. We are interested in publishing both quantitative and qualitative research. Review articles, especially those targeting the hospital medicine core competencies, are eagerly sought. We also seek descriptions of interventions that transform hospital care delivery in the hospital. For example, accounts of the implementation of quality‐improvement projects and outcomes, including barriers that were overcome or that blocked implementation, would be invaluable to hospitalists throughout the country. Clinical conundrums should describe clinical cases that present diagnostic dilemmas or involve issues of medical errors. To facilitate the professional development of hospitalists, we seek articles focused on their professional development in community, academic, and administrative settings. Examples of leadership topics are managing physician performance, leading and managing change, and self‐evaluation. Teaching tips or descriptions of educational programs or curricula also are desired. For researchers, potential topics include descriptions of specific techniques used for surveys, meta‐analyses, economic evaluations, and statistical analyses.Penetrating point manuscripts, those that go beyond the cutting edge to explain the next potential breakthrough or intervention in the developing field of hospital medicine, may be authored by thought leaders inside and outside the health care field as well as by hospitalists with novel ideas. Equally vital, I want to share the illuminating perspectives of physicians, patients, and families of patients as they reflect on the experience of being in the hospitalhospitalists can enlighten us through their handoffs, and patients and their families can inform us about their view from the hospital bed.

Finally, never forget that this is your journal. Let me know what you like and what changes you think can make it better. Please e‐mail your suggestions, comments, criticisms, and ideas to us at JHMeditor@ hospitalmedicine.org. This is your chance to help shape the practice of hospital medicine and the future of hospital care. I look forward to your guidance. Together we can expand our knowledge and continue to grow in our careers.

You hold in your hands the inaugural issue of the Journal of Hospital Medicine (JHM). Our goal is for JHM to become the premier forum for peer‐reviewed research articles and evidence‐based reviews in the specialty of hospital medicine.

Yes, the specialty of hospital medicine. This official publication of the Society of Hospital Medicine signifies another step forward in the evolution of this specialty. With the publication of JHM the Society of Hospital Medicine continues its pivotal educational and leadership role in shaping the practice of hospital medicine. The Society is dedicated to promoting the highest‐quality care for all hospitalized patients and excellence in hospital medicine through education, advocacy, and research. As part of the Society's effort to improve care and standards, it is providing JHM to all members as part of their membership. We hope that our readership will grow to include individuals involved in all aspects of hospital care.

Packed with the results of new studies and state‐of‐the‐art reviews, JHM is not aimed solely at academicians and voracious readers of the medical literature. Rather, we hope that it fills a practical need to promote lifelong learning in both hospitalists and their hospital colleagues. For example, in this issue, national experts in palliative care and geriatrics summarize the pertinent literature and the important role of such care for hospitalized patients. JHM will also serve as a key venue for hospital medicine researchers to disseminate their findings and for educators to share their knowledge and techniques.

Why bother to create yet another journal? Given the stacks of journals that adorn many of our desks (and some of our chairs and windowsills), do we really need another to get lost among the mail that inundates us? We believe the field of hospital medicine involves a growing body of knowledge deserving of a journal focused solely on it. Hospital medicine evolved from efforts to fill a need identified by overstretched primary care physicians in the late 1980s. Physicians like the cofounders of SHM, John Nelson in Florida and Win Whitcomb in Massachusetts, began careers in a field that today numbers more than 12,000 physicians. Labeled with the moniker hospitalist given us by Bob Wachter and Lee Goldman,1 we now make up the fastest‐growing medical specialty in the United States.2 Yet, until now, no journal was devoted solely to this specialty.

The Journal of Hospital Medicine aims to provide physicians and other health care professionals with continuing insight into the basic and clinical sciences to support informed clinical decision making in the hospital. As hospitalists increasingly take an active role in the successful delivery of bench research discoveries to the bedside and become vigorous participants in the translational and clinical research sought by the National Institutes of Health,3 JHM will disseminate their findings. In addition, we hope to foster balanced debates on medical issues and health care trends that affect hospital medicine and patient care. Nonclinical aspects of hospital medicine also will be featured, including public health and the political, philosophic, ethical, legal, environmental, economic, historical, and cultural issues surrounding hospital care. We especially want to encourage submissions that evaluate projects involving the entire hospital care team: physicians and our colleagues in the hospitalnurses, pharmacists, administrators, physical and occupational therapists, social workers, and case managers.

Two articles (see pages 48 and 57) highlight this inaugural issue. One describes the development of The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (a supplement to this issue), and the other demonstrates how this document can be applied to curriculum development.4, 5 This milestone in the evolution of hospital medicine provides an initial structural framework to guide medical educators in developing curricula that incorporate these competencies into the training and evaluation of students, clinicians‐in‐training, and practicing hospitalists.4 The president and CEO of the American Board of Internal Medicine (ABIM), Christine Cassel, offers her perspective on this landmark document.6 Its timeliness is reflected by the current efforts of the American College of Physicians, the ABIM, and others to redesign the training and the certification requirements of internists. As this supplement demonstrates, the Society of Hospital Medicine will be intimately involved in this process.

After this auspicious start, subsequent issues will include articles in the following categories. Original research articles will report results of randomized controlled trials, evaluations of diagnostic tests, prospective cohort studies, casecontrol studies, and high‐quality observational studies. We are interested in publishing both quantitative and qualitative research. Review articles, especially those targeting the hospital medicine core competencies, are eagerly sought. We also seek descriptions of interventions that transform hospital care delivery in the hospital. For example, accounts of the implementation of quality‐improvement projects and outcomes, including barriers that were overcome or that blocked implementation, would be invaluable to hospitalists throughout the country. Clinical conundrums should describe clinical cases that present diagnostic dilemmas or involve issues of medical errors. To facilitate the professional development of hospitalists, we seek articles focused on their professional development in community, academic, and administrative settings. Examples of leadership topics are managing physician performance, leading and managing change, and self‐evaluation. Teaching tips or descriptions of educational programs or curricula also are desired. For researchers, potential topics include descriptions of specific techniques used for surveys, meta‐analyses, economic evaluations, and statistical analyses.Penetrating point manuscripts, those that go beyond the cutting edge to explain the next potential breakthrough or intervention in the developing field of hospital medicine, may be authored by thought leaders inside and outside the health care field as well as by hospitalists with novel ideas. Equally vital, I want to share the illuminating perspectives of physicians, patients, and families of patients as they reflect on the experience of being in the hospitalhospitalists can enlighten us through their handoffs, and patients and their families can inform us about their view from the hospital bed.

Finally, never forget that this is your journal. Let me know what you like and what changes you think can make it better. Please e‐mail your suggestions, comments, criticisms, and ideas to us at JHMeditor@ hospitalmedicine.org. This is your chance to help shape the practice of hospital medicine and the future of hospital care. I look forward to your guidance. Together we can expand our knowledge and continue to grow in our careers.

You hold in your hands the inaugural issue of the Journal of Hospital Medicine (JHM). Our goal is for JHM to become the premier forum for peer‐reviewed research articles and evidence‐based reviews in the specialty of hospital medicine.

Yes, the specialty of hospital medicine. This official publication of the Society of Hospital Medicine signifies another step forward in the evolution of this specialty. With the publication of JHM the Society of Hospital Medicine continues its pivotal educational and leadership role in shaping the practice of hospital medicine. The Society is dedicated to promoting the highest‐quality care for all hospitalized patients and excellence in hospital medicine through education, advocacy, and research. As part of the Society's effort to improve care and standards, it is providing JHM to all members as part of their membership. We hope that our readership will grow to include individuals involved in all aspects of hospital care.

Packed with the results of new studies and state‐of‐the‐art reviews, JHM is not aimed solely at academicians and voracious readers of the medical literature. Rather, we hope that it fills a practical need to promote lifelong learning in both hospitalists and their hospital colleagues. For example, in this issue, national experts in palliative care and geriatrics summarize the pertinent literature and the important role of such care for hospitalized patients. JHM will also serve as a key venue for hospital medicine researchers to disseminate their findings and for educators to share their knowledge and techniques.

Why bother to create yet another journal? Given the stacks of journals that adorn many of our desks (and some of our chairs and windowsills), do we really need another to get lost among the mail that inundates us? We believe the field of hospital medicine involves a growing body of knowledge deserving of a journal focused solely on it. Hospital medicine evolved from efforts to fill a need identified by overstretched primary care physicians in the late 1980s. Physicians like the cofounders of SHM, John Nelson in Florida and Win Whitcomb in Massachusetts, began careers in a field that today numbers more than 12,000 physicians. Labeled with the moniker hospitalist given us by Bob Wachter and Lee Goldman,1 we now make up the fastest‐growing medical specialty in the United States.2 Yet, until now, no journal was devoted solely to this specialty.

The Journal of Hospital Medicine aims to provide physicians and other health care professionals with continuing insight into the basic and clinical sciences to support informed clinical decision making in the hospital. As hospitalists increasingly take an active role in the successful delivery of bench research discoveries to the bedside and become vigorous participants in the translational and clinical research sought by the National Institutes of Health,3 JHM will disseminate their findings. In addition, we hope to foster balanced debates on medical issues and health care trends that affect hospital medicine and patient care. Nonclinical aspects of hospital medicine also will be featured, including public health and the political, philosophic, ethical, legal, environmental, economic, historical, and cultural issues surrounding hospital care. We especially want to encourage submissions that evaluate projects involving the entire hospital care team: physicians and our colleagues in the hospitalnurses, pharmacists, administrators, physical and occupational therapists, social workers, and case managers.

Two articles (see pages 48 and 57) highlight this inaugural issue. One describes the development of The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (a supplement to this issue), and the other demonstrates how this document can be applied to curriculum development.4, 5 This milestone in the evolution of hospital medicine provides an initial structural framework to guide medical educators in developing curricula that incorporate these competencies into the training and evaluation of students, clinicians‐in‐training, and practicing hospitalists.4 The president and CEO of the American Board of Internal Medicine (ABIM), Christine Cassel, offers her perspective on this landmark document.6 Its timeliness is reflected by the current efforts of the American College of Physicians, the ABIM, and others to redesign the training and the certification requirements of internists. As this supplement demonstrates, the Society of Hospital Medicine will be intimately involved in this process.

After this auspicious start, subsequent issues will include articles in the following categories. Original research articles will report results of randomized controlled trials, evaluations of diagnostic tests, prospective cohort studies, casecontrol studies, and high‐quality observational studies. We are interested in publishing both quantitative and qualitative research. Review articles, especially those targeting the hospital medicine core competencies, are eagerly sought. We also seek descriptions of interventions that transform hospital care delivery in the hospital. For example, accounts of the implementation of quality‐improvement projects and outcomes, including barriers that were overcome or that blocked implementation, would be invaluable to hospitalists throughout the country. Clinical conundrums should describe clinical cases that present diagnostic dilemmas or involve issues of medical errors. To facilitate the professional development of hospitalists, we seek articles focused on their professional development in community, academic, and administrative settings. Examples of leadership topics are managing physician performance, leading and managing change, and self‐evaluation. Teaching tips or descriptions of educational programs or curricula also are desired. For researchers, potential topics include descriptions of specific techniques used for surveys, meta‐analyses, economic evaluations, and statistical analyses.Penetrating point manuscripts, those that go beyond the cutting edge to explain the next potential breakthrough or intervention in the developing field of hospital medicine, may be authored by thought leaders inside and outside the health care field as well as by hospitalists with novel ideas. Equally vital, I want to share the illuminating perspectives of physicians, patients, and families of patients as they reflect on the experience of being in the hospitalhospitalists can enlighten us through their handoffs, and patients and their families can inform us about their view from the hospital bed.

Finally, never forget that this is your journal. Let me know what you like and what changes you think can make it better. Please e‐mail your suggestions, comments, criticisms, and ideas to us at JHMeditor@ hospitalmedicine.org. This is your chance to help shape the practice of hospital medicine and the future of hospital care. I look forward to your guidance. Together we can expand our knowledge and continue to grow in our careers.

For many of you, the hospital has by now become your home away from home. You spend a great deal of time there. You know your way from the ER to the ICU and the morgue. You've learned the hierarchy of who can tell whom what to do, and when it's your turn to do so, you can rattle off an impressive string of acronyms and medspeak in rapid fire. And then, there's that white coat that gives you added stature and authority.

We, the patients, family members, and other concerned visitors, are babes in the woods in this setting. If we've been lucky in life heretofore, we find that visiting a hospital can be like stepping off a hijacked plane into a foreign country we never planned to visit. Few things look familiar. We don't fully understand what we're being made to do. We don't speak the language well enough to communicate with those surrounding us, and we're not certain how friendly they are or what might provoke them into hurting us or our loved ones.

The signs we see don't mean much to usthe few words we recognize tend to scare us more than anything else. We don't know how to interpret the various uniforms people are wearing, other than the white coats we're all familiar with. Quite a few of the busy people moving with confidence around us have the aura of authority figures, no matter what they're wearing. When it's our turn, they focus on us or our loved ones, freely taking samples of blood, attaching instruments, probing private body parts, and asking intensely personal questions. But they don't really say much at all directly to us, and they don't seem interested in a lot of what we try to tell them. We're left feeling confused, humiliated, and somewhat stupid. Obviously, we're not astute enough to figure out what they want us to tell them. Why couldn't we remember everything we'd eaten or taken in the last 24 hours? We failed the test, and the consequences could be life threatening.

I am not exaggerating the situation. Last winter, my husbandwho had some chronic health issues but was still able to hold down a demanding job and carry on a fairly normal lifewas taken down by a nasty anonymous virus that attacked several major organ systems. We thought it was a bad case of the flu. I only took him to the emergency room because his weakness failed to pass in a few days and listening to him struggle to breathe scared me badly. It was the doctor's answering service (not the doctor on call, who never returned my call) that advised me to take him to the ER.

Within the first 24 hours at the hospital, I lost all ability to communicate with my husband when he was sedated and hooked up to a ventilator. For the next three and a half weeks, he lay unconscious, struggling for survival, and I lived on what his doctors and nurses chose to tell me. And they weren't saying a lot that I could make sense of.

For one thing, as his condition worsened he was in the care of eight specialists. Each would tell me something different, and I wasn't equipped to put all these pieces of information together in a meaningful way. For example, early on, I heard the following statements from different doctors all in the same day: He has a virus. His lungs are in really bad shape, and he could die. There are some indications he had a heart attack. His kidneys are failing, and he's going to need dialysis.

I knew that viruses can kill people. I knew that my husband was considered a high risk for heart attacks and that his lungs had been compromised by years of smoking. But I could not fathom how all of these things were related, let alone what was causing the kidneys to fail at this particular time. It took a very long timedays, maybe a week or morebefore I had both the courage and opportunity to pester my husband's infectious disease specialist with so many questions that he explained that the virus had attacked the heart, lungs, and kidneys and that most of what we were seeing was the aftermath of that battle.

This same doctor also helped me by shedding light on why the brief reports I was receiving from different specialists often seemed, to my layman's ears, to contradict each other. (One day the cardiologist told me, His heart's basically in pretty good shape. Yet, a scant hour later, the pulmonary specialist informed me, He's getting worse. He could die.) Each specialist, he told me, tends to focus on the area of the body he or she specializes in, not the patient's overall condition, and their comments reflect that narrow focus. How long would it have taken me to figure that out, if not for this man?

A lot of the frustration I felt as I chased after valuable tidbits of information about my husband's condition could have been alleviated with just a few words. Some days it would have been enough just to have had my anguish acknowledged with something as simple as I know you're frustrated and tired of hearing that we have no clear answers. Believe me, we want a better understanding of what's happening to your husband, too.

Aside from having to assemble the comments my husband's many doctors gave me into a comprehensive picture, I grew very weary of trying to catch these men and women as they came through on their rounds. Some routinely came through the ICU before the start of visiting hours each day. A few had no discernable routine at allI was as likely to encounter them at 8:30 p.m. as at 3 p.m. or 10 a.m. Yet if I was not at my husband's bedside or in the ICU waiting room, I'd get no report from them that day. This system forces the family to forgo any semblance of a normal life. In my case, there were no other family members with which to trade off this vigil, so I missed doctors whenever I went home or out of the room for a bite to eat.

I do not believe that our local hospital is unusual in any of these respects. In talking to people in other parts of the country who've been through a hospital experience, I have heard similar complaints voiced over and over.

And I do not question the quality of the medical care my husband received. As far as I know, everyone involved did their best to save him. Sadly, they did not succeed. Doug died on March 16, 2005, after five and a half weeks in the ICU. Many very good‐hearted, caring people worked on him during that time.

But some, though pleasant, didn't go out of their way to help me one iota. The day my husband started waking up after 25 days in a comalike state, I was in a funk and had found excuses to stay home until midafternoon, figuring there'd be no change in his condition. When I finally dragged myself into his room and spoke to him, I was astonished to see him react with a very slight head movement. Overjoyed, I immediately informed his nurse that he had responded to me, and she replied with a smile, Yes, I know. He's been responsive all day!

Now, these people knew that I'd been hovering at his bedside for 25 days, anxiously waiting for him to wake up, pestering them about why he wasn't and asking what was wrong. Did no one think this development worth a phone call to me?

Since my husband's death, I have heard that some hospitals have patient advocates and hospitalists, but my impression is that a fairly small percentage of hospitals have invested in these types of positions. And I question how well one or two such people in a hospital full of sick patients can help everyone who needs their services. It was hard enough for me to connect with the one woman in our hospital who, during the short time my husband seemed to be on the way to recovering, could help to arrange his transfer to a long‐term care facility.

My point is, the system that is routinely followed in most hospitalsthe system that determines doctors' routines, the system that causes health care workers to tend to treat patients and their families more like objects than human beingsdoes not do service to those it was set up to serve.

My point is, when it's everyone's responsibility to communicate with a patient's family, it winds up being no one's responsibility. Hospitals need to assign this responsibility to a specific person when a critically ill patient is in the care of a team of specialists.

My point is, please think of us wandering lost and scared in that foreign land you call home the next time you encounter one of us there.

For many of you, the hospital has by now become your home away from home. You spend a great deal of time there. You know your way from the ER to the ICU and the morgue. You've learned the hierarchy of who can tell whom what to do, and when it's your turn to do so, you can rattle off an impressive string of acronyms and medspeak in rapid fire. And then, there's that white coat that gives you added stature and authority.

We, the patients, family members, and other concerned visitors, are babes in the woods in this setting. If we've been lucky in life heretofore, we find that visiting a hospital can be like stepping off a hijacked plane into a foreign country we never planned to visit. Few things look familiar. We don't fully understand what we're being made to do. We don't speak the language well enough to communicate with those surrounding us, and we're not certain how friendly they are or what might provoke them into hurting us or our loved ones.

The signs we see don't mean much to usthe few words we recognize tend to scare us more than anything else. We don't know how to interpret the various uniforms people are wearing, other than the white coats we're all familiar with. Quite a few of the busy people moving with confidence around us have the aura of authority figures, no matter what they're wearing. When it's our turn, they focus on us or our loved ones, freely taking samples of blood, attaching instruments, probing private body parts, and asking intensely personal questions. But they don't really say much at all directly to us, and they don't seem interested in a lot of what we try to tell them. We're left feeling confused, humiliated, and somewhat stupid. Obviously, we're not astute enough to figure out what they want us to tell them. Why couldn't we remember everything we'd eaten or taken in the last 24 hours? We failed the test, and the consequences could be life threatening.

I am not exaggerating the situation. Last winter, my husbandwho had some chronic health issues but was still able to hold down a demanding job and carry on a fairly normal lifewas taken down by a nasty anonymous virus that attacked several major organ systems. We thought it was a bad case of the flu. I only took him to the emergency room because his weakness failed to pass in a few days and listening to him struggle to breathe scared me badly. It was the doctor's answering service (not the doctor on call, who never returned my call) that advised me to take him to the ER.

Within the first 24 hours at the hospital, I lost all ability to communicate with my husband when he was sedated and hooked up to a ventilator. For the next three and a half weeks, he lay unconscious, struggling for survival, and I lived on what his doctors and nurses chose to tell me. And they weren't saying a lot that I could make sense of.

For one thing, as his condition worsened he was in the care of eight specialists. Each would tell me something different, and I wasn't equipped to put all these pieces of information together in a meaningful way. For example, early on, I heard the following statements from different doctors all in the same day: He has a virus. His lungs are in really bad shape, and he could die. There are some indications he had a heart attack. His kidneys are failing, and he's going to need dialysis.

I knew that viruses can kill people. I knew that my husband was considered a high risk for heart attacks and that his lungs had been compromised by years of smoking. But I could not fathom how all of these things were related, let alone what was causing the kidneys to fail at this particular time. It took a very long timedays, maybe a week or morebefore I had both the courage and opportunity to pester my husband's infectious disease specialist with so many questions that he explained that the virus had attacked the heart, lungs, and kidneys and that most of what we were seeing was the aftermath of that battle.

This same doctor also helped me by shedding light on why the brief reports I was receiving from different specialists often seemed, to my layman's ears, to contradict each other. (One day the cardiologist told me, His heart's basically in pretty good shape. Yet, a scant hour later, the pulmonary specialist informed me, He's getting worse. He could die.) Each specialist, he told me, tends to focus on the area of the body he or she specializes in, not the patient's overall condition, and their comments reflect that narrow focus. How long would it have taken me to figure that out, if not for this man?

A lot of the frustration I felt as I chased after valuable tidbits of information about my husband's condition could have been alleviated with just a few words. Some days it would have been enough just to have had my anguish acknowledged with something as simple as I know you're frustrated and tired of hearing that we have no clear answers. Believe me, we want a better understanding of what's happening to your husband, too.

Aside from having to assemble the comments my husband's many doctors gave me into a comprehensive picture, I grew very weary of trying to catch these men and women as they came through on their rounds. Some routinely came through the ICU before the start of visiting hours each day. A few had no discernable routine at allI was as likely to encounter them at 8:30 p.m. as at 3 p.m. or 10 a.m. Yet if I was not at my husband's bedside or in the ICU waiting room, I'd get no report from them that day. This system forces the family to forgo any semblance of a normal life. In my case, there were no other family members with which to trade off this vigil, so I missed doctors whenever I went home or out of the room for a bite to eat.

I do not believe that our local hospital is unusual in any of these respects. In talking to people in other parts of the country who've been through a hospital experience, I have heard similar complaints voiced over and over.

And I do not question the quality of the medical care my husband received. As far as I know, everyone involved did their best to save him. Sadly, they did not succeed. Doug died on March 16, 2005, after five and a half weeks in the ICU. Many very good‐hearted, caring people worked on him during that time.

But some, though pleasant, didn't go out of their way to help me one iota. The day my husband started waking up after 25 days in a comalike state, I was in a funk and had found excuses to stay home until midafternoon, figuring there'd be no change in his condition. When I finally dragged myself into his room and spoke to him, I was astonished to see him react with a very slight head movement. Overjoyed, I immediately informed his nurse that he had responded to me, and she replied with a smile, Yes, I know. He's been responsive all day!

Now, these people knew that I'd been hovering at his bedside for 25 days, anxiously waiting for him to wake up, pestering them about why he wasn't and asking what was wrong. Did no one think this development worth a phone call to me?

Since my husband's death, I have heard that some hospitals have patient advocates and hospitalists, but my impression is that a fairly small percentage of hospitals have invested in these types of positions. And I question how well one or two such people in a hospital full of sick patients can help everyone who needs their services. It was hard enough for me to connect with the one woman in our hospital who, during the short time my husband seemed to be on the way to recovering, could help to arrange his transfer to a long‐term care facility.

My point is, the system that is routinely followed in most hospitalsthe system that determines doctors' routines, the system that causes health care workers to tend to treat patients and their families more like objects than human beingsdoes not do service to those it was set up to serve.

My point is, when it's everyone's responsibility to communicate with a patient's family, it winds up being no one's responsibility. Hospitals need to assign this responsibility to a specific person when a critically ill patient is in the care of a team of specialists.

My point is, please think of us wandering lost and scared in that foreign land you call home the next time you encounter one of us there.

For many of you, the hospital has by now become your home away from home. You spend a great deal of time there. You know your way from the ER to the ICU and the morgue. You've learned the hierarchy of who can tell whom what to do, and when it's your turn to do so, you can rattle off an impressive string of acronyms and medspeak in rapid fire. And then, there's that white coat that gives you added stature and authority.

We, the patients, family members, and other concerned visitors, are babes in the woods in this setting. If we've been lucky in life heretofore, we find that visiting a hospital can be like stepping off a hijacked plane into a foreign country we never planned to visit. Few things look familiar. We don't fully understand what we're being made to do. We don't speak the language well enough to communicate with those surrounding us, and we're not certain how friendly they are or what might provoke them into hurting us or our loved ones.

The signs we see don't mean much to usthe few words we recognize tend to scare us more than anything else. We don't know how to interpret the various uniforms people are wearing, other than the white coats we're all familiar with. Quite a few of the busy people moving with confidence around us have the aura of authority figures, no matter what they're wearing. When it's our turn, they focus on us or our loved ones, freely taking samples of blood, attaching instruments, probing private body parts, and asking intensely personal questions. But they don't really say much at all directly to us, and they don't seem interested in a lot of what we try to tell them. We're left feeling confused, humiliated, and somewhat stupid. Obviously, we're not astute enough to figure out what they want us to tell them. Why couldn't we remember everything we'd eaten or taken in the last 24 hours? We failed the test, and the consequences could be life threatening.

I am not exaggerating the situation. Last winter, my husbandwho had some chronic health issues but was still able to hold down a demanding job and carry on a fairly normal lifewas taken down by a nasty anonymous virus that attacked several major organ systems. We thought it was a bad case of the flu. I only took him to the emergency room because his weakness failed to pass in a few days and listening to him struggle to breathe scared me badly. It was the doctor's answering service (not the doctor on call, who never returned my call) that advised me to take him to the ER.

Within the first 24 hours at the hospital, I lost all ability to communicate with my husband when he was sedated and hooked up to a ventilator. For the next three and a half weeks, he lay unconscious, struggling for survival, and I lived on what his doctors and nurses chose to tell me. And they weren't saying a lot that I could make sense of.

For one thing, as his condition worsened he was in the care of eight specialists. Each would tell me something different, and I wasn't equipped to put all these pieces of information together in a meaningful way. For example, early on, I heard the following statements from different doctors all in the same day: He has a virus. His lungs are in really bad shape, and he could die. There are some indications he had a heart attack. His kidneys are failing, and he's going to need dialysis.

I knew that viruses can kill people. I knew that my husband was considered a high risk for heart attacks and that his lungs had been compromised by years of smoking. But I could not fathom how all of these things were related, let alone what was causing the kidneys to fail at this particular time. It took a very long timedays, maybe a week or morebefore I had both the courage and opportunity to pester my husband's infectious disease specialist with so many questions that he explained that the virus had attacked the heart, lungs, and kidneys and that most of what we were seeing was the aftermath of that battle.

This same doctor also helped me by shedding light on why the brief reports I was receiving from different specialists often seemed, to my layman's ears, to contradict each other. (One day the cardiologist told me, His heart's basically in pretty good shape. Yet, a scant hour later, the pulmonary specialist informed me, He's getting worse. He could die.) Each specialist, he told me, tends to focus on the area of the body he or she specializes in, not the patient's overall condition, and their comments reflect that narrow focus. How long would it have taken me to figure that out, if not for this man?

A lot of the frustration I felt as I chased after valuable tidbits of information about my husband's condition could have been alleviated with just a few words. Some days it would have been enough just to have had my anguish acknowledged with something as simple as I know you're frustrated and tired of hearing that we have no clear answers. Believe me, we want a better understanding of what's happening to your husband, too.

Aside from having to assemble the comments my husband's many doctors gave me into a comprehensive picture, I grew very weary of trying to catch these men and women as they came through on their rounds. Some routinely came through the ICU before the start of visiting hours each day. A few had no discernable routine at allI was as likely to encounter them at 8:30 p.m. as at 3 p.m. or 10 a.m. Yet if I was not at my husband's bedside or in the ICU waiting room, I'd get no report from them that day. This system forces the family to forgo any semblance of a normal life. In my case, there were no other family members with which to trade off this vigil, so I missed doctors whenever I went home or out of the room for a bite to eat.

I do not believe that our local hospital is unusual in any of these respects. In talking to people in other parts of the country who've been through a hospital experience, I have heard similar complaints voiced over and over.

And I do not question the quality of the medical care my husband received. As far as I know, everyone involved did their best to save him. Sadly, they did not succeed. Doug died on March 16, 2005, after five and a half weeks in the ICU. Many very good‐hearted, caring people worked on him during that time.

But some, though pleasant, didn't go out of their way to help me one iota. The day my husband started waking up after 25 days in a comalike state, I was in a funk and had found excuses to stay home until midafternoon, figuring there'd be no change in his condition. When I finally dragged myself into his room and spoke to him, I was astonished to see him react with a very slight head movement. Overjoyed, I immediately informed his nurse that he had responded to me, and she replied with a smile, Yes, I know. He's been responsive all day!

Now, these people knew that I'd been hovering at his bedside for 25 days, anxiously waiting for him to wake up, pestering them about why he wasn't and asking what was wrong. Did no one think this development worth a phone call to me?

Since my husband's death, I have heard that some hospitals have patient advocates and hospitalists, but my impression is that a fairly small percentage of hospitals have invested in these types of positions. And I question how well one or two such people in a hospital full of sick patients can help everyone who needs their services. It was hard enough for me to connect with the one woman in our hospital who, during the short time my husband seemed to be on the way to recovering, could help to arrange his transfer to a long‐term care facility.

My point is, the system that is routinely followed in most hospitalsthe system that determines doctors' routines, the system that causes health care workers to tend to treat patients and their families more like objects than human beingsdoes not do service to those it was set up to serve.

My point is, when it's everyone's responsibility to communicate with a patient's family, it winds up being no one's responsibility. Hospitals need to assign this responsibility to a specific person when a critically ill patient is in the care of a team of specialists.

My point is, please think of us wandering lost and scared in that foreign land you call home the next time you encounter one of us there.

It is right and fitting that an article focused on palliative care appears in the inaugural issue of the Journal of Hospital Medicine (JHM).1 Both hospital medicine and palliative care are rapidly growing fields expanding in response to quality and economic imperatives. Both fields recognize the need to develop systems to care for seriously ill patients and to work within interdisciplinary teams. In fact, a natural and mutually beneficial relationship should exist between these two fields. For palliative care, hospital medicine and hospitalists offer the physicians and systems approach to care that could guarantee access to high‐quality palliative care for all hospitalized patients. In addition, hospitalists offer the promise of increasing the number of hospital‐based palliative care programs as the presence of a hospitalist program is strongly associated with having or starting such a program.2, 3 For hospital medicine and hospitalists, palliative care offers a compassionate and high‐quality response to the challenge of caring for seriously and terminally ill patients and their families. By each embracing the other, both fields could find willing and eager partners in the quest to provide the highest possible quality of care for hospitalized patients.

In this first issue of JHM, Dr. Meier offers hospitalists an intriguing and attractive picture of palliative care. She describes how the growth of palliative care is driven by the needs of an ever‐larger group of patients living with chronic and life‐threatening illness and evidence of high quality and satisfaction for these patients who have many physical, emotional, psychological, and spiritual concerns. Dr. Meier also demonstrates how hospital‐based palliative care can coordinate with hospices to provide the continuity of care for terminally ill patients that is often elusive at hospital discharge. Finally, Dr. Meier provides a practical list of resources for clinicians seeking further training in the field. No doubt hospitalists will appreciate this list as the core competencies in hospital medicine, published as a supplement to this issue of JHM, include palliative care, pain management, communication, and discharge planning.

As Dr. Meier states in her article Palliative Care in Hospitals, many types of clinicians can provide palliative care in hospitals, including general internists, nurses, geriatricians, oncologists, hospitalists, and others, yet hospitalists are likely to emerge as the predominant providers of palliative care to hospitalized patients.4 That 75% of Americans die in institutionalized settings, where hospitalists are becoming the dominant providers of care, will drive this prediction.5 In addition, hospitalists are increasingly leading efforts in quality improvement, patient satisfaction, and patient safety.6 Of necessity these initiatives will involve the sickest hospitalized patients and will look to palliative care as a proven response for improving quality and increasing satisfaction.

Hospital medicine and palliative care have other aspects in common that make a melding of the two fields beneficial. Both fields recognize and emphasize the need for interdisciplinary care; good communication between members of the health care team and between health care providers and patients; and timely, effective, and responsible discharge planning. Finally, both fields often rely on multiple sources of funding including professional fee billing and support from the hospital for the added value that programs provide. Sharing so many issues in common should help hospital medicine and palliative care form strong links.

For these links to take hold and for the benefits of this partnership to bear fruit, members of both fields, and especially those with a foot in each, need to reach out. For hospitalists this means getting educated in palliative care, an area for which hospitalists recognize they are underprepared.7 Each hospitalist must be able to provide primary, basic palliative care to each patient.8 Some hospitalists will discover the rewards of palliative care and seek further training and even board certification. These hospitalists can start or join palliative care teams in their institutions. Finally, some hospitalists will become experts in palliative care and join or lead palliative care programs at tertiary care centers. In turn, palliative care providers must reach out to hospitalists. Palliative care clinicians should seek out hospitalists at their institutions and hospices should contact hospitalists at their local hospitals. These programs need to invite hospitalists to participate in the palliative care team and suggest how their services can help the patients of hospitalists. This natural alliance can come about only if both sides reach out.

A partnership between palliative care and hospital medicine will be good for patients and their families as well as for each field, as hospitalists enable realization of the goal of providing palliative care to every patient in the United States. In addition, this partnership will be good for hospitalists who embrace this work. Palliative care can connect us to the humanism and compassion that brought so many of us to medicine and can serve as an antidote to burnout. Furthermore, by caring for patients with life‐threatening illnesses we remember that our time is limited and that each day is a gift. We recognize the importance of making the most of our time regardless of how long we have and of choosing carefully how and with whom we spend our time.

In this first issue of JHM, Dr. Meier makes a strong argument for the need and continued growth of palliative care in hospitals, lays out a strategy for achieving this growth through education and program development, and in doing so, opens the door to hope for the future. Through palliative care we can offer patients hope for healing when cure is not possible, for comfort in the face of suffering, and for what can still be despite all that cannot. The possibility that hospitalists could provide all patients access to palliative care is cause enough for hope. The knowledge that hospitalists will play a major role in making this possibility a reality and may become the predominant providers of palliative care can make that hope a reality.

It is right and fitting that an article focused on palliative care appears in the inaugural issue of the Journal of Hospital Medicine (JHM).1 Both hospital medicine and palliative care are rapidly growing fields expanding in response to quality and economic imperatives. Both fields recognize the need to develop systems to care for seriously ill patients and to work within interdisciplinary teams. In fact, a natural and mutually beneficial relationship should exist between these two fields. For palliative care, hospital medicine and hospitalists offer the physicians and systems approach to care that could guarantee access to high‐quality palliative care for all hospitalized patients. In addition, hospitalists offer the promise of increasing the number of hospital‐based palliative care programs as the presence of a hospitalist program is strongly associated with having or starting such a program.2, 3 For hospital medicine and hospitalists, palliative care offers a compassionate and high‐quality response to the challenge of caring for seriously and terminally ill patients and their families. By each embracing the other, both fields could find willing and eager partners in the quest to provide the highest possible quality of care for hospitalized patients.

In this first issue of JHM, Dr. Meier offers hospitalists an intriguing and attractive picture of palliative care. She describes how the growth of palliative care is driven by the needs of an ever‐larger group of patients living with chronic and life‐threatening illness and evidence of high quality and satisfaction for these patients who have many physical, emotional, psychological, and spiritual concerns. Dr. Meier also demonstrates how hospital‐based palliative care can coordinate with hospices to provide the continuity of care for terminally ill patients that is often elusive at hospital discharge. Finally, Dr. Meier provides a practical list of resources for clinicians seeking further training in the field. No doubt hospitalists will appreciate this list as the core competencies in hospital medicine, published as a supplement to this issue of JHM, include palliative care, pain management, communication, and discharge planning.

As Dr. Meier states in her article Palliative Care in Hospitals, many types of clinicians can provide palliative care in hospitals, including general internists, nurses, geriatricians, oncologists, hospitalists, and others, yet hospitalists are likely to emerge as the predominant providers of palliative care to hospitalized patients.4 That 75% of Americans die in institutionalized settings, where hospitalists are becoming the dominant providers of care, will drive this prediction.5 In addition, hospitalists are increasingly leading efforts in quality improvement, patient satisfaction, and patient safety.6 Of necessity these initiatives will involve the sickest hospitalized patients and will look to palliative care as a proven response for improving quality and increasing satisfaction.

Hospital medicine and palliative care have other aspects in common that make a melding of the two fields beneficial. Both fields recognize and emphasize the need for interdisciplinary care; good communication between members of the health care team and between health care providers and patients; and timely, effective, and responsible discharge planning. Finally, both fields often rely on multiple sources of funding including professional fee billing and support from the hospital for the added value that programs provide. Sharing so many issues in common should help hospital medicine and palliative care form strong links.

For these links to take hold and for the benefits of this partnership to bear fruit, members of both fields, and especially those with a foot in each, need to reach out. For hospitalists this means getting educated in palliative care, an area for which hospitalists recognize they are underprepared.7 Each hospitalist must be able to provide primary, basic palliative care to each patient.8 Some hospitalists will discover the rewards of palliative care and seek further training and even board certification. These hospitalists can start or join palliative care teams in their institutions. Finally, some hospitalists will become experts in palliative care and join or lead palliative care programs at tertiary care centers. In turn, palliative care providers must reach out to hospitalists. Palliative care clinicians should seek out hospitalists at their institutions and hospices should contact hospitalists at their local hospitals. These programs need to invite hospitalists to participate in the palliative care team and suggest how their services can help the patients of hospitalists. This natural alliance can come about only if both sides reach out.

A partnership between palliative care and hospital medicine will be good for patients and their families as well as for each field, as hospitalists enable realization of the goal of providing palliative care to every patient in the United States. In addition, this partnership will be good for hospitalists who embrace this work. Palliative care can connect us to the humanism and compassion that brought so many of us to medicine and can serve as an antidote to burnout. Furthermore, by caring for patients with life‐threatening illnesses we remember that our time is limited and that each day is a gift. We recognize the importance of making the most of our time regardless of how long we have and of choosing carefully how and with whom we spend our time.

In this first issue of JHM, Dr. Meier makes a strong argument for the need and continued growth of palliative care in hospitals, lays out a strategy for achieving this growth through education and program development, and in doing so, opens the door to hope for the future. Through palliative care we can offer patients hope for healing when cure is not possible, for comfort in the face of suffering, and for what can still be despite all that cannot. The possibility that hospitalists could provide all patients access to palliative care is cause enough for hope. The knowledge that hospitalists will play a major role in making this possibility a reality and may become the predominant providers of palliative care can make that hope a reality.

It is right and fitting that an article focused on palliative care appears in the inaugural issue of the Journal of Hospital Medicine (JHM).1 Both hospital medicine and palliative care are rapidly growing fields expanding in response to quality and economic imperatives. Both fields recognize the need to develop systems to care for seriously ill patients and to work within interdisciplinary teams. In fact, a natural and mutually beneficial relationship should exist between these two fields. For palliative care, hospital medicine and hospitalists offer the physicians and systems approach to care that could guarantee access to high‐quality palliative care for all hospitalized patients. In addition, hospitalists offer the promise of increasing the number of hospital‐based palliative care programs as the presence of a hospitalist program is strongly associated with having or starting such a program.2, 3 For hospital medicine and hospitalists, palliative care offers a compassionate and high‐quality response to the challenge of caring for seriously and terminally ill patients and their families. By each embracing the other, both fields could find willing and eager partners in the quest to provide the highest possible quality of care for hospitalized patients.

In this first issue of JHM, Dr. Meier offers hospitalists an intriguing and attractive picture of palliative care. She describes how the growth of palliative care is driven by the needs of an ever‐larger group of patients living with chronic and life‐threatening illness and evidence of high quality and satisfaction for these patients who have many physical, emotional, psychological, and spiritual concerns. Dr. Meier also demonstrates how hospital‐based palliative care can coordinate with hospices to provide the continuity of care for terminally ill patients that is often elusive at hospital discharge. Finally, Dr. Meier provides a practical list of resources for clinicians seeking further training in the field. No doubt hospitalists will appreciate this list as the core competencies in hospital medicine, published as a supplement to this issue of JHM, include palliative care, pain management, communication, and discharge planning.

As Dr. Meier states in her article Palliative Care in Hospitals, many types of clinicians can provide palliative care in hospitals, including general internists, nurses, geriatricians, oncologists, hospitalists, and others, yet hospitalists are likely to emerge as the predominant providers of palliative care to hospitalized patients.4 That 75% of Americans die in institutionalized settings, where hospitalists are becoming the dominant providers of care, will drive this prediction.5 In addition, hospitalists are increasingly leading efforts in quality improvement, patient satisfaction, and patient safety.6 Of necessity these initiatives will involve the sickest hospitalized patients and will look to palliative care as a proven response for improving quality and increasing satisfaction.

Hospital medicine and palliative care have other aspects in common that make a melding of the two fields beneficial. Both fields recognize and emphasize the need for interdisciplinary care; good communication between members of the health care team and between health care providers and patients; and timely, effective, and responsible discharge planning. Finally, both fields often rely on multiple sources of funding including professional fee billing and support from the hospital for the added value that programs provide. Sharing so many issues in common should help hospital medicine and palliative care form strong links.

For these links to take hold and for the benefits of this partnership to bear fruit, members of both fields, and especially those with a foot in each, need to reach out. For hospitalists this means getting educated in palliative care, an area for which hospitalists recognize they are underprepared.7 Each hospitalist must be able to provide primary, basic palliative care to each patient.8 Some hospitalists will discover the rewards of palliative care and seek further training and even board certification. These hospitalists can start or join palliative care teams in their institutions. Finally, some hospitalists will become experts in palliative care and join or lead palliative care programs at tertiary care centers. In turn, palliative care providers must reach out to hospitalists. Palliative care clinicians should seek out hospitalists at their institutions and hospices should contact hospitalists at their local hospitals. These programs need to invite hospitalists to participate in the palliative care team and suggest how their services can help the patients of hospitalists. This natural alliance can come about only if both sides reach out.

A partnership between palliative care and hospital medicine will be good for patients and their families as well as for each field, as hospitalists enable realization of the goal of providing palliative care to every patient in the United States. In addition, this partnership will be good for hospitalists who embrace this work. Palliative care can connect us to the humanism and compassion that brought so many of us to medicine and can serve as an antidote to burnout. Furthermore, by caring for patients with life‐threatening illnesses we remember that our time is limited and that each day is a gift. We recognize the importance of making the most of our time regardless of how long we have and of choosing carefully how and with whom we spend our time.

In this first issue of JHM, Dr. Meier makes a strong argument for the need and continued growth of palliative care in hospitals, lays out a strategy for achieving this growth through education and program development, and in doing so, opens the door to hope for the future. Through palliative care we can offer patients hope for healing when cure is not possible, for comfort in the face of suffering, and for what can still be despite all that cannot. The possibility that hospitalists could provide all patients access to palliative care is cause enough for hope. The knowledge that hospitalists will play a major role in making this possibility a reality and may become the predominant providers of palliative care can make that hope a reality.

Congratulations to the Society of Hospital Medicine (SHM) for launching this important new journal. Congratulations as well to the SHM members, who have identified an important patient care need and moved to meet that need by defining the special competencies of the hospitalist. The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (the Core Competencies), by the Society of Hospital Medicine, accompanies this inaugural issue of the Journal of Hospital Medicine.

As a geriatrician, I can personally attest to the need to have skilled physicians on‐site in the hospital to care for elderly patients. Older people with complex illnesses are susceptible to multiple hospital complications, which often present subtly but can quickly turn into life‐threateningbut potentially reversibleillnesses. Given the demography of hospitalized patients in the 21st century in the United States, every good hospitalist also has to be a good geriatrician.

As evidenced in the Core Competencies, the hospitalist community recognizes as well the importance of developing expertise in caring for both the medical and surgical conditions of patients. Providing attentive diagnostic and management skills to pre‐ and postoperative patients, especially those with preexisting chronic conditions, will surely improve outcomes.

Continuity and coordination within a single hospital episode and across multiple hospitalizations are major challenges for our fragmented and often chaotic health care system. The Core Competencies recognizes the centrality of systems‐based practice to the foundation of hospitalist skills. We at the American Board of Internal Medicine (ABIM) share the belief that every physician must understand the principles of quality improvement; accordingly, this competency is now demanded of every resident and is assessed in the maintenance of certification (MOC) of every internal medicine specialist. That hospitalists have grabbed the quality‐improvement mantle is a welcome development and shows that hospitalists are likely to become key teachers of systems‐based care and quality‐improvement competencies in teaching hospitals.

The growth of hospital medicine in the United States has raised many important issues concerning quality of care that cannot be totally solved by the creation of a hospital‐based practice discipline. The vexing issues of continuity of care, continuing relationships, and efficient management of resources over the entire trajectory of a patient's illness (not just during a hospitalization) are not fundamentally addressed by the existence of hospital medicine as a discipline. However, hospitalists can partner with others in the health care system to create a clinically meaningful continuum that truly would serve patients, especially those with the greatest need such as the elderly and the chronically ill. The ABIM has been in discussions with the Society of Hospital Medicine, the Society of General Internal Medicine, the American College of Physicians, and the Alliance of Academic Internal Medicine to develop a response to the important and evolving arenas of specific expertise in hospital and outpatient medicine. The Core Competencies in Hospital Medicine will significantly help to further these discussions.

Let me raise two concerns whose resolution will need the input of hospitalists as the discipline of hospital medicine becomes more mature. First, hospitalist models are quite variable. Many academic physicians who call themselves hospitalists attend on an inpatient service 2, 3, or 5 months a year and still see outpatients. Many physicians who consider themselves general internists (and not hospitalists) have a weekly half‐day clinic and attend on the wards 3 months a year. Which is a hospitalist? Does it matter? Will the definition of a hospitalist be based on achievement of the competencies described here, or will it be based primarily on the amount of time in hospital‐based practice? This will be an important question to resolve, especially as we embark on a path toward offering a hospitalist credential.

Second, general internal medicine is becoming an increasingly vital part of the continuum of care for patients with multiple complex chronic illnesses, at the same time that poor reimbursement has undermined its vitality and threatens its existence. (Family medicine is also suffering from reduced interest among medical students.) Because most institutions function on an each tub on its own bottom model, it is unrealistic to expect the practice of ambulatory general internal medicine to support itself. Generalist practices thrive in integrated group models. These practices recognize the importance of the physician who provides a coordinating function for all the specialists who care for a complex patient. Such an outpatient generalist thus reduces excess and unnecessary care while identifying gaps where relevant specialties could improve function or quality of life. Ambulatory practice also requires skill in systems and improvement, but few of the 80% of generalists who practice in small groups have sufficient infrastructure and resources to support practice redesign. Indeed, a new report from Mercer consultants coined the phrase ambulatory intensivists to identify practices with Medicare patients and recognizes that these practices are every bit as intense and complex and in need of systems management as an inpatient practice. What the complex patient needs is a seamless interface between the two.

The authors of the Core Competencies in Hospital Medicine hope that this document will stand the test of time as it evolves. I would urge that the document remain flexiblea living documentbecause the one thing about which we can be sure is that hospital practice will change. More and more critical care will be delivered throughout the hospital, more and more of all kinds of care will be performed outside the hospital, and the nature of hospitals will surely change with shifts in reimbursement that we cannot yet imagine but that might be right around the corner. If able to provide hands‐on care less expensively, physician assistants and nurse‐practitioners functioning according to protocols developed by systems thinkers, only some of whom will be physicians, may replace the physician in some settings. What will become of hospitalists as these systems change? I hope that hospitalists, together with other general internists, will be at the forefront of ensuring that the changes in practice that result from the combination of new technologies and financing structures will ultimately also serve the needs of patients. The patient is at the center of our discipline and, as articulated so clearly in the Core Competencies, should always be the focus of our future thinking.

Congratulations to the Society of Hospital Medicine (SHM) for launching this important new journal. Congratulations as well to the SHM members, who have identified an important patient care need and moved to meet that need by defining the special competencies of the hospitalist. The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (the Core Competencies), by the Society of Hospital Medicine, accompanies this inaugural issue of the Journal of Hospital Medicine.

As a geriatrician, I can personally attest to the need to have skilled physicians on‐site in the hospital to care for elderly patients. Older people with complex illnesses are susceptible to multiple hospital complications, which often present subtly but can quickly turn into life‐threateningbut potentially reversibleillnesses. Given the demography of hospitalized patients in the 21st century in the United States, every good hospitalist also has to be a good geriatrician.

As evidenced in the Core Competencies, the hospitalist community recognizes as well the importance of developing expertise in caring for both the medical and surgical conditions of patients. Providing attentive diagnostic and management skills to pre‐ and postoperative patients, especially those with preexisting chronic conditions, will surely improve outcomes.

Continuity and coordination within a single hospital episode and across multiple hospitalizations are major challenges for our fragmented and often chaotic health care system. The Core Competencies recognizes the centrality of systems‐based practice to the foundation of hospitalist skills. We at the American Board of Internal Medicine (ABIM) share the belief that every physician must understand the principles of quality improvement; accordingly, this competency is now demanded of every resident and is assessed in the maintenance of certification (MOC) of every internal medicine specialist. That hospitalists have grabbed the quality‐improvement mantle is a welcome development and shows that hospitalists are likely to become key teachers of systems‐based care and quality‐improvement competencies in teaching hospitals.

The growth of hospital medicine in the United States has raised many important issues concerning quality of care that cannot be totally solved by the creation of a hospital‐based practice discipline. The vexing issues of continuity of care, continuing relationships, and efficient management of resources over the entire trajectory of a patient's illness (not just during a hospitalization) are not fundamentally addressed by the existence of hospital medicine as a discipline. However, hospitalists can partner with others in the health care system to create a clinically meaningful continuum that truly would serve patients, especially those with the greatest need such as the elderly and the chronically ill. The ABIM has been in discussions with the Society of Hospital Medicine, the Society of General Internal Medicine, the American College of Physicians, and the Alliance of Academic Internal Medicine to develop a response to the important and evolving arenas of specific expertise in hospital and outpatient medicine. The Core Competencies in Hospital Medicine will significantly help to further these discussions.

Let me raise two concerns whose resolution will need the input of hospitalists as the discipline of hospital medicine becomes more mature. First, hospitalist models are quite variable. Many academic physicians who call themselves hospitalists attend on an inpatient service 2, 3, or 5 months a year and still see outpatients. Many physicians who consider themselves general internists (and not hospitalists) have a weekly half‐day clinic and attend on the wards 3 months a year. Which is a hospitalist? Does it matter? Will the definition of a hospitalist be based on achievement of the competencies described here, or will it be based primarily on the amount of time in hospital‐based practice? This will be an important question to resolve, especially as we embark on a path toward offering a hospitalist credential.

Second, general internal medicine is becoming an increasingly vital part of the continuum of care for patients with multiple complex chronic illnesses, at the same time that poor reimbursement has undermined its vitality and threatens its existence. (Family medicine is also suffering from reduced interest among medical students.) Because most institutions function on an each tub on its own bottom model, it is unrealistic to expect the practice of ambulatory general internal medicine to support itself. Generalist practices thrive in integrated group models. These practices recognize the importance of the physician who provides a coordinating function for all the specialists who care for a complex patient. Such an outpatient generalist thus reduces excess and unnecessary care while identifying gaps where relevant specialties could improve function or quality of life. Ambulatory practice also requires skill in systems and improvement, but few of the 80% of generalists who practice in small groups have sufficient infrastructure and resources to support practice redesign. Indeed, a new report from Mercer consultants coined the phrase ambulatory intensivists to identify practices with Medicare patients and recognizes that these practices are every bit as intense and complex and in need of systems management as an inpatient practice. What the complex patient needs is a seamless interface between the two.

The authors of the Core Competencies in Hospital Medicine hope that this document will stand the test of time as it evolves. I would urge that the document remain flexiblea living documentbecause the one thing about which we can be sure is that hospital practice will change. More and more critical care will be delivered throughout the hospital, more and more of all kinds of care will be performed outside the hospital, and the nature of hospitals will surely change with shifts in reimbursement that we cannot yet imagine but that might be right around the corner. If able to provide hands‐on care less expensively, physician assistants and nurse‐practitioners functioning according to protocols developed by systems thinkers, only some of whom will be physicians, may replace the physician in some settings. What will become of hospitalists as these systems change? I hope that hospitalists, together with other general internists, will be at the forefront of ensuring that the changes in practice that result from the combination of new technologies and financing structures will ultimately also serve the needs of patients. The patient is at the center of our discipline and, as articulated so clearly in the Core Competencies, should always be the focus of our future thinking.

Congratulations to the Society of Hospital Medicine (SHM) for launching this important new journal. Congratulations as well to the SHM members, who have identified an important patient care need and moved to meet that need by defining the special competencies of the hospitalist. The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (the Core Competencies), by the Society of Hospital Medicine, accompanies this inaugural issue of the Journal of Hospital Medicine.

As a geriatrician, I can personally attest to the need to have skilled physicians on‐site in the hospital to care for elderly patients. Older people with complex illnesses are susceptible to multiple hospital complications, which often present subtly but can quickly turn into life‐threateningbut potentially reversibleillnesses. Given the demography of hospitalized patients in the 21st century in the United States, every good hospitalist also has to be a good geriatrician.

As evidenced in the Core Competencies, the hospitalist community recognizes as well the importance of developing expertise in caring for both the medical and surgical conditions of patients. Providing attentive diagnostic and management skills to pre‐ and postoperative patients, especially those with preexisting chronic conditions, will surely improve outcomes.

Continuity and coordination within a single hospital episode and across multiple hospitalizations are major challenges for our fragmented and often chaotic health care system. The Core Competencies recognizes the centrality of systems‐based practice to the foundation of hospitalist skills. We at the American Board of Internal Medicine (ABIM) share the belief that every physician must understand the principles of quality improvement; accordingly, this competency is now demanded of every resident and is assessed in the maintenance of certification (MOC) of every internal medicine specialist. That hospitalists have grabbed the quality‐improvement mantle is a welcome development and shows that hospitalists are likely to become key teachers of systems‐based care and quality‐improvement competencies in teaching hospitals.

The growth of hospital medicine in the United States has raised many important issues concerning quality of care that cannot be totally solved by the creation of a hospital‐based practice discipline. The vexing issues of continuity of care, continuing relationships, and efficient management of resources over the entire trajectory of a patient's illness (not just during a hospitalization) are not fundamentally addressed by the existence of hospital medicine as a discipline. However, hospitalists can partner with others in the health care system to create a clinically meaningful continuum that truly would serve patients, especially those with the greatest need such as the elderly and the chronically ill. The ABIM has been in discussions with the Society of Hospital Medicine, the Society of General Internal Medicine, the American College of Physicians, and the Alliance of Academic Internal Medicine to develop a response to the important and evolving arenas of specific expertise in hospital and outpatient medicine. The Core Competencies in Hospital Medicine will significantly help to further these discussions.

Let me raise two concerns whose resolution will need the input of hospitalists as the discipline of hospital medicine becomes more mature. First, hospitalist models are quite variable. Many academic physicians who call themselves hospitalists attend on an inpatient service 2, 3, or 5 months a year and still see outpatients. Many physicians who consider themselves general internists (and not hospitalists) have a weekly half‐day clinic and attend on the wards 3 months a year. Which is a hospitalist? Does it matter? Will the definition of a hospitalist be based on achievement of the competencies described here, or will it be based primarily on the amount of time in hospital‐based practice? This will be an important question to resolve, especially as we embark on a path toward offering a hospitalist credential.

Second, general internal medicine is becoming an increasingly vital part of the continuum of care for patients with multiple complex chronic illnesses, at the same time that poor reimbursement has undermined its vitality and threatens its existence. (Family medicine is also suffering from reduced interest among medical students.) Because most institutions function on an each tub on its own bottom model, it is unrealistic to expect the practice of ambulatory general internal medicine to support itself. Generalist practices thrive in integrated group models. These practices recognize the importance of the physician who provides a coordinating function for all the specialists who care for a complex patient. Such an outpatient generalist thus reduces excess and unnecessary care while identifying gaps where relevant specialties could improve function or quality of life. Ambulatory practice also requires skill in systems and improvement, but few of the 80% of generalists who practice in small groups have sufficient infrastructure and resources to support practice redesign. Indeed, a new report from Mercer consultants coined the phrase ambulatory intensivists to identify practices with Medicare patients and recognizes that these practices are every bit as intense and complex and in need of systems management as an inpatient practice. What the complex patient needs is a seamless interface between the two.

The authors of the Core Competencies in Hospital Medicine hope that this document will stand the test of time as it evolves. I would urge that the document remain flexiblea living documentbecause the one thing about which we can be sure is that hospital practice will change. More and more critical care will be delivered throughout the hospital, more and more of all kinds of care will be performed outside the hospital, and the nature of hospitals will surely change with shifts in reimbursement that we cannot yet imagine but that might be right around the corner. If able to provide hands‐on care less expensively, physician assistants and nurse‐practitioners functioning according to protocols developed by systems thinkers, only some of whom will be physicians, may replace the physician in some settings. What will become of hospitalists as these systems change? I hope that hospitalists, together with other general internists, will be at the forefront of ensuring that the changes in practice that result from the combination of new technologies and financing structures will ultimately also serve the needs of patients. The patient is at the center of our discipline and, as articulated so clearly in the Core Competencies, should always be the focus of our future thinking.