Editorial

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Insanity: doing the same thing over and over again and expecting different results.Albert Einstein

Diabetes is one of the most common diagnoses in hospitalized patients.1 A third of all persons admitted to urban general hospitals have glucose levels qualifying them for the diagnosis of diabetes, and a third of these hyperglycemic patients have not previously been diagnosed with diabetes.2 The impact of hyperglycemia on the mortality rate of hospitalized patients has been increasingly appreciated. Extensive evidence from observational studies indicates that hyperglycemia in patients with or without a history of diabetes is a marker of a poor clinical outcome.38 In addition, the results of prospective randomized trials in patients with critical illness or those undergoing coronary bypass surgery suggest that aggressive glycemic control improves clinical outcomes including reductions in: a) short‐ and long‐term mortality, b) multiorgan failure and systemic infection, and c) length of hospitalization.7, 911

The importance of glycemic control is not limited to patients in critical care areas but may also apply to patients admitted to general surgical and medical wards. The development of hyperglycemia in such patients with or without a history of diabetes has been associated with prolonged hospital stay, infection, disability after hospital discharge, and death.12, 13 In general‐surgical patients, serum glucose > 220 mg/dL on postoperative day 1 has been shown to be a sensitive, albeit nonspecific, predictor of the development of serious postoperative hospital‐acquired infection.14 A retrospective review of 1886 admissions to a community hospital in Atlanta, Georgia, found an 18‐fold increase in mortality in hyperglycemic patients without a history of diabetes and a 2.5‐fold increase in mortality in patients with known diabetes compared with controls.2 A meta‐analysis of 26 studies identified an association of admission glucose > 110 mg/dL with the increased mortality of patients hospitalized for acute stroke.15 More recently, hyperglycemia on admission was also shown to be independently associated with adverse outcomes in patients with community acquired pneumonia.16, 17

In view of the increasing evidence supporting better glycemic control in the hospital, the American Association of Clinical Endocrinologists (AACE) in late 2003 convened a consensus conference on the inpatient with diabetes, cosponsored or supported by other prominent professional organizations, including the Society of Hospital Medicine (SHM). An expert panel agreed on and published glycemic targets and recommendations for inpatient management of hyperglycemia.18 The American Diabetes Association (ADA) subsequently published an excellent technical review evaluating the evidence and outlining treatment, monitoring, and educational strategies13 for the hospitalized patient, and these recommendations were largely incorporated into the 2005 ADA Clinical Practice Guidelines for Hospitalized Patients.19 The recommended glycemic targets for hospitalized patients in the intensive care unit are between 80 and 110 mg/dL. In noncritical care settings a preprandial glucose of 90130 mg/dL (midpoint 110 mg/dL) and a postprandial or random glucose of less than 180 mg/dL are the recommended glycemic targets. Physiologic and safe insulin regimen strategies for virtually all patient situations were succinctly presented. Although there have been modest (and occasionally dramatic) improvements in glycemic control in several institutions, the reviews and guidelines have not yet resulted in widespread change in clinical practice on the inpatient wards.

Two retrospective studies from prestigious medical institutions reported in this issue of the Journal of Hospital Medicine dramatically illustrate that glycemic control and insulin‐ordering practices in general medicine services continue to be deficient and underscore the contribution of physician inertia in the management of hyperglycemia in noncritically ill patients.20, 21 From their findings and experiences in our institutions, you should expect the following at your institution unless you have embarked on an organized program to improve noncritical care inpatient glycemic control.

• Around one third of your patients with hyperglycemia have a mean glucose of more than 200 mg/dL during their hospital stay.

• Despite these out‐of‐control values, 60% of your inpatients will remain on a static regimen of sliding‐scale insulin over the duration of their stay. Unfortunately, this degree of hyperglycemia is not protective for hypoglycemic episodes.

• Around 10% of your monitored ward inpatients will have at least one hypoglycemic episode during their stay. Many of these episodes will be precipitated by poor coordination of nutrition and insulin administration and nonsensical insulin regimens that lead to insulin stacking.

• Discharge summaries and plans will include mention and follow‐up of hyperglycemia only a minority of the time.

• Your nursing and medical staffs are unevenly educated about the proper use of insulin, even though insulin errors are very common, and insulin is one of the top 3 drugs involved in adverse drug events in your institution.

• Transitions in care will lead to an inconsistent approach to glycemic control, leaving some of your patients confused and others just plain angry.

The ubiquitous use of the insulin sliding scale as the single routine response for controlling hyperglycemia in inpatients has been discredited for a long time.2224 Strong terms have been used the condemnation of this method: mindless medicine, paralysis of thought, and action without benefit, for example.25, 26 Yet this remains the most popular default regimen in most institutions across the country. Clinical inertia is defined as not initiating or intensifying therapy when doing so is indicated,27, 28 and that term certainly applies to glycemic control practices and the continued heavy use of sliding‐scale insulin across the nation.

Why is clinical inertia so strong in this area? Why have well‐done practice guidelines and reviews not eradicated the use of sliding‐scale insulin? First, hyperglycemia is rarely the focus of care during the hospital stay, as the overwhelming majority of hospitalizations of patients with hyperglycemia occur for comorbid conditions.2, 29 Second, fear of hypoglycemia constitutes a major barrier to efforts to improve glycemic control in hospitalized patients, especially in those with poor caloric intake.13, 30 Third, practitioners initiate sliding‐scale insulin regimens, even though this has been a thoroughly discredited approach, simply because it is the easiest thing to do in their current practice environment.31

How do we break this inertia and redesign our practice environment in such a way that using a more physiologic and sensible insulin regimen is the easiest thing to do? It starts with local physician leadership. On noncritical care wards, hospitalists and endocrinologists are the natural candidates to own the issue of inpatient diabetes care. These physician leaders need to garner appropriate institutional support, form a multidisciplinary steering committee or team, and formulate interventions.

Implementing a standardized subcutaneous insulin order set promoting the use of scheduled insulin therapy is a key intervention in the inpatient management of diabetes. These order sets should encourage basal replacement insulin therapy (ie, NPH, glargine, detemir) and scheduled nutritional/prandial short‐/rapid‐acting insulin (ie, regular, aspart, lispro, glulisine). The order set should also state the glycemic target, eliminate improper abbreviations and notations, incorporate a hypoglycemia protocol, and provide a range of default correction insulin dosage scales appropriate for varied levels of insulin sensitivity. Examples of such order sets are widely available.13, 32 This simple intervention can result in a tripling of insulin regimens including scheduled basal insulin, substantial subsequent improvement in glycemic control on the hospital floor, and significant reduction in hypoglycemic event rates.

The standardized order set can be much more effective when it is complemented by institution‐specific algorithms, protocols, and policies that support their effective use. These tools must not merely exist; they must be widely disseminated and used and, if possible, embedded in the order set. They should outline the calculation of insulin dosages, define recommended insulin regimens for patients with different forms of nutritional intake, guide transitions from insulin infusion to subcutaneous regimens, and enhance discharge planning and education.

The SHM, AACE, ADA, and other organizations are partnering to create a compendium of tested tools and strategies to assist hospitalists and their hospitals in these and other interventions and to assist them in devising reliable and practical metrics to gauge the impact of their efforts. These tools and a guidebook to walk teams through the improvement process step by step should be available on the SHM (www.hospitalmedicine.org) and other Web sites in the fall of 2006.

Look around and take stock. Does your hospital have standardized subcutaneous insulin order sets, algorithms and protocols supporting the order set, a multidisciplinary team tasked with improving insulin safety and glycemic control, and metrics to gauge whether your efforts are making a difference? Expecting better results without these essential elements is not only foolhardy but fits Einstein's definition of insanity: doing the same thing over and over again and expecting different results. Let's stop this sliding‐scale insulin insanity now.

Insanity: doing the same thing over and over again and expecting different results.Albert Einstein

Diabetes is one of the most common diagnoses in hospitalized patients.1 A third of all persons admitted to urban general hospitals have glucose levels qualifying them for the diagnosis of diabetes, and a third of these hyperglycemic patients have not previously been diagnosed with diabetes.2 The impact of hyperglycemia on the mortality rate of hospitalized patients has been increasingly appreciated. Extensive evidence from observational studies indicates that hyperglycemia in patients with or without a history of diabetes is a marker of a poor clinical outcome.38 In addition, the results of prospective randomized trials in patients with critical illness or those undergoing coronary bypass surgery suggest that aggressive glycemic control improves clinical outcomes including reductions in: a) short‐ and long‐term mortality, b) multiorgan failure and systemic infection, and c) length of hospitalization.7, 911

The importance of glycemic control is not limited to patients in critical care areas but may also apply to patients admitted to general surgical and medical wards. The development of hyperglycemia in such patients with or without a history of diabetes has been associated with prolonged hospital stay, infection, disability after hospital discharge, and death.12, 13 In general‐surgical patients, serum glucose > 220 mg/dL on postoperative day 1 has been shown to be a sensitive, albeit nonspecific, predictor of the development of serious postoperative hospital‐acquired infection.14 A retrospective review of 1886 admissions to a community hospital in Atlanta, Georgia, found an 18‐fold increase in mortality in hyperglycemic patients without a history of diabetes and a 2.5‐fold increase in mortality in patients with known diabetes compared with controls.2 A meta‐analysis of 26 studies identified an association of admission glucose > 110 mg/dL with the increased mortality of patients hospitalized for acute stroke.15 More recently, hyperglycemia on admission was also shown to be independently associated with adverse outcomes in patients with community acquired pneumonia.16, 17

In view of the increasing evidence supporting better glycemic control in the hospital, the American Association of Clinical Endocrinologists (AACE) in late 2003 convened a consensus conference on the inpatient with diabetes, cosponsored or supported by other prominent professional organizations, including the Society of Hospital Medicine (SHM). An expert panel agreed on and published glycemic targets and recommendations for inpatient management of hyperglycemia.18 The American Diabetes Association (ADA) subsequently published an excellent technical review evaluating the evidence and outlining treatment, monitoring, and educational strategies13 for the hospitalized patient, and these recommendations were largely incorporated into the 2005 ADA Clinical Practice Guidelines for Hospitalized Patients.19 The recommended glycemic targets for hospitalized patients in the intensive care unit are between 80 and 110 mg/dL. In noncritical care settings a preprandial glucose of 90130 mg/dL (midpoint 110 mg/dL) and a postprandial or random glucose of less than 180 mg/dL are the recommended glycemic targets. Physiologic and safe insulin regimen strategies for virtually all patient situations were succinctly presented. Although there have been modest (and occasionally dramatic) improvements in glycemic control in several institutions, the reviews and guidelines have not yet resulted in widespread change in clinical practice on the inpatient wards.

Two retrospective studies from prestigious medical institutions reported in this issue of the Journal of Hospital Medicine dramatically illustrate that glycemic control and insulin‐ordering practices in general medicine services continue to be deficient and underscore the contribution of physician inertia in the management of hyperglycemia in noncritically ill patients.20, 21 From their findings and experiences in our institutions, you should expect the following at your institution unless you have embarked on an organized program to improve noncritical care inpatient glycemic control.

• Around one third of your patients with hyperglycemia have a mean glucose of more than 200 mg/dL during their hospital stay.

• Despite these out‐of‐control values, 60% of your inpatients will remain on a static regimen of sliding‐scale insulin over the duration of their stay. Unfortunately, this degree of hyperglycemia is not protective for hypoglycemic episodes.

• Around 10% of your monitored ward inpatients will have at least one hypoglycemic episode during their stay. Many of these episodes will be precipitated by poor coordination of nutrition and insulin administration and nonsensical insulin regimens that lead to insulin stacking.

• Discharge summaries and plans will include mention and follow‐up of hyperglycemia only a minority of the time.

• Your nursing and medical staffs are unevenly educated about the proper use of insulin, even though insulin errors are very common, and insulin is one of the top 3 drugs involved in adverse drug events in your institution.

• Transitions in care will lead to an inconsistent approach to glycemic control, leaving some of your patients confused and others just plain angry.

The ubiquitous use of the insulin sliding scale as the single routine response for controlling hyperglycemia in inpatients has been discredited for a long time.2224 Strong terms have been used the condemnation of this method: mindless medicine, paralysis of thought, and action without benefit, for example.25, 26 Yet this remains the most popular default regimen in most institutions across the country. Clinical inertia is defined as not initiating or intensifying therapy when doing so is indicated,27, 28 and that term certainly applies to glycemic control practices and the continued heavy use of sliding‐scale insulin across the nation.

Why is clinical inertia so strong in this area? Why have well‐done practice guidelines and reviews not eradicated the use of sliding‐scale insulin? First, hyperglycemia is rarely the focus of care during the hospital stay, as the overwhelming majority of hospitalizations of patients with hyperglycemia occur for comorbid conditions.2, 29 Second, fear of hypoglycemia constitutes a major barrier to efforts to improve glycemic control in hospitalized patients, especially in those with poor caloric intake.13, 30 Third, practitioners initiate sliding‐scale insulin regimens, even though this has been a thoroughly discredited approach, simply because it is the easiest thing to do in their current practice environment.31

How do we break this inertia and redesign our practice environment in such a way that using a more physiologic and sensible insulin regimen is the easiest thing to do? It starts with local physician leadership. On noncritical care wards, hospitalists and endocrinologists are the natural candidates to own the issue of inpatient diabetes care. These physician leaders need to garner appropriate institutional support, form a multidisciplinary steering committee or team, and formulate interventions.

Implementing a standardized subcutaneous insulin order set promoting the use of scheduled insulin therapy is a key intervention in the inpatient management of diabetes. These order sets should encourage basal replacement insulin therapy (ie, NPH, glargine, detemir) and scheduled nutritional/prandial short‐/rapid‐acting insulin (ie, regular, aspart, lispro, glulisine). The order set should also state the glycemic target, eliminate improper abbreviations and notations, incorporate a hypoglycemia protocol, and provide a range of default correction insulin dosage scales appropriate for varied levels of insulin sensitivity. Examples of such order sets are widely available.13, 32 This simple intervention can result in a tripling of insulin regimens including scheduled basal insulin, substantial subsequent improvement in glycemic control on the hospital floor, and significant reduction in hypoglycemic event rates.

The standardized order set can be much more effective when it is complemented by institution‐specific algorithms, protocols, and policies that support their effective use. These tools must not merely exist; they must be widely disseminated and used and, if possible, embedded in the order set. They should outline the calculation of insulin dosages, define recommended insulin regimens for patients with different forms of nutritional intake, guide transitions from insulin infusion to subcutaneous regimens, and enhance discharge planning and education.

The SHM, AACE, ADA, and other organizations are partnering to create a compendium of tested tools and strategies to assist hospitalists and their hospitals in these and other interventions and to assist them in devising reliable and practical metrics to gauge the impact of their efforts. These tools and a guidebook to walk teams through the improvement process step by step should be available on the SHM (www.hospitalmedicine.org) and other Web sites in the fall of 2006.

Look around and take stock. Does your hospital have standardized subcutaneous insulin order sets, algorithms and protocols supporting the order set, a multidisciplinary team tasked with improving insulin safety and glycemic control, and metrics to gauge whether your efforts are making a difference? Expecting better results without these essential elements is not only foolhardy but fits Einstein's definition of insanity: doing the same thing over and over again and expecting different results. Let's stop this sliding‐scale insulin insanity now.

Insanity: doing the same thing over and over again and expecting different results.Albert Einstein

Diabetes is one of the most common diagnoses in hospitalized patients.1 A third of all persons admitted to urban general hospitals have glucose levels qualifying them for the diagnosis of diabetes, and a third of these hyperglycemic patients have not previously been diagnosed with diabetes.2 The impact of hyperglycemia on the mortality rate of hospitalized patients has been increasingly appreciated. Extensive evidence from observational studies indicates that hyperglycemia in patients with or without a history of diabetes is a marker of a poor clinical outcome.38 In addition, the results of prospective randomized trials in patients with critical illness or those undergoing coronary bypass surgery suggest that aggressive glycemic control improves clinical outcomes including reductions in: a) short‐ and long‐term mortality, b) multiorgan failure and systemic infection, and c) length of hospitalization.7, 911

The importance of glycemic control is not limited to patients in critical care areas but may also apply to patients admitted to general surgical and medical wards. The development of hyperglycemia in such patients with or without a history of diabetes has been associated with prolonged hospital stay, infection, disability after hospital discharge, and death.12, 13 In general‐surgical patients, serum glucose > 220 mg/dL on postoperative day 1 has been shown to be a sensitive, albeit nonspecific, predictor of the development of serious postoperative hospital‐acquired infection.14 A retrospective review of 1886 admissions to a community hospital in Atlanta, Georgia, found an 18‐fold increase in mortality in hyperglycemic patients without a history of diabetes and a 2.5‐fold increase in mortality in patients with known diabetes compared with controls.2 A meta‐analysis of 26 studies identified an association of admission glucose > 110 mg/dL with the increased mortality of patients hospitalized for acute stroke.15 More recently, hyperglycemia on admission was also shown to be independently associated with adverse outcomes in patients with community acquired pneumonia.16, 17

In view of the increasing evidence supporting better glycemic control in the hospital, the American Association of Clinical Endocrinologists (AACE) in late 2003 convened a consensus conference on the inpatient with diabetes, cosponsored or supported by other prominent professional organizations, including the Society of Hospital Medicine (SHM). An expert panel agreed on and published glycemic targets and recommendations for inpatient management of hyperglycemia.18 The American Diabetes Association (ADA) subsequently published an excellent technical review evaluating the evidence and outlining treatment, monitoring, and educational strategies13 for the hospitalized patient, and these recommendations were largely incorporated into the 2005 ADA Clinical Practice Guidelines for Hospitalized Patients.19 The recommended glycemic targets for hospitalized patients in the intensive care unit are between 80 and 110 mg/dL. In noncritical care settings a preprandial glucose of 90130 mg/dL (midpoint 110 mg/dL) and a postprandial or random glucose of less than 180 mg/dL are the recommended glycemic targets. Physiologic and safe insulin regimen strategies for virtually all patient situations were succinctly presented. Although there have been modest (and occasionally dramatic) improvements in glycemic control in several institutions, the reviews and guidelines have not yet resulted in widespread change in clinical practice on the inpatient wards.

Two retrospective studies from prestigious medical institutions reported in this issue of the Journal of Hospital Medicine dramatically illustrate that glycemic control and insulin‐ordering practices in general medicine services continue to be deficient and underscore the contribution of physician inertia in the management of hyperglycemia in noncritically ill patients.20, 21 From their findings and experiences in our institutions, you should expect the following at your institution unless you have embarked on an organized program to improve noncritical care inpatient glycemic control.

• Around one third of your patients with hyperglycemia have a mean glucose of more than 200 mg/dL during their hospital stay.

• Despite these out‐of‐control values, 60% of your inpatients will remain on a static regimen of sliding‐scale insulin over the duration of their stay. Unfortunately, this degree of hyperglycemia is not protective for hypoglycemic episodes.

• Around 10% of your monitored ward inpatients will have at least one hypoglycemic episode during their stay. Many of these episodes will be precipitated by poor coordination of nutrition and insulin administration and nonsensical insulin regimens that lead to insulin stacking.

• Discharge summaries and plans will include mention and follow‐up of hyperglycemia only a minority of the time.

• Your nursing and medical staffs are unevenly educated about the proper use of insulin, even though insulin errors are very common, and insulin is one of the top 3 drugs involved in adverse drug events in your institution.

• Transitions in care will lead to an inconsistent approach to glycemic control, leaving some of your patients confused and others just plain angry.

The ubiquitous use of the insulin sliding scale as the single routine response for controlling hyperglycemia in inpatients has been discredited for a long time.2224 Strong terms have been used the condemnation of this method: mindless medicine, paralysis of thought, and action without benefit, for example.25, 26 Yet this remains the most popular default regimen in most institutions across the country. Clinical inertia is defined as not initiating or intensifying therapy when doing so is indicated,27, 28 and that term certainly applies to glycemic control practices and the continued heavy use of sliding‐scale insulin across the nation.

Why is clinical inertia so strong in this area? Why have well‐done practice guidelines and reviews not eradicated the use of sliding‐scale insulin? First, hyperglycemia is rarely the focus of care during the hospital stay, as the overwhelming majority of hospitalizations of patients with hyperglycemia occur for comorbid conditions.2, 29 Second, fear of hypoglycemia constitutes a major barrier to efforts to improve glycemic control in hospitalized patients, especially in those with poor caloric intake.13, 30 Third, practitioners initiate sliding‐scale insulin regimens, even though this has been a thoroughly discredited approach, simply because it is the easiest thing to do in their current practice environment.31

How do we break this inertia and redesign our practice environment in such a way that using a more physiologic and sensible insulin regimen is the easiest thing to do? It starts with local physician leadership. On noncritical care wards, hospitalists and endocrinologists are the natural candidates to own the issue of inpatient diabetes care. These physician leaders need to garner appropriate institutional support, form a multidisciplinary steering committee or team, and formulate interventions.

Implementing a standardized subcutaneous insulin order set promoting the use of scheduled insulin therapy is a key intervention in the inpatient management of diabetes. These order sets should encourage basal replacement insulin therapy (ie, NPH, glargine, detemir) and scheduled nutritional/prandial short‐/rapid‐acting insulin (ie, regular, aspart, lispro, glulisine). The order set should also state the glycemic target, eliminate improper abbreviations and notations, incorporate a hypoglycemia protocol, and provide a range of default correction insulin dosage scales appropriate for varied levels of insulin sensitivity. Examples of such order sets are widely available.13, 32 This simple intervention can result in a tripling of insulin regimens including scheduled basal insulin, substantial subsequent improvement in glycemic control on the hospital floor, and significant reduction in hypoglycemic event rates.

The standardized order set can be much more effective when it is complemented by institution‐specific algorithms, protocols, and policies that support their effective use. These tools must not merely exist; they must be widely disseminated and used and, if possible, embedded in the order set. They should outline the calculation of insulin dosages, define recommended insulin regimens for patients with different forms of nutritional intake, guide transitions from insulin infusion to subcutaneous regimens, and enhance discharge planning and education.

The SHM, AACE, ADA, and other organizations are partnering to create a compendium of tested tools and strategies to assist hospitalists and their hospitals in these and other interventions and to assist them in devising reliable and practical metrics to gauge the impact of their efforts. These tools and a guidebook to walk teams through the improvement process step by step should be available on the SHM (www.hospitalmedicine.org) and other Web sites in the fall of 2006.

Look around and take stock. Does your hospital have standardized subcutaneous insulin order sets, algorithms and protocols supporting the order set, a multidisciplinary team tasked with improving insulin safety and glycemic control, and metrics to gauge whether your efforts are making a difference? Expecting better results without these essential elements is not only foolhardy but fits Einstein's definition of insanity: doing the same thing over and over again and expecting different results. Let's stop this sliding‐scale insulin insanity now.

Being a hospitalist provides us with many rewards in life: a secure job, decent income, intellectually stimulating experiences at work, and gratification from helping the patients we encounter. Importantly, without patients none of this would be possible. Their role in our work lives and their personal experience in the hospital vary dramatically from ours, and that experience may be relatively invisible to many of us. Be honesthave you fully recognized the apprehension and even terror experienced by some patients when nightfall sweeps through the hospital wards and the commotion and attention of the day shift dissipates?1 Have you been fully aware of the desperate need of patients or their family members for timely communication of understandable information in the midst of critical illness?2 We willingly believe what we wishpatients and their families are having a comforting experience while hospitalized, and we are doing wonderful jobs as hospitalists caring for them. However, the lay press indicates that the patient's perception may differ radically from this reassuring point of view.3

To comprehend fully the hospital experience of patients and their families, we can benefit from them telling us their stories. The narrative stories from a patient1 and the wife of a patient2 clearly convey the apprehension and fear both patients and their loved ones suffer. Without this appreciation, we cannot empathetically deliver the care patients deserve. Not surprisingly, as medical technology guides physicians to focus more on the disease instead of the person, a backlash of an increasing emphasis on patient‐centered care is emerging.4, 5 Through short essays on illuminating experiences of physicians, patients, or families of patients, I hope to bring the patient's perspective to the forefront of hospital medicine care. View from the Hospital Bed can educate us about patients' perspectives on the experience of being hospitalized. We can also learn from the families of patients in View from the Hospital Room. The next time you recognize that a patient or family member has a potent story to tell (good or bad), encourage them to send it to us at the Journal of Hospital Medicine.

Being a hospitalist provides us with many rewards in life: a secure job, decent income, intellectually stimulating experiences at work, and gratification from helping the patients we encounter. Importantly, without patients none of this would be possible. Their role in our work lives and their personal experience in the hospital vary dramatically from ours, and that experience may be relatively invisible to many of us. Be honesthave you fully recognized the apprehension and even terror experienced by some patients when nightfall sweeps through the hospital wards and the commotion and attention of the day shift dissipates?1 Have you been fully aware of the desperate need of patients or their family members for timely communication of understandable information in the midst of critical illness?2 We willingly believe what we wishpatients and their families are having a comforting experience while hospitalized, and we are doing wonderful jobs as hospitalists caring for them. However, the lay press indicates that the patient's perception may differ radically from this reassuring point of view.3

To comprehend fully the hospital experience of patients and their families, we can benefit from them telling us their stories. The narrative stories from a patient1 and the wife of a patient2 clearly convey the apprehension and fear both patients and their loved ones suffer. Without this appreciation, we cannot empathetically deliver the care patients deserve. Not surprisingly, as medical technology guides physicians to focus more on the disease instead of the person, a backlash of an increasing emphasis on patient‐centered care is emerging.4, 5 Through short essays on illuminating experiences of physicians, patients, or families of patients, I hope to bring the patient's perspective to the forefront of hospital medicine care. View from the Hospital Bed can educate us about patients' perspectives on the experience of being hospitalized. We can also learn from the families of patients in View from the Hospital Room. The next time you recognize that a patient or family member has a potent story to tell (good or bad), encourage them to send it to us at the Journal of Hospital Medicine.

Being a hospitalist provides us with many rewards in life: a secure job, decent income, intellectually stimulating experiences at work, and gratification from helping the patients we encounter. Importantly, without patients none of this would be possible. Their role in our work lives and their personal experience in the hospital vary dramatically from ours, and that experience may be relatively invisible to many of us. Be honesthave you fully recognized the apprehension and even terror experienced by some patients when nightfall sweeps through the hospital wards and the commotion and attention of the day shift dissipates?1 Have you been fully aware of the desperate need of patients or their family members for timely communication of understandable information in the midst of critical illness?2 We willingly believe what we wishpatients and their families are having a comforting experience while hospitalized, and we are doing wonderful jobs as hospitalists caring for them. However, the lay press indicates that the patient's perception may differ radically from this reassuring point of view.3

To comprehend fully the hospital experience of patients and their families, we can benefit from them telling us their stories. The narrative stories from a patient1 and the wife of a patient2 clearly convey the apprehension and fear both patients and their loved ones suffer. Without this appreciation, we cannot empathetically deliver the care patients deserve. Not surprisingly, as medical technology guides physicians to focus more on the disease instead of the person, a backlash of an increasing emphasis on patient‐centered care is emerging.4, 5 Through short essays on illuminating experiences of physicians, patients, or families of patients, I hope to bring the patient's perspective to the forefront of hospital medicine care. View from the Hospital Bed can educate us about patients' perspectives on the experience of being hospitalized. We can also learn from the families of patients in View from the Hospital Room. The next time you recognize that a patient or family member has a potent story to tell (good or bad), encourage them to send it to us at the Journal of Hospital Medicine.

She is not, however, without a certain, well, grim sense of humor.

The voice throws you at first. It's deceptively mild and calm, more Gwyneth Paltrow than James Earl Jones. To the best of my knowledge, however, Gwyneth Paltrow has never shown up in a patient's room wearing a hooded black robe and sporting a scythe.

Hmm, bad case of sepsis, huh? she asked.

I was still cleaning up from the central line, so I tried to get rid of her gracefully. Now's not really a good time. That line always seems to work with pesky administrators.

Death, however, would not be dissuaded. HIV positive for nearly 10 years now, flirting with CD4 counts in double digits, rising viral load the past 3 years. Picked a bad time to have her gallbladder go bad on her, didn't she?

Or a bad time to pick a surgeon who was less than fastidious about his sterile fields, I muttered.

Death, however, chose to ignore me. Ventilator, pressors, antibiotics. She reached for the girl's right hand, attached as it was to an arterial line blood pressure monitor, and somethingdamn, if it didn't look like a scarabfell out of the robe and then scrambled across my patient's chest, right next to my newly placed and oh‐so‐deftly sutured plastic catheter, ducking away from the light.

Hey, that was my sterile field, I complained. I, unlike the aforementioned surgeon, had been fastidious about it. I hoped the scarab was sterile, at least.

Splinter hemorrhages, Death noted with obvious glee, taking particular interest in the little streaks of blood under my patient's fingernails. Septic emboli. Death seems to have Gwnyeth Paltrow's laugh along with her voice. It's a light and airy thing, almost like a favorite wind chime. That laugh could almost make you think Death had a heart. Endocarditis, she said fondly. One of my favorites.

Almost make you think she had a heart.

Go away. I tried to look more busy than worried, but I didn't think she was buying it.

It's been a good month for me here in the ICU. Heck, you yourself have 4 kills. Why don't you throw in this one and call yourself an ace?

Very funny. Now get out. I would imagine it's best not to lose your temper with Death. Or with any of the other three Horsemen of the Apocalypse, for that matter. Didn't anyone ever tell you it's poor form to make fun of your host? You're in Donna Smith's house now, buddy. Don't be dissin' my nurse manager.

Come on, she pushed. She's pathetic, she's tired, she lives alone in a tiny room in a forgotten crack house that she pretends is her apartment, and her parents haven't taken her calls for years.

Donna? I asked. That was some serious disrespect.

Don't go all medical student on me. I was talking about your patient, she explained evenly. She'd be better off with me anyway. You know that.

She can be persuasive when she might be right. Death and I have been having similar conversations all the way back to my surgical rotation as a third‐year medical student. Although she has never been above making the easy score, she typically only makes serious plays for patients who, in all honesty, just might be better off heading with her beyond the vale. That's not my decision to make, I told Death, tweaking the pressors. I have this thing about systolic blood pressure less than room temperature. By being here, she's placed her life in my hands, I said, staring down into what almost looked like a lifeless face. Until and unless I have a compelling reason to do otherwise, I will do whatever is necessary to ensure she comes out of this thing as well as she can. I turned to look Death in those beady little eyes. Even go 15 rounds with you, if that's what it takes.

There was a moment of silence, during which I began to think that perhaps I had made my point. Rock, paper, scissors? Death asked with a hopeful lilt.

I sighed. Damn, but she was persistent. I don't gamble with death. That's something my mommy taught me, way back when I used to think I'd be able to fly if I jumped from that really tall tree on the hill.

Oh, come on. Your patient in the next bed did. Overdosed on Ativan with a fifth of Johnny Walker Black as a chaser? Now there's a lifestyle choice I can find myself endorsing.

I was out of witty comebacks. Everyone deserves another chance, I told her, my eyes fixed now on the hollowed, closed eyes of my patient in the ICU bed. Evenor maybe even especiallymy patient in the next bed. I don't know what it was about his life that had driven him to the lifestyle choices he had made. There's a part of every physician that thinks that he or she can make that difference in a patient's life. All too often, though, we see enough repeat business to learn, the hard way, that we rarely make the kind of differences we'd like to. With a little luck, and no small amount of medical diligence, both my patients would survive this hospitalization.

But would they survive their next?

Would there be a next?

Would this be the time they'd turn the corner?

I had to hope so, because I still consider myself far too young to be any more cynical than I already am.

What about your partner? Death asked suddenly.

No, I said with something I hoped sounded like authority. You can't have her either.

No, I meanhow about I work a deal with her? She's young, she's impressionable, she's idealisticwe could make it not your fault.

She's got enough to do; please just leave her alone.

The hood shook slowly back and forth, so I assumed she was shaking her head. Or her skull. Whichever. Look, you wouldn't even have to do anything, that sweet, seductive voice told me. Just head back to your call room for a few minutes. Turn off your pager.

I don't know why we're even having this conversation, I groaned. We both know that you're just a hallucination caused by way too little sleep and way too much caffeine. Last call night I caught myself discussing the relative merits of high‐frequency jet ventilation with Galen.

Galen, Death reflected, suddenly nostalgic. Highly overrated, a positive trait in a doctor if you don't mind my saying so. Has an ego that would make an orthopedist seem humble.

You're lying, I decided.

Yes, I am. And you're stalling. Her voice suddenly became a whole lot more James Earl Jonesish. I'm taking the septic chick with endocarditis. You can lose all the sleep you want, she still goes Home with me.

I glanced over the drips one more time. I've just added norepi. That's a whole bag full of bite me that says differently. So back off, sweetheart.

As with most true medical emergencies, I was too busy thinking ahead to realize just how much trouble my patient could have been in at that moment.

Now morning, like her fever, has broken.

The sun, for those that haven't noticed, gives off a beautiful red glow as it rises over Boot Hill. I got to see it from the rocking chair in my patient's room. Nurse Donna was finishing the night's vital sign flow sheet, politely pretending she hadn't heard me snoring away the past 15 minutes. I was trying to decide if that odor drifting into the room was someone's attempt at coffee or melana. Donna smiled politely at me as I rubbed the Sandman's crud out of my eyes. It was a very Chicago Hope kinda moment.

If I'd been playing a doctor on TV, I'd have made some reassuring comment about how my patient had made it through the night, and so she was now out of the woods. Uh‐huh. With Death sneaking up behind me, my bite‐me norepinephrine wasn't going to be weaned just yet.

Good morning, I greeted.

She seemed a bit put off that I had heard her sneaking in. But then, Death is not exactly graced with kitty‐cat feet.

You never turned your pager off. She said it like an accusation. The way my wife does.

Never do. An answer my wife doesn't appreciate, either. My patient's still with me, I said, managing to keep the victory dance out of my voice. Pressure is better, heart rate is lower, fever seems to have broken.

Death is patient, death is kind, she warned.

It took my postcall mind a moment to wrap itself around that one. Isn't that supposed to be Love? I asked her.

The shoulders of the robe shrugged. Love gets all the cool lines, she complained. What do I get? Be not proud, nothing's for sure but me and taxes, Yea, though I walk through the valley of the shadow of me, give me liberty or give me me. She turned to face me. I like that one, by the way.

Never fails to bring a tear to my eye. I'd give her that. She had lost the patient, I could afford to be gracious and throw her a bone. As long as said bone didn't belong to one of my patients.

Death was silent for a long moment. Well, I'm outta here, she finally decided. What about you?

I've got a few more hours. Rounds, orders, more rounds, discussions with families, likely more rounds

I thought I could hear a wry grin in her voice. Well, you be careful driving home, she suggested. It'd be a shame if you fell asleep at the wheel. And then ended up on my doorstep.

Damn.

She is not, however, without a certain, well, grim sense of humor.

The voice throws you at first. It's deceptively mild and calm, more Gwyneth Paltrow than James Earl Jones. To the best of my knowledge, however, Gwyneth Paltrow has never shown up in a patient's room wearing a hooded black robe and sporting a scythe.

Hmm, bad case of sepsis, huh? she asked.

I was still cleaning up from the central line, so I tried to get rid of her gracefully. Now's not really a good time. That line always seems to work with pesky administrators.

Death, however, would not be dissuaded. HIV positive for nearly 10 years now, flirting with CD4 counts in double digits, rising viral load the past 3 years. Picked a bad time to have her gallbladder go bad on her, didn't she?

Or a bad time to pick a surgeon who was less than fastidious about his sterile fields, I muttered.

Death, however, chose to ignore me. Ventilator, pressors, antibiotics. She reached for the girl's right hand, attached as it was to an arterial line blood pressure monitor, and somethingdamn, if it didn't look like a scarabfell out of the robe and then scrambled across my patient's chest, right next to my newly placed and oh‐so‐deftly sutured plastic catheter, ducking away from the light.

Hey, that was my sterile field, I complained. I, unlike the aforementioned surgeon, had been fastidious about it. I hoped the scarab was sterile, at least.

Splinter hemorrhages, Death noted with obvious glee, taking particular interest in the little streaks of blood under my patient's fingernails. Septic emboli. Death seems to have Gwnyeth Paltrow's laugh along with her voice. It's a light and airy thing, almost like a favorite wind chime. That laugh could almost make you think Death had a heart. Endocarditis, she said fondly. One of my favorites.

Almost make you think she had a heart.

Go away. I tried to look more busy than worried, but I didn't think she was buying it.

It's been a good month for me here in the ICU. Heck, you yourself have 4 kills. Why don't you throw in this one and call yourself an ace?

Very funny. Now get out. I would imagine it's best not to lose your temper with Death. Or with any of the other three Horsemen of the Apocalypse, for that matter. Didn't anyone ever tell you it's poor form to make fun of your host? You're in Donna Smith's house now, buddy. Don't be dissin' my nurse manager.

Come on, she pushed. She's pathetic, she's tired, she lives alone in a tiny room in a forgotten crack house that she pretends is her apartment, and her parents haven't taken her calls for years.

Donna? I asked. That was some serious disrespect.

Don't go all medical student on me. I was talking about your patient, she explained evenly. She'd be better off with me anyway. You know that.

She can be persuasive when she might be right. Death and I have been having similar conversations all the way back to my surgical rotation as a third‐year medical student. Although she has never been above making the easy score, she typically only makes serious plays for patients who, in all honesty, just might be better off heading with her beyond the vale. That's not my decision to make, I told Death, tweaking the pressors. I have this thing about systolic blood pressure less than room temperature. By being here, she's placed her life in my hands, I said, staring down into what almost looked like a lifeless face. Until and unless I have a compelling reason to do otherwise, I will do whatever is necessary to ensure she comes out of this thing as well as she can. I turned to look Death in those beady little eyes. Even go 15 rounds with you, if that's what it takes.

There was a moment of silence, during which I began to think that perhaps I had made my point. Rock, paper, scissors? Death asked with a hopeful lilt.

I sighed. Damn, but she was persistent. I don't gamble with death. That's something my mommy taught me, way back when I used to think I'd be able to fly if I jumped from that really tall tree on the hill.

Oh, come on. Your patient in the next bed did. Overdosed on Ativan with a fifth of Johnny Walker Black as a chaser? Now there's a lifestyle choice I can find myself endorsing.

I was out of witty comebacks. Everyone deserves another chance, I told her, my eyes fixed now on the hollowed, closed eyes of my patient in the ICU bed. Evenor maybe even especiallymy patient in the next bed. I don't know what it was about his life that had driven him to the lifestyle choices he had made. There's a part of every physician that thinks that he or she can make that difference in a patient's life. All too often, though, we see enough repeat business to learn, the hard way, that we rarely make the kind of differences we'd like to. With a little luck, and no small amount of medical diligence, both my patients would survive this hospitalization.

But would they survive their next?

Would there be a next?

Would this be the time they'd turn the corner?

I had to hope so, because I still consider myself far too young to be any more cynical than I already am.

What about your partner? Death asked suddenly.

No, I said with something I hoped sounded like authority. You can't have her either.

No, I meanhow about I work a deal with her? She's young, she's impressionable, she's idealisticwe could make it not your fault.

She's got enough to do; please just leave her alone.

The hood shook slowly back and forth, so I assumed she was shaking her head. Or her skull. Whichever. Look, you wouldn't even have to do anything, that sweet, seductive voice told me. Just head back to your call room for a few minutes. Turn off your pager.

I don't know why we're even having this conversation, I groaned. We both know that you're just a hallucination caused by way too little sleep and way too much caffeine. Last call night I caught myself discussing the relative merits of high‐frequency jet ventilation with Galen.

Galen, Death reflected, suddenly nostalgic. Highly overrated, a positive trait in a doctor if you don't mind my saying so. Has an ego that would make an orthopedist seem humble.

You're lying, I decided.

Yes, I am. And you're stalling. Her voice suddenly became a whole lot more James Earl Jonesish. I'm taking the septic chick with endocarditis. You can lose all the sleep you want, she still goes Home with me.

I glanced over the drips one more time. I've just added norepi. That's a whole bag full of bite me that says differently. So back off, sweetheart.

As with most true medical emergencies, I was too busy thinking ahead to realize just how much trouble my patient could have been in at that moment.

Now morning, like her fever, has broken.

The sun, for those that haven't noticed, gives off a beautiful red glow as it rises over Boot Hill. I got to see it from the rocking chair in my patient's room. Nurse Donna was finishing the night's vital sign flow sheet, politely pretending she hadn't heard me snoring away the past 15 minutes. I was trying to decide if that odor drifting into the room was someone's attempt at coffee or melana. Donna smiled politely at me as I rubbed the Sandman's crud out of my eyes. It was a very Chicago Hope kinda moment.

If I'd been playing a doctor on TV, I'd have made some reassuring comment about how my patient had made it through the night, and so she was now out of the woods. Uh‐huh. With Death sneaking up behind me, my bite‐me norepinephrine wasn't going to be weaned just yet.

Good morning, I greeted.

She seemed a bit put off that I had heard her sneaking in. But then, Death is not exactly graced with kitty‐cat feet.

You never turned your pager off. She said it like an accusation. The way my wife does.

Never do. An answer my wife doesn't appreciate, either. My patient's still with me, I said, managing to keep the victory dance out of my voice. Pressure is better, heart rate is lower, fever seems to have broken.

Death is patient, death is kind, she warned.

It took my postcall mind a moment to wrap itself around that one. Isn't that supposed to be Love? I asked her.

The shoulders of the robe shrugged. Love gets all the cool lines, she complained. What do I get? Be not proud, nothing's for sure but me and taxes, Yea, though I walk through the valley of the shadow of me, give me liberty or give me me. She turned to face me. I like that one, by the way.

Never fails to bring a tear to my eye. I'd give her that. She had lost the patient, I could afford to be gracious and throw her a bone. As long as said bone didn't belong to one of my patients.

Death was silent for a long moment. Well, I'm outta here, she finally decided. What about you?

I've got a few more hours. Rounds, orders, more rounds, discussions with families, likely more rounds

I thought I could hear a wry grin in her voice. Well, you be careful driving home, she suggested. It'd be a shame if you fell asleep at the wheel. And then ended up on my doorstep.

Damn.

She is not, however, without a certain, well, grim sense of humor.

The voice throws you at first. It's deceptively mild and calm, more Gwyneth Paltrow than James Earl Jones. To the best of my knowledge, however, Gwyneth Paltrow has never shown up in a patient's room wearing a hooded black robe and sporting a scythe.

Hmm, bad case of sepsis, huh? she asked.

I was still cleaning up from the central line, so I tried to get rid of her gracefully. Now's not really a good time. That line always seems to work with pesky administrators.

Death, however, would not be dissuaded. HIV positive for nearly 10 years now, flirting with CD4 counts in double digits, rising viral load the past 3 years. Picked a bad time to have her gallbladder go bad on her, didn't she?

Or a bad time to pick a surgeon who was less than fastidious about his sterile fields, I muttered.

Death, however, chose to ignore me. Ventilator, pressors, antibiotics. She reached for the girl's right hand, attached as it was to an arterial line blood pressure monitor, and somethingdamn, if it didn't look like a scarabfell out of the robe and then scrambled across my patient's chest, right next to my newly placed and oh‐so‐deftly sutured plastic catheter, ducking away from the light.

Hey, that was my sterile field, I complained. I, unlike the aforementioned surgeon, had been fastidious about it. I hoped the scarab was sterile, at least.

Splinter hemorrhages, Death noted with obvious glee, taking particular interest in the little streaks of blood under my patient's fingernails. Septic emboli. Death seems to have Gwnyeth Paltrow's laugh along with her voice. It's a light and airy thing, almost like a favorite wind chime. That laugh could almost make you think Death had a heart. Endocarditis, she said fondly. One of my favorites.

Almost make you think she had a heart.

Go away. I tried to look more busy than worried, but I didn't think she was buying it.

It's been a good month for me here in the ICU. Heck, you yourself have 4 kills. Why don't you throw in this one and call yourself an ace?

Very funny. Now get out. I would imagine it's best not to lose your temper with Death. Or with any of the other three Horsemen of the Apocalypse, for that matter. Didn't anyone ever tell you it's poor form to make fun of your host? You're in Donna Smith's house now, buddy. Don't be dissin' my nurse manager.

Come on, she pushed. She's pathetic, she's tired, she lives alone in a tiny room in a forgotten crack house that she pretends is her apartment, and her parents haven't taken her calls for years.

Donna? I asked. That was some serious disrespect.

Don't go all medical student on me. I was talking about your patient, she explained evenly. She'd be better off with me anyway. You know that.

She can be persuasive when she might be right. Death and I have been having similar conversations all the way back to my surgical rotation as a third‐year medical student. Although she has never been above making the easy score, she typically only makes serious plays for patients who, in all honesty, just might be better off heading with her beyond the vale. That's not my decision to make, I told Death, tweaking the pressors. I have this thing about systolic blood pressure less than room temperature. By being here, she's placed her life in my hands, I said, staring down into what almost looked like a lifeless face. Until and unless I have a compelling reason to do otherwise, I will do whatever is necessary to ensure she comes out of this thing as well as she can. I turned to look Death in those beady little eyes. Even go 15 rounds with you, if that's what it takes.

There was a moment of silence, during which I began to think that perhaps I had made my point. Rock, paper, scissors? Death asked with a hopeful lilt.

I sighed. Damn, but she was persistent. I don't gamble with death. That's something my mommy taught me, way back when I used to think I'd be able to fly if I jumped from that really tall tree on the hill.

Oh, come on. Your patient in the next bed did. Overdosed on Ativan with a fifth of Johnny Walker Black as a chaser? Now there's a lifestyle choice I can find myself endorsing.

I was out of witty comebacks. Everyone deserves another chance, I told her, my eyes fixed now on the hollowed, closed eyes of my patient in the ICU bed. Evenor maybe even especiallymy patient in the next bed. I don't know what it was about his life that had driven him to the lifestyle choices he had made. There's a part of every physician that thinks that he or she can make that difference in a patient's life. All too often, though, we see enough repeat business to learn, the hard way, that we rarely make the kind of differences we'd like to. With a little luck, and no small amount of medical diligence, both my patients would survive this hospitalization.

But would they survive their next?

Would there be a next?

Would this be the time they'd turn the corner?

I had to hope so, because I still consider myself far too young to be any more cynical than I already am.

What about your partner? Death asked suddenly.

No, I said with something I hoped sounded like authority. You can't have her either.

No, I meanhow about I work a deal with her? She's young, she's impressionable, she's idealisticwe could make it not your fault.

She's got enough to do; please just leave her alone.

The hood shook slowly back and forth, so I assumed she was shaking her head. Or her skull. Whichever. Look, you wouldn't even have to do anything, that sweet, seductive voice told me. Just head back to your call room for a few minutes. Turn off your pager.

I don't know why we're even having this conversation, I groaned. We both know that you're just a hallucination caused by way too little sleep and way too much caffeine. Last call night I caught myself discussing the relative merits of high‐frequency jet ventilation with Galen.

Galen, Death reflected, suddenly nostalgic. Highly overrated, a positive trait in a doctor if you don't mind my saying so. Has an ego that would make an orthopedist seem humble.

You're lying, I decided.

Yes, I am. And you're stalling. Her voice suddenly became a whole lot more James Earl Jonesish. I'm taking the septic chick with endocarditis. You can lose all the sleep you want, she still goes Home with me.

I glanced over the drips one more time. I've just added norepi. That's a whole bag full of bite me that says differently. So back off, sweetheart.

As with most true medical emergencies, I was too busy thinking ahead to realize just how much trouble my patient could have been in at that moment.

Now morning, like her fever, has broken.

The sun, for those that haven't noticed, gives off a beautiful red glow as it rises over Boot Hill. I got to see it from the rocking chair in my patient's room. Nurse Donna was finishing the night's vital sign flow sheet, politely pretending she hadn't heard me snoring away the past 15 minutes. I was trying to decide if that odor drifting into the room was someone's attempt at coffee or melana. Donna smiled politely at me as I rubbed the Sandman's crud out of my eyes. It was a very Chicago Hope kinda moment.

If I'd been playing a doctor on TV, I'd have made some reassuring comment about how my patient had made it through the night, and so she was now out of the woods. Uh‐huh. With Death sneaking up behind me, my bite‐me norepinephrine wasn't going to be weaned just yet.

Good morning, I greeted.

She seemed a bit put off that I had heard her sneaking in. But then, Death is not exactly graced with kitty‐cat feet.

You never turned your pager off. She said it like an accusation. The way my wife does.

Never do. An answer my wife doesn't appreciate, either. My patient's still with me, I said, managing to keep the victory dance out of my voice. Pressure is better, heart rate is lower, fever seems to have broken.

Death is patient, death is kind, she warned.

It took my postcall mind a moment to wrap itself around that one. Isn't that supposed to be Love? I asked her.

The shoulders of the robe shrugged. Love gets all the cool lines, she complained. What do I get? Be not proud, nothing's for sure but me and taxes, Yea, though I walk through the valley of the shadow of me, give me liberty or give me me. She turned to face me. I like that one, by the way.

Never fails to bring a tear to my eye. I'd give her that. She had lost the patient, I could afford to be gracious and throw her a bone. As long as said bone didn't belong to one of my patients.

Death was silent for a long moment. Well, I'm outta here, she finally decided. What about you?

I've got a few more hours. Rounds, orders, more rounds, discussions with families, likely more rounds

I thought I could hear a wry grin in her voice. Well, you be careful driving home, she suggested. It'd be a shame if you fell asleep at the wheel. And then ended up on my doorstep.

Damn.

Six years ago, at the age of 76, I suffered a type B aortic dissection while lifting weights. At the time, I managed a busy architecture practice, jogged a 9‐minute mile, and had never experienced a serious illness. My only medication was a baby aspirin every morning. The dissection was diagnosed promptly and treated medically with a stay of less than a week in the hospital. My son Eric, a hospitalist, immediately flew in from Denver and stayed with me throughout my hospitalization. Within days of my discharge, however, I began experiencing a series of mild discomforts. I had difficulty sleeping, mild indigestion, and a burning sensation in my thighs after walking relatively short distances. My primary care physician and cardiologist didn't seem concerned about these symptoms, and as they were initially mild, I accepted them as the residual effects of sleep deprivation, hospital food, and muscle atrophy. Nobody recognized that my dissection had propagated, effectively cutting off blood flow below my diaphragm.

To my good fortune, Eric had previously scheduled a second visit long before I had become ill. I vividly recall him walking into our house in the early evening, taking one look at me, and saying, I don't like what I see. My most notable memory of the return ambulance trip was how cold my feet were. I had never experienced that intense a sensation of cold before. I recall arriving at a very busy, crowded ER and Eric aggressively trying to get priority attention. The next thing I remember was waking up in the ICU the next afternoon. My kidneys had failed, and my intestines were not getting blood flow. By then, I had become too unstable to undergo aortic surgery. As a last‐ditch effort, an interventional radiologist tried to open my aorta using four large biliary stents, none of which deployed properly. Then a vascular surgeon suggested performing an axillo‐bifemoral bypass, which is much less invasive than aortic surgery, in order to restore blood flow to my kidneys and intestines. It saved my life.

There are many things about the hospital environment that elevate anxiety and vulnerability, and perhaps that is inevitable. The concentration of sick people is depressing. I had several roommates, each much younger than I, with prognoses that appeared far less favorable than mine. I listened to their doctors, some with bedside manners so clinical that they bordered on insensitivity. In one instance, when there was clearly a communication barrier, I saw a patient and family become bewildered and overwhelmed. Watching this unfold only heightened my own sense of vulnerability.

When it became evident that I was not going to die, my emotions ranged from elation at having beaten the odds to outright fear. I had come to the hospital healthy, fit, and independent. Now a host of new concerns emerged. What would my limitations be, and to what kind of lifestyle could I look forward? Would I be self‐sufficient, or would I become a burden to my family? Perhaps these were ungrateful responses to having just dodged the bullet, but I take no responsibility for my subconscious. Nights were the worst, especially when sleep was elusive. My days were filled with tests and visitors, but I had ample time to court my anxieties after dark. As an artillery reconnaissance officer during World War II, I had known fear, but this was different. Fear during combat was shared by all and functionally accommodated by most. It became part of a common bond. Maybe because of our youth and inexperience, we only worried about being killeda singular event, and then it was all over. Thoughts of permanent disability and its consequences never crossed our minds.

My physical recovery was far more rapid than my psychological and emotional recovery. My physicians told me that they had never encountered a case like mine and that we were in uncharted waters. Although I appreciated their candor, this was less than reassuring. Furthermore, the mild symptoms I had experienced during my re‐dissection sensitized me to every new little pain, twinge, or discomfort. How was I to differentiate relevant and significant new symptoms from hypochondria? It took a very long time to recover my sense of well‐being. The support of my wife and family was invaluable, but ultimately this is something one must sort out for oneself. I recognized that I could not face the rest of my life with fear and anxiety. I tried professional counseling without noticeable benefit. Eventually, I learned to analyze each concern as it surfaced, recognize it for what it was, and put it in perspective. The passage of time and daily meditation also contributed to my emotional healing. Today, some of the old ghosts still emerge from the shadows, but now they have no substance and rapidly disappear.

I attribute my survival and recovery over the past six years to the marvels of modern medicine (accompanied by some miscues and imperfections), the forceful advocacy of a loving wife and a physician son who were always there at critical moments, and a significant dose of pure good luck. As I write this, a few days before my 82nd birthday, I remain actively engaged in my practice, still work out, albeit more prudently than before, and walk a brisk 16‐minute mile. I will forever be grateful for the professionalism and dedication of the health care personnel I encountered and for the astonishing technology and infrastructure that saved my life.

Six years ago, at the age of 76, I suffered a type B aortic dissection while lifting weights. At the time, I managed a busy architecture practice, jogged a 9‐minute mile, and had never experienced a serious illness. My only medication was a baby aspirin every morning. The dissection was diagnosed promptly and treated medically with a stay of less than a week in the hospital. My son Eric, a hospitalist, immediately flew in from Denver and stayed with me throughout my hospitalization. Within days of my discharge, however, I began experiencing a series of mild discomforts. I had difficulty sleeping, mild indigestion, and a burning sensation in my thighs after walking relatively short distances. My primary care physician and cardiologist didn't seem concerned about these symptoms, and as they were initially mild, I accepted them as the residual effects of sleep deprivation, hospital food, and muscle atrophy. Nobody recognized that my dissection had propagated, effectively cutting off blood flow below my diaphragm.

To my good fortune, Eric had previously scheduled a second visit long before I had become ill. I vividly recall him walking into our house in the early evening, taking one look at me, and saying, I don't like what I see. My most notable memory of the return ambulance trip was how cold my feet were. I had never experienced that intense a sensation of cold before. I recall arriving at a very busy, crowded ER and Eric aggressively trying to get priority attention. The next thing I remember was waking up in the ICU the next afternoon. My kidneys had failed, and my intestines were not getting blood flow. By then, I had become too unstable to undergo aortic surgery. As a last‐ditch effort, an interventional radiologist tried to open my aorta using four large biliary stents, none of which deployed properly. Then a vascular surgeon suggested performing an axillo‐bifemoral bypass, which is much less invasive than aortic surgery, in order to restore blood flow to my kidneys and intestines. It saved my life.

There are many things about the hospital environment that elevate anxiety and vulnerability, and perhaps that is inevitable. The concentration of sick people is depressing. I had several roommates, each much younger than I, with prognoses that appeared far less favorable than mine. I listened to their doctors, some with bedside manners so clinical that they bordered on insensitivity. In one instance, when there was clearly a communication barrier, I saw a patient and family become bewildered and overwhelmed. Watching this unfold only heightened my own sense of vulnerability.

When it became evident that I was not going to die, my emotions ranged from elation at having beaten the odds to outright fear. I had come to the hospital healthy, fit, and independent. Now a host of new concerns emerged. What would my limitations be, and to what kind of lifestyle could I look forward? Would I be self‐sufficient, or would I become a burden to my family? Perhaps these were ungrateful responses to having just dodged the bullet, but I take no responsibility for my subconscious. Nights were the worst, especially when sleep was elusive. My days were filled with tests and visitors, but I had ample time to court my anxieties after dark. As an artillery reconnaissance officer during World War II, I had known fear, but this was different. Fear during combat was shared by all and functionally accommodated by most. It became part of a common bond. Maybe because of our youth and inexperience, we only worried about being killeda singular event, and then it was all over. Thoughts of permanent disability and its consequences never crossed our minds.

My physical recovery was far more rapid than my psychological and emotional recovery. My physicians told me that they had never encountered a case like mine and that we were in uncharted waters. Although I appreciated their candor, this was less than reassuring. Furthermore, the mild symptoms I had experienced during my re‐dissection sensitized me to every new little pain, twinge, or discomfort. How was I to differentiate relevant and significant new symptoms from hypochondria? It took a very long time to recover my sense of well‐being. The support of my wife and family was invaluable, but ultimately this is something one must sort out for oneself. I recognized that I could not face the rest of my life with fear and anxiety. I tried professional counseling without noticeable benefit. Eventually, I learned to analyze each concern as it surfaced, recognize it for what it was, and put it in perspective. The passage of time and daily meditation also contributed to my emotional healing. Today, some of the old ghosts still emerge from the shadows, but now they have no substance and rapidly disappear.

I attribute my survival and recovery over the past six years to the marvels of modern medicine (accompanied by some miscues and imperfections), the forceful advocacy of a loving wife and a physician son who were always there at critical moments, and a significant dose of pure good luck. As I write this, a few days before my 82nd birthday, I remain actively engaged in my practice, still work out, albeit more prudently than before, and walk a brisk 16‐minute mile. I will forever be grateful for the professionalism and dedication of the health care personnel I encountered and for the astonishing technology and infrastructure that saved my life.

Six years ago, at the age of 76, I suffered a type B aortic dissection while lifting weights. At the time, I managed a busy architecture practice, jogged a 9‐minute mile, and had never experienced a serious illness. My only medication was a baby aspirin every morning. The dissection was diagnosed promptly and treated medically with a stay of less than a week in the hospital. My son Eric, a hospitalist, immediately flew in from Denver and stayed with me throughout my hospitalization. Within days of my discharge, however, I began experiencing a series of mild discomforts. I had difficulty sleeping, mild indigestion, and a burning sensation in my thighs after walking relatively short distances. My primary care physician and cardiologist didn't seem concerned about these symptoms, and as they were initially mild, I accepted them as the residual effects of sleep deprivation, hospital food, and muscle atrophy. Nobody recognized that my dissection had propagated, effectively cutting off blood flow below my diaphragm.

To my good fortune, Eric had previously scheduled a second visit long before I had become ill. I vividly recall him walking into our house in the early evening, taking one look at me, and saying, I don't like what I see. My most notable memory of the return ambulance trip was how cold my feet were. I had never experienced that intense a sensation of cold before. I recall arriving at a very busy, crowded ER and Eric aggressively trying to get priority attention. The next thing I remember was waking up in the ICU the next afternoon. My kidneys had failed, and my intestines were not getting blood flow. By then, I had become too unstable to undergo aortic surgery. As a last‐ditch effort, an interventional radiologist tried to open my aorta using four large biliary stents, none of which deployed properly. Then a vascular surgeon suggested performing an axillo‐bifemoral bypass, which is much less invasive than aortic surgery, in order to restore blood flow to my kidneys and intestines. It saved my life.

There are many things about the hospital environment that elevate anxiety and vulnerability, and perhaps that is inevitable. The concentration of sick people is depressing. I had several roommates, each much younger than I, with prognoses that appeared far less favorable than mine. I listened to their doctors, some with bedside manners so clinical that they bordered on insensitivity. In one instance, when there was clearly a communication barrier, I saw a patient and family become bewildered and overwhelmed. Watching this unfold only heightened my own sense of vulnerability.

When it became evident that I was not going to die, my emotions ranged from elation at having beaten the odds to outright fear. I had come to the hospital healthy, fit, and independent. Now a host of new concerns emerged. What would my limitations be, and to what kind of lifestyle could I look forward? Would I be self‐sufficient, or would I become a burden to my family? Perhaps these were ungrateful responses to having just dodged the bullet, but I take no responsibility for my subconscious. Nights were the worst, especially when sleep was elusive. My days were filled with tests and visitors, but I had ample time to court my anxieties after dark. As an artillery reconnaissance officer during World War II, I had known fear, but this was different. Fear during combat was shared by all and functionally accommodated by most. It became part of a common bond. Maybe because of our youth and inexperience, we only worried about being killeda singular event, and then it was all over. Thoughts of permanent disability and its consequences never crossed our minds.

My physical recovery was far more rapid than my psychological and emotional recovery. My physicians told me that they had never encountered a case like mine and that we were in uncharted waters. Although I appreciated their candor, this was less than reassuring. Furthermore, the mild symptoms I had experienced during my re‐dissection sensitized me to every new little pain, twinge, or discomfort. How was I to differentiate relevant and significant new symptoms from hypochondria? It took a very long time to recover my sense of well‐being. The support of my wife and family was invaluable, but ultimately this is something one must sort out for oneself. I recognized that I could not face the rest of my life with fear and anxiety. I tried professional counseling without noticeable benefit. Eventually, I learned to analyze each concern as it surfaced, recognize it for what it was, and put it in perspective. The passage of time and daily meditation also contributed to my emotional healing. Today, some of the old ghosts still emerge from the shadows, but now they have no substance and rapidly disappear.

I attribute my survival and recovery over the past six years to the marvels of modern medicine (accompanied by some miscues and imperfections), the forceful advocacy of a loving wife and a physician son who were always there at critical moments, and a significant dose of pure good luck. As I write this, a few days before my 82nd birthday, I remain actively engaged in my practice, still work out, albeit more prudently than before, and walk a brisk 16‐minute mile. I will forever be grateful for the professionalism and dedication of the health care personnel I encountered and for the astonishing technology and infrastructure that saved my life.

I recently performed a PubMed search for hospitalists, which returned 561 citations, yet a second search for pediatric hospitalists produced only 37 citations. Growing up in Boston as a sports fan, my memories are filled with images that parallel these findings. One particularly vivid memory is of a Patriots game years ago. During that game, a very dynamic member of the opposing team was caught on camera picking up a phone on the sideline and telling the caller to call out the National Guard because we are killing the Patriots.

Now, pediatric hospital medicine is hardly being killed, and admittedly there were several methodological flaws in how I collected my data. However, this gap in number of publications must shrink if pediatric hospital medicine is to thrive. Like both hospital medicine and emergency medicine before it, pediatric hospital medicine must demonstrate what makes the field distinct and unique if is to be truly recognized as a medical subspecialty. The surest way to succeed in this endeavor is through the dissemination of information via peer‐reviewed journals such as the Journal of Hospital Medicine, potentially an ideal home for us.

It is important to note that dissemination of information is not limited to publication of original research. Pediatric hospital medicine is primarily a clinical field, and as such, practitioners may be spending 80%‐90% of their time (or more) caring for patients. This obviously does not leave much time for other academic pursuits. That being said, sharing many kinds of information can promote excellence in the care of hospitalized pediatric patients. Here are some types of articles that may prove useful.

• Writing that integrates, rather than discovers, new knowledge

• Review articles addressing the diagnosis and treatment of clinical conditions

• Illustrative case reports or series drawn from clinical practice

• Descriptions of best practice

• QI/QA programs

• Patient safety initiatives

• Use of decision support or other information technology tools

• Strategies to maintain physician wellness and career longevity

• Creation of educational curricula or competency assessment methods

• Leadership and professional development

This suggestion to share information of many types is not meant to downplay the importance of original research. As pediatric hospital medicine grows, its research component must grow as well in order to continually define and redefine the field itself, especially with regard to collaborative studies. In the future, it will no longer be acceptable for pediatric hospital programs to be practicing in isolation, without regard for nationally recognized and published benchmarks or other measures of quality. However, I believe that it is equally important for individuals to have outlets for these other forms of scholarship. Both the Society of Hospital Medicine and the Journal of Hospital Medicine are committed to the growth and development of pediatric hospital medicine. We encourage pediatric hospitalists to submit manuscripts and to become reviewers. You can do both at http://mc.manuscriptcentral.com/jhm.

I recently performed a PubMed search for hospitalists, which returned 561 citations, yet a second search for pediatric hospitalists produced only 37 citations. Growing up in Boston as a sports fan, my memories are filled with images that parallel these findings. One particularly vivid memory is of a Patriots game years ago. During that game, a very dynamic member of the opposing team was caught on camera picking up a phone on the sideline and telling the caller to call out the National Guard because we are killing the Patriots.

Now, pediatric hospital medicine is hardly being killed, and admittedly there were several methodological flaws in how I collected my data. However, this gap in number of publications must shrink if pediatric hospital medicine is to thrive. Like both hospital medicine and emergency medicine before it, pediatric hospital medicine must demonstrate what makes the field distinct and unique if is to be truly recognized as a medical subspecialty. The surest way to succeed in this endeavor is through the dissemination of information via peer‐reviewed journals such as the Journal of Hospital Medicine, potentially an ideal home for us.

It is important to note that dissemination of information is not limited to publication of original research. Pediatric hospital medicine is primarily a clinical field, and as such, practitioners may be spending 80%‐90% of their time (or more) caring for patients. This obviously does not leave much time for other academic pursuits. That being said, sharing many kinds of information can promote excellence in the care of hospitalized pediatric patients. Here are some types of articles that may prove useful.

• Writing that integrates, rather than discovers, new knowledge

• Review articles addressing the diagnosis and treatment of clinical conditions

• Illustrative case reports or series drawn from clinical practice

• Descriptions of best practice

• QI/QA programs

• Patient safety initiatives

• Use of decision support or other information technology tools

• Strategies to maintain physician wellness and career longevity

• Creation of educational curricula or competency assessment methods

• Leadership and professional development

This suggestion to share information of many types is not meant to downplay the importance of original research. As pediatric hospital medicine grows, its research component must grow as well in order to continually define and redefine the field itself, especially with regard to collaborative studies. In the future, it will no longer be acceptable for pediatric hospital programs to be practicing in isolation, without regard for nationally recognized and published benchmarks or other measures of quality. However, I believe that it is equally important for individuals to have outlets for these other forms of scholarship. Both the Society of Hospital Medicine and the Journal of Hospital Medicine are committed to the growth and development of pediatric hospital medicine. We encourage pediatric hospitalists to submit manuscripts and to become reviewers. You can do both at http://mc.manuscriptcentral.com/jhm.

I recently performed a PubMed search for hospitalists, which returned 561 citations, yet a second search for pediatric hospitalists produced only 37 citations. Growing up in Boston as a sports fan, my memories are filled with images that parallel these findings. One particularly vivid memory is of a Patriots game years ago. During that game, a very dynamic member of the opposing team was caught on camera picking up a phone on the sideline and telling the caller to call out the National Guard because we are killing the Patriots.

Now, pediatric hospital medicine is hardly being killed, and admittedly there were several methodological flaws in how I collected my data. However, this gap in number of publications must shrink if pediatric hospital medicine is to thrive. Like both hospital medicine and emergency medicine before it, pediatric hospital medicine must demonstrate what makes the field distinct and unique if is to be truly recognized as a medical subspecialty. The surest way to succeed in this endeavor is through the dissemination of information via peer‐reviewed journals such as the Journal of Hospital Medicine, potentially an ideal home for us.

It is important to note that dissemination of information is not limited to publication of original research. Pediatric hospital medicine is primarily a clinical field, and as such, practitioners may be spending 80%‐90% of their time (or more) caring for patients. This obviously does not leave much time for other academic pursuits. That being said, sharing many kinds of information can promote excellence in the care of hospitalized pediatric patients. Here are some types of articles that may prove useful.

• Writing that integrates, rather than discovers, new knowledge

• Review articles addressing the diagnosis and treatment of clinical conditions

• Illustrative case reports or series drawn from clinical practice

• Descriptions of best practice

• QI/QA programs

• Patient safety initiatives

• Use of decision support or other information technology tools

• Strategies to maintain physician wellness and career longevity

• Creation of educational curricula or competency assessment methods

• Leadership and professional development

This suggestion to share information of many types is not meant to downplay the importance of original research. As pediatric hospital medicine grows, its research component must grow as well in order to continually define and redefine the field itself, especially with regard to collaborative studies. In the future, it will no longer be acceptable for pediatric hospital programs to be practicing in isolation, without regard for nationally recognized and published benchmarks or other measures of quality. However, I believe that it is equally important for individuals to have outlets for these other forms of scholarship. Both the Society of Hospital Medicine and the Journal of Hospital Medicine are committed to the growth and development of pediatric hospital medicine. We encourage pediatric hospitalists to submit manuscripts and to become reviewers. You can do both at http://mc.manuscriptcentral.com/jhm.