Editorial

A looming gap in the supply of intensivists prompted the American College of Chest Physicians (ACCP), the American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM) to publish a report in 2000 by the Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). This study predicted that beginning in 2007 a shortfall would become apparent and steadily increase to 22% by 2020 and to 35% by 2030. Subsequent reports have reiterated those projections, including a report to Congress in 2006 by the U.S. Department of Health and Human Services/Health Resources and Services Administration.14

The concern regarding the shortage of intensivists has been increased by the growing evidence that supports improved critical care outcomesespecially decreased intensive care unit (ICU) and hospital mortalitywith intensivist staffing of ICUs.5, 6 Based on this data and on recommendations from the Society of Critical Care Medicine, the Leapfrog Group made onsite, high‐intensity ICU staffing with intensivists 1 of their 4 leaps.7 A paper by Pronovost et al.8 published in 2001, however, noted that in order for all ICUs in the United States to meet the Leapfrog ICU Physician Staffing (IPS) standard, the number of intensivists would need to increase by a factor of 2.6. Interestingly, a retrospective study published in the Annals of Internal Medicine in June of 2008 by Levy et al.9 suggested that mortality rates may actually be higher in intensivist‐staffed ICUs. An accompanying editorial raised concerns about limitations of the study design, but endorsed Levy's recommendation that more carefully designed, prospective studies were needed; (ie, we still are not certain as to optimal physician staffing for the care of patients requiring the sophisticated treatment available only in an ICU.)10

The health policy challenge, however, remains clear: while there is basic consensus that care of critically ill patients by intensivists improves outcomes, the reality is that the shortage of intensivists in the United States as predicted by the COMPACCS report will only increase, leading some to refer to this as a healthcare crisis. Two major task forces attempted to address this situation, resulting in the publication of the 2004 Framing Options for Critical Care in the United States (FOCCUS) report, The Critical Care Medicine Crisis: A Call for Federal ActionA White Paper from the Critical Care Professional Societies; and the 2007 Prioritizing the Organization and Management of Intensive Care Services in the Unites States (PrOMIS) Conference Report.11, 12 Both reports made specific recommendations including, for example, development of uniform standards for accreditation of institutional critical care capacity, identification and endorsement of core competencies in critical care, investment in health services research, the use of uniform protocols for ICU care, leverage of information technology to promote standardization and improve efficiency, and the development of incentives to attract healthcare professionals to critical care medicine.

A Possible Solution: The Role of Hospitalists

Multiple important efforts are already underway to increase the competency of professionals providing critical care services including the Society of Critical Care's Fundamentals in Critical Care Support (FCCS) program. Additionally, physician assistants and nurse practitioners are playing an increasingly important role as members of critical care services. As another component of this collaborative effort, the PrOMIS Report noted the potential impact of hospitalists in addressing this crisis.

As early as 1999, surveys revealed that as many as 35% of hospitalists were providing critical care services.13 According to the 2005/2006 Society of Hospital Medicine (SHM) National Survey, that number has increased to 75% with a low of 66% in the eastern United States and a high of 84% in the western United States. In community hospitals, 87% of hospitalists care for patients in the ICU, and 30% provide critical care services in academic medical centers.13 While there is some research14, 15 and many anecdotal reports that suggest hospitalists perform well in the ICU, there is, unfortunately, little data addressing outcomes for patients cared for by hospitalists. The results from a prospective, severity‐adjusted study from the Emory University Section of Hospital Medicine and the Division of Pulmonary/Critical Care Medicine examining outcomes for critical care patients cared for by hospitalists with criteria for Pulmonary/Intensivist consults vs. patients cared for by the Pulmonary/Critical Care Medical ICU Service await peer‐review publication.

Despite the lack of outcome data regarding adult hospitalists, it is clear that by default they are already providing a significant proportion of critical care services across the healthcare system, including in tertiary care centers. The two primary models of care include: (1) hospitalists serving as the primary provider without critical care consultant services and (2) comanagement of patients where intensivists and hospitalists collaborate. These collaborative models involve hospitalists actively co‐managing critical care patients along with intensivists or hospitalists managing less critically ill patients with intensivist consultation when indicated. In hospitals lacking intensivists, hospitalists often manage critically ill patients either with intensivist phone consultation, or with the intent to stabilize and transfer. Electronic ICUs are another expanding model of care that provide intensivist support to hospitalists and other primary care providersdecreasing ICU length of stay and severity‐adjusted ICU mortality.16 There are now 40 electronic ICU programs in the United States, and that number continues to grow.

In 2003, there were approximately 10,000 hospitalists in the United States,17 and recent data from an American Hospital Association survey indicates that the number has grown to about 28,000 in 2009. Recent research also documents that hospitalists are soon likely to care for the majority of elderly hospitalized patients in America.18 Aware that the number of intensivists is unlikely to change significantly over the next 25 years the question is no longer if hospitalists should be in the ICU; rather, the question is how to assure quality and improved clinical outcomes through enhanced collaboration between Hospital Medicine and Critical Care Medicine.

Recommendations

There are 3 steps that should be taken urgently to meet this challenge:

• 1

  Per the recommendation of the FOCCUS Report and the PrOMIS Conference Report, uniform protocols for intensive care treatmentmany of which already exist but are not used consistentlyshould be identified and implemented across all ICUs regardless of the level or certification of the provider.

• 2

  Also per the PrOMIS Report, a process for certification of physicians providing critical care services should be established by the appropriate governing bodies, including the Society for Critical Care Medicine, the Society of Hospital Medicine, and the American Thoracic Society, among others. While the PrOMIS Report called for cross‐training of hospital‐based providers to provide intensive care services in lower tier hospitals, a more realistic recommendation given current involvement of hospitalists in the provision of critical care services in secondary and tertiary centers is a competency‐assurance process that includes hospitalists practicing at all levels. This would not be equivalent to board certification, but would be based on a rigorous, comprehensive education and skills training process leading to recognition that would distinguish the recipient as having competencies beyond those obtained in internal medicine residency training. Models for certification could include 4‐month onsite training or a distance learning curriculum with regular blocks of onsite training. Another strategy might be for appropriate governing bodies to establish basic criteria for competency that would then be provided by individual institutions. Emory University, for example, has developed a pilot program incorporating significant components from the European Society for Critical Care Medicine's Syllabus for Competency Based Training in Intensive Care Medicine in Europe.19 Other institutions are also exploring the creation of certification/competency programs. Minimally, and prior to any decision about establishing formal criteria, institutions could identify designated hospitalists within groups who have particular interest and ability in the critical care setting. These providers, based on models already in place at sites across the United States, could, as an example, be required to spend a minimum of 50% of their clinical time in the ICU and to complete 10 to 20 hours of critical care continuing medical education (CME) per year. One strategy to address this issue and develop clear consensus and guidelines would be to convene the often discussed PrOMIS II working group.

• 3

  Per both the FOCCUS Report and the PrOMIS Report as well as a number of other publications,19 health services research in ICU care should be identified, funded, and implemented. A major focus of this effort should be the evaluation of clinical outcomes for ICU patients cared for by hospitalists. This research is needed for at least 2 reasons:

• As noted, there is little research that has assessed hospitalists' impact on outcomes of ICU patients. Hospitalists are already caring for patients in ICUs across the United States and given the research that has identified the outcomes benefit provided by intensivists, it is important to know objectively if hospitalists have similar levels of performance.

• An increasing number of hospitals and healthcare systems are now committed to achieving the Leapfrog IPS standard‐a challenge for many because of the difficulty with recruiting intensivists. If new research reveals that hospitalists with board certification in Internal Medicine, and more specifically with additional competency training in critical care, also improve outcomes in the ICU then it may be possible for Leapfrog to revise the criteria for meeting the IPS standard.

Summary

As discussed in a number of publications,20 including an article from the Mayo Clinic in the April 2009 edition of Chest entitled, Physicians Staffing Models and Patient Safety in the ICU,21 along with an accompanying editorial, Should Intensive Care Medicine Itself Be on the Critical List,22 creative and realistic solutions are urgently needed to address the crisis in critical care in the U.S. Collaborative efforts between Critical Care Medicine and Hospital Medicine to meet this challenge benefit all involved:

• Intensivists will continue to direct tertiary care units and/or co‐manage patients in tertiary and secondary care centers with Hospitalists.

• Hospitalists will benefit by having the opportunity to secure critical care competency training and by having their appropriate role in the ICU defined.

• All secondary and tertiary care institutions will have a realistic opportunity to meet Leapfrog IPS criteria and therefore benefit from the potential decreased length of stay (LOS), decreased mortality, and improved quality.

• Patients benefit by receiving uniform, evidence‐based, protocol‐driven care.

There is now a need and an opportunity for ACCP, SCCM, ATS, and the American Association of Critical Care Nurses (ACCN), to expand the important work they have already begun through the Critical Care Workforce Partnership. The Partnership should join with the SHM to take the lead in supporting and promoting this collaborative relationship between intensivists and hospitalists: aware that in the final analysis, it is the patients we serve who will benefit the most.

A looming gap in the supply of intensivists prompted the American College of Chest Physicians (ACCP), the American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM) to publish a report in 2000 by the Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). This study predicted that beginning in 2007 a shortfall would become apparent and steadily increase to 22% by 2020 and to 35% by 2030. Subsequent reports have reiterated those projections, including a report to Congress in 2006 by the U.S. Department of Health and Human Services/Health Resources and Services Administration.14

The concern regarding the shortage of intensivists has been increased by the growing evidence that supports improved critical care outcomesespecially decreased intensive care unit (ICU) and hospital mortalitywith intensivist staffing of ICUs.5, 6 Based on this data and on recommendations from the Society of Critical Care Medicine, the Leapfrog Group made onsite, high‐intensity ICU staffing with intensivists 1 of their 4 leaps.7 A paper by Pronovost et al.8 published in 2001, however, noted that in order for all ICUs in the United States to meet the Leapfrog ICU Physician Staffing (IPS) standard, the number of intensivists would need to increase by a factor of 2.6. Interestingly, a retrospective study published in the Annals of Internal Medicine in June of 2008 by Levy et al.9 suggested that mortality rates may actually be higher in intensivist‐staffed ICUs. An accompanying editorial raised concerns about limitations of the study design, but endorsed Levy's recommendation that more carefully designed, prospective studies were needed; (ie, we still are not certain as to optimal physician staffing for the care of patients requiring the sophisticated treatment available only in an ICU.)10

The health policy challenge, however, remains clear: while there is basic consensus that care of critically ill patients by intensivists improves outcomes, the reality is that the shortage of intensivists in the United States as predicted by the COMPACCS report will only increase, leading some to refer to this as a healthcare crisis. Two major task forces attempted to address this situation, resulting in the publication of the 2004 Framing Options for Critical Care in the United States (FOCCUS) report, The Critical Care Medicine Crisis: A Call for Federal ActionA White Paper from the Critical Care Professional Societies; and the 2007 Prioritizing the Organization and Management of Intensive Care Services in the Unites States (PrOMIS) Conference Report.11, 12 Both reports made specific recommendations including, for example, development of uniform standards for accreditation of institutional critical care capacity, identification and endorsement of core competencies in critical care, investment in health services research, the use of uniform protocols for ICU care, leverage of information technology to promote standardization and improve efficiency, and the development of incentives to attract healthcare professionals to critical care medicine.

A Possible Solution: The Role of Hospitalists

Multiple important efforts are already underway to increase the competency of professionals providing critical care services including the Society of Critical Care's Fundamentals in Critical Care Support (FCCS) program. Additionally, physician assistants and nurse practitioners are playing an increasingly important role as members of critical care services. As another component of this collaborative effort, the PrOMIS Report noted the potential impact of hospitalists in addressing this crisis.

As early as 1999, surveys revealed that as many as 35% of hospitalists were providing critical care services.13 According to the 2005/2006 Society of Hospital Medicine (SHM) National Survey, that number has increased to 75% with a low of 66% in the eastern United States and a high of 84% in the western United States. In community hospitals, 87% of hospitalists care for patients in the ICU, and 30% provide critical care services in academic medical centers.13 While there is some research14, 15 and many anecdotal reports that suggest hospitalists perform well in the ICU, there is, unfortunately, little data addressing outcomes for patients cared for by hospitalists. The results from a prospective, severity‐adjusted study from the Emory University Section of Hospital Medicine and the Division of Pulmonary/Critical Care Medicine examining outcomes for critical care patients cared for by hospitalists with criteria for Pulmonary/Intensivist consults vs. patients cared for by the Pulmonary/Critical Care Medical ICU Service await peer‐review publication.

Despite the lack of outcome data regarding adult hospitalists, it is clear that by default they are already providing a significant proportion of critical care services across the healthcare system, including in tertiary care centers. The two primary models of care include: (1) hospitalists serving as the primary provider without critical care consultant services and (2) comanagement of patients where intensivists and hospitalists collaborate. These collaborative models involve hospitalists actively co‐managing critical care patients along with intensivists or hospitalists managing less critically ill patients with intensivist consultation when indicated. In hospitals lacking intensivists, hospitalists often manage critically ill patients either with intensivist phone consultation, or with the intent to stabilize and transfer. Electronic ICUs are another expanding model of care that provide intensivist support to hospitalists and other primary care providersdecreasing ICU length of stay and severity‐adjusted ICU mortality.16 There are now 40 electronic ICU programs in the United States, and that number continues to grow.

In 2003, there were approximately 10,000 hospitalists in the United States,17 and recent data from an American Hospital Association survey indicates that the number has grown to about 28,000 in 2009. Recent research also documents that hospitalists are soon likely to care for the majority of elderly hospitalized patients in America.18 Aware that the number of intensivists is unlikely to change significantly over the next 25 years the question is no longer if hospitalists should be in the ICU; rather, the question is how to assure quality and improved clinical outcomes through enhanced collaboration between Hospital Medicine and Critical Care Medicine.

Recommendations

There are 3 steps that should be taken urgently to meet this challenge:

• 1

  Per the recommendation of the FOCCUS Report and the PrOMIS Conference Report, uniform protocols for intensive care treatmentmany of which already exist but are not used consistentlyshould be identified and implemented across all ICUs regardless of the level or certification of the provider.

• 2

  Also per the PrOMIS Report, a process for certification of physicians providing critical care services should be established by the appropriate governing bodies, including the Society for Critical Care Medicine, the Society of Hospital Medicine, and the American Thoracic Society, among others. While the PrOMIS Report called for cross‐training of hospital‐based providers to provide intensive care services in lower tier hospitals, a more realistic recommendation given current involvement of hospitalists in the provision of critical care services in secondary and tertiary centers is a competency‐assurance process that includes hospitalists practicing at all levels. This would not be equivalent to board certification, but would be based on a rigorous, comprehensive education and skills training process leading to recognition that would distinguish the recipient as having competencies beyond those obtained in internal medicine residency training. Models for certification could include 4‐month onsite training or a distance learning curriculum with regular blocks of onsite training. Another strategy might be for appropriate governing bodies to establish basic criteria for competency that would then be provided by individual institutions. Emory University, for example, has developed a pilot program incorporating significant components from the European Society for Critical Care Medicine's Syllabus for Competency Based Training in Intensive Care Medicine in Europe.19 Other institutions are also exploring the creation of certification/competency programs. Minimally, and prior to any decision about establishing formal criteria, institutions could identify designated hospitalists within groups who have particular interest and ability in the critical care setting. These providers, based on models already in place at sites across the United States, could, as an example, be required to spend a minimum of 50% of their clinical time in the ICU and to complete 10 to 20 hours of critical care continuing medical education (CME) per year. One strategy to address this issue and develop clear consensus and guidelines would be to convene the often discussed PrOMIS II working group.

• 3

  Per both the FOCCUS Report and the PrOMIS Report as well as a number of other publications,19 health services research in ICU care should be identified, funded, and implemented. A major focus of this effort should be the evaluation of clinical outcomes for ICU patients cared for by hospitalists. This research is needed for at least 2 reasons:

• As noted, there is little research that has assessed hospitalists' impact on outcomes of ICU patients. Hospitalists are already caring for patients in ICUs across the United States and given the research that has identified the outcomes benefit provided by intensivists, it is important to know objectively if hospitalists have similar levels of performance.

• An increasing number of hospitals and healthcare systems are now committed to achieving the Leapfrog IPS standard‐a challenge for many because of the difficulty with recruiting intensivists. If new research reveals that hospitalists with board certification in Internal Medicine, and more specifically with additional competency training in critical care, also improve outcomes in the ICU then it may be possible for Leapfrog to revise the criteria for meeting the IPS standard.

Summary

As discussed in a number of publications,20 including an article from the Mayo Clinic in the April 2009 edition of Chest entitled, Physicians Staffing Models and Patient Safety in the ICU,21 along with an accompanying editorial, Should Intensive Care Medicine Itself Be on the Critical List,22 creative and realistic solutions are urgently needed to address the crisis in critical care in the U.S. Collaborative efforts between Critical Care Medicine and Hospital Medicine to meet this challenge benefit all involved:

• Intensivists will continue to direct tertiary care units and/or co‐manage patients in tertiary and secondary care centers with Hospitalists.

• Hospitalists will benefit by having the opportunity to secure critical care competency training and by having their appropriate role in the ICU defined.

• All secondary and tertiary care institutions will have a realistic opportunity to meet Leapfrog IPS criteria and therefore benefit from the potential decreased length of stay (LOS), decreased mortality, and improved quality.

• Patients benefit by receiving uniform, evidence‐based, protocol‐driven care.

There is now a need and an opportunity for ACCP, SCCM, ATS, and the American Association of Critical Care Nurses (ACCN), to expand the important work they have already begun through the Critical Care Workforce Partnership. The Partnership should join with the SHM to take the lead in supporting and promoting this collaborative relationship between intensivists and hospitalists: aware that in the final analysis, it is the patients we serve who will benefit the most.

A looming gap in the supply of intensivists prompted the American College of Chest Physicians (ACCP), the American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM) to publish a report in 2000 by the Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). This study predicted that beginning in 2007 a shortfall would become apparent and steadily increase to 22% by 2020 and to 35% by 2030. Subsequent reports have reiterated those projections, including a report to Congress in 2006 by the U.S. Department of Health and Human Services/Health Resources and Services Administration.14

The concern regarding the shortage of intensivists has been increased by the growing evidence that supports improved critical care outcomesespecially decreased intensive care unit (ICU) and hospital mortalitywith intensivist staffing of ICUs.5, 6 Based on this data and on recommendations from the Society of Critical Care Medicine, the Leapfrog Group made onsite, high‐intensity ICU staffing with intensivists 1 of their 4 leaps.7 A paper by Pronovost et al.8 published in 2001, however, noted that in order for all ICUs in the United States to meet the Leapfrog ICU Physician Staffing (IPS) standard, the number of intensivists would need to increase by a factor of 2.6. Interestingly, a retrospective study published in the Annals of Internal Medicine in June of 2008 by Levy et al.9 suggested that mortality rates may actually be higher in intensivist‐staffed ICUs. An accompanying editorial raised concerns about limitations of the study design, but endorsed Levy's recommendation that more carefully designed, prospective studies were needed; (ie, we still are not certain as to optimal physician staffing for the care of patients requiring the sophisticated treatment available only in an ICU.)10

The health policy challenge, however, remains clear: while there is basic consensus that care of critically ill patients by intensivists improves outcomes, the reality is that the shortage of intensivists in the United States as predicted by the COMPACCS report will only increase, leading some to refer to this as a healthcare crisis. Two major task forces attempted to address this situation, resulting in the publication of the 2004 Framing Options for Critical Care in the United States (FOCCUS) report, The Critical Care Medicine Crisis: A Call for Federal ActionA White Paper from the Critical Care Professional Societies; and the 2007 Prioritizing the Organization and Management of Intensive Care Services in the Unites States (PrOMIS) Conference Report.11, 12 Both reports made specific recommendations including, for example, development of uniform standards for accreditation of institutional critical care capacity, identification and endorsement of core competencies in critical care, investment in health services research, the use of uniform protocols for ICU care, leverage of information technology to promote standardization and improve efficiency, and the development of incentives to attract healthcare professionals to critical care medicine.

A Possible Solution: The Role of Hospitalists

Multiple important efforts are already underway to increase the competency of professionals providing critical care services including the Society of Critical Care's Fundamentals in Critical Care Support (FCCS) program. Additionally, physician assistants and nurse practitioners are playing an increasingly important role as members of critical care services. As another component of this collaborative effort, the PrOMIS Report noted the potential impact of hospitalists in addressing this crisis.

As early as 1999, surveys revealed that as many as 35% of hospitalists were providing critical care services.13 According to the 2005/2006 Society of Hospital Medicine (SHM) National Survey, that number has increased to 75% with a low of 66% in the eastern United States and a high of 84% in the western United States. In community hospitals, 87% of hospitalists care for patients in the ICU, and 30% provide critical care services in academic medical centers.13 While there is some research14, 15 and many anecdotal reports that suggest hospitalists perform well in the ICU, there is, unfortunately, little data addressing outcomes for patients cared for by hospitalists. The results from a prospective, severity‐adjusted study from the Emory University Section of Hospital Medicine and the Division of Pulmonary/Critical Care Medicine examining outcomes for critical care patients cared for by hospitalists with criteria for Pulmonary/Intensivist consults vs. patients cared for by the Pulmonary/Critical Care Medical ICU Service await peer‐review publication.

Despite the lack of outcome data regarding adult hospitalists, it is clear that by default they are already providing a significant proportion of critical care services across the healthcare system, including in tertiary care centers. The two primary models of care include: (1) hospitalists serving as the primary provider without critical care consultant services and (2) comanagement of patients where intensivists and hospitalists collaborate. These collaborative models involve hospitalists actively co‐managing critical care patients along with intensivists or hospitalists managing less critically ill patients with intensivist consultation when indicated. In hospitals lacking intensivists, hospitalists often manage critically ill patients either with intensivist phone consultation, or with the intent to stabilize and transfer. Electronic ICUs are another expanding model of care that provide intensivist support to hospitalists and other primary care providersdecreasing ICU length of stay and severity‐adjusted ICU mortality.16 There are now 40 electronic ICU programs in the United States, and that number continues to grow.

In 2003, there were approximately 10,000 hospitalists in the United States,17 and recent data from an American Hospital Association survey indicates that the number has grown to about 28,000 in 2009. Recent research also documents that hospitalists are soon likely to care for the majority of elderly hospitalized patients in America.18 Aware that the number of intensivists is unlikely to change significantly over the next 25 years the question is no longer if hospitalists should be in the ICU; rather, the question is how to assure quality and improved clinical outcomes through enhanced collaboration between Hospital Medicine and Critical Care Medicine.

Recommendations

There are 3 steps that should be taken urgently to meet this challenge:

• 1

  Per the recommendation of the FOCCUS Report and the PrOMIS Conference Report, uniform protocols for intensive care treatmentmany of which already exist but are not used consistentlyshould be identified and implemented across all ICUs regardless of the level or certification of the provider.

• 2

  Also per the PrOMIS Report, a process for certification of physicians providing critical care services should be established by the appropriate governing bodies, including the Society for Critical Care Medicine, the Society of Hospital Medicine, and the American Thoracic Society, among others. While the PrOMIS Report called for cross‐training of hospital‐based providers to provide intensive care services in lower tier hospitals, a more realistic recommendation given current involvement of hospitalists in the provision of critical care services in secondary and tertiary centers is a competency‐assurance process that includes hospitalists practicing at all levels. This would not be equivalent to board certification, but would be based on a rigorous, comprehensive education and skills training process leading to recognition that would distinguish the recipient as having competencies beyond those obtained in internal medicine residency training. Models for certification could include 4‐month onsite training or a distance learning curriculum with regular blocks of onsite training. Another strategy might be for appropriate governing bodies to establish basic criteria for competency that would then be provided by individual institutions. Emory University, for example, has developed a pilot program incorporating significant components from the European Society for Critical Care Medicine's Syllabus for Competency Based Training in Intensive Care Medicine in Europe.19 Other institutions are also exploring the creation of certification/competency programs. Minimally, and prior to any decision about establishing formal criteria, institutions could identify designated hospitalists within groups who have particular interest and ability in the critical care setting. These providers, based on models already in place at sites across the United States, could, as an example, be required to spend a minimum of 50% of their clinical time in the ICU and to complete 10 to 20 hours of critical care continuing medical education (CME) per year. One strategy to address this issue and develop clear consensus and guidelines would be to convene the often discussed PrOMIS II working group.

• 3

  Per both the FOCCUS Report and the PrOMIS Report as well as a number of other publications,19 health services research in ICU care should be identified, funded, and implemented. A major focus of this effort should be the evaluation of clinical outcomes for ICU patients cared for by hospitalists. This research is needed for at least 2 reasons:

• As noted, there is little research that has assessed hospitalists' impact on outcomes of ICU patients. Hospitalists are already caring for patients in ICUs across the United States and given the research that has identified the outcomes benefit provided by intensivists, it is important to know objectively if hospitalists have similar levels of performance.

• An increasing number of hospitals and healthcare systems are now committed to achieving the Leapfrog IPS standard‐a challenge for many because of the difficulty with recruiting intensivists. If new research reveals that hospitalists with board certification in Internal Medicine, and more specifically with additional competency training in critical care, also improve outcomes in the ICU then it may be possible for Leapfrog to revise the criteria for meeting the IPS standard.

Summary

As discussed in a number of publications,20 including an article from the Mayo Clinic in the April 2009 edition of Chest entitled, Physicians Staffing Models and Patient Safety in the ICU,21 along with an accompanying editorial, Should Intensive Care Medicine Itself Be on the Critical List,22 creative and realistic solutions are urgently needed to address the crisis in critical care in the U.S. Collaborative efforts between Critical Care Medicine and Hospital Medicine to meet this challenge benefit all involved:

• Intensivists will continue to direct tertiary care units and/or co‐manage patients in tertiary and secondary care centers with Hospitalists.

• Hospitalists will benefit by having the opportunity to secure critical care competency training and by having their appropriate role in the ICU defined.

• All secondary and tertiary care institutions will have a realistic opportunity to meet Leapfrog IPS criteria and therefore benefit from the potential decreased length of stay (LOS), decreased mortality, and improved quality.

• Patients benefit by receiving uniform, evidence‐based, protocol‐driven care.

There is now a need and an opportunity for ACCP, SCCM, ATS, and the American Association of Critical Care Nurses (ACCN), to expand the important work they have already begun through the Critical Care Workforce Partnership. The Partnership should join with the SHM to take the lead in supporting and promoting this collaborative relationship between intensivists and hospitalists: aware that in the final analysis, it is the patients we serve who will benefit the most.

Tears well up in my eyes. Not from pain, but frustration.

I pleaded with my 3‐year‐olds to come to me, so I could help them wash and dress for the day. Ordinarily, I would have come into their room, leaned over their beds, and whispered good morning into their ears.

Four days after surgery, I wasn't able to do that. Not without the crutches. Even with the crutches, I was moving slowly. I scooted up, put a few pillows behind my back, and carefully lifted up my leg. Putting on the knee immobilizer would take too long; I would only be crossing the hall.

Weighing less than 800 g, the immobilizer is an adjustable aluminum frame attached to foam rubber and 4 wide Velcro straps. It is a device of torment. I can never seem to find the proper fit. If it is too tight, my leg hurts and starts turning blue. When it is too loose, it pulls on my incision, multiplying the pain. You put it on while sitting, but you only discover whether it is too tight or too loose when you stand up.

With one foot on the floor at the edge of the bed, I took one crutch in hand, shifted to the left, and grabbed for the other crutch. I squeezed the handgrips of the crutches tightly and pulled myself up.

Put your weight on your hands, NOT your armpits, the instructions said. Easier said than done, because my armpits were now sore too.

Keep your crutches even with each other. I tried to remember to make an equilateral triangle with my good foot and 2 crutches, but the instructions only seemed to account for movement in a straight line.

Keep your elbows slightly bent and close to your sides to help keep the crutches under your arm. I am trying that too.

Lock your elbows. This instruction contradicts the previous one. Which should I follow?

Place your crutches 2 to 3 inches outside of each foot. How do I do this and keep my elbows close to my sides?

Swing your injured leg through first. But not too much, or I'll pole vault across the room.

After 3 steps, my leg started to throb, and my quadriceps went into a spasm. I needed to sit down, immediately.

Non‐weight‐bearing for next 4 weeks, was written on the doctor's note. Four weeks feels like an eternity. If my heel or toe even touched the ground, I felt an immediate throb of pain in my knee.

How do my orthopedic patients do it: those with broken hips and bad or broken knees, with hip replacements, or knee replacements? I was sensitive to their pain and could optimize control. Postoperatively, I could support gastrointestinal and other organ systems. I made sure that the basic weight‐bearing order was correct. I carefully followed the physical and/or occupational therapy recommendation for home, rehabilitation, or a nursing home. I spoke with families. Yet I did not dwell on activities of daily living nor how my patients felt to be dependent on others for simple things they needed. Some patients were non‐weight‐bearing for weeks, some for months, others never walked again. How can one deeply understand it if one has never experienced it?

According to Centers for Disease Control and Prevention (CDC) statistics,1 unintentional injuries are the leading cause of death between the ages of 1 and 44 years. Accidents are again the leading cause of death after age 75 years. More startling is the fact that these numbers have not been significantly reduced since these data were first collected. Nor do these numbers reveal the number of those debilitated, but still living. In my case, I was not playing basketball, water skiing, or rock climbing: I slipped and fell while stepping into a wading pool with my children, severing ligaments, tearing meniscus, and creating a hairline fracture of my tibia.

Expect to move slowly with the crutches. Yes, I am moving very slowly, only 1 to 2 feet with each stride. If I take a longer stride, I lose my balance.

Learn to sit down with the crutches. Learn to stand up. Learn to get into a car.

Learn to go up the stairs. Learn to go down the stairs.

Avoid wet surfaces. Otherwise you'll start skating and reinjure that knee.

It was effortless to think of patients and colleagues of mine. Mr. S., how do you do it? At age 30 years, he was quadriplegic from falling from a tree as a teenager. Mr. D, how about you, in a wheelchair, after being hit by a car and multiple postoperative leg infections and amputations: living in hotels, with estranged family and no social support. How did you do it, while we nagged you about controlling your glucose. Dr. J? The sadness fills my heart. At only 60 years old, my wonderful professor now made rounds in an electric wheelchair, the victim of amyotrophic lateral sclerosis (ALS). My fate, in comparison, is fortunate; my immobility only temporary. I can still think. And talk. And use a phone. And eat, as well as write this essay. And, best of all, read stories to my children. Be careful about this leg, I remind them. Don't come too close!

Maybe what life is trying to tell you is, slow down. In fact, it's forcing you to do that, a colleague and friend said. I had prided myself in thorough and compassionate doctoring. Now, having been a patient on crutches, I have a greater understanding of how limits to mobility can impact daily living on my patients after I discharge them. And the mundane subject of accident prevention has gained a new urgency.

Tears well up in my eyes. Not from pain, but frustration.

I pleaded with my 3‐year‐olds to come to me, so I could help them wash and dress for the day. Ordinarily, I would have come into their room, leaned over their beds, and whispered good morning into their ears.

Four days after surgery, I wasn't able to do that. Not without the crutches. Even with the crutches, I was moving slowly. I scooted up, put a few pillows behind my back, and carefully lifted up my leg. Putting on the knee immobilizer would take too long; I would only be crossing the hall.

Weighing less than 800 g, the immobilizer is an adjustable aluminum frame attached to foam rubber and 4 wide Velcro straps. It is a device of torment. I can never seem to find the proper fit. If it is too tight, my leg hurts and starts turning blue. When it is too loose, it pulls on my incision, multiplying the pain. You put it on while sitting, but you only discover whether it is too tight or too loose when you stand up.

With one foot on the floor at the edge of the bed, I took one crutch in hand, shifted to the left, and grabbed for the other crutch. I squeezed the handgrips of the crutches tightly and pulled myself up.

Put your weight on your hands, NOT your armpits, the instructions said. Easier said than done, because my armpits were now sore too.

Keep your crutches even with each other. I tried to remember to make an equilateral triangle with my good foot and 2 crutches, but the instructions only seemed to account for movement in a straight line.

Keep your elbows slightly bent and close to your sides to help keep the crutches under your arm. I am trying that too.

Lock your elbows. This instruction contradicts the previous one. Which should I follow?

Place your crutches 2 to 3 inches outside of each foot. How do I do this and keep my elbows close to my sides?

Swing your injured leg through first. But not too much, or I'll pole vault across the room.

After 3 steps, my leg started to throb, and my quadriceps went into a spasm. I needed to sit down, immediately.

Non‐weight‐bearing for next 4 weeks, was written on the doctor's note. Four weeks feels like an eternity. If my heel or toe even touched the ground, I felt an immediate throb of pain in my knee.

How do my orthopedic patients do it: those with broken hips and bad or broken knees, with hip replacements, or knee replacements? I was sensitive to their pain and could optimize control. Postoperatively, I could support gastrointestinal and other organ systems. I made sure that the basic weight‐bearing order was correct. I carefully followed the physical and/or occupational therapy recommendation for home, rehabilitation, or a nursing home. I spoke with families. Yet I did not dwell on activities of daily living nor how my patients felt to be dependent on others for simple things they needed. Some patients were non‐weight‐bearing for weeks, some for months, others never walked again. How can one deeply understand it if one has never experienced it?

According to Centers for Disease Control and Prevention (CDC) statistics,1 unintentional injuries are the leading cause of death between the ages of 1 and 44 years. Accidents are again the leading cause of death after age 75 years. More startling is the fact that these numbers have not been significantly reduced since these data were first collected. Nor do these numbers reveal the number of those debilitated, but still living. In my case, I was not playing basketball, water skiing, or rock climbing: I slipped and fell while stepping into a wading pool with my children, severing ligaments, tearing meniscus, and creating a hairline fracture of my tibia.

Expect to move slowly with the crutches. Yes, I am moving very slowly, only 1 to 2 feet with each stride. If I take a longer stride, I lose my balance.

Learn to sit down with the crutches. Learn to stand up. Learn to get into a car.

Learn to go up the stairs. Learn to go down the stairs.

Avoid wet surfaces. Otherwise you'll start skating and reinjure that knee.

It was effortless to think of patients and colleagues of mine. Mr. S., how do you do it? At age 30 years, he was quadriplegic from falling from a tree as a teenager. Mr. D, how about you, in a wheelchair, after being hit by a car and multiple postoperative leg infections and amputations: living in hotels, with estranged family and no social support. How did you do it, while we nagged you about controlling your glucose. Dr. J? The sadness fills my heart. At only 60 years old, my wonderful professor now made rounds in an electric wheelchair, the victim of amyotrophic lateral sclerosis (ALS). My fate, in comparison, is fortunate; my immobility only temporary. I can still think. And talk. And use a phone. And eat, as well as write this essay. And, best of all, read stories to my children. Be careful about this leg, I remind them. Don't come too close!

Maybe what life is trying to tell you is, slow down. In fact, it's forcing you to do that, a colleague and friend said. I had prided myself in thorough and compassionate doctoring. Now, having been a patient on crutches, I have a greater understanding of how limits to mobility can impact daily living on my patients after I discharge them. And the mundane subject of accident prevention has gained a new urgency.

Tears well up in my eyes. Not from pain, but frustration.

I pleaded with my 3‐year‐olds to come to me, so I could help them wash and dress for the day. Ordinarily, I would have come into their room, leaned over their beds, and whispered good morning into their ears.

Four days after surgery, I wasn't able to do that. Not without the crutches. Even with the crutches, I was moving slowly. I scooted up, put a few pillows behind my back, and carefully lifted up my leg. Putting on the knee immobilizer would take too long; I would only be crossing the hall.

Weighing less than 800 g, the immobilizer is an adjustable aluminum frame attached to foam rubber and 4 wide Velcro straps. It is a device of torment. I can never seem to find the proper fit. If it is too tight, my leg hurts and starts turning blue. When it is too loose, it pulls on my incision, multiplying the pain. You put it on while sitting, but you only discover whether it is too tight or too loose when you stand up.

With one foot on the floor at the edge of the bed, I took one crutch in hand, shifted to the left, and grabbed for the other crutch. I squeezed the handgrips of the crutches tightly and pulled myself up.

Put your weight on your hands, NOT your armpits, the instructions said. Easier said than done, because my armpits were now sore too.

Keep your crutches even with each other. I tried to remember to make an equilateral triangle with my good foot and 2 crutches, but the instructions only seemed to account for movement in a straight line.

Keep your elbows slightly bent and close to your sides to help keep the crutches under your arm. I am trying that too.

Lock your elbows. This instruction contradicts the previous one. Which should I follow?

Place your crutches 2 to 3 inches outside of each foot. How do I do this and keep my elbows close to my sides?

Swing your injured leg through first. But not too much, or I'll pole vault across the room.

After 3 steps, my leg started to throb, and my quadriceps went into a spasm. I needed to sit down, immediately.

Non‐weight‐bearing for next 4 weeks, was written on the doctor's note. Four weeks feels like an eternity. If my heel or toe even touched the ground, I felt an immediate throb of pain in my knee.

How do my orthopedic patients do it: those with broken hips and bad or broken knees, with hip replacements, or knee replacements? I was sensitive to their pain and could optimize control. Postoperatively, I could support gastrointestinal and other organ systems. I made sure that the basic weight‐bearing order was correct. I carefully followed the physical and/or occupational therapy recommendation for home, rehabilitation, or a nursing home. I spoke with families. Yet I did not dwell on activities of daily living nor how my patients felt to be dependent on others for simple things they needed. Some patients were non‐weight‐bearing for weeks, some for months, others never walked again. How can one deeply understand it if one has never experienced it?

According to Centers for Disease Control and Prevention (CDC) statistics,1 unintentional injuries are the leading cause of death between the ages of 1 and 44 years. Accidents are again the leading cause of death after age 75 years. More startling is the fact that these numbers have not been significantly reduced since these data were first collected. Nor do these numbers reveal the number of those debilitated, but still living. In my case, I was not playing basketball, water skiing, or rock climbing: I slipped and fell while stepping into a wading pool with my children, severing ligaments, tearing meniscus, and creating a hairline fracture of my tibia.

Expect to move slowly with the crutches. Yes, I am moving very slowly, only 1 to 2 feet with each stride. If I take a longer stride, I lose my balance.

Learn to sit down with the crutches. Learn to stand up. Learn to get into a car.

Learn to go up the stairs. Learn to go down the stairs.

Avoid wet surfaces. Otherwise you'll start skating and reinjure that knee.

It was effortless to think of patients and colleagues of mine. Mr. S., how do you do it? At age 30 years, he was quadriplegic from falling from a tree as a teenager. Mr. D, how about you, in a wheelchair, after being hit by a car and multiple postoperative leg infections and amputations: living in hotels, with estranged family and no social support. How did you do it, while we nagged you about controlling your glucose. Dr. J? The sadness fills my heart. At only 60 years old, my wonderful professor now made rounds in an electric wheelchair, the victim of amyotrophic lateral sclerosis (ALS). My fate, in comparison, is fortunate; my immobility only temporary. I can still think. And talk. And use a phone. And eat, as well as write this essay. And, best of all, read stories to my children. Be careful about this leg, I remind them. Don't come too close!

Maybe what life is trying to tell you is, slow down. In fact, it's forcing you to do that, a colleague and friend said. I had prided myself in thorough and compassionate doctoring. Now, having been a patient on crutches, I have a greater understanding of how limits to mobility can impact daily living on my patients after I discharge them. And the mundane subject of accident prevention has gained a new urgency.

I lay tossing and turning in the uncomfortable bed; the strange room with cables and stands strewn everywhere was very familiar but at the same time alien to me. I lay there thinking how I ended up here. Only a few short weeks ago I was on my way to a successful career as a hospitalist. I had just finished my chief residency, confident in my skills as a clinician. I considered myself to be a strong patient advocate and felt proud of the fact that I kept the patient above everything else. But I had no inkling of what the future had in store for me. I was not supposed to be a patient, I was young and healthy; surely this had to be a mistake. I realized that I just wasn't ready to handle the situation from the other side!

My nightmare started about a week before, when I woke up with excruciating abdominal pain, too weak to even call out for help. I eventually mustered enough strength to call Emergency Medical Services (EMS), the differential diagnosis of my symptoms going through my head. Surely I had perforated an ulcer! The increased proton pump inhibitor consumption wasn't just because of the rigors of the chief residency.

At the triage station, I could see the nurse looking at me, I knew that look, Great! She thinks I am a pain medication seeker. Even though it was a rude awakening, I realized I was disheveled, unkempt, and looked like anyone else on the street. Between spasms of pain and nursing my bruised ego, I blurted out, Can I have something for this pain!? I can't take it any more. All I got back was a blank stare and a dry, We will have to wait till the doctor sees you.

The Emergency Room (ER) physician recognized me as one of the new hospitalists. The demeanor of the staff changed perceptibly; I got the pain medications and the nurses paid close attention to my overall comfort. A battery of tests was ordered and an abdominal computed tomography (CT) scan revealed acute cholecystitis. I underwent an emergent cholecystectomy. On the third postoperative day I developed a nonproductive cough. The fever started within the next 24 hours. A CT scan revealed a large left lower lobe pneumonia.

God, why is this happening to me? I was in a daze while arrangements were being made to admit me. It was a different hospital, but here the treatment from the nurses was completely different. They had known me for almost 4 years, and had followed my progress from a green, wet‐behind‐the‐ears intern, to a chief resident, and eventually to an attending physician. Over the years they had learned to trust and respect me, but more importantly they had a bond with me that had developed over the years. This familiarity affected their interaction with me in this different role. I was astonished by how different our behaviors can be, based on our perception of the patient. As medical professionals we want to think that we look at people through the same lens, but our biases can creep up on us without us even realizing it.

I required a week of intravenous (IV) antibiotics before I was discharged home. Multiple blood draws, sometimes scheduled an hour apart; nurse evaluations in the middle of the night; and the nurse call light for the entire floor waking me up at odd hours exposed me to a new dimension of being hospitalized. This incident opened my eyes to a power differential that exists between patients and the healthcare providers. I realized that we are very quick to point out that we are doing what is best for a patient, even if it is uncomfortable or downright scarywithout ever considering the emotional and physical turmoil a patient is going through. My experience changed me; I recognize the anger a patient feels because of multiple blood draws every day. I now understand how the constant interruption of sleep cycles because of laboratory draws and vital sign monitoring would inexplicably make an octogenarian lose all bearings of time and place when hospitalized. I find myself asking if I really need to make my patients go through an entire battery of tests, or is there something else that I can do to make their hospital course any easier. I feel the need to sit down with my patients and ask them about small things, their pain control, and their sleep patterns during the hospitalization. I have realized that these small gestures can make a significant impact in the interaction between a physician and a patient.

As physicians and medical professionals, we come with our own set of biases, but our profession further jaundices our opinions about patient needs and demands. Biases are not just based on age, sex, or socioeconomic background, but also on our perception of the severity of a disease process. Perhaps words like frequent fliers and gomers are just a manifestation of this prejudice. We are taught to be objective in our daily interactions with patients, but this also indoctrinates a degree of cynicism. Slowly, this cynicism creeps into our daily patient interactions. We forget that patients with multiple medical problems and frequent admissions also need our help. A lack of tangible diagnosis does not mean the absence of disease. As physicians, we need to evaluate our interaction with patients closely. It is the frequent fliers and the old and debilitated individuals that need the closest scrutiny. If a patient with multiple admissions for pain has come in, we need to give them the benefit of the doubt when we address their complaints. I have realized that the occasional manipulative patient will let me down, but in order to practice this profession I have to leave skepticism out of any patient interaction. I recognize that I am not going to transform patient behavior, but I can try to give them the advantage whenever I can.

Our education system values compassion and professionalism, and we try to inculcate these values in our young physicians. Our curriculums try to incorporate compassion in our daily patient interactions, but I feel that simulated patient encounters and checklists make patient contact mechanical. We develop skills to diagnose diseases through repetition, but we fail to teach our students about the individuality of a patient. In the age of quality improvement and patient safety, the ethics and basic decency of our profession has taken a back seat. My illness has forced me to consider my role as a clinician‐educator. I feel that this experience was as important as any training I received in my journey as a physician. Looking at the spectrum of disease from the other side has opened new avenues for me as a physician. I have come to realize that as educators we have the responsibility to teach our students to become empathic and considerate healers.

Feedback surveys and simulated patient encounters give us an inaccurate assessment of student interaction with patients. These controlled environments can never take the place of a real patient. Time spent at the bedside with a patient or a family is becoming scarcer because of time constraints and work hour rules. But despite these changes we can devise new ways to stimulate critical thinking. Interaction of residents with patients can be outside of their daily responsibilities. Perhaps a rotation in which the residents review charts and interact with patients in a purely nonclinical role will force them to look at people as individuals rather than just patients. A desensitization at the end of residency to make them think as human beings first and physicians second might modify their decision making. Role reversals can serve as a valuable tool to achieve this goal. Perhaps our evaluation system needs to change from a retrospective subjective scrutiny of resident performance to a more objective analysis of patient care.

I strongly feel that we need to instill these virtues in our trainees. Perhaps they will never fully grasp the vulnerability a patient feels while lying in a hospital bed, but it is neither naive nor overly optimistic to suppose that this education can have a constructive effect on their behavior.

I lay tossing and turning in the uncomfortable bed; the strange room with cables and stands strewn everywhere was very familiar but at the same time alien to me. I lay there thinking how I ended up here. Only a few short weeks ago I was on my way to a successful career as a hospitalist. I had just finished my chief residency, confident in my skills as a clinician. I considered myself to be a strong patient advocate and felt proud of the fact that I kept the patient above everything else. But I had no inkling of what the future had in store for me. I was not supposed to be a patient, I was young and healthy; surely this had to be a mistake. I realized that I just wasn't ready to handle the situation from the other side!

My nightmare started about a week before, when I woke up with excruciating abdominal pain, too weak to even call out for help. I eventually mustered enough strength to call Emergency Medical Services (EMS), the differential diagnosis of my symptoms going through my head. Surely I had perforated an ulcer! The increased proton pump inhibitor consumption wasn't just because of the rigors of the chief residency.

At the triage station, I could see the nurse looking at me, I knew that look, Great! She thinks I am a pain medication seeker. Even though it was a rude awakening, I realized I was disheveled, unkempt, and looked like anyone else on the street. Between spasms of pain and nursing my bruised ego, I blurted out, Can I have something for this pain!? I can't take it any more. All I got back was a blank stare and a dry, We will have to wait till the doctor sees you.

The Emergency Room (ER) physician recognized me as one of the new hospitalists. The demeanor of the staff changed perceptibly; I got the pain medications and the nurses paid close attention to my overall comfort. A battery of tests was ordered and an abdominal computed tomography (CT) scan revealed acute cholecystitis. I underwent an emergent cholecystectomy. On the third postoperative day I developed a nonproductive cough. The fever started within the next 24 hours. A CT scan revealed a large left lower lobe pneumonia.

God, why is this happening to me? I was in a daze while arrangements were being made to admit me. It was a different hospital, but here the treatment from the nurses was completely different. They had known me for almost 4 years, and had followed my progress from a green, wet‐behind‐the‐ears intern, to a chief resident, and eventually to an attending physician. Over the years they had learned to trust and respect me, but more importantly they had a bond with me that had developed over the years. This familiarity affected their interaction with me in this different role. I was astonished by how different our behaviors can be, based on our perception of the patient. As medical professionals we want to think that we look at people through the same lens, but our biases can creep up on us without us even realizing it.

I required a week of intravenous (IV) antibiotics before I was discharged home. Multiple blood draws, sometimes scheduled an hour apart; nurse evaluations in the middle of the night; and the nurse call light for the entire floor waking me up at odd hours exposed me to a new dimension of being hospitalized. This incident opened my eyes to a power differential that exists between patients and the healthcare providers. I realized that we are very quick to point out that we are doing what is best for a patient, even if it is uncomfortable or downright scarywithout ever considering the emotional and physical turmoil a patient is going through. My experience changed me; I recognize the anger a patient feels because of multiple blood draws every day. I now understand how the constant interruption of sleep cycles because of laboratory draws and vital sign monitoring would inexplicably make an octogenarian lose all bearings of time and place when hospitalized. I find myself asking if I really need to make my patients go through an entire battery of tests, or is there something else that I can do to make their hospital course any easier. I feel the need to sit down with my patients and ask them about small things, their pain control, and their sleep patterns during the hospitalization. I have realized that these small gestures can make a significant impact in the interaction between a physician and a patient.

As physicians and medical professionals, we come with our own set of biases, but our profession further jaundices our opinions about patient needs and demands. Biases are not just based on age, sex, or socioeconomic background, but also on our perception of the severity of a disease process. Perhaps words like frequent fliers and gomers are just a manifestation of this prejudice. We are taught to be objective in our daily interactions with patients, but this also indoctrinates a degree of cynicism. Slowly, this cynicism creeps into our daily patient interactions. We forget that patients with multiple medical problems and frequent admissions also need our help. A lack of tangible diagnosis does not mean the absence of disease. As physicians, we need to evaluate our interaction with patients closely. It is the frequent fliers and the old and debilitated individuals that need the closest scrutiny. If a patient with multiple admissions for pain has come in, we need to give them the benefit of the doubt when we address their complaints. I have realized that the occasional manipulative patient will let me down, but in order to practice this profession I have to leave skepticism out of any patient interaction. I recognize that I am not going to transform patient behavior, but I can try to give them the advantage whenever I can.

Our education system values compassion and professionalism, and we try to inculcate these values in our young physicians. Our curriculums try to incorporate compassion in our daily patient interactions, but I feel that simulated patient encounters and checklists make patient contact mechanical. We develop skills to diagnose diseases through repetition, but we fail to teach our students about the individuality of a patient. In the age of quality improvement and patient safety, the ethics and basic decency of our profession has taken a back seat. My illness has forced me to consider my role as a clinician‐educator. I feel that this experience was as important as any training I received in my journey as a physician. Looking at the spectrum of disease from the other side has opened new avenues for me as a physician. I have come to realize that as educators we have the responsibility to teach our students to become empathic and considerate healers.

Feedback surveys and simulated patient encounters give us an inaccurate assessment of student interaction with patients. These controlled environments can never take the place of a real patient. Time spent at the bedside with a patient or a family is becoming scarcer because of time constraints and work hour rules. But despite these changes we can devise new ways to stimulate critical thinking. Interaction of residents with patients can be outside of their daily responsibilities. Perhaps a rotation in which the residents review charts and interact with patients in a purely nonclinical role will force them to look at people as individuals rather than just patients. A desensitization at the end of residency to make them think as human beings first and physicians second might modify their decision making. Role reversals can serve as a valuable tool to achieve this goal. Perhaps our evaluation system needs to change from a retrospective subjective scrutiny of resident performance to a more objective analysis of patient care.

I strongly feel that we need to instill these virtues in our trainees. Perhaps they will never fully grasp the vulnerability a patient feels while lying in a hospital bed, but it is neither naive nor overly optimistic to suppose that this education can have a constructive effect on their behavior.

I lay tossing and turning in the uncomfortable bed; the strange room with cables and stands strewn everywhere was very familiar but at the same time alien to me. I lay there thinking how I ended up here. Only a few short weeks ago I was on my way to a successful career as a hospitalist. I had just finished my chief residency, confident in my skills as a clinician. I considered myself to be a strong patient advocate and felt proud of the fact that I kept the patient above everything else. But I had no inkling of what the future had in store for me. I was not supposed to be a patient, I was young and healthy; surely this had to be a mistake. I realized that I just wasn't ready to handle the situation from the other side!

My nightmare started about a week before, when I woke up with excruciating abdominal pain, too weak to even call out for help. I eventually mustered enough strength to call Emergency Medical Services (EMS), the differential diagnosis of my symptoms going through my head. Surely I had perforated an ulcer! The increased proton pump inhibitor consumption wasn't just because of the rigors of the chief residency.

At the triage station, I could see the nurse looking at me, I knew that look, Great! She thinks I am a pain medication seeker. Even though it was a rude awakening, I realized I was disheveled, unkempt, and looked like anyone else on the street. Between spasms of pain and nursing my bruised ego, I blurted out, Can I have something for this pain!? I can't take it any more. All I got back was a blank stare and a dry, We will have to wait till the doctor sees you.

The Emergency Room (ER) physician recognized me as one of the new hospitalists. The demeanor of the staff changed perceptibly; I got the pain medications and the nurses paid close attention to my overall comfort. A battery of tests was ordered and an abdominal computed tomography (CT) scan revealed acute cholecystitis. I underwent an emergent cholecystectomy. On the third postoperative day I developed a nonproductive cough. The fever started within the next 24 hours. A CT scan revealed a large left lower lobe pneumonia.

God, why is this happening to me? I was in a daze while arrangements were being made to admit me. It was a different hospital, but here the treatment from the nurses was completely different. They had known me for almost 4 years, and had followed my progress from a green, wet‐behind‐the‐ears intern, to a chief resident, and eventually to an attending physician. Over the years they had learned to trust and respect me, but more importantly they had a bond with me that had developed over the years. This familiarity affected their interaction with me in this different role. I was astonished by how different our behaviors can be, based on our perception of the patient. As medical professionals we want to think that we look at people through the same lens, but our biases can creep up on us without us even realizing it.

I required a week of intravenous (IV) antibiotics before I was discharged home. Multiple blood draws, sometimes scheduled an hour apart; nurse evaluations in the middle of the night; and the nurse call light for the entire floor waking me up at odd hours exposed me to a new dimension of being hospitalized. This incident opened my eyes to a power differential that exists between patients and the healthcare providers. I realized that we are very quick to point out that we are doing what is best for a patient, even if it is uncomfortable or downright scarywithout ever considering the emotional and physical turmoil a patient is going through. My experience changed me; I recognize the anger a patient feels because of multiple blood draws every day. I now understand how the constant interruption of sleep cycles because of laboratory draws and vital sign monitoring would inexplicably make an octogenarian lose all bearings of time and place when hospitalized. I find myself asking if I really need to make my patients go through an entire battery of tests, or is there something else that I can do to make their hospital course any easier. I feel the need to sit down with my patients and ask them about small things, their pain control, and their sleep patterns during the hospitalization. I have realized that these small gestures can make a significant impact in the interaction between a physician and a patient.

As physicians and medical professionals, we come with our own set of biases, but our profession further jaundices our opinions about patient needs and demands. Biases are not just based on age, sex, or socioeconomic background, but also on our perception of the severity of a disease process. Perhaps words like frequent fliers and gomers are just a manifestation of this prejudice. We are taught to be objective in our daily interactions with patients, but this also indoctrinates a degree of cynicism. Slowly, this cynicism creeps into our daily patient interactions. We forget that patients with multiple medical problems and frequent admissions also need our help. A lack of tangible diagnosis does not mean the absence of disease. As physicians, we need to evaluate our interaction with patients closely. It is the frequent fliers and the old and debilitated individuals that need the closest scrutiny. If a patient with multiple admissions for pain has come in, we need to give them the benefit of the doubt when we address their complaints. I have realized that the occasional manipulative patient will let me down, but in order to practice this profession I have to leave skepticism out of any patient interaction. I recognize that I am not going to transform patient behavior, but I can try to give them the advantage whenever I can.

Our education system values compassion and professionalism, and we try to inculcate these values in our young physicians. Our curriculums try to incorporate compassion in our daily patient interactions, but I feel that simulated patient encounters and checklists make patient contact mechanical. We develop skills to diagnose diseases through repetition, but we fail to teach our students about the individuality of a patient. In the age of quality improvement and patient safety, the ethics and basic decency of our profession has taken a back seat. My illness has forced me to consider my role as a clinician‐educator. I feel that this experience was as important as any training I received in my journey as a physician. Looking at the spectrum of disease from the other side has opened new avenues for me as a physician. I have come to realize that as educators we have the responsibility to teach our students to become empathic and considerate healers.

Feedback surveys and simulated patient encounters give us an inaccurate assessment of student interaction with patients. These controlled environments can never take the place of a real patient. Time spent at the bedside with a patient or a family is becoming scarcer because of time constraints and work hour rules. But despite these changes we can devise new ways to stimulate critical thinking. Interaction of residents with patients can be outside of their daily responsibilities. Perhaps a rotation in which the residents review charts and interact with patients in a purely nonclinical role will force them to look at people as individuals rather than just patients. A desensitization at the end of residency to make them think as human beings first and physicians second might modify their decision making. Role reversals can serve as a valuable tool to achieve this goal. Perhaps our evaluation system needs to change from a retrospective subjective scrutiny of resident performance to a more objective analysis of patient care.

I strongly feel that we need to instill these virtues in our trainees. Perhaps they will never fully grasp the vulnerability a patient feels while lying in a hospital bed, but it is neither naive nor overly optimistic to suppose that this education can have a constructive effect on their behavior.

Hospitalists are increasingly assuming a primary role in medical education in the hospital setting, as they also steadily care for a larger portion of hospitalized patients.1 This issue of the Journal of Hospital Medicine highlights the role of hospitalists as teachers in academic medical centers, confirming their expanding and positive role in resident and medical student education. A survey of academic medical centers, a systematic review, an evaluation of the implementation of an educational curriculum, and a survey of residents hint at the challenges hospitalists face in teaching, but also expose us to a more advanced yet facile approach to evaluating the effectiveness of a teaching intervention.25 These publications provoke interesting questions about clinical teaching that hospital medicine educators and researchers should pursue answering. I believe they will also encourage us to innovate in medical education and assessment of that teaching.

Traditionally, teaching attendings for resident teams on medicine or pediatric services rotated through these duties for 1 to 3 months each year, while spending the majority of their time in clinic or research activities. The increasing complexity of hospitalized patients and the pressure to reduce length of stay prompted closer oversight of trainees. With the advent of resident work‐hour restrictions, the need for greater clinical involvement by attending physicians made it increasingly difficult to maintain the traditional model of limited engagement by faculty attendings. Simply put, the dwindling pool of willing and able teaching attendings encouraged teaching hospitals to employ hospitalists to fill the gap in teaching and supervision, as well as clinical coverage.6

Beasley et al.2 report that resident work‐hour restrictions were associated with an increase in the number of teaching hospitals employing hospitalists to 79% of 193 surveyed hospitals in 2007. Of those hospitals with hospitalists, 92% reported that hospitalists serve as attendings on the teaching service. Hospitalists also teach in a number of other venues within these programs, including formal teaching rounds without direct care responsibility, along with delivering didactic lectures and clinical skills education.

How well are teaching hospitalists performing compared to traditional teaching attendings? Natarajan et al.4 provide an important summary of the evidence in a systematic review of studies comparing teaching efforts of hospitalist attendings to those of nonhospitalist attendings. Eight studies from a variety of institutions measured trainee (resident or medical student) attitudes. It is gratifying to learn that hospitalists were generally rated higher at overall teaching effectiveness, provision of feedback, knowledge base, and involvement of the learner in patient care. It seems likely that publication bias would overestimate the positive effect of hospitalists on learner attitudes. However, there are plausible reasons that the positive effect is accurate. Because their professional responsibilities are focused in the hospital, hospitalists should naturally be more available to learners for teaching and feedback. Hospitalists tend to be younger in their academic careers, placing them closer to the cutting edge of knowledge gained during residency and possibly fellowship. They may be more in tune with the needs and pressures faced by their learners, having dealt with these same challenges either during recent training or during nonteaching rotations.

As a relatively young specialty with young and developing academic hospitalists, will the advantage suggested by the Natarajan et al.4 systematic review be sustained over the long term as careers in hospital medicine mature? A 2005 systematic review studying this question among practicing clinicians found, somewhat paradoxically, that older, more experienced clinicians appeared to be at risk for providing lower‐quality care.7 To avoid this decline in clinical effectiveness, hospitalists should proactively seek innovative ways to refresh and update their knowledge and skills throughout their careers. This is particularly critical for teaching physicians. We should seize the opportunity to study the relationship between advancing clinical/teaching experience and educational quality within our teaching programs.

The review by Natarajan et al.4 should also challenge the hospitalist community to achieve even higher levels of proficiency as teachers of medicine. The review alludes to bedside teaching and attention to psychosocial aspects of care as opportunities for improvement by hospitalist teachers. A recent study suggested that physical examination instruction receives declining attention from inpatient teachers and that there are opportunities to increase the amount of bedside teaching.8 A provocative study of inpatients admitted to a teaching service found that physical examination could substantially impact patient care, but that trainees often failed to appreciate significant findings on initial examination.9 How do teaching hospitalists become proficient at physical examination and bedside teaching? Are there models around the country that are successfully developing outstanding clinician educators, incorporating teach‐the‐teacher models to improve physical examination and bedside teaching?

A practical limitation of attitude surveys and learner evaluation is the well‐known phenomenon of grade inflation that resulted in high ratings for all attending groups in the studies summarized by Natarajan et al.4 This limits the ability of surveys or evaluations to distinguish truly outstanding teachers and consequently makes it difficult to analyze the attributes of these teachers. We need better tools to detect and learn teaching techniques from great teachers in the clinical environment. We need studies evaluating the effect of teaching hospitalists on learner knowledge or, even more importantly, learner outcomes. Ultimately, we need studies of educational interventions that evaluate the impact of these interventions on patient outcome.

Wright et al.5 provide guidance as they describe the evaluation of a teaching intervention that moves beyond measurement of knowledge or attitudes. The Johns Hopkins Bayview hospitalist group sought to improve the quality of medical consultations performed by hospitalists and by residents rotating on the consultation service using a case‐based teaching module with audits of recent notes. The participants then audited their most recent consultation notes with feedback from the module teacher. The study employed pretests and posttests of knowledgea standard evaluation for educational interventions. This tells us little about the true impact of the teaching module. However, the study then assessed the quality of written consultations done by hospitalists before and after the educational interventions. Scores of consult notes improved significantly after the intervention, although the number of assessments for each physician was limited. Importantly, we need to know if interventions such as this are sustained over time. Wright's well‐established medical education research group's study design assessed the impact of an intervention on physician performance and moves us closer to assessment of the impact on actual patient outcomes. As clinical teachers, we would like to believe that our teaching and our educational innovations are having a positive impact on patient care. Can we demonstrate this?

As academic medical centers contend with further resident work‐hour restrictions proposed by the Institute of Medicine (IOM),10 how will this affect hospitalist teachers? The study by Mazotti et al.3 from the University of California at San Francisco residency program found that about one‐quarter of residents reported spending less time teaching after implementation of the Accreditation Council for Graduate Medical Education (ACGME) duty‐hour restrictions in 2003. Interestingly, those residents reporting less time spent teaching also reported less emotional exhaustion and perceived that they were delivering higher‐quality patient care. This raises a fascinating question for academic hospitalists. Would these findings be similar among teaching hospitalists and nonteaching hospitalists? What about hospitalists who rotate through months of teaching and nonteaching services? Is teaching emotionally exhausting for experienced teachers? A Mayo Clinic study suggested that the extent that faculty physicians are able to engage in work that is most meaningful to them as individuals is a strong determinant of faculty burnout.11 Is the hospitalist who finds teaching most rewarding at risk of burnout if they are assigned only 2 weeks a year as a teaching attending? The answers to these questions will be critical to hospitalist program leaders trying to assure sustainable careers for hospitalists in their programs.

Although the study by Mazotti et al.3 did not assess the impact of the reduction in resident teaching time on the teaching responsibilities for academic hospitalists, previous studies suggest that faculty are also teaching less since the introduction of work‐hour restrictions.12, 13 If the new IOM recommendations are enacted, who will teach? Although the reported experience following the 2003 work‐hour restrictions begs pessimism, the anticipated changes represent an opportunity for creative hospitalist teachers to demonstrate effective adaptations to the changing and compressed inpatient teaching environment.

In summary, this issue of the Journal presents studies that praise the role hospitalists play in teaching the next generation of physicians, but also gives a glimpse of future challenges and opportunities. We should take advantage of hospitalists' central position in clinical education in the hospital to innovate, study the effect on both learner outcomes and patient outcomes, and share our experiences with the hospitalist and medical education communities.

Hospitalists are increasingly assuming a primary role in medical education in the hospital setting, as they also steadily care for a larger portion of hospitalized patients.1 This issue of the Journal of Hospital Medicine highlights the role of hospitalists as teachers in academic medical centers, confirming their expanding and positive role in resident and medical student education. A survey of academic medical centers, a systematic review, an evaluation of the implementation of an educational curriculum, and a survey of residents hint at the challenges hospitalists face in teaching, but also expose us to a more advanced yet facile approach to evaluating the effectiveness of a teaching intervention.25 These publications provoke interesting questions about clinical teaching that hospital medicine educators and researchers should pursue answering. I believe they will also encourage us to innovate in medical education and assessment of that teaching.

Traditionally, teaching attendings for resident teams on medicine or pediatric services rotated through these duties for 1 to 3 months each year, while spending the majority of their time in clinic or research activities. The increasing complexity of hospitalized patients and the pressure to reduce length of stay prompted closer oversight of trainees. With the advent of resident work‐hour restrictions, the need for greater clinical involvement by attending physicians made it increasingly difficult to maintain the traditional model of limited engagement by faculty attendings. Simply put, the dwindling pool of willing and able teaching attendings encouraged teaching hospitals to employ hospitalists to fill the gap in teaching and supervision, as well as clinical coverage.6

Beasley et al.2 report that resident work‐hour restrictions were associated with an increase in the number of teaching hospitals employing hospitalists to 79% of 193 surveyed hospitals in 2007. Of those hospitals with hospitalists, 92% reported that hospitalists serve as attendings on the teaching service. Hospitalists also teach in a number of other venues within these programs, including formal teaching rounds without direct care responsibility, along with delivering didactic lectures and clinical skills education.

How well are teaching hospitalists performing compared to traditional teaching attendings? Natarajan et al.4 provide an important summary of the evidence in a systematic review of studies comparing teaching efforts of hospitalist attendings to those of nonhospitalist attendings. Eight studies from a variety of institutions measured trainee (resident or medical student) attitudes. It is gratifying to learn that hospitalists were generally rated higher at overall teaching effectiveness, provision of feedback, knowledge base, and involvement of the learner in patient care. It seems likely that publication bias would overestimate the positive effect of hospitalists on learner attitudes. However, there are plausible reasons that the positive effect is accurate. Because their professional responsibilities are focused in the hospital, hospitalists should naturally be more available to learners for teaching and feedback. Hospitalists tend to be younger in their academic careers, placing them closer to the cutting edge of knowledge gained during residency and possibly fellowship. They may be more in tune with the needs and pressures faced by their learners, having dealt with these same challenges either during recent training or during nonteaching rotations.

As a relatively young specialty with young and developing academic hospitalists, will the advantage suggested by the Natarajan et al.4 systematic review be sustained over the long term as careers in hospital medicine mature? A 2005 systematic review studying this question among practicing clinicians found, somewhat paradoxically, that older, more experienced clinicians appeared to be at risk for providing lower‐quality care.7 To avoid this decline in clinical effectiveness, hospitalists should proactively seek innovative ways to refresh and update their knowledge and skills throughout their careers. This is particularly critical for teaching physicians. We should seize the opportunity to study the relationship between advancing clinical/teaching experience and educational quality within our teaching programs.

The review by Natarajan et al.4 should also challenge the hospitalist community to achieve even higher levels of proficiency as teachers of medicine. The review alludes to bedside teaching and attention to psychosocial aspects of care as opportunities for improvement by hospitalist teachers. A recent study suggested that physical examination instruction receives declining attention from inpatient teachers and that there are opportunities to increase the amount of bedside teaching.8 A provocative study of inpatients admitted to a teaching service found that physical examination could substantially impact patient care, but that trainees often failed to appreciate significant findings on initial examination.9 How do teaching hospitalists become proficient at physical examination and bedside teaching? Are there models around the country that are successfully developing outstanding clinician educators, incorporating teach‐the‐teacher models to improve physical examination and bedside teaching?

A practical limitation of attitude surveys and learner evaluation is the well‐known phenomenon of grade inflation that resulted in high ratings for all attending groups in the studies summarized by Natarajan et al.4 This limits the ability of surveys or evaluations to distinguish truly outstanding teachers and consequently makes it difficult to analyze the attributes of these teachers. We need better tools to detect and learn teaching techniques from great teachers in the clinical environment. We need studies evaluating the effect of teaching hospitalists on learner knowledge or, even more importantly, learner outcomes. Ultimately, we need studies of educational interventions that evaluate the impact of these interventions on patient outcome.

Wright et al.5 provide guidance as they describe the evaluation of a teaching intervention that moves beyond measurement of knowledge or attitudes. The Johns Hopkins Bayview hospitalist group sought to improve the quality of medical consultations performed by hospitalists and by residents rotating on the consultation service using a case‐based teaching module with audits of recent notes. The participants then audited their most recent consultation notes with feedback from the module teacher. The study employed pretests and posttests of knowledgea standard evaluation for educational interventions. This tells us little about the true impact of the teaching module. However, the study then assessed the quality of written consultations done by hospitalists before and after the educational interventions. Scores of consult notes improved significantly after the intervention, although the number of assessments for each physician was limited. Importantly, we need to know if interventions such as this are sustained over time. Wright's well‐established medical education research group's study design assessed the impact of an intervention on physician performance and moves us closer to assessment of the impact on actual patient outcomes. As clinical teachers, we would like to believe that our teaching and our educational innovations are having a positive impact on patient care. Can we demonstrate this?

As academic medical centers contend with further resident work‐hour restrictions proposed by the Institute of Medicine (IOM),10 how will this affect hospitalist teachers? The study by Mazotti et al.3 from the University of California at San Francisco residency program found that about one‐quarter of residents reported spending less time teaching after implementation of the Accreditation Council for Graduate Medical Education (ACGME) duty‐hour restrictions in 2003. Interestingly, those residents reporting less time spent teaching also reported less emotional exhaustion and perceived that they were delivering higher‐quality patient care. This raises a fascinating question for academic hospitalists. Would these findings be similar among teaching hospitalists and nonteaching hospitalists? What about hospitalists who rotate through months of teaching and nonteaching services? Is teaching emotionally exhausting for experienced teachers? A Mayo Clinic study suggested that the extent that faculty physicians are able to engage in work that is most meaningful to them as individuals is a strong determinant of faculty burnout.11 Is the hospitalist who finds teaching most rewarding at risk of burnout if they are assigned only 2 weeks a year as a teaching attending? The answers to these questions will be critical to hospitalist program leaders trying to assure sustainable careers for hospitalists in their programs.

Although the study by Mazotti et al.3 did not assess the impact of the reduction in resident teaching time on the teaching responsibilities for academic hospitalists, previous studies suggest that faculty are also teaching less since the introduction of work‐hour restrictions.12, 13 If the new IOM recommendations are enacted, who will teach? Although the reported experience following the 2003 work‐hour restrictions begs pessimism, the anticipated changes represent an opportunity for creative hospitalist teachers to demonstrate effective adaptations to the changing and compressed inpatient teaching environment.

In summary, this issue of the Journal presents studies that praise the role hospitalists play in teaching the next generation of physicians, but also gives a glimpse of future challenges and opportunities. We should take advantage of hospitalists' central position in clinical education in the hospital to innovate, study the effect on both learner outcomes and patient outcomes, and share our experiences with the hospitalist and medical education communities.

Hospitalists are increasingly assuming a primary role in medical education in the hospital setting, as they also steadily care for a larger portion of hospitalized patients.1 This issue of the Journal of Hospital Medicine highlights the role of hospitalists as teachers in academic medical centers, confirming their expanding and positive role in resident and medical student education. A survey of academic medical centers, a systematic review, an evaluation of the implementation of an educational curriculum, and a survey of residents hint at the challenges hospitalists face in teaching, but also expose us to a more advanced yet facile approach to evaluating the effectiveness of a teaching intervention.25 These publications provoke interesting questions about clinical teaching that hospital medicine educators and researchers should pursue answering. I believe they will also encourage us to innovate in medical education and assessment of that teaching.

Traditionally, teaching attendings for resident teams on medicine or pediatric services rotated through these duties for 1 to 3 months each year, while spending the majority of their time in clinic or research activities. The increasing complexity of hospitalized patients and the pressure to reduce length of stay prompted closer oversight of trainees. With the advent of resident work‐hour restrictions, the need for greater clinical involvement by attending physicians made it increasingly difficult to maintain the traditional model of limited engagement by faculty attendings. Simply put, the dwindling pool of willing and able teaching attendings encouraged teaching hospitals to employ hospitalists to fill the gap in teaching and supervision, as well as clinical coverage.6

Beasley et al.2 report that resident work‐hour restrictions were associated with an increase in the number of teaching hospitals employing hospitalists to 79% of 193 surveyed hospitals in 2007. Of those hospitals with hospitalists, 92% reported that hospitalists serve as attendings on the teaching service. Hospitalists also teach in a number of other venues within these programs, including formal teaching rounds without direct care responsibility, along with delivering didactic lectures and clinical skills education.

How well are teaching hospitalists performing compared to traditional teaching attendings? Natarajan et al.4 provide an important summary of the evidence in a systematic review of studies comparing teaching efforts of hospitalist attendings to those of nonhospitalist attendings. Eight studies from a variety of institutions measured trainee (resident or medical student) attitudes. It is gratifying to learn that hospitalists were generally rated higher at overall teaching effectiveness, provision of feedback, knowledge base, and involvement of the learner in patient care. It seems likely that publication bias would overestimate the positive effect of hospitalists on learner attitudes. However, there are plausible reasons that the positive effect is accurate. Because their professional responsibilities are focused in the hospital, hospitalists should naturally be more available to learners for teaching and feedback. Hospitalists tend to be younger in their academic careers, placing them closer to the cutting edge of knowledge gained during residency and possibly fellowship. They may be more in tune with the needs and pressures faced by their learners, having dealt with these same challenges either during recent training or during nonteaching rotations.

As a relatively young specialty with young and developing academic hospitalists, will the advantage suggested by the Natarajan et al.4 systematic review be sustained over the long term as careers in hospital medicine mature? A 2005 systematic review studying this question among practicing clinicians found, somewhat paradoxically, that older, more experienced clinicians appeared to be at risk for providing lower‐quality care.7 To avoid this decline in clinical effectiveness, hospitalists should proactively seek innovative ways to refresh and update their knowledge and skills throughout their careers. This is particularly critical for teaching physicians. We should seize the opportunity to study the relationship between advancing clinical/teaching experience and educational quality within our teaching programs.

The review by Natarajan et al.4 should also challenge the hospitalist community to achieve even higher levels of proficiency as teachers of medicine. The review alludes to bedside teaching and attention to psychosocial aspects of care as opportunities for improvement by hospitalist teachers. A recent study suggested that physical examination instruction receives declining attention from inpatient teachers and that there are opportunities to increase the amount of bedside teaching.8 A provocative study of inpatients admitted to a teaching service found that physical examination could substantially impact patient care, but that trainees often failed to appreciate significant findings on initial examination.9 How do teaching hospitalists become proficient at physical examination and bedside teaching? Are there models around the country that are successfully developing outstanding clinician educators, incorporating teach‐the‐teacher models to improve physical examination and bedside teaching?

A practical limitation of attitude surveys and learner evaluation is the well‐known phenomenon of grade inflation that resulted in high ratings for all attending groups in the studies summarized by Natarajan et al.4 This limits the ability of surveys or evaluations to distinguish truly outstanding teachers and consequently makes it difficult to analyze the attributes of these teachers. We need better tools to detect and learn teaching techniques from great teachers in the clinical environment. We need studies evaluating the effect of teaching hospitalists on learner knowledge or, even more importantly, learner outcomes. Ultimately, we need studies of educational interventions that evaluate the impact of these interventions on patient outcome.

Wright et al.5 provide guidance as they describe the evaluation of a teaching intervention that moves beyond measurement of knowledge or attitudes. The Johns Hopkins Bayview hospitalist group sought to improve the quality of medical consultations performed by hospitalists and by residents rotating on the consultation service using a case‐based teaching module with audits of recent notes. The participants then audited their most recent consultation notes with feedback from the module teacher. The study employed pretests and posttests of knowledgea standard evaluation for educational interventions. This tells us little about the true impact of the teaching module. However, the study then assessed the quality of written consultations done by hospitalists before and after the educational interventions. Scores of consult notes improved significantly after the intervention, although the number of assessments for each physician was limited. Importantly, we need to know if interventions such as this are sustained over time. Wright's well‐established medical education research group's study design assessed the impact of an intervention on physician performance and moves us closer to assessment of the impact on actual patient outcomes. As clinical teachers, we would like to believe that our teaching and our educational innovations are having a positive impact on patient care. Can we demonstrate this?

As academic medical centers contend with further resident work‐hour restrictions proposed by the Institute of Medicine (IOM),10 how will this affect hospitalist teachers? The study by Mazotti et al.3 from the University of California at San Francisco residency program found that about one‐quarter of residents reported spending less time teaching after implementation of the Accreditation Council for Graduate Medical Education (ACGME) duty‐hour restrictions in 2003. Interestingly, those residents reporting less time spent teaching also reported less emotional exhaustion and perceived that they were delivering higher‐quality patient care. This raises a fascinating question for academic hospitalists. Would these findings be similar among teaching hospitalists and nonteaching hospitalists? What about hospitalists who rotate through months of teaching and nonteaching services? Is teaching emotionally exhausting for experienced teachers? A Mayo Clinic study suggested that the extent that faculty physicians are able to engage in work that is most meaningful to them as individuals is a strong determinant of faculty burnout.11 Is the hospitalist who finds teaching most rewarding at risk of burnout if they are assigned only 2 weeks a year as a teaching attending? The answers to these questions will be critical to hospitalist program leaders trying to assure sustainable careers for hospitalists in their programs.

Although the study by Mazotti et al.3 did not assess the impact of the reduction in resident teaching time on the teaching responsibilities for academic hospitalists, previous studies suggest that faculty are also teaching less since the introduction of work‐hour restrictions.12, 13 If the new IOM recommendations are enacted, who will teach? Although the reported experience following the 2003 work‐hour restrictions begs pessimism, the anticipated changes represent an opportunity for creative hospitalist teachers to demonstrate effective adaptations to the changing and compressed inpatient teaching environment.

In summary, this issue of the Journal presents studies that praise the role hospitalists play in teaching the next generation of physicians, but also gives a glimpse of future challenges and opportunities. We should take advantage of hospitalists' central position in clinical education in the hospital to innovate, study the effect on both learner outcomes and patient outcomes, and share our experiences with the hospitalist and medical education communities.

‐Sir William Osler

For a typical hospitalist in the 21^st century, going to sea is not a concern. Getting lost at sea, or worse yet, drowning, loom larger as threats to today's hospitals‐based providers. To help our readers navigate the rapidly changing waters that are today's hospitals, the Journal is launching a new feature. Starting with this issue of the Journal of Hospital Medicine, we are pleased to provide CME credits pertaining to articles published in the Journal at no additional cost to the reader. As the newly appointed CME Editor, I will be charged with identifying an article to be published in upcoming issues of the Journal that is likely to impact the practice of the majority of our readership. Based on the article, a series of multiple‐choice questions will be developed and readers interested in pursuing CME credit will be directed to an on‐line site to complete the questions and receive immediate CME credit along with the answers to the questions.

For our first article, CME questions have been developed for the well‐done review by Abu Jawdeh and colleagues, Evidence‐based approach for prevention of radiocontrast‐induced nephropathy,2 a topic encountered by hospitalists daily. While clinical topics will likely comprise the majority of selected topics, CME activity in the Journal will reflect the diverse roles filled by hospitalists as champions of quality improvement, patient safety, care transitions, teaching, research, and team leadership.

What may seem straightforward at first glance is actually a more complicated process behind the scenes. The Editorial Office and the production team at Wiley have worked hard to make the CME process as seamless as possible for our readers. User‐friendly features include: direct linking between the on‐line Journal and the Journal's web‐based CME activity; on‐line tracking of individual CME credits and certificates; answers to CME questions, along with explanations, available immediately upon submitting your responses; and performance measurement related to the program. In the future, we hope to take advantage of technology to enhance the CME process to reach our diverse readership. We hope you enjoy this new feature of the Journal, and please give us your feedback on it.

‐Sir William Osler

For a typical hospitalist in the 21^st century, going to sea is not a concern. Getting lost at sea, or worse yet, drowning, loom larger as threats to today's hospitals‐based providers. To help our readers navigate the rapidly changing waters that are today's hospitals, the Journal is launching a new feature. Starting with this issue of the Journal of Hospital Medicine, we are pleased to provide CME credits pertaining to articles published in the Journal at no additional cost to the reader. As the newly appointed CME Editor, I will be charged with identifying an article to be published in upcoming issues of the Journal that is likely to impact the practice of the majority of our readership. Based on the article, a series of multiple‐choice questions will be developed and readers interested in pursuing CME credit will be directed to an on‐line site to complete the questions and receive immediate CME credit along with the answers to the questions.

For our first article, CME questions have been developed for the well‐done review by Abu Jawdeh and colleagues, Evidence‐based approach for prevention of radiocontrast‐induced nephropathy,2 a topic encountered by hospitalists daily. While clinical topics will likely comprise the majority of selected topics, CME activity in the Journal will reflect the diverse roles filled by hospitalists as champions of quality improvement, patient safety, care transitions, teaching, research, and team leadership.

What may seem straightforward at first glance is actually a more complicated process behind the scenes. The Editorial Office and the production team at Wiley have worked hard to make the CME process as seamless as possible for our readers. User‐friendly features include: direct linking between the on‐line Journal and the Journal's web‐based CME activity; on‐line tracking of individual CME credits and certificates; answers to CME questions, along with explanations, available immediately upon submitting your responses; and performance measurement related to the program. In the future, we hope to take advantage of technology to enhance the CME process to reach our diverse readership. We hope you enjoy this new feature of the Journal, and please give us your feedback on it.

‐Sir William Osler

For a typical hospitalist in the 21^st century, going to sea is not a concern. Getting lost at sea, or worse yet, drowning, loom larger as threats to today's hospitals‐based providers. To help our readers navigate the rapidly changing waters that are today's hospitals, the Journal is launching a new feature. Starting with this issue of the Journal of Hospital Medicine, we are pleased to provide CME credits pertaining to articles published in the Journal at no additional cost to the reader. As the newly appointed CME Editor, I will be charged with identifying an article to be published in upcoming issues of the Journal that is likely to impact the practice of the majority of our readership. Based on the article, a series of multiple‐choice questions will be developed and readers interested in pursuing CME credit will be directed to an on‐line site to complete the questions and receive immediate CME credit along with the answers to the questions.

For our first article, CME questions have been developed for the well‐done review by Abu Jawdeh and colleagues, Evidence‐based approach for prevention of radiocontrast‐induced nephropathy,2 a topic encountered by hospitalists daily. While clinical topics will likely comprise the majority of selected topics, CME activity in the Journal will reflect the diverse roles filled by hospitalists as champions of quality improvement, patient safety, care transitions, teaching, research, and team leadership.

What may seem straightforward at first glance is actually a more complicated process behind the scenes. The Editorial Office and the production team at Wiley have worked hard to make the CME process as seamless as possible for our readers. User‐friendly features include: direct linking between the on‐line Journal and the Journal's web‐based CME activity; on‐line tracking of individual CME credits and certificates; answers to CME questions, along with explanations, available immediately upon submitting your responses; and performance measurement related to the program. In the future, we hope to take advantage of technology to enhance the CME process to reach our diverse readership. We hope you enjoy this new feature of the Journal, and please give us your feedback on it.

Maintaining a balance between productivity (what we do now), and production capacity (the ability to continue to do what we now do in the future) is one of the central tenets of successful organizations and societies. The economic benefits of industrialization (production) must be balanced with the needs of the environment (production capacity). It is appropriate then, that this issue of The Journal of Hospital Medicine juxtaposes Conway's1 article on hospitalists' current production of ensuring value, with articles addressing medical education, our production capacity.

What is the role of hospitalists in medical education? The article by Beasley et al.,2 confirms what has long been suspected: the growth of hospitalists in medical education has paralleled the growth of the movement as a whole. The meta‐analysis by Natarajan et al.3 further suggests that hospitalists are at the very least no worse in medical education than other specialists, and in some domains, may be superior. The theoretical fears of hospitalists as medical educators have not been borne out: utilizing hospitalists as educators does not lead to a decline in resident autonomy, nor does it lead to a decline in educational ability. But despite the fact that 73% of residency training programs utilize hospitalists, there are several reasons why the hospitalists' role in inpatient medical education should be even more robust.

The landscape of graduate medical education has dramatically changed in the past 10 years. The knowledge‐only paradigm has evolved to a comprehensive focus on the trainee's overall performance, including understanding the healthcare system in which she works (systems of care), self‐reflection on her practice (practice‐based learning), and an augmented emphasis on professionalism and interpersonal skills.4 Unfortunately, many systems have not undergone a similar paradigm change, opting instead to merely rearrange components of the old knowledge‐focused system. For example, practice‐based learning may remain relegated to journal clubs, where the focus is on the knowledge contained in the chosen article, instead of active exercises in which the resident self‐reflects on his patient care performance and seeks ways to improve that performance. Instruction in systems‐of‐care may remain within a knowledge‐only paradigm: a didactic lecture on Medicare/Medicaid and reimbursement instead of residents actively participating in quality improvement projects.

The article by Mazotti et al.,5 provides insight into the reason for this developmental arrest: there isn't enough time in the old system. The duty‐hours have decreased for residents, but since the work product has remained the same, the result has been an increase in work intensity. As work intensity increases, production capacity (medical education) is the first to be sacrificed in an effort to maintain production (getting the work done).

Here is the yet unrealized role of the hospitalist. The same degree of systems reengineering that brought about improved efficiency in patient care (shorter lengths of stay, fewer readmissions), must be applied to the inpatient education system if duty hours, a reasonable work intensity, and meaningful education in each of the core competencies are to coexist. But there is no panacea for these issues: each system is unique, and the solutions to improving the efficiency of the inpatient education environment are just as unique. Solutions require a systems architect (ie, the hospitalist) to redesign the educational environment in his particular system. It is natural to assume that the hospitalist educator, familiar with the strengths and weakness of the educational system in which he routinely works, will be best equipped to enact meaningful solutions that improve efficiency while protecting the principles of medical education.

What does it mean to change the educational system? Taiichi Ohno,6 Toyota's Chief Engineer, provides Seven Organizational Wastes, a framework for identifying areas of improvement in the educational work environment. Consider, for example, the following selected opportunities for improving the efficiency of the inpatient medical education system: (1) excessive testing or consultation leading to delayed discharge and more resident work effort (Overproduction); (2) the resident team waiting for the attending to arrive from a procedure or clinic (Waiting); (3) inadequate teaching about the principles of transitions of care, resulting in more readmissions to the teaching service (Transporting); (4) failure to have quality improvement conferences to discuss the appropriateness of admissions (Inappropriate processing); (5) failure to teach residents how to work with social work/placement services to facilitate early discharge (Unnecessary inventory); (6) failure to construct a training program that limits fragmentation, with residents moving from 1 task to the next and back again (Unnecessary motion); and (7) medical errors resulting in prolonged lengths of stay and resident work effort (Defects). There is no shortage of opportunities for improving the efficiency of the inpatient educational environment, but it requires that the systems architect is sufficiently familiar with the system to design interventions that are meaningful and effective. This is the unique advantage of the hospitalist.

But the greatest risk to inpatient medical education is yet to come, and it may be on the hospitalist's shoulders to reverse a dangerous trend. With the advent of more extensive electronic medical records, the locus of patient care has begun to shift from the bedside to a computer terminal. An unbridled drive to efficiency, without a steward to ensure the primacy of patient‐centered care, is likely to inspire the next generation of physicians to see Mr. A. Huxley as the i‐Patient, in which the entirety of his management is conducted from the safety of a computer terminal.7 Despite the need for efficiency, the patient has to remain the focal point. It is at the bedside that the resident learns that observing 5 bags of potato chips on the nightstand might obviate a million‐dollar workup for refractory hypertension. And it is at the bedside that the resident learns that despite our elaborate protocols and decision analyses, the ultimate testing and management decisions hinge upon the patient's preferences. The single best thing than can be done to augment patient safety and quality is to maximize the time the patient spends with his healthcare team; and the hospitalist, who is not in a rush to complete morning rounds in an effort to get to a clinic or an endoscopy suite, may be the person who has the time to prioritize bedside rounds as a part of the educational environment.

The article by Nazario8 establishes the urgency of integrating the humanities into patient management. For meaningful humanities instruction to occur, however, it has to occur at the bedside, not in the classroom. And this requires that the supervising physician has the time to reflect with the resident upon the humanism issues that are unique to each patient encounter. Once again, it is time that enables the luxury of this self‐reflection, a commodity that the hospitalist enjoys as a part of her job description. It is also a commodity that the hospitalist can generate by augmenting efficiency in the educational system, provided patient‐centered care remains the priority.

The role of the hospitalist has to be much more than merely patching the current paradigm of graduate medical education. Overseeing nonteaching services and serving as the night float physician are examples of these patches. While valuable, these roles are useful only in preserving production of the current system, not in enabling production capacity for the next generation of physicians. Continuing in this role without also becoming an active part of the teaching service sends a message to residents that a career as a hospitalist in a teaching environment is only to be a fourth‐year or fifth‐year resident. Why would any resident embark upon that career? Meeting the demand for 30,000 hospitalists by 2012 requires a pipeline of physicians, and answering this question will be central to achieving that goal. Residents must have hospitalist role models, occupying careers devoted to patient safety and quality; careers that are meaningful and fulfilling.

To this end, the hospital medicine community cannot be satisfied with being no worse than other specialists in medical education. As Natarajan et al.3 point out, the evaluation of inpatient medical education has, with few exceptions, been solely based upon learner's subjective opinions. Meaningful change in the educational system will require meaningful objective endpoints: participation in the quality improvement projects; patient‐centered evaluations of resident performance; end‐user evaluations of resident communication skills (clinic physicians, nurses, other services); metrics to assess the efficacy of the transition of care; and resident profiles that enable self‐assessment of their practice. It will be up to the hospitalist to assess the system to define these meaningful endpoints that ensure that inpatient education is advancing quality, safety, and patient‐centered care.

Despite all of the reasons for why hospitalists should be more involved in the teaching service, there remains the 1 reason that they are not: hospitalists on average are young, and they may not have the teaching skills that more experienced generalists or subspecialists possess. To bring about the benefits hospitalists can offer to the inpatient education environment, hospitalists must be willing to compensate for their lack of teaching experience by seeking out formal training courses in medical education. The Academic Hospitalist Academy cosponsored by the Society of Hospital Medicine (SHM), the Society of General Internal Medicine (SGIM), and the Association of Chiefs of General Internal Medicine (ACGIM) is 1 example.9

As experience is accumulated, more hospitalists have to actively seek out leadership positions in graduate medical education, aligning our strengths, in patient safety, efficiency, and systems change, with the goals and objectives of the residency and student programs. The fact that 73% of residency training programs utilize hospitalists is exciting; the fact that there are only 15 hospitalists as program directors is disappointing.2 As was the case in the clinical care environment, leadership will be just as important in the education environment, as it is important for enacting the changes that will transform the inpatient education environment to a system that is efficient, safe, and patient‐centered.

Hospitalists have been effective in their production, augmenting efficiency and quality of patient care. But the reality is that the task of ensuring value, as it pertains to patient safety and quality, is too onerous of a task to be accomplished with arithmetic gains. Generations of physicians will have to adopt a cultural change to reach the ultimate goal. It is of little consequence that we improve safety for a moment in time, only to have it fall by the wayside as successive generations of physicians take our place. Now is the time for hospitalists to fully embrace the inpatient education environment as our responsibility. Too much time has already been wasted in arguing against duty‐hours regulations. These regulations are now here to stay, and this has created a system that is currently unable to handle the strains of multiple demands. Only by using the hospitalist's expertise in systems improvements and efficiency will a new inpatient educational system evolve; one that is efficient, safe, and patient‐focused, thus ensuring current production. And also one that enables meaningful development of communication, practice‐based learning, and systems‐of‐care skills, ensuring our production capacity for years to come.

Maintaining a balance between productivity (what we do now), and production capacity (the ability to continue to do what we now do in the future) is one of the central tenets of successful organizations and societies. The economic benefits of industrialization (production) must be balanced with the needs of the environment (production capacity). It is appropriate then, that this issue of The Journal of Hospital Medicine juxtaposes Conway's1 article on hospitalists' current production of ensuring value, with articles addressing medical education, our production capacity.

What is the role of hospitalists in medical education? The article by Beasley et al.,2 confirms what has long been suspected: the growth of hospitalists in medical education has paralleled the growth of the movement as a whole. The meta‐analysis by Natarajan et al.3 further suggests that hospitalists are at the very least no worse in medical education than other specialists, and in some domains, may be superior. The theoretical fears of hospitalists as medical educators have not been borne out: utilizing hospitalists as educators does not lead to a decline in resident autonomy, nor does it lead to a decline in educational ability. But despite the fact that 73% of residency training programs utilize hospitalists, there are several reasons why the hospitalists' role in inpatient medical education should be even more robust.

The landscape of graduate medical education has dramatically changed in the past 10 years. The knowledge‐only paradigm has evolved to a comprehensive focus on the trainee's overall performance, including understanding the healthcare system in which she works (systems of care), self‐reflection on her practice (practice‐based learning), and an augmented emphasis on professionalism and interpersonal skills.4 Unfortunately, many systems have not undergone a similar paradigm change, opting instead to merely rearrange components of the old knowledge‐focused system. For example, practice‐based learning may remain relegated to journal clubs, where the focus is on the knowledge contained in the chosen article, instead of active exercises in which the resident self‐reflects on his patient care performance and seeks ways to improve that performance. Instruction in systems‐of‐care may remain within a knowledge‐only paradigm: a didactic lecture on Medicare/Medicaid and reimbursement instead of residents actively participating in quality improvement projects.

The article by Mazotti et al.,5 provides insight into the reason for this developmental arrest: there isn't enough time in the old system. The duty‐hours have decreased for residents, but since the work product has remained the same, the result has been an increase in work intensity. As work intensity increases, production capacity (medical education) is the first to be sacrificed in an effort to maintain production (getting the work done).

Here is the yet unrealized role of the hospitalist. The same degree of systems reengineering that brought about improved efficiency in patient care (shorter lengths of stay, fewer readmissions), must be applied to the inpatient education system if duty hours, a reasonable work intensity, and meaningful education in each of the core competencies are to coexist. But there is no panacea for these issues: each system is unique, and the solutions to improving the efficiency of the inpatient education environment are just as unique. Solutions require a systems architect (ie, the hospitalist) to redesign the educational environment in his particular system. It is natural to assume that the hospitalist educator, familiar with the strengths and weakness of the educational system in which he routinely works, will be best equipped to enact meaningful solutions that improve efficiency while protecting the principles of medical education.

What does it mean to change the educational system? Taiichi Ohno,6 Toyota's Chief Engineer, provides Seven Organizational Wastes, a framework for identifying areas of improvement in the educational work environment. Consider, for example, the following selected opportunities for improving the efficiency of the inpatient medical education system: (1) excessive testing or consultation leading to delayed discharge and more resident work effort (Overproduction); (2) the resident team waiting for the attending to arrive from a procedure or clinic (Waiting); (3) inadequate teaching about the principles of transitions of care, resulting in more readmissions to the teaching service (Transporting); (4) failure to have quality improvement conferences to discuss the appropriateness of admissions (Inappropriate processing); (5) failure to teach residents how to work with social work/placement services to facilitate early discharge (Unnecessary inventory); (6) failure to construct a training program that limits fragmentation, with residents moving from 1 task to the next and back again (Unnecessary motion); and (7) medical errors resulting in prolonged lengths of stay and resident work effort (Defects). There is no shortage of opportunities for improving the efficiency of the inpatient educational environment, but it requires that the systems architect is sufficiently familiar with the system to design interventions that are meaningful and effective. This is the unique advantage of the hospitalist.

But the greatest risk to inpatient medical education is yet to come, and it may be on the hospitalist's shoulders to reverse a dangerous trend. With the advent of more extensive electronic medical records, the locus of patient care has begun to shift from the bedside to a computer terminal. An unbridled drive to efficiency, without a steward to ensure the primacy of patient‐centered care, is likely to inspire the next generation of physicians to see Mr. A. Huxley as the i‐Patient, in which the entirety of his management is conducted from the safety of a computer terminal.7 Despite the need for efficiency, the patient has to remain the focal point. It is at the bedside that the resident learns that observing 5 bags of potato chips on the nightstand might obviate a million‐dollar workup for refractory hypertension. And it is at the bedside that the resident learns that despite our elaborate protocols and decision analyses, the ultimate testing and management decisions hinge upon the patient's preferences. The single best thing than can be done to augment patient safety and quality is to maximize the time the patient spends with his healthcare team; and the hospitalist, who is not in a rush to complete morning rounds in an effort to get to a clinic or an endoscopy suite, may be the person who has the time to prioritize bedside rounds as a part of the educational environment.

The article by Nazario8 establishes the urgency of integrating the humanities into patient management. For meaningful humanities instruction to occur, however, it has to occur at the bedside, not in the classroom. And this requires that the supervising physician has the time to reflect with the resident upon the humanism issues that are unique to each patient encounter. Once again, it is time that enables the luxury of this self‐reflection, a commodity that the hospitalist enjoys as a part of her job description. It is also a commodity that the hospitalist can generate by augmenting efficiency in the educational system, provided patient‐centered care remains the priority.

The role of the hospitalist has to be much more than merely patching the current paradigm of graduate medical education. Overseeing nonteaching services and serving as the night float physician are examples of these patches. While valuable, these roles are useful only in preserving production of the current system, not in enabling production capacity for the next generation of physicians. Continuing in this role without also becoming an active part of the teaching service sends a message to residents that a career as a hospitalist in a teaching environment is only to be a fourth‐year or fifth‐year resident. Why would any resident embark upon that career? Meeting the demand for 30,000 hospitalists by 2012 requires a pipeline of physicians, and answering this question will be central to achieving that goal. Residents must have hospitalist role models, occupying careers devoted to patient safety and quality; careers that are meaningful and fulfilling.

To this end, the hospital medicine community cannot be satisfied with being no worse than other specialists in medical education. As Natarajan et al.3 point out, the evaluation of inpatient medical education has, with few exceptions, been solely based upon learner's subjective opinions. Meaningful change in the educational system will require meaningful objective endpoints: participation in the quality improvement projects; patient‐centered evaluations of resident performance; end‐user evaluations of resident communication skills (clinic physicians, nurses, other services); metrics to assess the efficacy of the transition of care; and resident profiles that enable self‐assessment of their practice. It will be up to the hospitalist to assess the system to define these meaningful endpoints that ensure that inpatient education is advancing quality, safety, and patient‐centered care.

Despite all of the reasons for why hospitalists should be more involved in the teaching service, there remains the 1 reason that they are not: hospitalists on average are young, and they may not have the teaching skills that more experienced generalists or subspecialists possess. To bring about the benefits hospitalists can offer to the inpatient education environment, hospitalists must be willing to compensate for their lack of teaching experience by seeking out formal training courses in medical education. The Academic Hospitalist Academy cosponsored by the Society of Hospital Medicine (SHM), the Society of General Internal Medicine (SGIM), and the Association of Chiefs of General Internal Medicine (ACGIM) is 1 example.9

As experience is accumulated, more hospitalists have to actively seek out leadership positions in graduate medical education, aligning our strengths, in patient safety, efficiency, and systems change, with the goals and objectives of the residency and student programs. The fact that 73% of residency training programs utilize hospitalists is exciting; the fact that there are only 15 hospitalists as program directors is disappointing.2 As was the case in the clinical care environment, leadership will be just as important in the education environment, as it is important for enacting the changes that will transform the inpatient education environment to a system that is efficient, safe, and patient‐centered.

Hospitalists have been effective in their production, augmenting efficiency and quality of patient care. But the reality is that the task of ensuring value, as it pertains to patient safety and quality, is too onerous of a task to be accomplished with arithmetic gains. Generations of physicians will have to adopt a cultural change to reach the ultimate goal. It is of little consequence that we improve safety for a moment in time, only to have it fall by the wayside as successive generations of physicians take our place. Now is the time for hospitalists to fully embrace the inpatient education environment as our responsibility. Too much time has already been wasted in arguing against duty‐hours regulations. These regulations are now here to stay, and this has created a system that is currently unable to handle the strains of multiple demands. Only by using the hospitalist's expertise in systems improvements and efficiency will a new inpatient educational system evolve; one that is efficient, safe, and patient‐focused, thus ensuring current production. And also one that enables meaningful development of communication, practice‐based learning, and systems‐of‐care skills, ensuring our production capacity for years to come.

Maintaining a balance between productivity (what we do now), and production capacity (the ability to continue to do what we now do in the future) is one of the central tenets of successful organizations and societies. The economic benefits of industrialization (production) must be balanced with the needs of the environment (production capacity). It is appropriate then, that this issue of The Journal of Hospital Medicine juxtaposes Conway's1 article on hospitalists' current production of ensuring value, with articles addressing medical education, our production capacity.

What is the role of hospitalists in medical education? The article by Beasley et al.,2 confirms what has long been suspected: the growth of hospitalists in medical education has paralleled the growth of the movement as a whole. The meta‐analysis by Natarajan et al.3 further suggests that hospitalists are at the very least no worse in medical education than other specialists, and in some domains, may be superior. The theoretical fears of hospitalists as medical educators have not been borne out: utilizing hospitalists as educators does not lead to a decline in resident autonomy, nor does it lead to a decline in educational ability. But despite the fact that 73% of residency training programs utilize hospitalists, there are several reasons why the hospitalists' role in inpatient medical education should be even more robust.

The landscape of graduate medical education has dramatically changed in the past 10 years. The knowledge‐only paradigm has evolved to a comprehensive focus on the trainee's overall performance, including understanding the healthcare system in which she works (systems of care), self‐reflection on her practice (practice‐based learning), and an augmented emphasis on professionalism and interpersonal skills.4 Unfortunately, many systems have not undergone a similar paradigm change, opting instead to merely rearrange components of the old knowledge‐focused system. For example, practice‐based learning may remain relegated to journal clubs, where the focus is on the knowledge contained in the chosen article, instead of active exercises in which the resident self‐reflects on his patient care performance and seeks ways to improve that performance. Instruction in systems‐of‐care may remain within a knowledge‐only paradigm: a didactic lecture on Medicare/Medicaid and reimbursement instead of residents actively participating in quality improvement projects.

The article by Mazotti et al.,5 provides insight into the reason for this developmental arrest: there isn't enough time in the old system. The duty‐hours have decreased for residents, but since the work product has remained the same, the result has been an increase in work intensity. As work intensity increases, production capacity (medical education) is the first to be sacrificed in an effort to maintain production (getting the work done).

Here is the yet unrealized role of the hospitalist. The same degree of systems reengineering that brought about improved efficiency in patient care (shorter lengths of stay, fewer readmissions), must be applied to the inpatient education system if duty hours, a reasonable work intensity, and meaningful education in each of the core competencies are to coexist. But there is no panacea for these issues: each system is unique, and the solutions to improving the efficiency of the inpatient education environment are just as unique. Solutions require a systems architect (ie, the hospitalist) to redesign the educational environment in his particular system. It is natural to assume that the hospitalist educator, familiar with the strengths and weakness of the educational system in which he routinely works, will be best equipped to enact meaningful solutions that improve efficiency while protecting the principles of medical education.

What does it mean to change the educational system? Taiichi Ohno,6 Toyota's Chief Engineer, provides Seven Organizational Wastes, a framework for identifying areas of improvement in the educational work environment. Consider, for example, the following selected opportunities for improving the efficiency of the inpatient medical education system: (1) excessive testing or consultation leading to delayed discharge and more resident work effort (Overproduction); (2) the resident team waiting for the attending to arrive from a procedure or clinic (Waiting); (3) inadequate teaching about the principles of transitions of care, resulting in more readmissions to the teaching service (Transporting); (4) failure to have quality improvement conferences to discuss the appropriateness of admissions (Inappropriate processing); (5) failure to teach residents how to work with social work/placement services to facilitate early discharge (Unnecessary inventory); (6) failure to construct a training program that limits fragmentation, with residents moving from 1 task to the next and back again (Unnecessary motion); and (7) medical errors resulting in prolonged lengths of stay and resident work effort (Defects). There is no shortage of opportunities for improving the efficiency of the inpatient educational environment, but it requires that the systems architect is sufficiently familiar with the system to design interventions that are meaningful and effective. This is the unique advantage of the hospitalist.

But the greatest risk to inpatient medical education is yet to come, and it may be on the hospitalist's shoulders to reverse a dangerous trend. With the advent of more extensive electronic medical records, the locus of patient care has begun to shift from the bedside to a computer terminal. An unbridled drive to efficiency, without a steward to ensure the primacy of patient‐centered care, is likely to inspire the next generation of physicians to see Mr. A. Huxley as the i‐Patient, in which the entirety of his management is conducted from the safety of a computer terminal.7 Despite the need for efficiency, the patient has to remain the focal point. It is at the bedside that the resident learns that observing 5 bags of potato chips on the nightstand might obviate a million‐dollar workup for refractory hypertension. And it is at the bedside that the resident learns that despite our elaborate protocols and decision analyses, the ultimate testing and management decisions hinge upon the patient's preferences. The single best thing than can be done to augment patient safety and quality is to maximize the time the patient spends with his healthcare team; and the hospitalist, who is not in a rush to complete morning rounds in an effort to get to a clinic or an endoscopy suite, may be the person who has the time to prioritize bedside rounds as a part of the educational environment.

The article by Nazario8 establishes the urgency of integrating the humanities into patient management. For meaningful humanities instruction to occur, however, it has to occur at the bedside, not in the classroom. And this requires that the supervising physician has the time to reflect with the resident upon the humanism issues that are unique to each patient encounter. Once again, it is time that enables the luxury of this self‐reflection, a commodity that the hospitalist enjoys as a part of her job description. It is also a commodity that the hospitalist can generate by augmenting efficiency in the educational system, provided patient‐centered care remains the priority.

The role of the hospitalist has to be much more than merely patching the current paradigm of graduate medical education. Overseeing nonteaching services and serving as the night float physician are examples of these patches. While valuable, these roles are useful only in preserving production of the current system, not in enabling production capacity for the next generation of physicians. Continuing in this role without also becoming an active part of the teaching service sends a message to residents that a career as a hospitalist in a teaching environment is only to be a fourth‐year or fifth‐year resident. Why would any resident embark upon that career? Meeting the demand for 30,000 hospitalists by 2012 requires a pipeline of physicians, and answering this question will be central to achieving that goal. Residents must have hospitalist role models, occupying careers devoted to patient safety and quality; careers that are meaningful and fulfilling.

To this end, the hospital medicine community cannot be satisfied with being no worse than other specialists in medical education. As Natarajan et al.3 point out, the evaluation of inpatient medical education has, with few exceptions, been solely based upon learner's subjective opinions. Meaningful change in the educational system will require meaningful objective endpoints: participation in the quality improvement projects; patient‐centered evaluations of resident performance; end‐user evaluations of resident communication skills (clinic physicians, nurses, other services); metrics to assess the efficacy of the transition of care; and resident profiles that enable self‐assessment of their practice. It will be up to the hospitalist to assess the system to define these meaningful endpoints that ensure that inpatient education is advancing quality, safety, and patient‐centered care.

Despite all of the reasons for why hospitalists should be more involved in the teaching service, there remains the 1 reason that they are not: hospitalists on average are young, and they may not have the teaching skills that more experienced generalists or subspecialists possess. To bring about the benefits hospitalists can offer to the inpatient education environment, hospitalists must be willing to compensate for their lack of teaching experience by seeking out formal training courses in medical education. The Academic Hospitalist Academy cosponsored by the Society of Hospital Medicine (SHM), the Society of General Internal Medicine (SGIM), and the Association of Chiefs of General Internal Medicine (ACGIM) is 1 example.9

As experience is accumulated, more hospitalists have to actively seek out leadership positions in graduate medical education, aligning our strengths, in patient safety, efficiency, and systems change, with the goals and objectives of the residency and student programs. The fact that 73% of residency training programs utilize hospitalists is exciting; the fact that there are only 15 hospitalists as program directors is disappointing.2 As was the case in the clinical care environment, leadership will be just as important in the education environment, as it is important for enacting the changes that will transform the inpatient education environment to a system that is efficient, safe, and patient‐centered.

Hospitalists have been effective in their production, augmenting efficiency and quality of patient care. But the reality is that the task of ensuring value, as it pertains to patient safety and quality, is too onerous of a task to be accomplished with arithmetic gains. Generations of physicians will have to adopt a cultural change to reach the ultimate goal. It is of little consequence that we improve safety for a moment in time, only to have it fall by the wayside as successive generations of physicians take our place. Now is the time for hospitalists to fully embrace the inpatient education environment as our responsibility. Too much time has already been wasted in arguing against duty‐hours regulations. These regulations are now here to stay, and this has created a system that is currently unable to handle the strains of multiple demands. Only by using the hospitalist's expertise in systems improvements and efficiency will a new inpatient educational system evolve; one that is efficient, safe, and patient‐focused, thus ensuring current production. And also one that enables meaningful development of communication, practice‐based learning, and systems‐of‐care skills, ensuring our production capacity for years to come.

Internal medicine residency programs, the major pipeline for incoming hospitalists, often provide little hands‐on experience in bedside procedures. Some residents may only insert 1 central venous catheter every 4 months on the general medicine wards,1 and others may gain little more experience during intensive care unit rotations. As seen in the survey presented by Grover et al.2 in this issue of the Journal, after 3 years of training in all types of patient care units, residents often count their accumulated experience on their fingers and toes. Such sparse experience hardly leads to expertise. Recognizing this pervasive lack of training the American Board of Internal Medicine narrowed its certification requirements for bedside procedures in 2006.3 Residents are no longer expected to perform bedside procedures but instead to know them. This important revision acknowledges that manual skills training should neither be assumed nor expendablecontinuing to do so is too risky.4 Yet as internal medicine residency programs focus their bedside procedure training on cognitive competence, the ongoing exodus of bedside procedures to the up‐market hands of subspecialists, surgeons, anesthesiologists, and interventional radiologists5 will likely accelerate.

But why should hospitalists disrupt this trend? Bedside procedures are common and not always conveniently needed during daytime hours. Roughly one‐tenth of general medicine inpatients receive a central venous catheter (CVC) insertion, a lumbar puncture, an abdominal paracentesis, or a thoracentesis.6 Among these patients, about one‐half will urgently need procedures during off‐hours. Outside of the emergency department, hospitalists will likely remain the only group of physicians available at the bedsides of general medicine inpatients 7 days a week, 24 hours per day. Thus, in developing our particular practice system to best serve our patients,7 we believe that hospitalists ought to remain principals in ensuring that inpatients have ready access to expertly performed bedside procedures.

Yet unfortunately, given the limited training in manual skills that today's internal medicine residents receive, hospitalists are increasingly less prepared to provide this access themselves.8 State‐of‐the‐art training methods developed by medical specialties that depend largely on manual skills provide promising potential solutions for both future and practicing hospitalists.9 In particular, patient simulators can provide trainees with the essential hands‐on experience they often lack. In contrast to the ad hoc see‐one, do‐one, teach‐one method in current widespread use, training with simulators has distinct advantages. First, simulators obviate the increasingly awkward consent as patients grow savvier about safety concerns and (understandably) less tolerant of a novice's need to acquire experience.10 Second, training with simulators is controlled so that anatomic variations, comorbidities, patient discomfort, and time pressuresthough important real‐world factorscan be artificially removed in the earlier cognitive and integrative stages of training.11 Third, immediate feedback, which at the bedside of real patients is often empathetically avoided or delivered in cryptic hand signals, can be unmistakably unmuted and honest in the simulator setting. Fourth, and most important to the development of expertise, simulators can be used repeatedly, allowing trainees first to become facile in the mechanics of their performance (eg, holding an ultrasound probe for real‐time guidance or knowing how it feels to enter a vein) before attempting a procedure on a patient.

Three examples of patient simulators used to train internal medicine residents in CVC insertion are presented in this issue of the Journal.1214 Using observers who adhered to objective, a priori assessment criteria, both Rosen et al.13 and Millington et al.14 carefully demonstrate that internal medicine residents' manual skills can improve with patient simulators. Given the understood importance of hands‐on experience in manual skills training,15 these anticipated findings are important validations of simulator theory. The work by Barsuk et al.12 goes further to begin to examine whether or not simulator training actually leads to improved patient outcomesthe holy grail of such research. In this observational study, compared to residents who did not undergo simulator training, those who did undergo such training had 1 fewer needle passes during successful CVC insertions. Given the relative infrequency of periprocedural complications, this study was understandably underpowered to measure true complications, relying instead on the often‐used surrogate of needle passes. Nonetheless, this work will serve as an important initial example of why simulator training may be worth the effort.

To direct participation in simulator training, we endorse selecting trainees who will perform bedside procedures in their future practice.16 Given the trend in manual skills training among internal medicine residency training programs, hospitalist programs may need to shoulder this effort themselves. Thankfully, simulator training need not be expensive. Based on transfer‐of‐learning research,17 the fidelity of the simulator is less important than the accumulated experience it can afford. Even low‐fidelity simulators, such as the store‐bought whole chicken used by Rosen et al.,13 may preserve trainees' manual skills just as effectively as the expensive, bionic, high‐fidelity simulators used by Barsuk et al.12 and Millington et al.14

Beyond the costs of training, however, hospital administrators and hospitalist group leaders have more complex externalities and opportunity costs to weigh when evaluating which physician groups should perform bedside procedures. The intuitively lower‐cost strategy for hospitals, we believe, would be to ask hospitalists to perform bedside procedures at patients' bedsides instead of asking, say, highly‐paid interventional radiologists to perform the same procedures in fully‐staffed fluoroscopy suites. There is, however, very little research to help inform these decisions. As hospitalists, we know firsthand that modern healthcare remuneration is based more on doing than on knowing. Yet, whether or not bedside procedures afford financial incentives for hospitalists is unclearmuch will depend on local factors. Regardless of the finances, we believe that hospitalists skilled in performing common bedside procedures can improve the quality and efficiency of care delivery at patients' bedsides. So, instead of a call to arms for yet another turf battle, let's continue development of state‐of‐the‐art training methods like simulators to ensure that future hospitalists can expertly perform bedside procedures. After all, fighting for improvements in patient safety is a battle that we hospitalists know how to win.

Internal medicine residency programs, the major pipeline for incoming hospitalists, often provide little hands‐on experience in bedside procedures. Some residents may only insert 1 central venous catheter every 4 months on the general medicine wards,1 and others may gain little more experience during intensive care unit rotations. As seen in the survey presented by Grover et al.2 in this issue of the Journal, after 3 years of training in all types of patient care units, residents often count their accumulated experience on their fingers and toes. Such sparse experience hardly leads to expertise. Recognizing this pervasive lack of training the American Board of Internal Medicine narrowed its certification requirements for bedside procedures in 2006.3 Residents are no longer expected to perform bedside procedures but instead to know them. This important revision acknowledges that manual skills training should neither be assumed nor expendablecontinuing to do so is too risky.4 Yet as internal medicine residency programs focus their bedside procedure training on cognitive competence, the ongoing exodus of bedside procedures to the up‐market hands of subspecialists, surgeons, anesthesiologists, and interventional radiologists5 will likely accelerate.

But why should hospitalists disrupt this trend? Bedside procedures are common and not always conveniently needed during daytime hours. Roughly one‐tenth of general medicine inpatients receive a central venous catheter (CVC) insertion, a lumbar puncture, an abdominal paracentesis, or a thoracentesis.6 Among these patients, about one‐half will urgently need procedures during off‐hours. Outside of the emergency department, hospitalists will likely remain the only group of physicians available at the bedsides of general medicine inpatients 7 days a week, 24 hours per day. Thus, in developing our particular practice system to best serve our patients,7 we believe that hospitalists ought to remain principals in ensuring that inpatients have ready access to expertly performed bedside procedures.

Yet unfortunately, given the limited training in manual skills that today's internal medicine residents receive, hospitalists are increasingly less prepared to provide this access themselves.8 State‐of‐the‐art training methods developed by medical specialties that depend largely on manual skills provide promising potential solutions for both future and practicing hospitalists.9 In particular, patient simulators can provide trainees with the essential hands‐on experience they often lack. In contrast to the ad hoc see‐one, do‐one, teach‐one method in current widespread use, training with simulators has distinct advantages. First, simulators obviate the increasingly awkward consent as patients grow savvier about safety concerns and (understandably) less tolerant of a novice's need to acquire experience.10 Second, training with simulators is controlled so that anatomic variations, comorbidities, patient discomfort, and time pressuresthough important real‐world factorscan be artificially removed in the earlier cognitive and integrative stages of training.11 Third, immediate feedback, which at the bedside of real patients is often empathetically avoided or delivered in cryptic hand signals, can be unmistakably unmuted and honest in the simulator setting. Fourth, and most important to the development of expertise, simulators can be used repeatedly, allowing trainees first to become facile in the mechanics of their performance (eg, holding an ultrasound probe for real‐time guidance or knowing how it feels to enter a vein) before attempting a procedure on a patient.

Three examples of patient simulators used to train internal medicine residents in CVC insertion are presented in this issue of the Journal.1214 Using observers who adhered to objective, a priori assessment criteria, both Rosen et al.13 and Millington et al.14 carefully demonstrate that internal medicine residents' manual skills can improve with patient simulators. Given the understood importance of hands‐on experience in manual skills training,15 these anticipated findings are important validations of simulator theory. The work by Barsuk et al.12 goes further to begin to examine whether or not simulator training actually leads to improved patient outcomesthe holy grail of such research. In this observational study, compared to residents who did not undergo simulator training, those who did undergo such training had 1 fewer needle passes during successful CVC insertions. Given the relative infrequency of periprocedural complications, this study was understandably underpowered to measure true complications, relying instead on the often‐used surrogate of needle passes. Nonetheless, this work will serve as an important initial example of why simulator training may be worth the effort.

To direct participation in simulator training, we endorse selecting trainees who will perform bedside procedures in their future practice.16 Given the trend in manual skills training among internal medicine residency training programs, hospitalist programs may need to shoulder this effort themselves. Thankfully, simulator training need not be expensive. Based on transfer‐of‐learning research,17 the fidelity of the simulator is less important than the accumulated experience it can afford. Even low‐fidelity simulators, such as the store‐bought whole chicken used by Rosen et al.,13 may preserve trainees' manual skills just as effectively as the expensive, bionic, high‐fidelity simulators used by Barsuk et al.12 and Millington et al.14

Beyond the costs of training, however, hospital administrators and hospitalist group leaders have more complex externalities and opportunity costs to weigh when evaluating which physician groups should perform bedside procedures. The intuitively lower‐cost strategy for hospitals, we believe, would be to ask hospitalists to perform bedside procedures at patients' bedsides instead of asking, say, highly‐paid interventional radiologists to perform the same procedures in fully‐staffed fluoroscopy suites. There is, however, very little research to help inform these decisions. As hospitalists, we know firsthand that modern healthcare remuneration is based more on doing than on knowing. Yet, whether or not bedside procedures afford financial incentives for hospitalists is unclearmuch will depend on local factors. Regardless of the finances, we believe that hospitalists skilled in performing common bedside procedures can improve the quality and efficiency of care delivery at patients' bedsides. So, instead of a call to arms for yet another turf battle, let's continue development of state‐of‐the‐art training methods like simulators to ensure that future hospitalists can expertly perform bedside procedures. After all, fighting for improvements in patient safety is a battle that we hospitalists know how to win.

Internal medicine residency programs, the major pipeline for incoming hospitalists, often provide little hands‐on experience in bedside procedures. Some residents may only insert 1 central venous catheter every 4 months on the general medicine wards,1 and others may gain little more experience during intensive care unit rotations. As seen in the survey presented by Grover et al.2 in this issue of the Journal, after 3 years of training in all types of patient care units, residents often count their accumulated experience on their fingers and toes. Such sparse experience hardly leads to expertise. Recognizing this pervasive lack of training the American Board of Internal Medicine narrowed its certification requirements for bedside procedures in 2006.3 Residents are no longer expected to perform bedside procedures but instead to know them. This important revision acknowledges that manual skills training should neither be assumed nor expendablecontinuing to do so is too risky.4 Yet as internal medicine residency programs focus their bedside procedure training on cognitive competence, the ongoing exodus of bedside procedures to the up‐market hands of subspecialists, surgeons, anesthesiologists, and interventional radiologists5 will likely accelerate.

But why should hospitalists disrupt this trend? Bedside procedures are common and not always conveniently needed during daytime hours. Roughly one‐tenth of general medicine inpatients receive a central venous catheter (CVC) insertion, a lumbar puncture, an abdominal paracentesis, or a thoracentesis.6 Among these patients, about one‐half will urgently need procedures during off‐hours. Outside of the emergency department, hospitalists will likely remain the only group of physicians available at the bedsides of general medicine inpatients 7 days a week, 24 hours per day. Thus, in developing our particular practice system to best serve our patients,7 we believe that hospitalists ought to remain principals in ensuring that inpatients have ready access to expertly performed bedside procedures.

Yet unfortunately, given the limited training in manual skills that today's internal medicine residents receive, hospitalists are increasingly less prepared to provide this access themselves.8 State‐of‐the‐art training methods developed by medical specialties that depend largely on manual skills provide promising potential solutions for both future and practicing hospitalists.9 In particular, patient simulators can provide trainees with the essential hands‐on experience they often lack. In contrast to the ad hoc see‐one, do‐one, teach‐one method in current widespread use, training with simulators has distinct advantages. First, simulators obviate the increasingly awkward consent as patients grow savvier about safety concerns and (understandably) less tolerant of a novice's need to acquire experience.10 Second, training with simulators is controlled so that anatomic variations, comorbidities, patient discomfort, and time pressuresthough important real‐world factorscan be artificially removed in the earlier cognitive and integrative stages of training.11 Third, immediate feedback, which at the bedside of real patients is often empathetically avoided or delivered in cryptic hand signals, can be unmistakably unmuted and honest in the simulator setting. Fourth, and most important to the development of expertise, simulators can be used repeatedly, allowing trainees first to become facile in the mechanics of their performance (eg, holding an ultrasound probe for real‐time guidance or knowing how it feels to enter a vein) before attempting a procedure on a patient.

Three examples of patient simulators used to train internal medicine residents in CVC insertion are presented in this issue of the Journal.1214 Using observers who adhered to objective, a priori assessment criteria, both Rosen et al.13 and Millington et al.14 carefully demonstrate that internal medicine residents' manual skills can improve with patient simulators. Given the understood importance of hands‐on experience in manual skills training,15 these anticipated findings are important validations of simulator theory. The work by Barsuk et al.12 goes further to begin to examine whether or not simulator training actually leads to improved patient outcomesthe holy grail of such research. In this observational study, compared to residents who did not undergo simulator training, those who did undergo such training had 1 fewer needle passes during successful CVC insertions. Given the relative infrequency of periprocedural complications, this study was understandably underpowered to measure true complications, relying instead on the often‐used surrogate of needle passes. Nonetheless, this work will serve as an important initial example of why simulator training may be worth the effort.

To direct participation in simulator training, we endorse selecting trainees who will perform bedside procedures in their future practice.16 Given the trend in manual skills training among internal medicine residency training programs, hospitalist programs may need to shoulder this effort themselves. Thankfully, simulator training need not be expensive. Based on transfer‐of‐learning research,17 the fidelity of the simulator is less important than the accumulated experience it can afford. Even low‐fidelity simulators, such as the store‐bought whole chicken used by Rosen et al.,13 may preserve trainees' manual skills just as effectively as the expensive, bionic, high‐fidelity simulators used by Barsuk et al.12 and Millington et al.14

Beyond the costs of training, however, hospital administrators and hospitalist group leaders have more complex externalities and opportunity costs to weigh when evaluating which physician groups should perform bedside procedures. The intuitively lower‐cost strategy for hospitals, we believe, would be to ask hospitalists to perform bedside procedures at patients' bedsides instead of asking, say, highly‐paid interventional radiologists to perform the same procedures in fully‐staffed fluoroscopy suites. There is, however, very little research to help inform these decisions. As hospitalists, we know firsthand that modern healthcare remuneration is based more on doing than on knowing. Yet, whether or not bedside procedures afford financial incentives for hospitalists is unclearmuch will depend on local factors. Regardless of the finances, we believe that hospitalists skilled in performing common bedside procedures can improve the quality and efficiency of care delivery at patients' bedsides. So, instead of a call to arms for yet another turf battle, let's continue development of state‐of‐the‐art training methods like simulators to ensure that future hospitalists can expertly perform bedside procedures. After all, fighting for improvements in patient safety is a battle that we hospitalists know how to win.

A lack of communication and accountability among healthcare professionals in general, and physicians in particular, jeopardizes quality and safety for our patients who are transitioning across sites of care.1, 2 Our patients, their family caregivers, and our health care professional colleagues on the receiving end of these transfers are often left flying blind without adequate information or direction to make sound clinical decisions.

Beyond our attempts to ensure effective transitions on a professional level, many of the readers of the Journal of Hospital Medicine likely have struggled to ensure seamless transitions for our families, despite the benefits of our training and experience.3 If some of the nation's most respected healthcare leaders are unable to make this work for their loved ones,48 one can only imagine the challenges faced by those without such advantages.

National and local quality collaboratives aimed at improving communication and collaboration across settings have found physicians difficult to engage as partners in these efforts.9 All too often there is a false expectation that these types of activities are best left to nonphysician healthcare professionals on the sending side of the transfer or to those receiving the transfer.10, 11

In this issue of the Journal, we commend the leadership provided by representatives of 6 of the nation's leading physician professional societies to join forces toward the common purpose of articulating physicians' roles and accountability for care delivered during transitions.12 Ensuring effective care transitions is a team sport, yet rarely do we have a clear understanding of who are the other members of our team, how to interact with them, or a clear delineation of their respective roles. Simply stated, this article is a key step to facilitating teamwork across settings among physicians, our interdisciplinary healthcare professional colleagues, our patients, and their family caregivers. These standards clearly convey the type of care we expect for our loved ones.

Drawing from proven strategies used in nonhealthcare industries, the standards assert that the sending provider or institution retains responsibility for the patient's care until the receiving team confirms receipt of the transfer and assumes responsibility. Further, the receiving team is given the opportunity to ask questions and clarify the proposed care plan in recognition of the fact that communication is more than simply the transfer of information. Rather, such communication involves the need to ensure comprehension and provide an opportunity to have a 2‐way dialog. These standards distinguish between the transmission of information and true communication.

The timing of the release of these standards is ideal. As physicians concentrate their practice within particular settings we can no longer rely on casual random interchanges in hospital parking lots or the hospital's physician lounge. Rather, we need to take a more active and reliable approach to ensuring timely and accurate exchanges. These standards cut to the essence of how we communicate with our physician and nonphysician colleagues alike, and in so doing move us away from nonproductive blame and finger‐pointing.

Although the implications for these standards are far reaching in terms of raising the quality bar, they could reach even further with respect to the types of settings they address. These standards need to extend beyond hospitals and the outpatient arena to include nursing homes, rehabilitation facilities, home care agencies, adult day health centers, and other settings where chronic care services are delivered.

Further, the standards devote considerable focus to the transfer of health information. Even with advances in health information exchange technologies, we must recognize that information is necessary but not sufficient for ensuring safe and high‐quality transfers. Implementing these standards will undoubtedly require that we reconfigure our daily workflows.13 The article in this issue by Graumlich et al.14 emphasizes the challenges of how to introduce technology into our daily clinical routines. The standards also open the door for how we can best ensure not just the transmission of information, but also the comprehension of transfer instructions to our patients with attention to health literacy, cognitive ability, and the patient's level of activation.15 Best and Young16 provide valuable action steps for how to address the needs of diverse and underserved populations.

These standards may serve to uncover the fact that most physicians have not received formal training in executing high‐quality care transitions in the role of either the sender or the receiver. Further, few physicians have a mechanism in place to evaluate their performance. The American Board of Internal Medicine and the American Board of Family Practice has developed Maintenance of Certification Practice Improvement Modules (PIM) on care coordination that provide an excellent opportunity to sharpen our skills. The HMO Care Management Workgroup has also attempted to summarize the essential skills necessary to care for patients during transitions.17

Perhaps the greatest value of these standards is that they lay the framework for actionable improvement. Local, state, and national quality collaboratives can immediately incorporate these recommendations into their overall strategy. These standards will likely influence the design and implementation of the Medical Home.18 As national attention focuses on how to operationalize bundled payment approaches and Accountable Care Organizations,19 these standards provide a clear consensus on communication, accountability, and ensuring patient‐centeredness. The standards are an excellent start and provide a framework for further innovation.

One area in particular may be the opportunity to reinvent the format, content, and medium by which essential information is transferred. For example, one might envision the value of producing a scaled down version of the discharge summary with a limited core set of data elements that could be quickly completed and communicated to the next care team via fax, e‐mail, or text messaging.

Complementing new strategies to improve the exchange of health information are opportunities to reconsider the culture within which this communication occurs. Our profession has a long‐standing tradition of not providing directives to our colleagues on the details of clinical management. Hospitalists develop important insights during a patient's hospital stay and are in an ideal position to anticipate potential developments in the subsequent course after discharge. Contrast this with the 5 to 10 minutes that a primary care physician or specialist may have to come up to speed on the hospital and posthospital events in order to manage the patient in the ambulatory arena. Thus, rather than the traditional historical orientation to a discharge summary, one could envision a more future‐orientated document characterized by a series of if‐then statements that outline a series of possible clinical scenarios that may play out over the weeks after discharge along with recommendations for adjustments to the treatment plan.

At a broader level, the release of these standards demonstrate to our communities and to our nation that physicians can join forces to address a particularly complex and challenging aspect of healthcare. Change can indeed come from within our profession rather than being imposed by outside influences such as government administrators, regulatory bodies, or malpractice attorneys. I applaud such efforts and believe that hospitalists will continue to play a central role in national efforts to improve transitions of care.

A lack of communication and accountability among healthcare professionals in general, and physicians in particular, jeopardizes quality and safety for our patients who are transitioning across sites of care.1, 2 Our patients, their family caregivers, and our health care professional colleagues on the receiving end of these transfers are often left flying blind without adequate information or direction to make sound clinical decisions.

Beyond our attempts to ensure effective transitions on a professional level, many of the readers of the Journal of Hospital Medicine likely have struggled to ensure seamless transitions for our families, despite the benefits of our training and experience.3 If some of the nation's most respected healthcare leaders are unable to make this work for their loved ones,48 one can only imagine the challenges faced by those without such advantages.

National and local quality collaboratives aimed at improving communication and collaboration across settings have found physicians difficult to engage as partners in these efforts.9 All too often there is a false expectation that these types of activities are best left to nonphysician healthcare professionals on the sending side of the transfer or to those receiving the transfer.10, 11

In this issue of the Journal, we commend the leadership provided by representatives of 6 of the nation's leading physician professional societies to join forces toward the common purpose of articulating physicians' roles and accountability for care delivered during transitions.12 Ensuring effective care transitions is a team sport, yet rarely do we have a clear understanding of who are the other members of our team, how to interact with them, or a clear delineation of their respective roles. Simply stated, this article is a key step to facilitating teamwork across settings among physicians, our interdisciplinary healthcare professional colleagues, our patients, and their family caregivers. These standards clearly convey the type of care we expect for our loved ones.

Drawing from proven strategies used in nonhealthcare industries, the standards assert that the sending provider or institution retains responsibility for the patient's care until the receiving team confirms receipt of the transfer and assumes responsibility. Further, the receiving team is given the opportunity to ask questions and clarify the proposed care plan in recognition of the fact that communication is more than simply the transfer of information. Rather, such communication involves the need to ensure comprehension and provide an opportunity to have a 2‐way dialog. These standards distinguish between the transmission of information and true communication.

The timing of the release of these standards is ideal. As physicians concentrate their practice within particular settings we can no longer rely on casual random interchanges in hospital parking lots or the hospital's physician lounge. Rather, we need to take a more active and reliable approach to ensuring timely and accurate exchanges. These standards cut to the essence of how we communicate with our physician and nonphysician colleagues alike, and in so doing move us away from nonproductive blame and finger‐pointing.

Although the implications for these standards are far reaching in terms of raising the quality bar, they could reach even further with respect to the types of settings they address. These standards need to extend beyond hospitals and the outpatient arena to include nursing homes, rehabilitation facilities, home care agencies, adult day health centers, and other settings where chronic care services are delivered.

Further, the standards devote considerable focus to the transfer of health information. Even with advances in health information exchange technologies, we must recognize that information is necessary but not sufficient for ensuring safe and high‐quality transfers. Implementing these standards will undoubtedly require that we reconfigure our daily workflows.13 The article in this issue by Graumlich et al.14 emphasizes the challenges of how to introduce technology into our daily clinical routines. The standards also open the door for how we can best ensure not just the transmission of information, but also the comprehension of transfer instructions to our patients with attention to health literacy, cognitive ability, and the patient's level of activation.15 Best and Young16 provide valuable action steps for how to address the needs of diverse and underserved populations.

These standards may serve to uncover the fact that most physicians have not received formal training in executing high‐quality care transitions in the role of either the sender or the receiver. Further, few physicians have a mechanism in place to evaluate their performance. The American Board of Internal Medicine and the American Board of Family Practice has developed Maintenance of Certification Practice Improvement Modules (PIM) on care coordination that provide an excellent opportunity to sharpen our skills. The HMO Care Management Workgroup has also attempted to summarize the essential skills necessary to care for patients during transitions.17

Perhaps the greatest value of these standards is that they lay the framework for actionable improvement. Local, state, and national quality collaboratives can immediately incorporate these recommendations into their overall strategy. These standards will likely influence the design and implementation of the Medical Home.18 As national attention focuses on how to operationalize bundled payment approaches and Accountable Care Organizations,19 these standards provide a clear consensus on communication, accountability, and ensuring patient‐centeredness. The standards are an excellent start and provide a framework for further innovation.

One area in particular may be the opportunity to reinvent the format, content, and medium by which essential information is transferred. For example, one might envision the value of producing a scaled down version of the discharge summary with a limited core set of data elements that could be quickly completed and communicated to the next care team via fax, e‐mail, or text messaging.

Complementing new strategies to improve the exchange of health information are opportunities to reconsider the culture within which this communication occurs. Our profession has a long‐standing tradition of not providing directives to our colleagues on the details of clinical management. Hospitalists develop important insights during a patient's hospital stay and are in an ideal position to anticipate potential developments in the subsequent course after discharge. Contrast this with the 5 to 10 minutes that a primary care physician or specialist may have to come up to speed on the hospital and posthospital events in order to manage the patient in the ambulatory arena. Thus, rather than the traditional historical orientation to a discharge summary, one could envision a more future‐orientated document characterized by a series of if‐then statements that outline a series of possible clinical scenarios that may play out over the weeks after discharge along with recommendations for adjustments to the treatment plan.

At a broader level, the release of these standards demonstrate to our communities and to our nation that physicians can join forces to address a particularly complex and challenging aspect of healthcare. Change can indeed come from within our profession rather than being imposed by outside influences such as government administrators, regulatory bodies, or malpractice attorneys. I applaud such efforts and believe that hospitalists will continue to play a central role in national efforts to improve transitions of care.

A lack of communication and accountability among healthcare professionals in general, and physicians in particular, jeopardizes quality and safety for our patients who are transitioning across sites of care.1, 2 Our patients, their family caregivers, and our health care professional colleagues on the receiving end of these transfers are often left flying blind without adequate information or direction to make sound clinical decisions.

Beyond our attempts to ensure effective transitions on a professional level, many of the readers of the Journal of Hospital Medicine likely have struggled to ensure seamless transitions for our families, despite the benefits of our training and experience.3 If some of the nation's most respected healthcare leaders are unable to make this work for their loved ones,48 one can only imagine the challenges faced by those without such advantages.

National and local quality collaboratives aimed at improving communication and collaboration across settings have found physicians difficult to engage as partners in these efforts.9 All too often there is a false expectation that these types of activities are best left to nonphysician healthcare professionals on the sending side of the transfer or to those receiving the transfer.10, 11

In this issue of the Journal, we commend the leadership provided by representatives of 6 of the nation's leading physician professional societies to join forces toward the common purpose of articulating physicians' roles and accountability for care delivered during transitions.12 Ensuring effective care transitions is a team sport, yet rarely do we have a clear understanding of who are the other members of our team, how to interact with them, or a clear delineation of their respective roles. Simply stated, this article is a key step to facilitating teamwork across settings among physicians, our interdisciplinary healthcare professional colleagues, our patients, and their family caregivers. These standards clearly convey the type of care we expect for our loved ones.

Drawing from proven strategies used in nonhealthcare industries, the standards assert that the sending provider or institution retains responsibility for the patient's care until the receiving team confirms receipt of the transfer and assumes responsibility. Further, the receiving team is given the opportunity to ask questions and clarify the proposed care plan in recognition of the fact that communication is more than simply the transfer of information. Rather, such communication involves the need to ensure comprehension and provide an opportunity to have a 2‐way dialog. These standards distinguish between the transmission of information and true communication.

The timing of the release of these standards is ideal. As physicians concentrate their practice within particular settings we can no longer rely on casual random interchanges in hospital parking lots or the hospital's physician lounge. Rather, we need to take a more active and reliable approach to ensuring timely and accurate exchanges. These standards cut to the essence of how we communicate with our physician and nonphysician colleagues alike, and in so doing move us away from nonproductive blame and finger‐pointing.

Although the implications for these standards are far reaching in terms of raising the quality bar, they could reach even further with respect to the types of settings they address. These standards need to extend beyond hospitals and the outpatient arena to include nursing homes, rehabilitation facilities, home care agencies, adult day health centers, and other settings where chronic care services are delivered.

Further, the standards devote considerable focus to the transfer of health information. Even with advances in health information exchange technologies, we must recognize that information is necessary but not sufficient for ensuring safe and high‐quality transfers. Implementing these standards will undoubtedly require that we reconfigure our daily workflows.13 The article in this issue by Graumlich et al.14 emphasizes the challenges of how to introduce technology into our daily clinical routines. The standards also open the door for how we can best ensure not just the transmission of information, but also the comprehension of transfer instructions to our patients with attention to health literacy, cognitive ability, and the patient's level of activation.15 Best and Young16 provide valuable action steps for how to address the needs of diverse and underserved populations.

These standards may serve to uncover the fact that most physicians have not received formal training in executing high‐quality care transitions in the role of either the sender or the receiver. Further, few physicians have a mechanism in place to evaluate their performance. The American Board of Internal Medicine and the American Board of Family Practice has developed Maintenance of Certification Practice Improvement Modules (PIM) on care coordination that provide an excellent opportunity to sharpen our skills. The HMO Care Management Workgroup has also attempted to summarize the essential skills necessary to care for patients during transitions.17

Perhaps the greatest value of these standards is that they lay the framework for actionable improvement. Local, state, and national quality collaboratives can immediately incorporate these recommendations into their overall strategy. These standards will likely influence the design and implementation of the Medical Home.18 As national attention focuses on how to operationalize bundled payment approaches and Accountable Care Organizations,19 these standards provide a clear consensus on communication, accountability, and ensuring patient‐centeredness. The standards are an excellent start and provide a framework for further innovation.

One area in particular may be the opportunity to reinvent the format, content, and medium by which essential information is transferred. For example, one might envision the value of producing a scaled down version of the discharge summary with a limited core set of data elements that could be quickly completed and communicated to the next care team via fax, e‐mail, or text messaging.

Complementing new strategies to improve the exchange of health information are opportunities to reconsider the culture within which this communication occurs. Our profession has a long‐standing tradition of not providing directives to our colleagues on the details of clinical management. Hospitalists develop important insights during a patient's hospital stay and are in an ideal position to anticipate potential developments in the subsequent course after discharge. Contrast this with the 5 to 10 minutes that a primary care physician or specialist may have to come up to speed on the hospital and posthospital events in order to manage the patient in the ambulatory arena. Thus, rather than the traditional historical orientation to a discharge summary, one could envision a more future‐orientated document characterized by a series of if‐then statements that outline a series of possible clinical scenarios that may play out over the weeks after discharge along with recommendations for adjustments to the treatment plan.

At a broader level, the release of these standards demonstrate to our communities and to our nation that physicians can join forces to address a particularly complex and challenging aspect of healthcare. Change can indeed come from within our profession rather than being imposed by outside influences such as government administrators, regulatory bodies, or malpractice attorneys. I applaud such efforts and believe that hospitalists will continue to play a central role in national efforts to improve transitions of care.