Editorial

Why measure hospital quality? One popular premise is that measurement and transparency will inform consumer decision making and drive volume to high‐quality programs, providing incentives for improvement and raising the bar nationally. In this issue of the Journal of Hospital Medicine, Halasyamani and Davis report that there is relatively poor correlation between the Hospital Compare scores of the Centers for Medicare and Medicaid Services (CMS) and U.S. News and World Report's Best Hospitals rankings.1 The authors note that this is not necessarily surprising, as the methodologies of these rating systems are quite different, although their purposes are functionally similar.

Clearly, these 2 popular quality evaluation systems reflect different underlying constructs (which may or may not actually describe quality). And therein lies a central dilemma for health care professionals and academics: we haven't agreed among ourselves on reliable and meaningful quality metrics; so how can we, or even should we, expect the public to use available data to make health care decisions?

The 2 constructs in this particular comparison are certainly divergent in design. For the Hospital Compare ratings, the CMS used detailed process‐of‐care measures, expensively abstracted from the medical record, for just 3 medical conditions: acute myocardial infarction, congestive heart failure, and community‐acquired pneumonia. The U.S. News Best Hospitals rankings used reputation (based on a survey of physicians), severity‐adjusted mortality rate, staffing ratio, and key technologies offered by hospitals. Halasyamani and Davis conclude that consumers may be left to wonder how to reconcile these discordant rating systems. At the same time, they acknowledge that it is not yet clear whether public reporting will affect consumers' health care choices. Available evidence suggests that when making choices about health care, patients are much more likely to consult family and friends than an Internet site that posts quality information.2 There is as yet no conclusive evidence that quality data drive consumer decision making. Furthermore, acute myocardial infarction patients rarely have the opportunity to choose a hospital, even if they had access to the data.

The assessment of hospital quality is not only a challenge for patients, it's still perplexing for those of us immersed in health care. The scope of measures of quality is both broad and incomplete. At the microsystem and individual clinical syndrome level, we have a plethora of process measures that are evidence based (such as the CMS Hospital Compare measures) but appear to move meaningful outcomes only slightly, if at all. The evidence linking the pneumonia measures, for instance, to significant outcomes such as lower mortality or (rarely studied) better functional outcomes is extremely limited or nonexistent.3, 4

At the other end of the continuum are sweeping metrics such as risk‐adjusted in‐hospital mortality, which may be important and yet has 2 significant limitations. First, mortality rates in acute care are generally so low that this is not a useful outcome of interest for most clinical conditions. Its utility is really limited to well‐studied procedures such as cardiac surgery. Second, mortality rate reduction is extraordinarily difficult to link meaningfully to specific process interventions with available information and tools. For high‐volume complex medical conditions, such as pneumonia, nonsurgically‐managed cardiac disease, and oncology, we cannot as yet reliably use in‐hospital mortality rate as a descriptor for quality of care because the populations are so diverse and the statistical tools so crude. The public reporting of these data is even more complex because it often lags behind current data by years and may be significantly affected by sample size.

Even when we settle on a few, well‐defined process metrics, we have problems with complete and accurate reporting of data. In Halasyamani and Davis's study, only 2.9% of hospitals reported all 14 Hospital Compare core performance measures used in their analysis.1 Evidence suggests that poor performance is a strong disincentive to voluntarily report quality measures to the public.5 And because there is no evidence that this type of transparency initiative will drive volume to higher‐quality programs, publicly reporting quality measures may not provide a strong enough incentive for hospitals to allocate resources to the improvement of the quality of care they deliver in these specific areas.

The CMS has introduced financial incentives to encourage hospitals to report performance measures (regardless of the actual level of performance which is reported), providing financial rewards to top‐performing hospitals and/or to hospitals that actually demonstrate that strong performance may have a greater impact. The results of early studies suggested that that pay‐for‐performance did improve the quality of health care.6 Lindenauer et al. recently published the results of a large study evaluating adherence to quality measures in hospitals that voluntarily reported measures compared with those participating in a pay‐for‐performance demonstration project funded by the CMS. Hospitals engaged in both public reporting and pay‐for‐performance achieved modestly greater improvements in quality compared with those that only did public reporting.7 It is notable that this demonstration project generally produced modest financial rewards to those hospitals that improved performance.8 The optimal model to reward performance remains to be determined.7, 9, 10

There are a number of potentially harmful unintended consequences of poorly designed quality measures and associated transparency and incentive programs. The most obvious is opportunity cost. As the incentives become more tangible and meaningful, hospital quality leaders will be expected to step up efforts to improve performance in the specific process of care measures for which they are rewarded. Without caution, however, hospital quality leaders may develop a narrow focus in deciding where to apply their limited resources and may become distracted from other areas in dire need of improvement. Their boards of directors might appropriately argue that it is their fiduciary responsibility to focus on improving those aspects of quality that the payer community has highlighted as most important. If the metrics are excellent and the underlying constructs are in fact the right ones to advance quality in American acute care, this is a direction to be applauded. If the metrics are flawed and limited, which is the case today, then the risk is that resources will be wasted and diverted from more important priorities.

Even worse, an overly narrow focus may have unintended adverse clinical consequences. Recently, Wachter discussed several real‐world examples of unintended consequences of quality improvement efforts, including giving patients multiple doses of pneumococcal vaccines and inappropriately treating patients with symptoms that might indicate community‐acquired pneumonia with antibiotics.11 As hospitals attempt to improve their report cards, a significant risk exists that patients will receive excessive or unnecessary care in an attempt to meet specified timeliness goals.

The most important issue that has still not been completely addressed is whether improvements in process‐of‐care measures will actually improve patient outcomes. In a recent issue of this journal, Seymann concluded that there is strong evidence for influenza vaccination and the use of appropriate antibiotics for community‐acquired pneumonia12 but that other pneumonia quality measures were of less obvious clinical benefit. Controversy continues over whether the optimal timing of the initial treatment of community‐acquired pneumonia with antibiotics is 4 hours, as it currently stands, or 8 hours. Patients hospitalized with pneumonia may be motivated to quit smoking, but CMS requirements for smoking cessation advice/counseling can be satisfied with a simple pamphlet or a video, rather than interventions that involve counseling by specifically trained professionals and the use of pharmacotherapy, which are more likely to succeed. Although smoking cessation is an admirable goal, whether this is performed will not affect the quality of care that a patient with pneumonia receives during the index admission. In fact, it would be more important to counsel all patients about the hazards of smoking in an attempt to prevent pneumonia and acute myocardial infarction as well as a host of other smoking‐related illnesses.

In another example, Fonarow and colleagues examined the association between heart failure clinical outcomes and performance measures in a large observational cohort.13 The study found that current heart failure performance measures, aside from prescribing angiotensin‐converting inhibitor or angiotensin receptor blocker at discharge, had little relationship to mortality in the first 60‐90 days following discharge. On the other hand, the team found that being discharged on a beta blocker was associated with a significant reduction in mortality; however, beta blocker use is not part of the current CMS core measures. In addition, many patients hospitalized for heart failure may benefit from implantable cardioverter‐defibrillator therapy and/or cardiac resynchronization therapy,14 yet referral to a cardiologist to evaluate patients who may be suitable for these therapies is not a CMS core measure.

A similar, more comprehensive study recently evaluated whether performance on CMS quality measures for acute myocardial infarction, heart failure, and pneumonia correlated with condition‐specific inpatient, 30‐day, and 1‐year risk‐adjusted mortality rates.15 The study found that the best hospitals, those performing at the 75th percentile on quality measures, did have lower mortality rates than did hospitals performing at the 25th percentile, but the absolute risk reduction was small. Specifically, the absolute risk reduction for 30‐day mortality was 0.6%, 0.1%, and 0.1% for acute myocardial infarction, heart failure, and pneumonia, respectively. In attempting to explain their findings, the authors noted that current quality measures include only a subset of activities involved in the care of hospitalized patients. In addition, mortality rates are likely influenced by factors not included in current quality measures, such as the use of electronic health records, staffing levels, and other activities of quality oversight committees.

The era of measurement and accountability for providing high‐quality health care is upon us. Public reporting may lead to improvement in quality measures, but it is incumbent on the academic and provider communities as well as the payer community to ensure that the metrics are meaningful, reliable, and reproducible and, equally important, that they make a difference in essential clinical outcomes such as mortality, return to function, and avoidance of adverse events.10 Emerging evidence suggests the measures may need to be linked to meaningful financial incentives to the provider in order to accelerate change. Incentives directed at patients appear to be ineffective, clumsy, and slow to produce results.16

The time is right to revisit the quality measures currently used for transparency and incentives. We need a tighter, more reliable set of metrics that actually correlate with meaningful outcomes. Some evidence‐based measures appear to be missing from the current leading lists and some remain inadequately defined with regard to compliance. As a system, the measurement program contains poorly understood risks of unintended consequences. Above all else, local and national quality leaders need to be mindful that improving patient outcomes must be the central goal in our efforts to improve performance on process‐of‐care measures.

Why measure hospital quality? One popular premise is that measurement and transparency will inform consumer decision making and drive volume to high‐quality programs, providing incentives for improvement and raising the bar nationally. In this issue of the Journal of Hospital Medicine, Halasyamani and Davis report that there is relatively poor correlation between the Hospital Compare scores of the Centers for Medicare and Medicaid Services (CMS) and U.S. News and World Report's Best Hospitals rankings.1 The authors note that this is not necessarily surprising, as the methodologies of these rating systems are quite different, although their purposes are functionally similar.

Clearly, these 2 popular quality evaluation systems reflect different underlying constructs (which may or may not actually describe quality). And therein lies a central dilemma for health care professionals and academics: we haven't agreed among ourselves on reliable and meaningful quality metrics; so how can we, or even should we, expect the public to use available data to make health care decisions?

The 2 constructs in this particular comparison are certainly divergent in design. For the Hospital Compare ratings, the CMS used detailed process‐of‐care measures, expensively abstracted from the medical record, for just 3 medical conditions: acute myocardial infarction, congestive heart failure, and community‐acquired pneumonia. The U.S. News Best Hospitals rankings used reputation (based on a survey of physicians), severity‐adjusted mortality rate, staffing ratio, and key technologies offered by hospitals. Halasyamani and Davis conclude that consumers may be left to wonder how to reconcile these discordant rating systems. At the same time, they acknowledge that it is not yet clear whether public reporting will affect consumers' health care choices. Available evidence suggests that when making choices about health care, patients are much more likely to consult family and friends than an Internet site that posts quality information.2 There is as yet no conclusive evidence that quality data drive consumer decision making. Furthermore, acute myocardial infarction patients rarely have the opportunity to choose a hospital, even if they had access to the data.

The assessment of hospital quality is not only a challenge for patients, it's still perplexing for those of us immersed in health care. The scope of measures of quality is both broad and incomplete. At the microsystem and individual clinical syndrome level, we have a plethora of process measures that are evidence based (such as the CMS Hospital Compare measures) but appear to move meaningful outcomes only slightly, if at all. The evidence linking the pneumonia measures, for instance, to significant outcomes such as lower mortality or (rarely studied) better functional outcomes is extremely limited or nonexistent.3, 4

At the other end of the continuum are sweeping metrics such as risk‐adjusted in‐hospital mortality, which may be important and yet has 2 significant limitations. First, mortality rates in acute care are generally so low that this is not a useful outcome of interest for most clinical conditions. Its utility is really limited to well‐studied procedures such as cardiac surgery. Second, mortality rate reduction is extraordinarily difficult to link meaningfully to specific process interventions with available information and tools. For high‐volume complex medical conditions, such as pneumonia, nonsurgically‐managed cardiac disease, and oncology, we cannot as yet reliably use in‐hospital mortality rate as a descriptor for quality of care because the populations are so diverse and the statistical tools so crude. The public reporting of these data is even more complex because it often lags behind current data by years and may be significantly affected by sample size.

Even when we settle on a few, well‐defined process metrics, we have problems with complete and accurate reporting of data. In Halasyamani and Davis's study, only 2.9% of hospitals reported all 14 Hospital Compare core performance measures used in their analysis.1 Evidence suggests that poor performance is a strong disincentive to voluntarily report quality measures to the public.5 And because there is no evidence that this type of transparency initiative will drive volume to higher‐quality programs, publicly reporting quality measures may not provide a strong enough incentive for hospitals to allocate resources to the improvement of the quality of care they deliver in these specific areas.

The CMS has introduced financial incentives to encourage hospitals to report performance measures (regardless of the actual level of performance which is reported), providing financial rewards to top‐performing hospitals and/or to hospitals that actually demonstrate that strong performance may have a greater impact. The results of early studies suggested that that pay‐for‐performance did improve the quality of health care.6 Lindenauer et al. recently published the results of a large study evaluating adherence to quality measures in hospitals that voluntarily reported measures compared with those participating in a pay‐for‐performance demonstration project funded by the CMS. Hospitals engaged in both public reporting and pay‐for‐performance achieved modestly greater improvements in quality compared with those that only did public reporting.7 It is notable that this demonstration project generally produced modest financial rewards to those hospitals that improved performance.8 The optimal model to reward performance remains to be determined.7, 9, 10

There are a number of potentially harmful unintended consequences of poorly designed quality measures and associated transparency and incentive programs. The most obvious is opportunity cost. As the incentives become more tangible and meaningful, hospital quality leaders will be expected to step up efforts to improve performance in the specific process of care measures for which they are rewarded. Without caution, however, hospital quality leaders may develop a narrow focus in deciding where to apply their limited resources and may become distracted from other areas in dire need of improvement. Their boards of directors might appropriately argue that it is their fiduciary responsibility to focus on improving those aspects of quality that the payer community has highlighted as most important. If the metrics are excellent and the underlying constructs are in fact the right ones to advance quality in American acute care, this is a direction to be applauded. If the metrics are flawed and limited, which is the case today, then the risk is that resources will be wasted and diverted from more important priorities.

Even worse, an overly narrow focus may have unintended adverse clinical consequences. Recently, Wachter discussed several real‐world examples of unintended consequences of quality improvement efforts, including giving patients multiple doses of pneumococcal vaccines and inappropriately treating patients with symptoms that might indicate community‐acquired pneumonia with antibiotics.11 As hospitals attempt to improve their report cards, a significant risk exists that patients will receive excessive or unnecessary care in an attempt to meet specified timeliness goals.

The most important issue that has still not been completely addressed is whether improvements in process‐of‐care measures will actually improve patient outcomes. In a recent issue of this journal, Seymann concluded that there is strong evidence for influenza vaccination and the use of appropriate antibiotics for community‐acquired pneumonia12 but that other pneumonia quality measures were of less obvious clinical benefit. Controversy continues over whether the optimal timing of the initial treatment of community‐acquired pneumonia with antibiotics is 4 hours, as it currently stands, or 8 hours. Patients hospitalized with pneumonia may be motivated to quit smoking, but CMS requirements for smoking cessation advice/counseling can be satisfied with a simple pamphlet or a video, rather than interventions that involve counseling by specifically trained professionals and the use of pharmacotherapy, which are more likely to succeed. Although smoking cessation is an admirable goal, whether this is performed will not affect the quality of care that a patient with pneumonia receives during the index admission. In fact, it would be more important to counsel all patients about the hazards of smoking in an attempt to prevent pneumonia and acute myocardial infarction as well as a host of other smoking‐related illnesses.

In another example, Fonarow and colleagues examined the association between heart failure clinical outcomes and performance measures in a large observational cohort.13 The study found that current heart failure performance measures, aside from prescribing angiotensin‐converting inhibitor or angiotensin receptor blocker at discharge, had little relationship to mortality in the first 60‐90 days following discharge. On the other hand, the team found that being discharged on a beta blocker was associated with a significant reduction in mortality; however, beta blocker use is not part of the current CMS core measures. In addition, many patients hospitalized for heart failure may benefit from implantable cardioverter‐defibrillator therapy and/or cardiac resynchronization therapy,14 yet referral to a cardiologist to evaluate patients who may be suitable for these therapies is not a CMS core measure.

A similar, more comprehensive study recently evaluated whether performance on CMS quality measures for acute myocardial infarction, heart failure, and pneumonia correlated with condition‐specific inpatient, 30‐day, and 1‐year risk‐adjusted mortality rates.15 The study found that the best hospitals, those performing at the 75th percentile on quality measures, did have lower mortality rates than did hospitals performing at the 25th percentile, but the absolute risk reduction was small. Specifically, the absolute risk reduction for 30‐day mortality was 0.6%, 0.1%, and 0.1% for acute myocardial infarction, heart failure, and pneumonia, respectively. In attempting to explain their findings, the authors noted that current quality measures include only a subset of activities involved in the care of hospitalized patients. In addition, mortality rates are likely influenced by factors not included in current quality measures, such as the use of electronic health records, staffing levels, and other activities of quality oversight committees.

The era of measurement and accountability for providing high‐quality health care is upon us. Public reporting may lead to improvement in quality measures, but it is incumbent on the academic and provider communities as well as the payer community to ensure that the metrics are meaningful, reliable, and reproducible and, equally important, that they make a difference in essential clinical outcomes such as mortality, return to function, and avoidance of adverse events.10 Emerging evidence suggests the measures may need to be linked to meaningful financial incentives to the provider in order to accelerate change. Incentives directed at patients appear to be ineffective, clumsy, and slow to produce results.16

The time is right to revisit the quality measures currently used for transparency and incentives. We need a tighter, more reliable set of metrics that actually correlate with meaningful outcomes. Some evidence‐based measures appear to be missing from the current leading lists and some remain inadequately defined with regard to compliance. As a system, the measurement program contains poorly understood risks of unintended consequences. Above all else, local and national quality leaders need to be mindful that improving patient outcomes must be the central goal in our efforts to improve performance on process‐of‐care measures.

Why measure hospital quality? One popular premise is that measurement and transparency will inform consumer decision making and drive volume to high‐quality programs, providing incentives for improvement and raising the bar nationally. In this issue of the Journal of Hospital Medicine, Halasyamani and Davis report that there is relatively poor correlation between the Hospital Compare scores of the Centers for Medicare and Medicaid Services (CMS) and U.S. News and World Report's Best Hospitals rankings.1 The authors note that this is not necessarily surprising, as the methodologies of these rating systems are quite different, although their purposes are functionally similar.

Clearly, these 2 popular quality evaluation systems reflect different underlying constructs (which may or may not actually describe quality). And therein lies a central dilemma for health care professionals and academics: we haven't agreed among ourselves on reliable and meaningful quality metrics; so how can we, or even should we, expect the public to use available data to make health care decisions?

The 2 constructs in this particular comparison are certainly divergent in design. For the Hospital Compare ratings, the CMS used detailed process‐of‐care measures, expensively abstracted from the medical record, for just 3 medical conditions: acute myocardial infarction, congestive heart failure, and community‐acquired pneumonia. The U.S. News Best Hospitals rankings used reputation (based on a survey of physicians), severity‐adjusted mortality rate, staffing ratio, and key technologies offered by hospitals. Halasyamani and Davis conclude that consumers may be left to wonder how to reconcile these discordant rating systems. At the same time, they acknowledge that it is not yet clear whether public reporting will affect consumers' health care choices. Available evidence suggests that when making choices about health care, patients are much more likely to consult family and friends than an Internet site that posts quality information.2 There is as yet no conclusive evidence that quality data drive consumer decision making. Furthermore, acute myocardial infarction patients rarely have the opportunity to choose a hospital, even if they had access to the data.

The assessment of hospital quality is not only a challenge for patients, it's still perplexing for those of us immersed in health care. The scope of measures of quality is both broad and incomplete. At the microsystem and individual clinical syndrome level, we have a plethora of process measures that are evidence based (such as the CMS Hospital Compare measures) but appear to move meaningful outcomes only slightly, if at all. The evidence linking the pneumonia measures, for instance, to significant outcomes such as lower mortality or (rarely studied) better functional outcomes is extremely limited or nonexistent.3, 4

At the other end of the continuum are sweeping metrics such as risk‐adjusted in‐hospital mortality, which may be important and yet has 2 significant limitations. First, mortality rates in acute care are generally so low that this is not a useful outcome of interest for most clinical conditions. Its utility is really limited to well‐studied procedures such as cardiac surgery. Second, mortality rate reduction is extraordinarily difficult to link meaningfully to specific process interventions with available information and tools. For high‐volume complex medical conditions, such as pneumonia, nonsurgically‐managed cardiac disease, and oncology, we cannot as yet reliably use in‐hospital mortality rate as a descriptor for quality of care because the populations are so diverse and the statistical tools so crude. The public reporting of these data is even more complex because it often lags behind current data by years and may be significantly affected by sample size.

Even when we settle on a few, well‐defined process metrics, we have problems with complete and accurate reporting of data. In Halasyamani and Davis's study, only 2.9% of hospitals reported all 14 Hospital Compare core performance measures used in their analysis.1 Evidence suggests that poor performance is a strong disincentive to voluntarily report quality measures to the public.5 And because there is no evidence that this type of transparency initiative will drive volume to higher‐quality programs, publicly reporting quality measures may not provide a strong enough incentive for hospitals to allocate resources to the improvement of the quality of care they deliver in these specific areas.

The CMS has introduced financial incentives to encourage hospitals to report performance measures (regardless of the actual level of performance which is reported), providing financial rewards to top‐performing hospitals and/or to hospitals that actually demonstrate that strong performance may have a greater impact. The results of early studies suggested that that pay‐for‐performance did improve the quality of health care.6 Lindenauer et al. recently published the results of a large study evaluating adherence to quality measures in hospitals that voluntarily reported measures compared with those participating in a pay‐for‐performance demonstration project funded by the CMS. Hospitals engaged in both public reporting and pay‐for‐performance achieved modestly greater improvements in quality compared with those that only did public reporting.7 It is notable that this demonstration project generally produced modest financial rewards to those hospitals that improved performance.8 The optimal model to reward performance remains to be determined.7, 9, 10

There are a number of potentially harmful unintended consequences of poorly designed quality measures and associated transparency and incentive programs. The most obvious is opportunity cost. As the incentives become more tangible and meaningful, hospital quality leaders will be expected to step up efforts to improve performance in the specific process of care measures for which they are rewarded. Without caution, however, hospital quality leaders may develop a narrow focus in deciding where to apply their limited resources and may become distracted from other areas in dire need of improvement. Their boards of directors might appropriately argue that it is their fiduciary responsibility to focus on improving those aspects of quality that the payer community has highlighted as most important. If the metrics are excellent and the underlying constructs are in fact the right ones to advance quality in American acute care, this is a direction to be applauded. If the metrics are flawed and limited, which is the case today, then the risk is that resources will be wasted and diverted from more important priorities.

Even worse, an overly narrow focus may have unintended adverse clinical consequences. Recently, Wachter discussed several real‐world examples of unintended consequences of quality improvement efforts, including giving patients multiple doses of pneumococcal vaccines and inappropriately treating patients with symptoms that might indicate community‐acquired pneumonia with antibiotics.11 As hospitals attempt to improve their report cards, a significant risk exists that patients will receive excessive or unnecessary care in an attempt to meet specified timeliness goals.

The most important issue that has still not been completely addressed is whether improvements in process‐of‐care measures will actually improve patient outcomes. In a recent issue of this journal, Seymann concluded that there is strong evidence for influenza vaccination and the use of appropriate antibiotics for community‐acquired pneumonia12 but that other pneumonia quality measures were of less obvious clinical benefit. Controversy continues over whether the optimal timing of the initial treatment of community‐acquired pneumonia with antibiotics is 4 hours, as it currently stands, or 8 hours. Patients hospitalized with pneumonia may be motivated to quit smoking, but CMS requirements for smoking cessation advice/counseling can be satisfied with a simple pamphlet or a video, rather than interventions that involve counseling by specifically trained professionals and the use of pharmacotherapy, which are more likely to succeed. Although smoking cessation is an admirable goal, whether this is performed will not affect the quality of care that a patient with pneumonia receives during the index admission. In fact, it would be more important to counsel all patients about the hazards of smoking in an attempt to prevent pneumonia and acute myocardial infarction as well as a host of other smoking‐related illnesses.

In another example, Fonarow and colleagues examined the association between heart failure clinical outcomes and performance measures in a large observational cohort.13 The study found that current heart failure performance measures, aside from prescribing angiotensin‐converting inhibitor or angiotensin receptor blocker at discharge, had little relationship to mortality in the first 60‐90 days following discharge. On the other hand, the team found that being discharged on a beta blocker was associated with a significant reduction in mortality; however, beta blocker use is not part of the current CMS core measures. In addition, many patients hospitalized for heart failure may benefit from implantable cardioverter‐defibrillator therapy and/or cardiac resynchronization therapy,14 yet referral to a cardiologist to evaluate patients who may be suitable for these therapies is not a CMS core measure.

A similar, more comprehensive study recently evaluated whether performance on CMS quality measures for acute myocardial infarction, heart failure, and pneumonia correlated with condition‐specific inpatient, 30‐day, and 1‐year risk‐adjusted mortality rates.15 The study found that the best hospitals, those performing at the 75th percentile on quality measures, did have lower mortality rates than did hospitals performing at the 25th percentile, but the absolute risk reduction was small. Specifically, the absolute risk reduction for 30‐day mortality was 0.6%, 0.1%, and 0.1% for acute myocardial infarction, heart failure, and pneumonia, respectively. In attempting to explain their findings, the authors noted that current quality measures include only a subset of activities involved in the care of hospitalized patients. In addition, mortality rates are likely influenced by factors not included in current quality measures, such as the use of electronic health records, staffing levels, and other activities of quality oversight committees.

The era of measurement and accountability for providing high‐quality health care is upon us. Public reporting may lead to improvement in quality measures, but it is incumbent on the academic and provider communities as well as the payer community to ensure that the metrics are meaningful, reliable, and reproducible and, equally important, that they make a difference in essential clinical outcomes such as mortality, return to function, and avoidance of adverse events.10 Emerging evidence suggests the measures may need to be linked to meaningful financial incentives to the provider in order to accelerate change. Incentives directed at patients appear to be ineffective, clumsy, and slow to produce results.16

The time is right to revisit the quality measures currently used for transparency and incentives. We need a tighter, more reliable set of metrics that actually correlate with meaningful outcomes. Some evidence‐based measures appear to be missing from the current leading lists and some remain inadequately defined with regard to compliance. As a system, the measurement program contains poorly understood risks of unintended consequences. Above all else, local and national quality leaders need to be mindful that improving patient outcomes must be the central goal in our efforts to improve performance on process‐of‐care measures.

See one, do one, teach one is a refrain familiar to all physicians. Historically, most procedural training has occurred at the bedside. In this model, senior residents, subspecialty fellows, or faculty members would demonstrate procedural skills to junior trainees, who would subsequently practice the procedures on patients, often with uneven, risky results. Acquisition of procedural skills by residents and fellows on inpatient wards is suboptimal for at least 2 reasons beyond the risks to patient safety: (1) clinical priorities are more important than educational priorities in this setting, and (2) the patient, not the medical learner, is the most important person in the room.

Recently, several new factors have challenged the traditional medical education model. For a variety of reasons, general internists currently perform far fewer invasive procedures than they used to.1 A heightened focus on patient safety and quality raises questions about the qualifications needed to perform invasive procedures. Assessment requirements have also become more stringent. The Accreditation Council for Graduate Medical Education (ACGME) now requires the use of measures that yield reliable and valid data to document the competence of trainees performing invasive procedures.2 In 2006 these factors, and the challenge to educate, assess, and certify residents, prompted the American Board of Internal Medicine to revise its certification requirements and remove the need for technical proficiency in several procedures including paracentesis, central venous catheter placement, and thoracentesis.3, 4

Two studies reported in this issue of the Journal of Hospital Medicine highlight important issues about preparing residents to perform invasive procedures. These include the educational limits of routine clinical care and the challenge to design rigorous educational interventions that improve residents' skills. Miranda and colleagues5 designed a clinical trial to evaluate an educational intervention in which residents practiced insertion of subclavian and internal jugular venous catheters under the supervision of a hospitalist faculty member. The goal was to reduce the frequency of femoral venous catheters placed at their institution. Although residents demonstrated increased knowledge and confidence after the educational intervention, the actual number of subclavian and internal jugular venous catheter insertions was lower in the intervention group, and was rare overall. The intervention did not achieve the stated goal of reducing the number of femoral venous catheters placed by residents. This research highlights that residents cannot be trained to perform invasive procedures through clinical experience alone. In addition, it demonstrates that brief educational interventions are also insufficient. Whether a longer and more robust educational intervention might have shown different results is uncertain, but many experts believe that opportunities for deliberate practice6 using standardized and sustained treatments7 can be a powerful tool to boost the procedural skills of physicians.

At the same institution, Lucas and colleagues studied the impact of a procedural service on the number of invasive procedures performed on a general medicine inpatient service.8 They found a 48% increase in procedure attempts when the procedure service staffed by an experienced faulty member was available. However, no improvement in success rate or reduction in complications was demonstrated. Thus, opportunities for trainees to perform procedures increased, but the presence of a faculty member to provide direct supervision did not improve the quality of the procedures accomplished.

Together these reports highlight challenges and opportunities in training residents to perform invasive procedures. Both studies involved the procedural skills of residents. One used an educational intervention, the other featured faculty supervision. Both studies produced outcomes that suggest improved procedural training, but neither improved the actual quality of delivered care. A brief educational intervention increased resident confidence and knowledge but did not increase the quality or number of procedures performed by residents. Opportunities to perform invasive procedures increased dramatically when an experienced attending physician was available to supervise residents. However, more education was not provided, and the quality of procedures performed did not improve.

Given these limitations, how should physicians learn to perform invasive procedures? We endorse a systematic approach to achieve high levels of procedural skills in resident physicians. First, procedures should be carefully selected. Only those essential to future practice should be required. If possible, opportunities should be available for selected trainees to develop skills in performing additional procedures relevant to their future careers. An example would be the opportunity for residents in a hospitalist track to develop proficiency in central venous catheter insertion through clinical experience, didactic education, and rigorous skill assessment. Second, dedicated programs are needed to train and assess residents in procedural skills. Reliance on clinical experience alone is inadequate because of the low frequency at which most procedures are performed and the inability to standardize assessments in routine clinical practice.

Simulation technology is a powerful adjunct to traditional clinical training and has been demonstrated to be highly effective in developing procedural skills in disciplines such as endoscopy9 and laparoscopic surgery.10 At our institution, a simulation‐based training program has been used to help residents achieve11 and maintain12 a high level of skill in performing advanced cardiac life support procedures. We use simulation to provide opportunities for deliberate practice in a controlled environment in which immediate feedback is emphasized and mastery levels are reached. The rigorous curriculum is standardized, but learner progress is individualized depending on the practice time needed to achieve competency standards.

Most important, when training physicians to perform invasive procedures, it is critical to use interventions and training programs that can be linked to improvements in actual clinical care. The studies by Miranda et al. and Lucas et al. highlight the utility of focused educational programs to complement clinical training as well as the positive impact of direct faculty supervision. These results are important starting points for programs to consider as they train and certify residents in required procedural skills. However, much work remains to be done. These studies have revealed that improvements in patient care outcomes are not likely to occur unless robust, learner‐centered educational programs are combined with adequate opportunities for residents to perform procedures under appropriate supervision.

See one, do one, teach one is a refrain familiar to all physicians. Historically, most procedural training has occurred at the bedside. In this model, senior residents, subspecialty fellows, or faculty members would demonstrate procedural skills to junior trainees, who would subsequently practice the procedures on patients, often with uneven, risky results. Acquisition of procedural skills by residents and fellows on inpatient wards is suboptimal for at least 2 reasons beyond the risks to patient safety: (1) clinical priorities are more important than educational priorities in this setting, and (2) the patient, not the medical learner, is the most important person in the room.

Recently, several new factors have challenged the traditional medical education model. For a variety of reasons, general internists currently perform far fewer invasive procedures than they used to.1 A heightened focus on patient safety and quality raises questions about the qualifications needed to perform invasive procedures. Assessment requirements have also become more stringent. The Accreditation Council for Graduate Medical Education (ACGME) now requires the use of measures that yield reliable and valid data to document the competence of trainees performing invasive procedures.2 In 2006 these factors, and the challenge to educate, assess, and certify residents, prompted the American Board of Internal Medicine to revise its certification requirements and remove the need for technical proficiency in several procedures including paracentesis, central venous catheter placement, and thoracentesis.3, 4

Two studies reported in this issue of the Journal of Hospital Medicine highlight important issues about preparing residents to perform invasive procedures. These include the educational limits of routine clinical care and the challenge to design rigorous educational interventions that improve residents' skills. Miranda and colleagues5 designed a clinical trial to evaluate an educational intervention in which residents practiced insertion of subclavian and internal jugular venous catheters under the supervision of a hospitalist faculty member. The goal was to reduce the frequency of femoral venous catheters placed at their institution. Although residents demonstrated increased knowledge and confidence after the educational intervention, the actual number of subclavian and internal jugular venous catheter insertions was lower in the intervention group, and was rare overall. The intervention did not achieve the stated goal of reducing the number of femoral venous catheters placed by residents. This research highlights that residents cannot be trained to perform invasive procedures through clinical experience alone. In addition, it demonstrates that brief educational interventions are also insufficient. Whether a longer and more robust educational intervention might have shown different results is uncertain, but many experts believe that opportunities for deliberate practice6 using standardized and sustained treatments7 can be a powerful tool to boost the procedural skills of physicians.

At the same institution, Lucas and colleagues studied the impact of a procedural service on the number of invasive procedures performed on a general medicine inpatient service.8 They found a 48% increase in procedure attempts when the procedure service staffed by an experienced faulty member was available. However, no improvement in success rate or reduction in complications was demonstrated. Thus, opportunities for trainees to perform procedures increased, but the presence of a faculty member to provide direct supervision did not improve the quality of the procedures accomplished.

Together these reports highlight challenges and opportunities in training residents to perform invasive procedures. Both studies involved the procedural skills of residents. One used an educational intervention, the other featured faculty supervision. Both studies produced outcomes that suggest improved procedural training, but neither improved the actual quality of delivered care. A brief educational intervention increased resident confidence and knowledge but did not increase the quality or number of procedures performed by residents. Opportunities to perform invasive procedures increased dramatically when an experienced attending physician was available to supervise residents. However, more education was not provided, and the quality of procedures performed did not improve.

Given these limitations, how should physicians learn to perform invasive procedures? We endorse a systematic approach to achieve high levels of procedural skills in resident physicians. First, procedures should be carefully selected. Only those essential to future practice should be required. If possible, opportunities should be available for selected trainees to develop skills in performing additional procedures relevant to their future careers. An example would be the opportunity for residents in a hospitalist track to develop proficiency in central venous catheter insertion through clinical experience, didactic education, and rigorous skill assessment. Second, dedicated programs are needed to train and assess residents in procedural skills. Reliance on clinical experience alone is inadequate because of the low frequency at which most procedures are performed and the inability to standardize assessments in routine clinical practice.

Simulation technology is a powerful adjunct to traditional clinical training and has been demonstrated to be highly effective in developing procedural skills in disciplines such as endoscopy9 and laparoscopic surgery.10 At our institution, a simulation‐based training program has been used to help residents achieve11 and maintain12 a high level of skill in performing advanced cardiac life support procedures. We use simulation to provide opportunities for deliberate practice in a controlled environment in which immediate feedback is emphasized and mastery levels are reached. The rigorous curriculum is standardized, but learner progress is individualized depending on the practice time needed to achieve competency standards.

Most important, when training physicians to perform invasive procedures, it is critical to use interventions and training programs that can be linked to improvements in actual clinical care. The studies by Miranda et al. and Lucas et al. highlight the utility of focused educational programs to complement clinical training as well as the positive impact of direct faculty supervision. These results are important starting points for programs to consider as they train and certify residents in required procedural skills. However, much work remains to be done. These studies have revealed that improvements in patient care outcomes are not likely to occur unless robust, learner‐centered educational programs are combined with adequate opportunities for residents to perform procedures under appropriate supervision.

See one, do one, teach one is a refrain familiar to all physicians. Historically, most procedural training has occurred at the bedside. In this model, senior residents, subspecialty fellows, or faculty members would demonstrate procedural skills to junior trainees, who would subsequently practice the procedures on patients, often with uneven, risky results. Acquisition of procedural skills by residents and fellows on inpatient wards is suboptimal for at least 2 reasons beyond the risks to patient safety: (1) clinical priorities are more important than educational priorities in this setting, and (2) the patient, not the medical learner, is the most important person in the room.

Recently, several new factors have challenged the traditional medical education model. For a variety of reasons, general internists currently perform far fewer invasive procedures than they used to.1 A heightened focus on patient safety and quality raises questions about the qualifications needed to perform invasive procedures. Assessment requirements have also become more stringent. The Accreditation Council for Graduate Medical Education (ACGME) now requires the use of measures that yield reliable and valid data to document the competence of trainees performing invasive procedures.2 In 2006 these factors, and the challenge to educate, assess, and certify residents, prompted the American Board of Internal Medicine to revise its certification requirements and remove the need for technical proficiency in several procedures including paracentesis, central venous catheter placement, and thoracentesis.3, 4

Two studies reported in this issue of the Journal of Hospital Medicine highlight important issues about preparing residents to perform invasive procedures. These include the educational limits of routine clinical care and the challenge to design rigorous educational interventions that improve residents' skills. Miranda and colleagues5 designed a clinical trial to evaluate an educational intervention in which residents practiced insertion of subclavian and internal jugular venous catheters under the supervision of a hospitalist faculty member. The goal was to reduce the frequency of femoral venous catheters placed at their institution. Although residents demonstrated increased knowledge and confidence after the educational intervention, the actual number of subclavian and internal jugular venous catheter insertions was lower in the intervention group, and was rare overall. The intervention did not achieve the stated goal of reducing the number of femoral venous catheters placed by residents. This research highlights that residents cannot be trained to perform invasive procedures through clinical experience alone. In addition, it demonstrates that brief educational interventions are also insufficient. Whether a longer and more robust educational intervention might have shown different results is uncertain, but many experts believe that opportunities for deliberate practice6 using standardized and sustained treatments7 can be a powerful tool to boost the procedural skills of physicians.

At the same institution, Lucas and colleagues studied the impact of a procedural service on the number of invasive procedures performed on a general medicine inpatient service.8 They found a 48% increase in procedure attempts when the procedure service staffed by an experienced faulty member was available. However, no improvement in success rate or reduction in complications was demonstrated. Thus, opportunities for trainees to perform procedures increased, but the presence of a faculty member to provide direct supervision did not improve the quality of the procedures accomplished.

Together these reports highlight challenges and opportunities in training residents to perform invasive procedures. Both studies involved the procedural skills of residents. One used an educational intervention, the other featured faculty supervision. Both studies produced outcomes that suggest improved procedural training, but neither improved the actual quality of delivered care. A brief educational intervention increased resident confidence and knowledge but did not increase the quality or number of procedures performed by residents. Opportunities to perform invasive procedures increased dramatically when an experienced attending physician was available to supervise residents. However, more education was not provided, and the quality of procedures performed did not improve.

Given these limitations, how should physicians learn to perform invasive procedures? We endorse a systematic approach to achieve high levels of procedural skills in resident physicians. First, procedures should be carefully selected. Only those essential to future practice should be required. If possible, opportunities should be available for selected trainees to develop skills in performing additional procedures relevant to their future careers. An example would be the opportunity for residents in a hospitalist track to develop proficiency in central venous catheter insertion through clinical experience, didactic education, and rigorous skill assessment. Second, dedicated programs are needed to train and assess residents in procedural skills. Reliance on clinical experience alone is inadequate because of the low frequency at which most procedures are performed and the inability to standardize assessments in routine clinical practice.

Simulation technology is a powerful adjunct to traditional clinical training and has been demonstrated to be highly effective in developing procedural skills in disciplines such as endoscopy9 and laparoscopic surgery.10 At our institution, a simulation‐based training program has been used to help residents achieve11 and maintain12 a high level of skill in performing advanced cardiac life support procedures. We use simulation to provide opportunities for deliberate practice in a controlled environment in which immediate feedback is emphasized and mastery levels are reached. The rigorous curriculum is standardized, but learner progress is individualized depending on the practice time needed to achieve competency standards.

Most important, when training physicians to perform invasive procedures, it is critical to use interventions and training programs that can be linked to improvements in actual clinical care. The studies by Miranda et al. and Lucas et al. highlight the utility of focused educational programs to complement clinical training as well as the positive impact of direct faculty supervision. These results are important starting points for programs to consider as they train and certify residents in required procedural skills. However, much work remains to be done. These studies have revealed that improvements in patient care outcomes are not likely to occur unless robust, learner‐centered educational programs are combined with adequate opportunities for residents to perform procedures under appropriate supervision.

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

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

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

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

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

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

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

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

My father seemed dehydrated.

Could you put some normal saline in? I asked.

He already got some, the charge nurse replied.

What did he get?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Oh, about 10 to 14 days.

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

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

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

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

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

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

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

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

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

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

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

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

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

My father seemed dehydrated.

Could you put some normal saline in? I asked.

He already got some, the charge nurse replied.

What did he get?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Oh, about 10 to 14 days.

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

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

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

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

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

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

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

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

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

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

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

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

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

My father seemed dehydrated.

Could you put some normal saline in? I asked.

He already got some, the charge nurse replied.

What did he get?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Oh, about 10 to 14 days.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Embracing, with strengthened spirits

Shades of Her Life

Embracing, with strengthened spirits

Shades of Her Life

Embracing, with strengthened spirits

Shades of Her Life

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sir Robert Hutchison (1871‐1960)

Print and Online Resources

1. Oxford Textbook of Palliative Medicine.

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

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

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

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

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

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

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

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

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

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

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

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

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

Sir Robert Hutchison (1871‐1960)

Print and Online Resources

1. Oxford Textbook of Palliative Medicine.

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

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

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

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

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

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

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

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

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

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

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

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

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

Sir Robert Hutchison (1871‐1960)

Print and Online Resources

1. Oxford Textbook of Palliative Medicine.

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

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

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