Editorial

Ms Chen acutely worse, altered, please assist, room 522Beth, chirped my pager. Ever increasing time pressures meant that hospitalists were supervising rounds almost daily. I had sent my resident, Beth, and the rest of the team to round separately that day, to foster their independence. It looked like we would be meeting ahead of schedule.

I'd received a similar page 2 years earlier when I was a junior resident myself. From the beginning of internship, our faculty never hesitated to challenge us. I will never forget when one of the hospitalists who had just come across an unresponsive patient tapped me on the shoulder and casually asked, Hey, you wanna run a code? and will never forget my inadequacy or the specific assistance I required in those tense few minutes. He, and the ICU team that arrived, gave me every chance to lead, and supported me each time I hesitated.

In similar fashion, I had sent my intern, David, to admit a patient with suspected CHF. I received his urgent update shortly after our patient arrived on the cardiology floor: Mr Johnson dropping sats, please help, room 207. I jogged to the patient's room, where I found David, 3 nurses, 2 medical students, and in the center, Mr Johnson: lethargic, gray, cachectic, and making no effort to rise from the 40 degree incline of his hospital bed. Weak respirations fogged his non‐rebreather mask about 28 times a minute.

David offered a quick report: 74‐year‐old male, CAD, hypertension, dementia CHF exacerbation hypertensive to 190. I think he needs IV nitroglycerin and another 80 of lasix.

I was pleased to hear him commit to a diagnosis and plan, but after sitting Mr Johnson up for a quick exam, I couldn't agree. Are you sure? He sounds more junky than crackly. Neck veins are flat.

His EF is 25% and he's been here 3 times with CHF.

Well, that won't protect him from anything else. Mr Johnson slumped forward, accessory muscles firing weakly, and only half‐opened his eyes to a loud command and vigorous shake. Well, let's get the diagnosis later, what does he need, now?

Well, the lasix and the nitro

Assuming this is CHF, looking at him now, will that work fast enough to prevent intubation? David shook his head no. He's full code, right? Let's just call a code before he gets any worse. Anyone disagree? A nurse made the call, then guarded the door to turn away everyone but anesthesia and the MICU as they arrived.

So what do you think it is? David asked.

This doesn't smell like failure. He's not anxious, he's more obtunded than dyspneic. He looks hypercarbic. He doesn't have COPD?

Nah, just vomiting, then weaker, more confused, restless.

Maybe he aspirated. We'll see. So what do you want to have ready for anesthesia?

Um, meds. An IV. Chest X‐ray ready.

Good they bring the meds he's got an IV how about we pull the bed from the wall and raise it up, get some suction ready, take the headboard off? Nurses sprang into action.

If he's hypercarbic, shouldn't we bag him? David asked.

Good point, I said. David took the mask from the bag of emergency gear from the wall and started to fit it on Mr Johnson. It's a 2‐person job, if you want to hold the mask2 hands, good. A nurse began ventilations, and I added some cricoid pressure. Keeps us from inflating his stomach.

Seconds later, anesthesia arrived, and David provided a concise, organized summary. Mr Johnson was intubated and whisked without incident to the MICU, where bronchoscopy extracted several mucus plugs. He was soon extubated, and later recovered from a delirium which began with promethazine for nausea. It was the last year before the 80‐hour workweek regulations, and not once in the entire processfrom admission, to emergency on the ward, to initial MICU managementdid I or my fellow residents think to call an attending, although I'm sure we would have learned something, as I hadn't suspected a mucous plug. We weren't hiding anything. We were just taking care of our patient.

Two years later, it didn't seem odd that my junior resident called me for assistance with Ms Cheninitially. In room 522, much as I found Mr Johnson, I found Ms Chen: elderly, lethargic, gray, frail, laboring to breathe, rhythmically fogging a non‐rebreather mask 30 times a minute, only half‐opening her eyes to a vigorous shake. It was day 4 of her fifth hospitalization for bronchiectasis‐related respiratory failure within 2 months.

She just got a treatment but she still sounds awful, offered Beth. Indeed, Ms Chen's chest was gurgly and wheezy throughout. We put her on a non‐rebreather, but that hasn't helped.

I glanced at her monitor. Sat's 99%. What was she before?

96%.

So hypoxia isn't the problemwho's this? I asked, as transportation staff arrived.

Stat head CT for Chen, he replied.

I'm sorry, she can't go off the floor right now. Thanks for coming, I apologized, and sent him away. Beth, can you lay her flat or send her off the unit right now?

She's altered and I need to rule out stroke.

Let's talk about that later. I did a quick neuro exam as I spoke: Besides, she resists weak but equal; pupils and face symmetricshe's not focal. What's a more likely cause?

Metabolic? We can repeat her morning labs

Will they be different? Why is she here? What's her exam telling you?

Beth took in the scene before her, as Ms Chen struggled weakly to ventilate her lungs, and after a brief pause she had it worked out. She's hypercarbic. She needs an ABG. You think she plugged? She shook her head, and grasped Ms Chen's hand in her own. But she really hates suctioning.

Well, she's DNI, and without it, she could die. Beth agreed; we also called for noninvasive ventilation. But the team missed much of the action. The medical student missed the entire eventaside from attempting to summarize it from second‐hand reports for rounds the following day. I realized only later that her intern had been pushed to the back of the room for the critical decisions (much like the students during Mr Johnson's emergency), and headed out midway to attend a mandatory teaching sessionthe chief residents had begun taking attendance. The resident soon left for noon conference and afternoon clinic, enlisting me to write transfer orders and call the family. Finished with her other work, and under pressure to bank time against work hour limitations, which she was at risk of violating, the intern signed her pager over to me and left in the early afternoon, after sheepishly asking me if I wouldn't mind keeping an eye on our patient.

Later, a translator and I met with the Chens to comfort them and plan care for the family matriarch, having found a quiet solarium we could use, with summery views of the city and ocean in the distance to belie the grim topic of discussion.

What is your understanding of her lung problem right now?

Nay yeega jee um'jee huigor fai ho jing yeung?

What were her hopes and fears about her health?

Nay jee um'jee huigor see seung hai mai ho tai hoi?

My mind drifted during the Cantonese as I thought about how I use the unique teaching opportunities offered by wholly translated meetings. Never check the time. This body language says I am listening. I am speaking to them, not the translator. I make notes because families don't remember much after the C‐word, I would whisper to trainees while families conversed with translators. Now, as I began to discuss hospice philosophy, I felt acutely alone.

My team had missed most of a great hospital medicine experience: applying knowledge to manage a physiologic crisis; using communication skills to ease the resulting human crisis. Recently, to manage the latest set of work hour restrictions, our residency program withdrew from medicine consultation at 2 of 3 sites, and from the medicine wards at the hospital that serves most of our insured, geriatric, and oncology patients. The cost of this experiment to the overall residency experience is unknown. But cases like Ms Chen's remind me how much I missed being the primary doctor. I do not mind the new tasks I perform for my trainees. But I worry about what they are missing: sufficient responsibility for making key clinical decisions while protected by supervision on demand. I am glad my internship challenged meit prepared me for residency, moonlighting, and attending positions. Without a doubt, residency remains challenging, but it seems that the greatestor firstchallenge imposed on residents is now to beat the clock, not to become a well‐rounded, capable, independent physician.

That night, I complained to my spouse, then a psychiatry intern: We weren't giving our trainees the best preparation for a career in medicine the lengthy shift I spent managing a hypotensive crisis would be forbidden now my pre‐work hours interns were much happier than their work hours successors a 4‐year residency must be around the corner. The response I got was more bemused smile than grave concern. You don't think that's important? I asked.

Of course I do. It's just that with all this talk about the days of the giants, he said gently, you're starting to sound like a grumpy old man. We chuckled. He was right. I expect a lot from myself, my trainees, and every clinician. I'd figured I'd be worthy of the title at some point.

But at 30?

Ms Chen acutely worse, altered, please assist, room 522Beth, chirped my pager. Ever increasing time pressures meant that hospitalists were supervising rounds almost daily. I had sent my resident, Beth, and the rest of the team to round separately that day, to foster their independence. It looked like we would be meeting ahead of schedule.

I'd received a similar page 2 years earlier when I was a junior resident myself. From the beginning of internship, our faculty never hesitated to challenge us. I will never forget when one of the hospitalists who had just come across an unresponsive patient tapped me on the shoulder and casually asked, Hey, you wanna run a code? and will never forget my inadequacy or the specific assistance I required in those tense few minutes. He, and the ICU team that arrived, gave me every chance to lead, and supported me each time I hesitated.

In similar fashion, I had sent my intern, David, to admit a patient with suspected CHF. I received his urgent update shortly after our patient arrived on the cardiology floor: Mr Johnson dropping sats, please help, room 207. I jogged to the patient's room, where I found David, 3 nurses, 2 medical students, and in the center, Mr Johnson: lethargic, gray, cachectic, and making no effort to rise from the 40 degree incline of his hospital bed. Weak respirations fogged his non‐rebreather mask about 28 times a minute.

David offered a quick report: 74‐year‐old male, CAD, hypertension, dementia CHF exacerbation hypertensive to 190. I think he needs IV nitroglycerin and another 80 of lasix.

I was pleased to hear him commit to a diagnosis and plan, but after sitting Mr Johnson up for a quick exam, I couldn't agree. Are you sure? He sounds more junky than crackly. Neck veins are flat.

His EF is 25% and he's been here 3 times with CHF.

Well, that won't protect him from anything else. Mr Johnson slumped forward, accessory muscles firing weakly, and only half‐opened his eyes to a loud command and vigorous shake. Well, let's get the diagnosis later, what does he need, now?

Well, the lasix and the nitro

Assuming this is CHF, looking at him now, will that work fast enough to prevent intubation? David shook his head no. He's full code, right? Let's just call a code before he gets any worse. Anyone disagree? A nurse made the call, then guarded the door to turn away everyone but anesthesia and the MICU as they arrived.

So what do you think it is? David asked.

This doesn't smell like failure. He's not anxious, he's more obtunded than dyspneic. He looks hypercarbic. He doesn't have COPD?

Nah, just vomiting, then weaker, more confused, restless.

Maybe he aspirated. We'll see. So what do you want to have ready for anesthesia?

Um, meds. An IV. Chest X‐ray ready.

Good they bring the meds he's got an IV how about we pull the bed from the wall and raise it up, get some suction ready, take the headboard off? Nurses sprang into action.

If he's hypercarbic, shouldn't we bag him? David asked.

Good point, I said. David took the mask from the bag of emergency gear from the wall and started to fit it on Mr Johnson. It's a 2‐person job, if you want to hold the mask2 hands, good. A nurse began ventilations, and I added some cricoid pressure. Keeps us from inflating his stomach.

Seconds later, anesthesia arrived, and David provided a concise, organized summary. Mr Johnson was intubated and whisked without incident to the MICU, where bronchoscopy extracted several mucus plugs. He was soon extubated, and later recovered from a delirium which began with promethazine for nausea. It was the last year before the 80‐hour workweek regulations, and not once in the entire processfrom admission, to emergency on the ward, to initial MICU managementdid I or my fellow residents think to call an attending, although I'm sure we would have learned something, as I hadn't suspected a mucous plug. We weren't hiding anything. We were just taking care of our patient.

Two years later, it didn't seem odd that my junior resident called me for assistance with Ms Cheninitially. In room 522, much as I found Mr Johnson, I found Ms Chen: elderly, lethargic, gray, frail, laboring to breathe, rhythmically fogging a non‐rebreather mask 30 times a minute, only half‐opening her eyes to a vigorous shake. It was day 4 of her fifth hospitalization for bronchiectasis‐related respiratory failure within 2 months.

She just got a treatment but she still sounds awful, offered Beth. Indeed, Ms Chen's chest was gurgly and wheezy throughout. We put her on a non‐rebreather, but that hasn't helped.

I glanced at her monitor. Sat's 99%. What was she before?

96%.

So hypoxia isn't the problemwho's this? I asked, as transportation staff arrived.

Stat head CT for Chen, he replied.

I'm sorry, she can't go off the floor right now. Thanks for coming, I apologized, and sent him away. Beth, can you lay her flat or send her off the unit right now?

She's altered and I need to rule out stroke.

Let's talk about that later. I did a quick neuro exam as I spoke: Besides, she resists weak but equal; pupils and face symmetricshe's not focal. What's a more likely cause?

Metabolic? We can repeat her morning labs

Will they be different? Why is she here? What's her exam telling you?

Beth took in the scene before her, as Ms Chen struggled weakly to ventilate her lungs, and after a brief pause she had it worked out. She's hypercarbic. She needs an ABG. You think she plugged? She shook her head, and grasped Ms Chen's hand in her own. But she really hates suctioning.

Well, she's DNI, and without it, she could die. Beth agreed; we also called for noninvasive ventilation. But the team missed much of the action. The medical student missed the entire eventaside from attempting to summarize it from second‐hand reports for rounds the following day. I realized only later that her intern had been pushed to the back of the room for the critical decisions (much like the students during Mr Johnson's emergency), and headed out midway to attend a mandatory teaching sessionthe chief residents had begun taking attendance. The resident soon left for noon conference and afternoon clinic, enlisting me to write transfer orders and call the family. Finished with her other work, and under pressure to bank time against work hour limitations, which she was at risk of violating, the intern signed her pager over to me and left in the early afternoon, after sheepishly asking me if I wouldn't mind keeping an eye on our patient.

Later, a translator and I met with the Chens to comfort them and plan care for the family matriarch, having found a quiet solarium we could use, with summery views of the city and ocean in the distance to belie the grim topic of discussion.

What is your understanding of her lung problem right now?

Nay yeega jee um'jee huigor fai ho jing yeung?

What were her hopes and fears about her health?

Nay jee um'jee huigor see seung hai mai ho tai hoi?

My mind drifted during the Cantonese as I thought about how I use the unique teaching opportunities offered by wholly translated meetings. Never check the time. This body language says I am listening. I am speaking to them, not the translator. I make notes because families don't remember much after the C‐word, I would whisper to trainees while families conversed with translators. Now, as I began to discuss hospice philosophy, I felt acutely alone.

My team had missed most of a great hospital medicine experience: applying knowledge to manage a physiologic crisis; using communication skills to ease the resulting human crisis. Recently, to manage the latest set of work hour restrictions, our residency program withdrew from medicine consultation at 2 of 3 sites, and from the medicine wards at the hospital that serves most of our insured, geriatric, and oncology patients. The cost of this experiment to the overall residency experience is unknown. But cases like Ms Chen's remind me how much I missed being the primary doctor. I do not mind the new tasks I perform for my trainees. But I worry about what they are missing: sufficient responsibility for making key clinical decisions while protected by supervision on demand. I am glad my internship challenged meit prepared me for residency, moonlighting, and attending positions. Without a doubt, residency remains challenging, but it seems that the greatestor firstchallenge imposed on residents is now to beat the clock, not to become a well‐rounded, capable, independent physician.

That night, I complained to my spouse, then a psychiatry intern: We weren't giving our trainees the best preparation for a career in medicine the lengthy shift I spent managing a hypotensive crisis would be forbidden now my pre‐work hours interns were much happier than their work hours successors a 4‐year residency must be around the corner. The response I got was more bemused smile than grave concern. You don't think that's important? I asked.

Of course I do. It's just that with all this talk about the days of the giants, he said gently, you're starting to sound like a grumpy old man. We chuckled. He was right. I expect a lot from myself, my trainees, and every clinician. I'd figured I'd be worthy of the title at some point.

But at 30?

Ms Chen acutely worse, altered, please assist, room 522Beth, chirped my pager. Ever increasing time pressures meant that hospitalists were supervising rounds almost daily. I had sent my resident, Beth, and the rest of the team to round separately that day, to foster their independence. It looked like we would be meeting ahead of schedule.

I'd received a similar page 2 years earlier when I was a junior resident myself. From the beginning of internship, our faculty never hesitated to challenge us. I will never forget when one of the hospitalists who had just come across an unresponsive patient tapped me on the shoulder and casually asked, Hey, you wanna run a code? and will never forget my inadequacy or the specific assistance I required in those tense few minutes. He, and the ICU team that arrived, gave me every chance to lead, and supported me each time I hesitated.

In similar fashion, I had sent my intern, David, to admit a patient with suspected CHF. I received his urgent update shortly after our patient arrived on the cardiology floor: Mr Johnson dropping sats, please help, room 207. I jogged to the patient's room, where I found David, 3 nurses, 2 medical students, and in the center, Mr Johnson: lethargic, gray, cachectic, and making no effort to rise from the 40 degree incline of his hospital bed. Weak respirations fogged his non‐rebreather mask about 28 times a minute.

David offered a quick report: 74‐year‐old male, CAD, hypertension, dementia CHF exacerbation hypertensive to 190. I think he needs IV nitroglycerin and another 80 of lasix.

I was pleased to hear him commit to a diagnosis and plan, but after sitting Mr Johnson up for a quick exam, I couldn't agree. Are you sure? He sounds more junky than crackly. Neck veins are flat.

His EF is 25% and he's been here 3 times with CHF.

Well, that won't protect him from anything else. Mr Johnson slumped forward, accessory muscles firing weakly, and only half‐opened his eyes to a loud command and vigorous shake. Well, let's get the diagnosis later, what does he need, now?

Well, the lasix and the nitro

Assuming this is CHF, looking at him now, will that work fast enough to prevent intubation? David shook his head no. He's full code, right? Let's just call a code before he gets any worse. Anyone disagree? A nurse made the call, then guarded the door to turn away everyone but anesthesia and the MICU as they arrived.

So what do you think it is? David asked.

This doesn't smell like failure. He's not anxious, he's more obtunded than dyspneic. He looks hypercarbic. He doesn't have COPD?

Nah, just vomiting, then weaker, more confused, restless.

Maybe he aspirated. We'll see. So what do you want to have ready for anesthesia?

Um, meds. An IV. Chest X‐ray ready.

Good they bring the meds he's got an IV how about we pull the bed from the wall and raise it up, get some suction ready, take the headboard off? Nurses sprang into action.

If he's hypercarbic, shouldn't we bag him? David asked.

Good point, I said. David took the mask from the bag of emergency gear from the wall and started to fit it on Mr Johnson. It's a 2‐person job, if you want to hold the mask2 hands, good. A nurse began ventilations, and I added some cricoid pressure. Keeps us from inflating his stomach.

Seconds later, anesthesia arrived, and David provided a concise, organized summary. Mr Johnson was intubated and whisked without incident to the MICU, where bronchoscopy extracted several mucus plugs. He was soon extubated, and later recovered from a delirium which began with promethazine for nausea. It was the last year before the 80‐hour workweek regulations, and not once in the entire processfrom admission, to emergency on the ward, to initial MICU managementdid I or my fellow residents think to call an attending, although I'm sure we would have learned something, as I hadn't suspected a mucous plug. We weren't hiding anything. We were just taking care of our patient.

Two years later, it didn't seem odd that my junior resident called me for assistance with Ms Cheninitially. In room 522, much as I found Mr Johnson, I found Ms Chen: elderly, lethargic, gray, frail, laboring to breathe, rhythmically fogging a non‐rebreather mask 30 times a minute, only half‐opening her eyes to a vigorous shake. It was day 4 of her fifth hospitalization for bronchiectasis‐related respiratory failure within 2 months.

She just got a treatment but she still sounds awful, offered Beth. Indeed, Ms Chen's chest was gurgly and wheezy throughout. We put her on a non‐rebreather, but that hasn't helped.

I glanced at her monitor. Sat's 99%. What was she before?

96%.

So hypoxia isn't the problemwho's this? I asked, as transportation staff arrived.

Stat head CT for Chen, he replied.

I'm sorry, she can't go off the floor right now. Thanks for coming, I apologized, and sent him away. Beth, can you lay her flat or send her off the unit right now?

She's altered and I need to rule out stroke.

Let's talk about that later. I did a quick neuro exam as I spoke: Besides, she resists weak but equal; pupils and face symmetricshe's not focal. What's a more likely cause?

Metabolic? We can repeat her morning labs

Will they be different? Why is she here? What's her exam telling you?

Beth took in the scene before her, as Ms Chen struggled weakly to ventilate her lungs, and after a brief pause she had it worked out. She's hypercarbic. She needs an ABG. You think she plugged? She shook her head, and grasped Ms Chen's hand in her own. But she really hates suctioning.

Well, she's DNI, and without it, she could die. Beth agreed; we also called for noninvasive ventilation. But the team missed much of the action. The medical student missed the entire eventaside from attempting to summarize it from second‐hand reports for rounds the following day. I realized only later that her intern had been pushed to the back of the room for the critical decisions (much like the students during Mr Johnson's emergency), and headed out midway to attend a mandatory teaching sessionthe chief residents had begun taking attendance. The resident soon left for noon conference and afternoon clinic, enlisting me to write transfer orders and call the family. Finished with her other work, and under pressure to bank time against work hour limitations, which she was at risk of violating, the intern signed her pager over to me and left in the early afternoon, after sheepishly asking me if I wouldn't mind keeping an eye on our patient.

Later, a translator and I met with the Chens to comfort them and plan care for the family matriarch, having found a quiet solarium we could use, with summery views of the city and ocean in the distance to belie the grim topic of discussion.

What is your understanding of her lung problem right now?

Nay yeega jee um'jee huigor fai ho jing yeung?

What were her hopes and fears about her health?

Nay jee um'jee huigor see seung hai mai ho tai hoi?

My mind drifted during the Cantonese as I thought about how I use the unique teaching opportunities offered by wholly translated meetings. Never check the time. This body language says I am listening. I am speaking to them, not the translator. I make notes because families don't remember much after the C‐word, I would whisper to trainees while families conversed with translators. Now, as I began to discuss hospice philosophy, I felt acutely alone.

My team had missed most of a great hospital medicine experience: applying knowledge to manage a physiologic crisis; using communication skills to ease the resulting human crisis. Recently, to manage the latest set of work hour restrictions, our residency program withdrew from medicine consultation at 2 of 3 sites, and from the medicine wards at the hospital that serves most of our insured, geriatric, and oncology patients. The cost of this experiment to the overall residency experience is unknown. But cases like Ms Chen's remind me how much I missed being the primary doctor. I do not mind the new tasks I perform for my trainees. But I worry about what they are missing: sufficient responsibility for making key clinical decisions while protected by supervision on demand. I am glad my internship challenged meit prepared me for residency, moonlighting, and attending positions. Without a doubt, residency remains challenging, but it seems that the greatestor firstchallenge imposed on residents is now to beat the clock, not to become a well‐rounded, capable, independent physician.

That night, I complained to my spouse, then a psychiatry intern: We weren't giving our trainees the best preparation for a career in medicine the lengthy shift I spent managing a hypotensive crisis would be forbidden now my pre‐work hours interns were much happier than their work hours successors a 4‐year residency must be around the corner. The response I got was more bemused smile than grave concern. You don't think that's important? I asked.

Of course I do. It's just that with all this talk about the days of the giants, he said gently, you're starting to sound like a grumpy old man. We chuckled. He was right. I expect a lot from myself, my trainees, and every clinician. I'd figured I'd be worthy of the title at some point.

But at 30?

Academic hospitalists have multiple duties including direct patient care, hospital management, teaching, and scholarly productivity. We are frequently pulled in divergent directions, while attending to these responsibilities. Without a framework to manage these assorted tasks, we are at risk of subpar performance and career dissatisfaction. Alternatively, we often thrive in our roles as utility players when armed with a developed skill set. Our profession could benefit greatly from encouraging future academic hospitalists to obtain further training prior to starting as an attending. Although hospital medicine fellowship training exists, there are still relatively few programs available. A well‐crafted year spent as a chief medical resident (CMR) may be a viable alternative.

My year as CMR allowed me to develop the skills necessary for success as an academic hospitalist in a supportive setting, and has given me an advantage in accelerating my career. This experience provided me with important tools that my initial 3 years of internal medicine residency did not. Even during my final year of residency, I was focused mostly on obtaining medical knowledge, learning its clinical applications, and honing team leadership skills. My mind rarely trespassed into the broader concerns of quality improvement initiatives, educational enhancements, or hospital management issues. Although the American College of Graduate Medical Education (ACGME) core competencies are helping to better focus residents' attention to these more diverse aspects of healthcare, residents still spend the majority of their time providing direct patient care.1 Now in my fourth year as an attending academic hospitalist, I continue to appreciate how my chief experience provided the foundation for much of the work I perform today.

My motivations for becoming a CMR included a desire to spend more time teaching and learning medicine, and an interest in helping to improve the residency program itself. I did not appreciate how much of the job would be spent managing people, and evaluating systems of care within the hospital, while working closely with nurses and hospital administrators. However, the skills I learned while addressing those unexpected tasks are what continue to help me in my position as a multifaceted hospitalist today. CMRs have been described as middle managers, being pushed and pulled by the demands and requirements of the groups above, below and around them.2 Academic hospitalists who frequently wear administrative and educational hats are not dissimilar. Retrospectively, I realize how fortunate I was to be exposed to those aspects as a CMR, with many of the same responsibilities but without the full expectations of a more seasoned attending.

The most memorable interaction during my first day as junior ward attending was with a revered internist, himself a former CMR, who dryly commented, So, you're pretending now. It took me a moment to catch his play on words until he clarified, you are now a pre‐attending. The true meaning of this was elucidated over the next several weeks as I was expected to perform many of the same duties of a seasoned attending, but often had the sense that I was only pretending to be an attending and still had much to learn.

CMR positions vary in terms of clinical, educational, and administrative responsibilities. Moreover, many institutions mix inpatient and outpatient roles. My position was focused almost entirely on inpatient duties at a single hospital, which gave me an in‐depth and longitudinal view of how a hospital is managed. Like many other CMRs, much of my time was spent on educational activities, such as running morning report, preparing for chief of medicine rounds, coordinating noon teaching conferences, and spending time with the medical students. Administrative tasks included various institutional‐based meetings for student grading, educational review committees, and program scheduling. In addition, I spent 1 month as junior attending on a ward team. Many other programs' CMRs spend more time as junior attending; however, by offloading some of this ward service requirement, I feel fortunate to have had that time to use for my own scholarly activity and teaching/administrative opportunities. Perhaps unique to my CMR position, I also was involved with the daily running of the hospital by working with administrators to evaluate patient transfer requests and addressing provider work flow issues. These additional tasks provided an invaluable learning experience.

Organizing morning report, running physical diagnosis rounds, and preparing cases and speakers for Chair's Rounds allowed me to hone and expand my teaching skills in ways that 3 years of residency did not. Moreover, it put me in direct contact with an energetic, inspiring group of learners that challenged me to solidify my own medical knowledge. (Try explaining the delta‐delta equation to figure out if there are 2 metabolic processes going on, in front of a group of 20 residents, and you'll discover what I mean.) I quickly learned that the one doing the talking is the one doing the learning and changed my teaching style to better facilitate student learning. My bedside learning was further augmented by attending Masters' Rounds to which I owe my ongoing interests in physical diagnosis. Masters Rounds were given once a week by 2 master clinicians. It was only for chief residents and was directed at teaching us how to teach others the art of bedside physical diagnosis. The majority of physical exam teaching points I focus on today come from those sessions.

As chief, I felt like I had the pulse of the hospital at all times. Most of my mornings were spent on the wards floating between teams. I owe thanks to my predecessor who told me that the true sign of a good CMR was to never sit long enough in your chair to let it get warm. My office was located on the wards, between a team room and a double patient room. Aside from times when I was having confidential conversations with residents, the door was open. Nurses looking to vent, phlebotomists wanting to sit down, and attendings needing a break from their teams to get work done were common visitors. Administrative personnel were also frequent visitors, usually requesting me to disseminate new policies to the residents. Because of this, I learned to understand and better interact with the diverse group of people responsible for making a teaching hospital function. These are the same constituencies that I now sit down with on various committees to attempt to make my present hospital operate more smoothly.

Despite running morning report, attending rounds with teams, and developing plans for better patient flow, I had time for scholarly work and found easy mentorship. I was able to revive 2 projects I had started as a resident and bring them close to conclusion under the continued mentorship of my coinvestigators. Offers for career skill development were also abound, and I benefited greatly from one associate director's tutorials on preparing effective PowerPoint presentations. Another attending mentored me in student feedback skills, which have allowed me to become a much more effective educator. I was also able to model that mentorship and begin to build my own mentor relationships with my students. In fact, this mentorship has become one of the most fulfilling aspects of my job. I was fortunate to have that mentorship early on in my career, as similar mentorship becomes difficult to obtain once in an attending hospitalist position.3

In conclusion, although current internal medicine residency training provides intensive direct patient care experiences, it only allows glimpses into the other aspects of an academic hospitalist's job. Unfortunately, it does not adequately prepare one to begin this type of position with a full complement of skills. Only a minority of hospitalists pursue additional structured training directly after residency; the majority jump into hospitalist positions and opt for on‐the‐job training. While there is an early economic advantage to starting an attending position without delay, I believe that the skills learned during an additional year of dedicated training allow for a more meaningful work experience and, ultimately, a faster rise within the track of an academic hospitalist.

The tasks that residency programs and hospitals may give to CMRs provide fertile material for developing the skills necessary to become a productive academic hospitalist. I thrived on the multifaceted work of caring for a diverse group of patients, teaching different levels of learners, helping to manage various hospital systems, and better understanding the hospital as the sum of its parts. As noted above, this pre‐attending league gave me the exposure to more fully develop my academic hospitalist game in a supportive environment. A CMR year may be beneficial for residents entering any career in internal medicine; however, I believe it is most aptly suited as a stepping stone for future academic hospitalists. I strongly recommend that current residents interested in academic hospital medicine consider a CMR position, and encourage program directors to consider molding their inpatient CMR experiences to facilitate this. Moreover, unless fellowship training in hospital medicine becomes the norm, I propose that current academic hospitalists do more to closely court and usher these pretenders into our ranks.

Academic hospitalists have multiple duties including direct patient care, hospital management, teaching, and scholarly productivity. We are frequently pulled in divergent directions, while attending to these responsibilities. Without a framework to manage these assorted tasks, we are at risk of subpar performance and career dissatisfaction. Alternatively, we often thrive in our roles as utility players when armed with a developed skill set. Our profession could benefit greatly from encouraging future academic hospitalists to obtain further training prior to starting as an attending. Although hospital medicine fellowship training exists, there are still relatively few programs available. A well‐crafted year spent as a chief medical resident (CMR) may be a viable alternative.

My year as CMR allowed me to develop the skills necessary for success as an academic hospitalist in a supportive setting, and has given me an advantage in accelerating my career. This experience provided me with important tools that my initial 3 years of internal medicine residency did not. Even during my final year of residency, I was focused mostly on obtaining medical knowledge, learning its clinical applications, and honing team leadership skills. My mind rarely trespassed into the broader concerns of quality improvement initiatives, educational enhancements, or hospital management issues. Although the American College of Graduate Medical Education (ACGME) core competencies are helping to better focus residents' attention to these more diverse aspects of healthcare, residents still spend the majority of their time providing direct patient care.1 Now in my fourth year as an attending academic hospitalist, I continue to appreciate how my chief experience provided the foundation for much of the work I perform today.

My motivations for becoming a CMR included a desire to spend more time teaching and learning medicine, and an interest in helping to improve the residency program itself. I did not appreciate how much of the job would be spent managing people, and evaluating systems of care within the hospital, while working closely with nurses and hospital administrators. However, the skills I learned while addressing those unexpected tasks are what continue to help me in my position as a multifaceted hospitalist today. CMRs have been described as middle managers, being pushed and pulled by the demands and requirements of the groups above, below and around them.2 Academic hospitalists who frequently wear administrative and educational hats are not dissimilar. Retrospectively, I realize how fortunate I was to be exposed to those aspects as a CMR, with many of the same responsibilities but without the full expectations of a more seasoned attending.

The most memorable interaction during my first day as junior ward attending was with a revered internist, himself a former CMR, who dryly commented, So, you're pretending now. It took me a moment to catch his play on words until he clarified, you are now a pre‐attending. The true meaning of this was elucidated over the next several weeks as I was expected to perform many of the same duties of a seasoned attending, but often had the sense that I was only pretending to be an attending and still had much to learn.

CMR positions vary in terms of clinical, educational, and administrative responsibilities. Moreover, many institutions mix inpatient and outpatient roles. My position was focused almost entirely on inpatient duties at a single hospital, which gave me an in‐depth and longitudinal view of how a hospital is managed. Like many other CMRs, much of my time was spent on educational activities, such as running morning report, preparing for chief of medicine rounds, coordinating noon teaching conferences, and spending time with the medical students. Administrative tasks included various institutional‐based meetings for student grading, educational review committees, and program scheduling. In addition, I spent 1 month as junior attending on a ward team. Many other programs' CMRs spend more time as junior attending; however, by offloading some of this ward service requirement, I feel fortunate to have had that time to use for my own scholarly activity and teaching/administrative opportunities. Perhaps unique to my CMR position, I also was involved with the daily running of the hospital by working with administrators to evaluate patient transfer requests and addressing provider work flow issues. These additional tasks provided an invaluable learning experience.

Organizing morning report, running physical diagnosis rounds, and preparing cases and speakers for Chair's Rounds allowed me to hone and expand my teaching skills in ways that 3 years of residency did not. Moreover, it put me in direct contact with an energetic, inspiring group of learners that challenged me to solidify my own medical knowledge. (Try explaining the delta‐delta equation to figure out if there are 2 metabolic processes going on, in front of a group of 20 residents, and you'll discover what I mean.) I quickly learned that the one doing the talking is the one doing the learning and changed my teaching style to better facilitate student learning. My bedside learning was further augmented by attending Masters' Rounds to which I owe my ongoing interests in physical diagnosis. Masters Rounds were given once a week by 2 master clinicians. It was only for chief residents and was directed at teaching us how to teach others the art of bedside physical diagnosis. The majority of physical exam teaching points I focus on today come from those sessions.

As chief, I felt like I had the pulse of the hospital at all times. Most of my mornings were spent on the wards floating between teams. I owe thanks to my predecessor who told me that the true sign of a good CMR was to never sit long enough in your chair to let it get warm. My office was located on the wards, between a team room and a double patient room. Aside from times when I was having confidential conversations with residents, the door was open. Nurses looking to vent, phlebotomists wanting to sit down, and attendings needing a break from their teams to get work done were common visitors. Administrative personnel were also frequent visitors, usually requesting me to disseminate new policies to the residents. Because of this, I learned to understand and better interact with the diverse group of people responsible for making a teaching hospital function. These are the same constituencies that I now sit down with on various committees to attempt to make my present hospital operate more smoothly.

Despite running morning report, attending rounds with teams, and developing plans for better patient flow, I had time for scholarly work and found easy mentorship. I was able to revive 2 projects I had started as a resident and bring them close to conclusion under the continued mentorship of my coinvestigators. Offers for career skill development were also abound, and I benefited greatly from one associate director's tutorials on preparing effective PowerPoint presentations. Another attending mentored me in student feedback skills, which have allowed me to become a much more effective educator. I was also able to model that mentorship and begin to build my own mentor relationships with my students. In fact, this mentorship has become one of the most fulfilling aspects of my job. I was fortunate to have that mentorship early on in my career, as similar mentorship becomes difficult to obtain once in an attending hospitalist position.3

In conclusion, although current internal medicine residency training provides intensive direct patient care experiences, it only allows glimpses into the other aspects of an academic hospitalist's job. Unfortunately, it does not adequately prepare one to begin this type of position with a full complement of skills. Only a minority of hospitalists pursue additional structured training directly after residency; the majority jump into hospitalist positions and opt for on‐the‐job training. While there is an early economic advantage to starting an attending position without delay, I believe that the skills learned during an additional year of dedicated training allow for a more meaningful work experience and, ultimately, a faster rise within the track of an academic hospitalist.

The tasks that residency programs and hospitals may give to CMRs provide fertile material for developing the skills necessary to become a productive academic hospitalist. I thrived on the multifaceted work of caring for a diverse group of patients, teaching different levels of learners, helping to manage various hospital systems, and better understanding the hospital as the sum of its parts. As noted above, this pre‐attending league gave me the exposure to more fully develop my academic hospitalist game in a supportive environment. A CMR year may be beneficial for residents entering any career in internal medicine; however, I believe it is most aptly suited as a stepping stone for future academic hospitalists. I strongly recommend that current residents interested in academic hospital medicine consider a CMR position, and encourage program directors to consider molding their inpatient CMR experiences to facilitate this. Moreover, unless fellowship training in hospital medicine becomes the norm, I propose that current academic hospitalists do more to closely court and usher these pretenders into our ranks.

Academic hospitalists have multiple duties including direct patient care, hospital management, teaching, and scholarly productivity. We are frequently pulled in divergent directions, while attending to these responsibilities. Without a framework to manage these assorted tasks, we are at risk of subpar performance and career dissatisfaction. Alternatively, we often thrive in our roles as utility players when armed with a developed skill set. Our profession could benefit greatly from encouraging future academic hospitalists to obtain further training prior to starting as an attending. Although hospital medicine fellowship training exists, there are still relatively few programs available. A well‐crafted year spent as a chief medical resident (CMR) may be a viable alternative.

My year as CMR allowed me to develop the skills necessary for success as an academic hospitalist in a supportive setting, and has given me an advantage in accelerating my career. This experience provided me with important tools that my initial 3 years of internal medicine residency did not. Even during my final year of residency, I was focused mostly on obtaining medical knowledge, learning its clinical applications, and honing team leadership skills. My mind rarely trespassed into the broader concerns of quality improvement initiatives, educational enhancements, or hospital management issues. Although the American College of Graduate Medical Education (ACGME) core competencies are helping to better focus residents' attention to these more diverse aspects of healthcare, residents still spend the majority of their time providing direct patient care.1 Now in my fourth year as an attending academic hospitalist, I continue to appreciate how my chief experience provided the foundation for much of the work I perform today.

My motivations for becoming a CMR included a desire to spend more time teaching and learning medicine, and an interest in helping to improve the residency program itself. I did not appreciate how much of the job would be spent managing people, and evaluating systems of care within the hospital, while working closely with nurses and hospital administrators. However, the skills I learned while addressing those unexpected tasks are what continue to help me in my position as a multifaceted hospitalist today. CMRs have been described as middle managers, being pushed and pulled by the demands and requirements of the groups above, below and around them.2 Academic hospitalists who frequently wear administrative and educational hats are not dissimilar. Retrospectively, I realize how fortunate I was to be exposed to those aspects as a CMR, with many of the same responsibilities but without the full expectations of a more seasoned attending.

The most memorable interaction during my first day as junior ward attending was with a revered internist, himself a former CMR, who dryly commented, So, you're pretending now. It took me a moment to catch his play on words until he clarified, you are now a pre‐attending. The true meaning of this was elucidated over the next several weeks as I was expected to perform many of the same duties of a seasoned attending, but often had the sense that I was only pretending to be an attending and still had much to learn.

CMR positions vary in terms of clinical, educational, and administrative responsibilities. Moreover, many institutions mix inpatient and outpatient roles. My position was focused almost entirely on inpatient duties at a single hospital, which gave me an in‐depth and longitudinal view of how a hospital is managed. Like many other CMRs, much of my time was spent on educational activities, such as running morning report, preparing for chief of medicine rounds, coordinating noon teaching conferences, and spending time with the medical students. Administrative tasks included various institutional‐based meetings for student grading, educational review committees, and program scheduling. In addition, I spent 1 month as junior attending on a ward team. Many other programs' CMRs spend more time as junior attending; however, by offloading some of this ward service requirement, I feel fortunate to have had that time to use for my own scholarly activity and teaching/administrative opportunities. Perhaps unique to my CMR position, I also was involved with the daily running of the hospital by working with administrators to evaluate patient transfer requests and addressing provider work flow issues. These additional tasks provided an invaluable learning experience.

Organizing morning report, running physical diagnosis rounds, and preparing cases and speakers for Chair's Rounds allowed me to hone and expand my teaching skills in ways that 3 years of residency did not. Moreover, it put me in direct contact with an energetic, inspiring group of learners that challenged me to solidify my own medical knowledge. (Try explaining the delta‐delta equation to figure out if there are 2 metabolic processes going on, in front of a group of 20 residents, and you'll discover what I mean.) I quickly learned that the one doing the talking is the one doing the learning and changed my teaching style to better facilitate student learning. My bedside learning was further augmented by attending Masters' Rounds to which I owe my ongoing interests in physical diagnosis. Masters Rounds were given once a week by 2 master clinicians. It was only for chief residents and was directed at teaching us how to teach others the art of bedside physical diagnosis. The majority of physical exam teaching points I focus on today come from those sessions.

As chief, I felt like I had the pulse of the hospital at all times. Most of my mornings were spent on the wards floating between teams. I owe thanks to my predecessor who told me that the true sign of a good CMR was to never sit long enough in your chair to let it get warm. My office was located on the wards, between a team room and a double patient room. Aside from times when I was having confidential conversations with residents, the door was open. Nurses looking to vent, phlebotomists wanting to sit down, and attendings needing a break from their teams to get work done were common visitors. Administrative personnel were also frequent visitors, usually requesting me to disseminate new policies to the residents. Because of this, I learned to understand and better interact with the diverse group of people responsible for making a teaching hospital function. These are the same constituencies that I now sit down with on various committees to attempt to make my present hospital operate more smoothly.

Despite running morning report, attending rounds with teams, and developing plans for better patient flow, I had time for scholarly work and found easy mentorship. I was able to revive 2 projects I had started as a resident and bring them close to conclusion under the continued mentorship of my coinvestigators. Offers for career skill development were also abound, and I benefited greatly from one associate director's tutorials on preparing effective PowerPoint presentations. Another attending mentored me in student feedback skills, which have allowed me to become a much more effective educator. I was also able to model that mentorship and begin to build my own mentor relationships with my students. In fact, this mentorship has become one of the most fulfilling aspects of my job. I was fortunate to have that mentorship early on in my career, as similar mentorship becomes difficult to obtain once in an attending hospitalist position.3

In conclusion, although current internal medicine residency training provides intensive direct patient care experiences, it only allows glimpses into the other aspects of an academic hospitalist's job. Unfortunately, it does not adequately prepare one to begin this type of position with a full complement of skills. Only a minority of hospitalists pursue additional structured training directly after residency; the majority jump into hospitalist positions and opt for on‐the‐job training. While there is an early economic advantage to starting an attending position without delay, I believe that the skills learned during an additional year of dedicated training allow for a more meaningful work experience and, ultimately, a faster rise within the track of an academic hospitalist.

The tasks that residency programs and hospitals may give to CMRs provide fertile material for developing the skills necessary to become a productive academic hospitalist. I thrived on the multifaceted work of caring for a diverse group of patients, teaching different levels of learners, helping to manage various hospital systems, and better understanding the hospital as the sum of its parts. As noted above, this pre‐attending league gave me the exposure to more fully develop my academic hospitalist game in a supportive environment. A CMR year may be beneficial for residents entering any career in internal medicine; however, I believe it is most aptly suited as a stepping stone for future academic hospitalists. I strongly recommend that current residents interested in academic hospital medicine consider a CMR position, and encourage program directors to consider molding their inpatient CMR experiences to facilitate this. Moreover, unless fellowship training in hospital medicine becomes the norm, I propose that current academic hospitalists do more to closely court and usher these pretenders into our ranks.

The tension between continuity of care and specialization is not new, but may have reached a tipping point when the hospitalist movement erupted onto the American medical scene in the late 1990s. By definition, when a hospitalist cares for an inpatient, there is some fragmentation of care, which is, at least in theory, avoidableif the primary care provider (PCP) can serve as attending physician in the hospital. Literature has since emerged suggesting that clinical and economic outcomes of care by hospitalists are at least as good as that provided by PCPs, and that patients are not, in general, opposed to hospitalist care.13

However, the degree of discontinuity is not just a feature of whether a hospitalist assumes care of the hospitalized patient. Discontinuity can be exacerbated by changing attendings throughout the hospital stay. And inpatient continuity is a potential issue for both the hospitalist model and traditional model of care (in which the PCP serves as inpatient attending physician). While one might assume that the hospitalist model fosters more inpatient discontinuity because most hospitalistswhether working a 7‐on7‐off schedule or another scheduledo not commit to caring for a patient throughout an entire hospitalization the way a PCP might, this question has not previously been examined. Even if the hospitalist model is a fait accompli in many hospitals, it is worth knowing how inpatient continuity differs between the 2 models.

In this issue of the Journal, Fletcher and colleagues4 used billing data to examine trends in inpatient continuity of care over a 10‐year period ending in 2006, and sought to determine: (1) whether inpatient care has become more fragmented over time (as defined by the number of generalists caring for a patient over the course of an average hospitalization), and (2) whether inpatient care provided by hospitalists tends to be more fragmented than care provided by PCPs. They found that continuity of inpatient care has indeed decreased over time. In 1996, just over 70% of patients received care from 1 generalist; this number declined to just under 60% a decade later, despite a decrease in length‐of‐stay during that period. However, and perhaps surprisingly, patients cared for exclusively by hospitalists saw fewer generalists in the hospital (ie, fewer different hospitalists) than those cared for exclusively by outpatient providers. The authors conclude that the doctorpatient continuity over the course of a hospital stay is not worse in the hospitalist model than in the traditional model. While reassuring, it is important to remember that the patient experience does not begin at admission or end at discharge, and a more patient‐centered analysis might take into account the outpatient providers too (ie, those seeing the patient before admission and after discharge), and would probably show that the hospitalist model indeed leads to more care fragmentation. After all, there are at least 2 providers involved in every patient's care when a hospitalist model is used, whereas a large subset of patients cared for by PCPs would have only 1 provider involved.

While not the primary focus of the analysis, Fletcher and colleagues4 identified additional predictors of inpatient continuity of care. Higher socioeconomic class and white race were associated with lower continuity. This suggests that care fragmentation is not a feature of inferior, or at least cheap, care. In keeping with this observation, there was also enormous geographic variation in inpatient care continuity, marked by greater fragmentation of care in the New England and the mid‐Atlantic regions than in other areas of the country, and more fragmentation in larger hospitals serving heavily populated metropolitan areas. This pattern is strikingly similar to the cost‐of‐care patterns observed by the Dartmouth Atlas researchers.5, 6 Densely populated areas tend to have more specialists per capita and also tend to deliver more expensive carewithout demonstrably higher quality. In parallel, it is easy to see how care fragmentation might increase length‐of‐stay7 and lead to excessive diagnostic testing and consultation. More cooks in the kitchen might make costlier stew.

How hospitalists tackle the issue of inpatient continuity is not only a matter of quality of care, but also a matter of job sustainability. The simple way to maximize continuityworking many consecutive dayscan lead to burnout if taken too far. But there are creative ways to assign admissions that maximize continuity for the average inpatient while allowing providers needed time off. The CICLE initiative (Creating Incentives and Continuity Leading to Efficiency in hospital medicine) at the Johns Hopkins Bayview Medical Center, for instance, assigns physicians to 4‐day cycles of clinical work; the first day of the cycle (a long‐call day) involves admitting a large number of patients during a busy shift, with no new patients admitted on the remaining days of the cycle. Thus, all patients whose length of stay is less than 5 days will have a single attending‐of‐record. Not only does this model increase continuity, it also incentivizes providers to augment throughput: more discharged patients on Tuesday means fewer patients to see on Wednesday, without any expectation to backfill. Other less aggressive but similar approaches are used elsewhere, such as exempting hospitalists from accepting new patients on the last 1 or 2 of the consecutive days they work. We eagerly await data on the impact of these programs on quality of care, patient satisfaction, and provider satisfaction.

The impact of other providers and staff cannot be ignored. While the most important handoff in many cases may indeed be between the PCP and attending hospitalist tasked with coordinating the overall care of the patient, for some patients, there may be a specialist who has known the patient for years who is driving the plan of care. For patients with severe chronic illnesses, such as end‐stage renal disease or asthma, a well‐structured specialty clinic may even serve as a patient‐centered medical home.8 And the current inpatient team includes night coverage physicians (whether moonlighters, house staff, or covering hospitalists), and an ever‐increasing number of non‐physicians who play a critical role in hospital care (non‐physician providers, nurses, social workers, pharmacists, case managers, physical therapists, and others). While it is tempting to focus on the attending physician as the main driver of healthcare quality, continuity, and the inpatient experience, this is an oversimplification.

If there is a take‐home message, it is probably that most hospitalized patients will be cared for by multiple providers and a team of non‐physicians. The Marcus Welby practice model may not be completely dead, but if Dr. Welby were still in practice, it would be a safe bet that he would be slower at computerized order entry than the average intern, that financial pressures would make it hard for him to attend to his hospitalized patients, and that he probably would have turned over much of his inpatient practice to the physicians and non‐physician caregivers who make the hospital their primary workplace.9 Going forward, research should examine ways to optimize care coordination under the hospitalist model,1013 rather than comparing it to the traditional model of inpatient care. The ingredients for success include coordinated care by a committee of caregivers, effective handoffs (throughout hospitalization and at discharge),12, 14 focused and deliberate multidisciplinary communication, and effective patient education,15 regardless of the attending‐du‐jour.

The tension between continuity of care and specialization is not new, but may have reached a tipping point when the hospitalist movement erupted onto the American medical scene in the late 1990s. By definition, when a hospitalist cares for an inpatient, there is some fragmentation of care, which is, at least in theory, avoidableif the primary care provider (PCP) can serve as attending physician in the hospital. Literature has since emerged suggesting that clinical and economic outcomes of care by hospitalists are at least as good as that provided by PCPs, and that patients are not, in general, opposed to hospitalist care.13

However, the degree of discontinuity is not just a feature of whether a hospitalist assumes care of the hospitalized patient. Discontinuity can be exacerbated by changing attendings throughout the hospital stay. And inpatient continuity is a potential issue for both the hospitalist model and traditional model of care (in which the PCP serves as inpatient attending physician). While one might assume that the hospitalist model fosters more inpatient discontinuity because most hospitalistswhether working a 7‐on7‐off schedule or another scheduledo not commit to caring for a patient throughout an entire hospitalization the way a PCP might, this question has not previously been examined. Even if the hospitalist model is a fait accompli in many hospitals, it is worth knowing how inpatient continuity differs between the 2 models.

In this issue of the Journal, Fletcher and colleagues4 used billing data to examine trends in inpatient continuity of care over a 10‐year period ending in 2006, and sought to determine: (1) whether inpatient care has become more fragmented over time (as defined by the number of generalists caring for a patient over the course of an average hospitalization), and (2) whether inpatient care provided by hospitalists tends to be more fragmented than care provided by PCPs. They found that continuity of inpatient care has indeed decreased over time. In 1996, just over 70% of patients received care from 1 generalist; this number declined to just under 60% a decade later, despite a decrease in length‐of‐stay during that period. However, and perhaps surprisingly, patients cared for exclusively by hospitalists saw fewer generalists in the hospital (ie, fewer different hospitalists) than those cared for exclusively by outpatient providers. The authors conclude that the doctorpatient continuity over the course of a hospital stay is not worse in the hospitalist model than in the traditional model. While reassuring, it is important to remember that the patient experience does not begin at admission or end at discharge, and a more patient‐centered analysis might take into account the outpatient providers too (ie, those seeing the patient before admission and after discharge), and would probably show that the hospitalist model indeed leads to more care fragmentation. After all, there are at least 2 providers involved in every patient's care when a hospitalist model is used, whereas a large subset of patients cared for by PCPs would have only 1 provider involved.

While not the primary focus of the analysis, Fletcher and colleagues4 identified additional predictors of inpatient continuity of care. Higher socioeconomic class and white race were associated with lower continuity. This suggests that care fragmentation is not a feature of inferior, or at least cheap, care. In keeping with this observation, there was also enormous geographic variation in inpatient care continuity, marked by greater fragmentation of care in the New England and the mid‐Atlantic regions than in other areas of the country, and more fragmentation in larger hospitals serving heavily populated metropolitan areas. This pattern is strikingly similar to the cost‐of‐care patterns observed by the Dartmouth Atlas researchers.5, 6 Densely populated areas tend to have more specialists per capita and also tend to deliver more expensive carewithout demonstrably higher quality. In parallel, it is easy to see how care fragmentation might increase length‐of‐stay7 and lead to excessive diagnostic testing and consultation. More cooks in the kitchen might make costlier stew.

How hospitalists tackle the issue of inpatient continuity is not only a matter of quality of care, but also a matter of job sustainability. The simple way to maximize continuityworking many consecutive dayscan lead to burnout if taken too far. But there are creative ways to assign admissions that maximize continuity for the average inpatient while allowing providers needed time off. The CICLE initiative (Creating Incentives and Continuity Leading to Efficiency in hospital medicine) at the Johns Hopkins Bayview Medical Center, for instance, assigns physicians to 4‐day cycles of clinical work; the first day of the cycle (a long‐call day) involves admitting a large number of patients during a busy shift, with no new patients admitted on the remaining days of the cycle. Thus, all patients whose length of stay is less than 5 days will have a single attending‐of‐record. Not only does this model increase continuity, it also incentivizes providers to augment throughput: more discharged patients on Tuesday means fewer patients to see on Wednesday, without any expectation to backfill. Other less aggressive but similar approaches are used elsewhere, such as exempting hospitalists from accepting new patients on the last 1 or 2 of the consecutive days they work. We eagerly await data on the impact of these programs on quality of care, patient satisfaction, and provider satisfaction.

The impact of other providers and staff cannot be ignored. While the most important handoff in many cases may indeed be between the PCP and attending hospitalist tasked with coordinating the overall care of the patient, for some patients, there may be a specialist who has known the patient for years who is driving the plan of care. For patients with severe chronic illnesses, such as end‐stage renal disease or asthma, a well‐structured specialty clinic may even serve as a patient‐centered medical home.8 And the current inpatient team includes night coverage physicians (whether moonlighters, house staff, or covering hospitalists), and an ever‐increasing number of non‐physicians who play a critical role in hospital care (non‐physician providers, nurses, social workers, pharmacists, case managers, physical therapists, and others). While it is tempting to focus on the attending physician as the main driver of healthcare quality, continuity, and the inpatient experience, this is an oversimplification.

If there is a take‐home message, it is probably that most hospitalized patients will be cared for by multiple providers and a team of non‐physicians. The Marcus Welby practice model may not be completely dead, but if Dr. Welby were still in practice, it would be a safe bet that he would be slower at computerized order entry than the average intern, that financial pressures would make it hard for him to attend to his hospitalized patients, and that he probably would have turned over much of his inpatient practice to the physicians and non‐physician caregivers who make the hospital their primary workplace.9 Going forward, research should examine ways to optimize care coordination under the hospitalist model,1013 rather than comparing it to the traditional model of inpatient care. The ingredients for success include coordinated care by a committee of caregivers, effective handoffs (throughout hospitalization and at discharge),12, 14 focused and deliberate multidisciplinary communication, and effective patient education,15 regardless of the attending‐du‐jour.

The tension between continuity of care and specialization is not new, but may have reached a tipping point when the hospitalist movement erupted onto the American medical scene in the late 1990s. By definition, when a hospitalist cares for an inpatient, there is some fragmentation of care, which is, at least in theory, avoidableif the primary care provider (PCP) can serve as attending physician in the hospital. Literature has since emerged suggesting that clinical and economic outcomes of care by hospitalists are at least as good as that provided by PCPs, and that patients are not, in general, opposed to hospitalist care.13

However, the degree of discontinuity is not just a feature of whether a hospitalist assumes care of the hospitalized patient. Discontinuity can be exacerbated by changing attendings throughout the hospital stay. And inpatient continuity is a potential issue for both the hospitalist model and traditional model of care (in which the PCP serves as inpatient attending physician). While one might assume that the hospitalist model fosters more inpatient discontinuity because most hospitalistswhether working a 7‐on7‐off schedule or another scheduledo not commit to caring for a patient throughout an entire hospitalization the way a PCP might, this question has not previously been examined. Even if the hospitalist model is a fait accompli in many hospitals, it is worth knowing how inpatient continuity differs between the 2 models.

In this issue of the Journal, Fletcher and colleagues4 used billing data to examine trends in inpatient continuity of care over a 10‐year period ending in 2006, and sought to determine: (1) whether inpatient care has become more fragmented over time (as defined by the number of generalists caring for a patient over the course of an average hospitalization), and (2) whether inpatient care provided by hospitalists tends to be more fragmented than care provided by PCPs. They found that continuity of inpatient care has indeed decreased over time. In 1996, just over 70% of patients received care from 1 generalist; this number declined to just under 60% a decade later, despite a decrease in length‐of‐stay during that period. However, and perhaps surprisingly, patients cared for exclusively by hospitalists saw fewer generalists in the hospital (ie, fewer different hospitalists) than those cared for exclusively by outpatient providers. The authors conclude that the doctorpatient continuity over the course of a hospital stay is not worse in the hospitalist model than in the traditional model. While reassuring, it is important to remember that the patient experience does not begin at admission or end at discharge, and a more patient‐centered analysis might take into account the outpatient providers too (ie, those seeing the patient before admission and after discharge), and would probably show that the hospitalist model indeed leads to more care fragmentation. After all, there are at least 2 providers involved in every patient's care when a hospitalist model is used, whereas a large subset of patients cared for by PCPs would have only 1 provider involved.

While not the primary focus of the analysis, Fletcher and colleagues4 identified additional predictors of inpatient continuity of care. Higher socioeconomic class and white race were associated with lower continuity. This suggests that care fragmentation is not a feature of inferior, or at least cheap, care. In keeping with this observation, there was also enormous geographic variation in inpatient care continuity, marked by greater fragmentation of care in the New England and the mid‐Atlantic regions than in other areas of the country, and more fragmentation in larger hospitals serving heavily populated metropolitan areas. This pattern is strikingly similar to the cost‐of‐care patterns observed by the Dartmouth Atlas researchers.5, 6 Densely populated areas tend to have more specialists per capita and also tend to deliver more expensive carewithout demonstrably higher quality. In parallel, it is easy to see how care fragmentation might increase length‐of‐stay7 and lead to excessive diagnostic testing and consultation. More cooks in the kitchen might make costlier stew.

How hospitalists tackle the issue of inpatient continuity is not only a matter of quality of care, but also a matter of job sustainability. The simple way to maximize continuityworking many consecutive dayscan lead to burnout if taken too far. But there are creative ways to assign admissions that maximize continuity for the average inpatient while allowing providers needed time off. The CICLE initiative (Creating Incentives and Continuity Leading to Efficiency in hospital medicine) at the Johns Hopkins Bayview Medical Center, for instance, assigns physicians to 4‐day cycles of clinical work; the first day of the cycle (a long‐call day) involves admitting a large number of patients during a busy shift, with no new patients admitted on the remaining days of the cycle. Thus, all patients whose length of stay is less than 5 days will have a single attending‐of‐record. Not only does this model increase continuity, it also incentivizes providers to augment throughput: more discharged patients on Tuesday means fewer patients to see on Wednesday, without any expectation to backfill. Other less aggressive but similar approaches are used elsewhere, such as exempting hospitalists from accepting new patients on the last 1 or 2 of the consecutive days they work. We eagerly await data on the impact of these programs on quality of care, patient satisfaction, and provider satisfaction.

The impact of other providers and staff cannot be ignored. While the most important handoff in many cases may indeed be between the PCP and attending hospitalist tasked with coordinating the overall care of the patient, for some patients, there may be a specialist who has known the patient for years who is driving the plan of care. For patients with severe chronic illnesses, such as end‐stage renal disease or asthma, a well‐structured specialty clinic may even serve as a patient‐centered medical home.8 And the current inpatient team includes night coverage physicians (whether moonlighters, house staff, or covering hospitalists), and an ever‐increasing number of non‐physicians who play a critical role in hospital care (non‐physician providers, nurses, social workers, pharmacists, case managers, physical therapists, and others). While it is tempting to focus on the attending physician as the main driver of healthcare quality, continuity, and the inpatient experience, this is an oversimplification.

If there is a take‐home message, it is probably that most hospitalized patients will be cared for by multiple providers and a team of non‐physicians. The Marcus Welby practice model may not be completely dead, but if Dr. Welby were still in practice, it would be a safe bet that he would be slower at computerized order entry than the average intern, that financial pressures would make it hard for him to attend to his hospitalized patients, and that he probably would have turned over much of his inpatient practice to the physicians and non‐physician caregivers who make the hospital their primary workplace.9 Going forward, research should examine ways to optimize care coordination under the hospitalist model,1013 rather than comparing it to the traditional model of inpatient care. The ingredients for success include coordinated care by a committee of caregivers, effective handoffs (throughout hospitalization and at discharge),12, 14 focused and deliberate multidisciplinary communication, and effective patient education,15 regardless of the attending‐du‐jour.

With 17 million Americans reporting heavy drinking (5 or more drinks on 5 different occasions in the last month) and 1.7 million hospital discharges in 2006 containing at least 1 alcohol‐related diagnosis, it would be hard to imagine a hospitalist who does not encounter patients with alcohol abuse.1, 2 Estimates from studies looking at the number of risky drinkers among medical inpatients vary widely2% to 60%with more detailed studies suggesting 17% to 25% prevalence.36 Yet despite the large numbers and great costs to the healthcare system, the inpatient treatment of alcohol withdrawal syndrome remains the ugly stepsister to more exciting topics, such as acute myocardial infarction, pulmonary embolism and procedures.7, 8 We hospitalists typically leave the clinical studies, research, and interest on substance abuse to addiction specialists and psychiatrists, perhaps due to our discomfort with these patients, negative attitudes, or belief that there is nothing new in the treatment of alcohol withdrawal syndrome since Dr Leo Henryk Sternbach discovered benzodiazepines in 1957.7, 9 Many of us just admit the alcoholic patient, check the alcohol‐pathway in our order entry system, and stop thinking about it.

But in this day of evidence‐based medicine and practice, what is the evidence behind the treatment of alcohol withdrawal, especially in relation to inpatient medicine? Shouldn't we hospitalists be thinking about this question? Hospitalists tend to see 2 types of inpatients with alcohol withdrawal: those solely admitted for withdrawal, and those admitted with active medical issues who then experience alcohol withdrawal. Is there a difference?

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM‐IV) defines early alcohol withdrawal as the first 48 hours where there is central nervous system (CNS) stimulation, adrenergic hyperactivity, and the risk of seizures. Late withdrawal, after 48 hours, includes delirium tremens (DTs) and Wernicke's encephalopathy.10 This is based on studies done in the 1950s, where researchers observed patients as they withdrew from alcohol and took notes.11, 12

The goal in treatment of alcohol withdrawal is to minimize symptoms and prevent seizures and DTs which, prior to benzodiazepines, had a mortality rate of 5% to 20%. Before the US Food and Drug Administration (FDA) approval of the first benzodiazepine in 1960 (chlordiazepoxide), physicians treated alcohol withdrawal with ethanol, antipsychotics, or paraldehyde.12 (That is why there is a P in the mnemonic MUDPILES for anion gap acidosis.) The first study to show a real benefit from benzodiazepine was published in 1969, when 537 men in a veterans detoxification unit were randomized to chlordiazepoxide (Librium), chlorpromazine (Thorazine), antihistamine, thiamine, or placebo.12 The primary outcome of DTs and seizures occurred in 10% to 16% of the patients, except for the chlordiazepoxide group where only 2% developed seizures and DTs (there was no P value calculated). Further studies published in the 1970s and early 1980s were too small to demonstrate a benefit. A 1997 meta‐analysis of all these studies, including the 1969 article,12 confirmed benzodiazepines statistically reduced seizures and DTs.13 Which benzodiazepine to use, however, is less clear. Long‐acting benzodiazepines with liver clearance (eg, chlordiazepoxide or diazepam) versus short‐acting with renal clearance (eg, oxazepam or lorazepam) is debated. While there are many strong opinions among clinicians, the same meta‐analysis did not find any difference between them, and a small 2009 study found no difference between a short‐acting and long‐acting benzodiazepine.13, 14

How much benzodiazepine to give and how frequently to dose it was looked at in 2 classic studies.15, 16 Both studies demonstrated that symptom‐triggered dosing of benzodiazepines, based on the Clinical Institute Withdrawal Assessment (CIWA) scale, performed equally well in terms of clinical outcomes, with less medication required as compared with fixed‐dose regimens. Based on these articles, many hospitals created alcohol pathways using solely symptom‐triggered dosing.

The CIWA scale is one of multiple rating scales in the assessment of alcohol withdrawal.17, 18 The CIWA‐Ar is a modified scale that was designed and validated for clinical use in inpatient detoxification centers, and excluded any active medical illness. It has gained popularity, though initial time for staff training and time for administration are limitations to its usefulness. Interestingly, vital signs, which many institutions use in their alcohol withdrawal pathways, were not strongly predictive in the CIWA study of severe withdrawal, seizures, or DTs.17

Finally, what about treatment when the patient does develop seizures or DTs? The evidence on how best to treat alcohol withdrawal seizures comes from a 1999 article which demonstrated a benefit of using lorazepam for recurrent seizures.19, 20 Unfortunately, the treatment for DTs is less clear. A 2004 meta‐analysis on the treatment of delirium tremens found benzodiazepines better than chlorpromazine (Thorazine), but benzodiazepines versus, or in addition to, newer antipsychotics have not been tested. The amount of benzodiazepine to give in DTs is only a Grade C (ie, expert opinion) recommendation: dose for light somnolence.21

All of these studies, however, come back to the basic question: Do they apply to the inpatients that hospitalists care for? A key factor to consider: All of the above‐mentioned studies, including the derivation and validation of the CIWA scale, were done in outpatient centers or inpatient detoxification centers. Patients with active medical illness or comorbidities were excluded. This data may be relevant for the patients admitted solely for alcohol withdrawal, but what about the 60 year old with diabetes, coronary artery disease, and chronic obstructive lung disease admitted for pneumonia who starts to withdraw; or the 72‐year‐old woman who breaks her hip and begins to withdraw on post‐op day 2?

There are 6 relatively recent studies that evaluate PRN (as needed) dosing of benzodiazepines on general medical inpatients.2227 While ideally these articles should apply to a hospitalist's patients, 2 of the studies excluded anyone with acute medical illness.24, 27 From the remaining 4, what do we learn? Weaver and colleagues did a randomized study on general medical patients and found less lorazepam was given with PRN versus fixed dosing.26 Unfortunately, the study was not blinded and there were statistically significant protocol errors. Comorbidity data was not given, leaving us to wonder to which inpatients this applies. Repper‐DeLisi et al. did a retrospective chart review, after implementing an alcohol pathway (not based on the CIWA scale), and did not find a statistical difference in dosing, length of stay, or delirium.25 Foy et al. looked at both medical and surgical patients, and dosed benzodiazepines based on an 18‐item CIWA scale which included vital signs.22 They found that the higher score did correlate with risk of developing severe alcohol withdrawal. However, the scale had limitations. Many patients with illness were at higher risk for severe alcohol withdrawal than their score indicated, and some high scores were believed, in part, due to illness. Jeager et al. did a pre‐comparison and post‐comparison of the implementation of a PRN CIWA protocol by chart review.23 They found a reduction in delirium in patients treated with PRN dosing, but no different in total benzodiazepine given. Because it was chart review, the authors acknowledge that defining delirium tremens was less reliable, and controlling for comorbidities was difficult. The difficult part of delirium in inpatients with alcohol abuse is that the delirium is not always just from DTs.

Two recent studies raised alarm about using a PRN CIWA pathway on patients.28, 29 A 2008 study found that 52% of patients were inappropriately put on a CIWA sliding scale when they either could not communicate or had not been recently drinking, or both.29 (The CIWA scale requires the person be able to answer symptom questions and is not applicable to non‐drinkers.) In 2005, during the implementation of an alcohol pathway at San Francisco General Hospital, an increase in mortality was noted with a PRN CIWA scale on inpatients.28

One of the conundrums for physicians is that whereas alcohol withdrawal has morbidity and mortality risks, benzodiazepine treatment itself has its own risks. Over sedation, respiratory depression, aspiration pneumonia, deconditioning from prolonged sedation, paradoxical agitation and disinhibition are the consequences of the dosing difficulties in alcohol withdrawal. Case reports on astronomical doses required to treat withdrawal (eg, 1600 mg of lorazepam in a day) raise questions of benzodiazepine resistance.30 Hence, multiple studies have been done to find alternatives for benzodiazepines. Our European counterparts lead the way in looking at: carbemazepine, gabapentin, gamma‐hydroxybuterate, corticotropin‐releasing hormone, baclofen, pregabalin, and phenobarbital. Again, the key issue for hospitalists: Are these benzodiazepine alternatives or additives applicable to our patients? These studies are done on outpatients with no concurrent medical illnesses. Yet, logic would suggest that it is the vulnerable hospitalized patients who might benefit the most from reducing the benzodiazepine amount using other agents.

In this issue of the Journal of Hospital Medicine, Lyon et al. provide a glimpse into possible ways to reduce the total benzodiazepine dose for general medical inpatients.31 They randomized inpatients withdrawing from alcohol to baclofen or placebo. Both groups still received PRN lorazepam based on their hospital's CIWA protocol. Prior outpatient studies have shown baclofen benefits patients undergoing alcohol withdrawal and the pathophysiology makes sense; baclofen acts on GABA b receptors. Lyon and collegaues' study results show significant reduction in the amount of benzodiazepine needed with no difference in CIWA scores.31

Is this a practice changer? Well, not yet. The numbers in the study are small and this is only 1 institution. These patients had only moderate alcohol withdrawal and the study was not powered to detect outcomes related to prevention of seizures and delirium tremens. However, the authors should be applauded for looking at alcohol withdrawal in medical inpatients.31 Trying to reduce the harm we cause with our benzodiazepine treatment regimens is a laudable goal. Inpatient alcohol withdrawal, especially for patients with medical comorbidities, is an area ripe for study and certainly deserves to have a spotlight shown on it.

Who better to do this than hospitalists? The Society of Hospital Medicine (SHM) core competency on Alcohol and Drug Withdrawal states, Hospitalists can lead their institutions in evidence based treatment protocols that improve care, reduce costs‐ and length of stay, and facilitate better overall outcomes in patients with substance related withdrawal syndromes.32 Hopefully, Lyon and collegaues' work will lead to the formation of multicenter hospitalist‐initiated studies to provide us with the best evidence for the treatment of inpatient alcohol withdrawal on our patients with comorbidities.31 Given the prevalence and potential severity of alcohol withdrawal in complex inpatients, isn't it time we really knew how to treat them?

With 17 million Americans reporting heavy drinking (5 or more drinks on 5 different occasions in the last month) and 1.7 million hospital discharges in 2006 containing at least 1 alcohol‐related diagnosis, it would be hard to imagine a hospitalist who does not encounter patients with alcohol abuse.1, 2 Estimates from studies looking at the number of risky drinkers among medical inpatients vary widely2% to 60%with more detailed studies suggesting 17% to 25% prevalence.36 Yet despite the large numbers and great costs to the healthcare system, the inpatient treatment of alcohol withdrawal syndrome remains the ugly stepsister to more exciting topics, such as acute myocardial infarction, pulmonary embolism and procedures.7, 8 We hospitalists typically leave the clinical studies, research, and interest on substance abuse to addiction specialists and psychiatrists, perhaps due to our discomfort with these patients, negative attitudes, or belief that there is nothing new in the treatment of alcohol withdrawal syndrome since Dr Leo Henryk Sternbach discovered benzodiazepines in 1957.7, 9 Many of us just admit the alcoholic patient, check the alcohol‐pathway in our order entry system, and stop thinking about it.

But in this day of evidence‐based medicine and practice, what is the evidence behind the treatment of alcohol withdrawal, especially in relation to inpatient medicine? Shouldn't we hospitalists be thinking about this question? Hospitalists tend to see 2 types of inpatients with alcohol withdrawal: those solely admitted for withdrawal, and those admitted with active medical issues who then experience alcohol withdrawal. Is there a difference?

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM‐IV) defines early alcohol withdrawal as the first 48 hours where there is central nervous system (CNS) stimulation, adrenergic hyperactivity, and the risk of seizures. Late withdrawal, after 48 hours, includes delirium tremens (DTs) and Wernicke's encephalopathy.10 This is based on studies done in the 1950s, where researchers observed patients as they withdrew from alcohol and took notes.11, 12

The goal in treatment of alcohol withdrawal is to minimize symptoms and prevent seizures and DTs which, prior to benzodiazepines, had a mortality rate of 5% to 20%. Before the US Food and Drug Administration (FDA) approval of the first benzodiazepine in 1960 (chlordiazepoxide), physicians treated alcohol withdrawal with ethanol, antipsychotics, or paraldehyde.12 (That is why there is a P in the mnemonic MUDPILES for anion gap acidosis.) The first study to show a real benefit from benzodiazepine was published in 1969, when 537 men in a veterans detoxification unit were randomized to chlordiazepoxide (Librium), chlorpromazine (Thorazine), antihistamine, thiamine, or placebo.12 The primary outcome of DTs and seizures occurred in 10% to 16% of the patients, except for the chlordiazepoxide group where only 2% developed seizures and DTs (there was no P value calculated). Further studies published in the 1970s and early 1980s were too small to demonstrate a benefit. A 1997 meta‐analysis of all these studies, including the 1969 article,12 confirmed benzodiazepines statistically reduced seizures and DTs.13 Which benzodiazepine to use, however, is less clear. Long‐acting benzodiazepines with liver clearance (eg, chlordiazepoxide or diazepam) versus short‐acting with renal clearance (eg, oxazepam or lorazepam) is debated. While there are many strong opinions among clinicians, the same meta‐analysis did not find any difference between them, and a small 2009 study found no difference between a short‐acting and long‐acting benzodiazepine.13, 14

How much benzodiazepine to give and how frequently to dose it was looked at in 2 classic studies.15, 16 Both studies demonstrated that symptom‐triggered dosing of benzodiazepines, based on the Clinical Institute Withdrawal Assessment (CIWA) scale, performed equally well in terms of clinical outcomes, with less medication required as compared with fixed‐dose regimens. Based on these articles, many hospitals created alcohol pathways using solely symptom‐triggered dosing.

The CIWA scale is one of multiple rating scales in the assessment of alcohol withdrawal.17, 18 The CIWA‐Ar is a modified scale that was designed and validated for clinical use in inpatient detoxification centers, and excluded any active medical illness. It has gained popularity, though initial time for staff training and time for administration are limitations to its usefulness. Interestingly, vital signs, which many institutions use in their alcohol withdrawal pathways, were not strongly predictive in the CIWA study of severe withdrawal, seizures, or DTs.17

Finally, what about treatment when the patient does develop seizures or DTs? The evidence on how best to treat alcohol withdrawal seizures comes from a 1999 article which demonstrated a benefit of using lorazepam for recurrent seizures.19, 20 Unfortunately, the treatment for DTs is less clear. A 2004 meta‐analysis on the treatment of delirium tremens found benzodiazepines better than chlorpromazine (Thorazine), but benzodiazepines versus, or in addition to, newer antipsychotics have not been tested. The amount of benzodiazepine to give in DTs is only a Grade C (ie, expert opinion) recommendation: dose for light somnolence.21

All of these studies, however, come back to the basic question: Do they apply to the inpatients that hospitalists care for? A key factor to consider: All of the above‐mentioned studies, including the derivation and validation of the CIWA scale, were done in outpatient centers or inpatient detoxification centers. Patients with active medical illness or comorbidities were excluded. This data may be relevant for the patients admitted solely for alcohol withdrawal, but what about the 60 year old with diabetes, coronary artery disease, and chronic obstructive lung disease admitted for pneumonia who starts to withdraw; or the 72‐year‐old woman who breaks her hip and begins to withdraw on post‐op day 2?

There are 6 relatively recent studies that evaluate PRN (as needed) dosing of benzodiazepines on general medical inpatients.2227 While ideally these articles should apply to a hospitalist's patients, 2 of the studies excluded anyone with acute medical illness.24, 27 From the remaining 4, what do we learn? Weaver and colleagues did a randomized study on general medical patients and found less lorazepam was given with PRN versus fixed dosing.26 Unfortunately, the study was not blinded and there were statistically significant protocol errors. Comorbidity data was not given, leaving us to wonder to which inpatients this applies. Repper‐DeLisi et al. did a retrospective chart review, after implementing an alcohol pathway (not based on the CIWA scale), and did not find a statistical difference in dosing, length of stay, or delirium.25 Foy et al. looked at both medical and surgical patients, and dosed benzodiazepines based on an 18‐item CIWA scale which included vital signs.22 They found that the higher score did correlate with risk of developing severe alcohol withdrawal. However, the scale had limitations. Many patients with illness were at higher risk for severe alcohol withdrawal than their score indicated, and some high scores were believed, in part, due to illness. Jeager et al. did a pre‐comparison and post‐comparison of the implementation of a PRN CIWA protocol by chart review.23 They found a reduction in delirium in patients treated with PRN dosing, but no different in total benzodiazepine given. Because it was chart review, the authors acknowledge that defining delirium tremens was less reliable, and controlling for comorbidities was difficult. The difficult part of delirium in inpatients with alcohol abuse is that the delirium is not always just from DTs.

Two recent studies raised alarm about using a PRN CIWA pathway on patients.28, 29 A 2008 study found that 52% of patients were inappropriately put on a CIWA sliding scale when they either could not communicate or had not been recently drinking, or both.29 (The CIWA scale requires the person be able to answer symptom questions and is not applicable to non‐drinkers.) In 2005, during the implementation of an alcohol pathway at San Francisco General Hospital, an increase in mortality was noted with a PRN CIWA scale on inpatients.28

One of the conundrums for physicians is that whereas alcohol withdrawal has morbidity and mortality risks, benzodiazepine treatment itself has its own risks. Over sedation, respiratory depression, aspiration pneumonia, deconditioning from prolonged sedation, paradoxical agitation and disinhibition are the consequences of the dosing difficulties in alcohol withdrawal. Case reports on astronomical doses required to treat withdrawal (eg, 1600 mg of lorazepam in a day) raise questions of benzodiazepine resistance.30 Hence, multiple studies have been done to find alternatives for benzodiazepines. Our European counterparts lead the way in looking at: carbemazepine, gabapentin, gamma‐hydroxybuterate, corticotropin‐releasing hormone, baclofen, pregabalin, and phenobarbital. Again, the key issue for hospitalists: Are these benzodiazepine alternatives or additives applicable to our patients? These studies are done on outpatients with no concurrent medical illnesses. Yet, logic would suggest that it is the vulnerable hospitalized patients who might benefit the most from reducing the benzodiazepine amount using other agents.

In this issue of the Journal of Hospital Medicine, Lyon et al. provide a glimpse into possible ways to reduce the total benzodiazepine dose for general medical inpatients.31 They randomized inpatients withdrawing from alcohol to baclofen or placebo. Both groups still received PRN lorazepam based on their hospital's CIWA protocol. Prior outpatient studies have shown baclofen benefits patients undergoing alcohol withdrawal and the pathophysiology makes sense; baclofen acts on GABA b receptors. Lyon and collegaues' study results show significant reduction in the amount of benzodiazepine needed with no difference in CIWA scores.31

Is this a practice changer? Well, not yet. The numbers in the study are small and this is only 1 institution. These patients had only moderate alcohol withdrawal and the study was not powered to detect outcomes related to prevention of seizures and delirium tremens. However, the authors should be applauded for looking at alcohol withdrawal in medical inpatients.31 Trying to reduce the harm we cause with our benzodiazepine treatment regimens is a laudable goal. Inpatient alcohol withdrawal, especially for patients with medical comorbidities, is an area ripe for study and certainly deserves to have a spotlight shown on it.

Who better to do this than hospitalists? The Society of Hospital Medicine (SHM) core competency on Alcohol and Drug Withdrawal states, Hospitalists can lead their institutions in evidence based treatment protocols that improve care, reduce costs‐ and length of stay, and facilitate better overall outcomes in patients with substance related withdrawal syndromes.32 Hopefully, Lyon and collegaues' work will lead to the formation of multicenter hospitalist‐initiated studies to provide us with the best evidence for the treatment of inpatient alcohol withdrawal on our patients with comorbidities.31 Given the prevalence and potential severity of alcohol withdrawal in complex inpatients, isn't it time we really knew how to treat them?

With 17 million Americans reporting heavy drinking (5 or more drinks on 5 different occasions in the last month) and 1.7 million hospital discharges in 2006 containing at least 1 alcohol‐related diagnosis, it would be hard to imagine a hospitalist who does not encounter patients with alcohol abuse.1, 2 Estimates from studies looking at the number of risky drinkers among medical inpatients vary widely2% to 60%with more detailed studies suggesting 17% to 25% prevalence.36 Yet despite the large numbers and great costs to the healthcare system, the inpatient treatment of alcohol withdrawal syndrome remains the ugly stepsister to more exciting topics, such as acute myocardial infarction, pulmonary embolism and procedures.7, 8 We hospitalists typically leave the clinical studies, research, and interest on substance abuse to addiction specialists and psychiatrists, perhaps due to our discomfort with these patients, negative attitudes, or belief that there is nothing new in the treatment of alcohol withdrawal syndrome since Dr Leo Henryk Sternbach discovered benzodiazepines in 1957.7, 9 Many of us just admit the alcoholic patient, check the alcohol‐pathway in our order entry system, and stop thinking about it.

But in this day of evidence‐based medicine and practice, what is the evidence behind the treatment of alcohol withdrawal, especially in relation to inpatient medicine? Shouldn't we hospitalists be thinking about this question? Hospitalists tend to see 2 types of inpatients with alcohol withdrawal: those solely admitted for withdrawal, and those admitted with active medical issues who then experience alcohol withdrawal. Is there a difference?

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM‐IV) defines early alcohol withdrawal as the first 48 hours where there is central nervous system (CNS) stimulation, adrenergic hyperactivity, and the risk of seizures. Late withdrawal, after 48 hours, includes delirium tremens (DTs) and Wernicke's encephalopathy.10 This is based on studies done in the 1950s, where researchers observed patients as they withdrew from alcohol and took notes.11, 12

The goal in treatment of alcohol withdrawal is to minimize symptoms and prevent seizures and DTs which, prior to benzodiazepines, had a mortality rate of 5% to 20%. Before the US Food and Drug Administration (FDA) approval of the first benzodiazepine in 1960 (chlordiazepoxide), physicians treated alcohol withdrawal with ethanol, antipsychotics, or paraldehyde.12 (That is why there is a P in the mnemonic MUDPILES for anion gap acidosis.) The first study to show a real benefit from benzodiazepine was published in 1969, when 537 men in a veterans detoxification unit were randomized to chlordiazepoxide (Librium), chlorpromazine (Thorazine), antihistamine, thiamine, or placebo.12 The primary outcome of DTs and seizures occurred in 10% to 16% of the patients, except for the chlordiazepoxide group where only 2% developed seizures and DTs (there was no P value calculated). Further studies published in the 1970s and early 1980s were too small to demonstrate a benefit. A 1997 meta‐analysis of all these studies, including the 1969 article,12 confirmed benzodiazepines statistically reduced seizures and DTs.13 Which benzodiazepine to use, however, is less clear. Long‐acting benzodiazepines with liver clearance (eg, chlordiazepoxide or diazepam) versus short‐acting with renal clearance (eg, oxazepam or lorazepam) is debated. While there are many strong opinions among clinicians, the same meta‐analysis did not find any difference between them, and a small 2009 study found no difference between a short‐acting and long‐acting benzodiazepine.13, 14

How much benzodiazepine to give and how frequently to dose it was looked at in 2 classic studies.15, 16 Both studies demonstrated that symptom‐triggered dosing of benzodiazepines, based on the Clinical Institute Withdrawal Assessment (CIWA) scale, performed equally well in terms of clinical outcomes, with less medication required as compared with fixed‐dose regimens. Based on these articles, many hospitals created alcohol pathways using solely symptom‐triggered dosing.

The CIWA scale is one of multiple rating scales in the assessment of alcohol withdrawal.17, 18 The CIWA‐Ar is a modified scale that was designed and validated for clinical use in inpatient detoxification centers, and excluded any active medical illness. It has gained popularity, though initial time for staff training and time for administration are limitations to its usefulness. Interestingly, vital signs, which many institutions use in their alcohol withdrawal pathways, were not strongly predictive in the CIWA study of severe withdrawal, seizures, or DTs.17

Finally, what about treatment when the patient does develop seizures or DTs? The evidence on how best to treat alcohol withdrawal seizures comes from a 1999 article which demonstrated a benefit of using lorazepam for recurrent seizures.19, 20 Unfortunately, the treatment for DTs is less clear. A 2004 meta‐analysis on the treatment of delirium tremens found benzodiazepines better than chlorpromazine (Thorazine), but benzodiazepines versus, or in addition to, newer antipsychotics have not been tested. The amount of benzodiazepine to give in DTs is only a Grade C (ie, expert opinion) recommendation: dose for light somnolence.21

All of these studies, however, come back to the basic question: Do they apply to the inpatients that hospitalists care for? A key factor to consider: All of the above‐mentioned studies, including the derivation and validation of the CIWA scale, were done in outpatient centers or inpatient detoxification centers. Patients with active medical illness or comorbidities were excluded. This data may be relevant for the patients admitted solely for alcohol withdrawal, but what about the 60 year old with diabetes, coronary artery disease, and chronic obstructive lung disease admitted for pneumonia who starts to withdraw; or the 72‐year‐old woman who breaks her hip and begins to withdraw on post‐op day 2?

There are 6 relatively recent studies that evaluate PRN (as needed) dosing of benzodiazepines on general medical inpatients.2227 While ideally these articles should apply to a hospitalist's patients, 2 of the studies excluded anyone with acute medical illness.24, 27 From the remaining 4, what do we learn? Weaver and colleagues did a randomized study on general medical patients and found less lorazepam was given with PRN versus fixed dosing.26 Unfortunately, the study was not blinded and there were statistically significant protocol errors. Comorbidity data was not given, leaving us to wonder to which inpatients this applies. Repper‐DeLisi et al. did a retrospective chart review, after implementing an alcohol pathway (not based on the CIWA scale), and did not find a statistical difference in dosing, length of stay, or delirium.25 Foy et al. looked at both medical and surgical patients, and dosed benzodiazepines based on an 18‐item CIWA scale which included vital signs.22 They found that the higher score did correlate with risk of developing severe alcohol withdrawal. However, the scale had limitations. Many patients with illness were at higher risk for severe alcohol withdrawal than their score indicated, and some high scores were believed, in part, due to illness. Jeager et al. did a pre‐comparison and post‐comparison of the implementation of a PRN CIWA protocol by chart review.23 They found a reduction in delirium in patients treated with PRN dosing, but no different in total benzodiazepine given. Because it was chart review, the authors acknowledge that defining delirium tremens was less reliable, and controlling for comorbidities was difficult. The difficult part of delirium in inpatients with alcohol abuse is that the delirium is not always just from DTs.

Two recent studies raised alarm about using a PRN CIWA pathway on patients.28, 29 A 2008 study found that 52% of patients were inappropriately put on a CIWA sliding scale when they either could not communicate or had not been recently drinking, or both.29 (The CIWA scale requires the person be able to answer symptom questions and is not applicable to non‐drinkers.) In 2005, during the implementation of an alcohol pathway at San Francisco General Hospital, an increase in mortality was noted with a PRN CIWA scale on inpatients.28

One of the conundrums for physicians is that whereas alcohol withdrawal has morbidity and mortality risks, benzodiazepine treatment itself has its own risks. Over sedation, respiratory depression, aspiration pneumonia, deconditioning from prolonged sedation, paradoxical agitation and disinhibition are the consequences of the dosing difficulties in alcohol withdrawal. Case reports on astronomical doses required to treat withdrawal (eg, 1600 mg of lorazepam in a day) raise questions of benzodiazepine resistance.30 Hence, multiple studies have been done to find alternatives for benzodiazepines. Our European counterparts lead the way in looking at: carbemazepine, gabapentin, gamma‐hydroxybuterate, corticotropin‐releasing hormone, baclofen, pregabalin, and phenobarbital. Again, the key issue for hospitalists: Are these benzodiazepine alternatives or additives applicable to our patients? These studies are done on outpatients with no concurrent medical illnesses. Yet, logic would suggest that it is the vulnerable hospitalized patients who might benefit the most from reducing the benzodiazepine amount using other agents.

In this issue of the Journal of Hospital Medicine, Lyon et al. provide a glimpse into possible ways to reduce the total benzodiazepine dose for general medical inpatients.31 They randomized inpatients withdrawing from alcohol to baclofen or placebo. Both groups still received PRN lorazepam based on their hospital's CIWA protocol. Prior outpatient studies have shown baclofen benefits patients undergoing alcohol withdrawal and the pathophysiology makes sense; baclofen acts on GABA b receptors. Lyon and collegaues' study results show significant reduction in the amount of benzodiazepine needed with no difference in CIWA scores.31

Is this a practice changer? Well, not yet. The numbers in the study are small and this is only 1 institution. These patients had only moderate alcohol withdrawal and the study was not powered to detect outcomes related to prevention of seizures and delirium tremens. However, the authors should be applauded for looking at alcohol withdrawal in medical inpatients.31 Trying to reduce the harm we cause with our benzodiazepine treatment regimens is a laudable goal. Inpatient alcohol withdrawal, especially for patients with medical comorbidities, is an area ripe for study and certainly deserves to have a spotlight shown on it.

Who better to do this than hospitalists? The Society of Hospital Medicine (SHM) core competency on Alcohol and Drug Withdrawal states, Hospitalists can lead their institutions in evidence based treatment protocols that improve care, reduce costs‐ and length of stay, and facilitate better overall outcomes in patients with substance related withdrawal syndromes.32 Hopefully, Lyon and collegaues' work will lead to the formation of multicenter hospitalist‐initiated studies to provide us with the best evidence for the treatment of inpatient alcohol withdrawal on our patients with comorbidities.31 Given the prevalence and potential severity of alcohol withdrawal in complex inpatients, isn't it time we really knew how to treat them?

In the 15 years since Wachter and Goldman coined the term hospitalists, the specialty of Hospital Medicine grew faster than any other in the history of American medicine.1 The early drivers for growth were largely economic: There were significant reductions in resource use, with a 13% decrease in hospital costs and a 16% decrease in hospital lengths of stay (LOS).2 Hospitalist clinician‐educators increased the satisfaction of residents and medical students in academic settings.2 Patient satisfaction and hospital mortality did not suffer.2

Recent growth of Hospital Medicine revolves around 3 drivers: 1) improving quality and safety of hospitalized patientsowing in large part to the Institute of Medicine's 2 compelling reports, To Err Is Human3 and Crossing the Quality Chasm4; 2) hospitalist and specialist (surgeon) comanagement; and 3) the effects of duty hours restrictions imposed by the Accreditation Council for Graduate Medical Education affecting United States (US) teaching hospitals.5

In this issue of the Journal of Hospital Medicine, Shu and colleagues6 report on the performance of a hospitalist program in Taiwan. To the best of our knowledge, this report from Asia is the first published report of a successful hospitalist model with measurable patient outcomes outside of North America. Specifically, over a year, the authors found that patients admitted by hospitalists had a shorter LOS and lower cost per case, with no difference in in‐hospital mortality and 30‐day readmission. These results were obtained despite the fact that the cohort of patients admitted to the hospitalist team was older, sicker, and had worse functional capacity. Additionally, the patients admitted to the hospitalist team, and who died during hospitalization, were more likely to have a do‐not‐resuscitate (DNR) order signed, when compared with those patients admitted to the general internal medicine teaching service. Comparing LOS with North America may be problematic. As Shu and colleagues6 point out, there are cultural and economic issues that affect the behavior of patients and physicians in Taiwan.

The healthcare system in Taiwan has similarities to the healthcare systems in the United Kingdom (UK) and the US. In 1995, Taiwan implemented a national health insurance system. The UK has had a National Health Service for many years that provides most services for free. The Taiwanese system requires modest copayments for services. The implementation of the national health insurance system in Taiwan increased healthcare access from 57% of the population to 98%.7 The increase in insurance across the population with modest copayments has made it possible for a larger percentage of the population to access the healthcare system.7 According to the authors, this has resulted in increased hospital admissions (35% in the decade since the introduction of national health insurance), resulting in a shortage of Hospital Medicine physicians and hospital beds.7 Compounding the stressors on this system is that the diagnosis related group (DRG) reimbursement model, similar to the American DRG reimbursement model, will soon take effect in Taiwan. As a result, our colleagues in Taiwan are experiencing issues commonly faced by mature hospitalist programs in the US: increased needs in efficiency to improve patient flow and decrease emergency room overcrowding and LOS; and concerns with safe discharges of high‐risk patients while ensuring outpatient follow‐up. This is a scenario with which US hospitalists are all too familiar.

The next step for Taiwan might be to implement a culturally specific patient education program regarding the discharge process. The first step would be a needs assessment survey of patients in Taiwan, inquiring about concerns regarding readiness for discharge. They might inquire about patient beliefs regarding understanding indications for inpatient hospitalization versus discharge to home, home with home services, or skilled nursing facilities. They might be able to drill down to the root cause of refusal to be discharged home. These data could help our colleagues in Taiwan create their own discharge program to drive down LOS closer to that of the US and other Western countries, in order to reap financial benefits and improve resource utilization.

What do we know about the growth of Hospital Medicine around the world? The Society of Hospital Medicine (SHM) reports international members from 26 countries around the world. In North America, SHM members are found in the US, Canada, and Bermuda. In Europe, SHM members are found in England, Ireland, Scotland, Spain, Belgium, Portugal, Italy, and Germany. In South America, SHM members are found in Brazil, Chile, Colombia, and Argentina. In Asia and the Middle East, SHM has members in Saudi Arabia, Israel, United Arab Emirates, Pakistan, Japan, China, the Philippines, and Singapore. In Oceania, SHM has members in Australia, and New Zealand. In Africa, 1 SHM member is from Nigeria (Society of Hospital Medicine Data, 2011). In fact, the International Hospitalists Section of SHM is 1 of only 2 sections that the Society recognizes.

Hospitalists are organizing themselves abroad as well. In Canada, the Canadian Society of Hospital Medicine was founded in 2001 and has had 8 national conferences to date.8 There are roughly 1,000 Canadian hospitalists (Wilton D, personal communication, 2011). Whereas most US hospitalists are internists or pediatricians, in Canada, most hospitalists are family physicians. In the US, hospitalists are more likely to perform the following services: consultation, intensive care unit patient care, rapid response team service, surgical comanagement, and evening on‐site coverage. Canadian hospitalists are more likely to provide pediatric care and psychiatry inpatient comanagement.9

In the UK, the professional organization of physicians most similar to US hospitalists, acute physicians, is called SAM (The Society for Acute Medicine). It was founded in 2000.10 In the UK, general practitioners (GPs) never care for inpatients; at the time, GPs referred all admissions to organ‐specific specialists (eg, cardiologists). Acute medicine was created due to the realization that medical inpatients were too complex to have specialists managing them. Training programs were set up circa 2003 to create this specialty and address this need. Acute physicians staff geographically localized acute medicine units near emergency departments. These patients stay 1 to 3 days in an effort to concentrate services and resources to these patients, to prevent longer stays once fully admitted (Smith R, personal communication, April 23, 2011). Acute medicine units in the UK, Ireland, and Australia have led to positive benefits on patient outcomes. A review article by Scott and colleagues revealed reductions in LOS, inpatient mortality, and emergency department LOS, without increased 30‐day readmission rates. They found increased staff and patient satisfaction, and more medical patients discharged directly to home from acute medical units.11 The development of acute medicine in Australia and New Zealand began around 2005 and derives from the geographic localization of the UK model. Whereas the UK model has a focus on the first 72 hours of hospitalization, the model in Australia and New Zealand is more similar to the US model of following patients through their entire admission.12 Unlike the UK, Australia does not have dedicated acute medicine training programs.

PASHA, the Pan‐American Society of Hospitalists, is a loose affiliation of hospitalists largely in South America, linking with their North American colleagues. PASHA grew out of SOBRAMH, Sociedade Brasileira de Medicina Hospitalarthe first Hospital Medicine Society in South America, tracing its roots to 2004. To date, PASHA has had 1 international conference, but there have been 2 national conferences each in Brazil and Chile, and 1 in Colombia. The concept and advantages of Hospital Medicine have been presented at a conference in Panama. Argentina has its first Hospital Medicine Congress scheduled for September 2011, in concert with PASHA.

Two Hospital Medicine programs abroad deserve special mention. Both started in 2005 and have instituted the full hospitalist package, including multiple evidence‐based order sets at both sites (eg, deep vein thrombosis [DVT] prophylaxis and hyperglycemia management). At the Pontificia Universidad Catlica in Santiago, Chile, they have been awarded national grants to study hyperglycemia in hospitalized patients, and they have sent their faculty to the US for additional training in patient safety, quality improvement, leadership, and medical informatics. They have succeeded in decreasing LOS and improved the exam grades of their learners. Their faculty has published in national journals and is now beginning to submit their work for publication in US‐based journals (Rojas L, personal communication, April 22, 2011). The Clnica Universidad de Navarra (CUN) in Pamplona, Spain is a Joint Commission certified facility with a full electronic medical record. Hospitalists there are looking at ways in which hospitalist‐staffed intermediate care units can benefit patient outcomes. Additionally, they have comanagement arrangements with nearly all surgical subspecialties. The Management of the Hospitalized Patient symposium was organized by CUN hospitalists in 2007the first Hospital Medicine Congress, to our knowledge, in continental Europe. At any one time, 30% of all residents in all specialties rotate with CUN hospitalists (Lucena F, personal communication, April 22, 2011).

The specialty of Hospital Medicine is truly global. Our colleagues around the world employing the hospitalist model of care are now producing outcomes similar to the published models in North America and to the acute medicine models in Europe and Australia. According to the Society of Hospital Medicine, there are over 30,000 hospitalists in the US. There could be well over 50,000 hospitalists around the world. In 5 years, the world may have 100,000 hospitalists. The same drivers are fueling the growth of Hospital Medicine around the world. The evidence is building that the hospitalist model of care has financial and quality benefits that transcend borders. We forecast that the hospitalist model of care will become an increasingly larger part of the solution around the world to fix these international healthcare systems.

In the 15 years since Wachter and Goldman coined the term hospitalists, the specialty of Hospital Medicine grew faster than any other in the history of American medicine.1 The early drivers for growth were largely economic: There were significant reductions in resource use, with a 13% decrease in hospital costs and a 16% decrease in hospital lengths of stay (LOS).2 Hospitalist clinician‐educators increased the satisfaction of residents and medical students in academic settings.2 Patient satisfaction and hospital mortality did not suffer.2

Recent growth of Hospital Medicine revolves around 3 drivers: 1) improving quality and safety of hospitalized patientsowing in large part to the Institute of Medicine's 2 compelling reports, To Err Is Human3 and Crossing the Quality Chasm4; 2) hospitalist and specialist (surgeon) comanagement; and 3) the effects of duty hours restrictions imposed by the Accreditation Council for Graduate Medical Education affecting United States (US) teaching hospitals.5

In this issue of the Journal of Hospital Medicine, Shu and colleagues6 report on the performance of a hospitalist program in Taiwan. To the best of our knowledge, this report from Asia is the first published report of a successful hospitalist model with measurable patient outcomes outside of North America. Specifically, over a year, the authors found that patients admitted by hospitalists had a shorter LOS and lower cost per case, with no difference in in‐hospital mortality and 30‐day readmission. These results were obtained despite the fact that the cohort of patients admitted to the hospitalist team was older, sicker, and had worse functional capacity. Additionally, the patients admitted to the hospitalist team, and who died during hospitalization, were more likely to have a do‐not‐resuscitate (DNR) order signed, when compared with those patients admitted to the general internal medicine teaching service. Comparing LOS with North America may be problematic. As Shu and colleagues6 point out, there are cultural and economic issues that affect the behavior of patients and physicians in Taiwan.

The healthcare system in Taiwan has similarities to the healthcare systems in the United Kingdom (UK) and the US. In 1995, Taiwan implemented a national health insurance system. The UK has had a National Health Service for many years that provides most services for free. The Taiwanese system requires modest copayments for services. The implementation of the national health insurance system in Taiwan increased healthcare access from 57% of the population to 98%.7 The increase in insurance across the population with modest copayments has made it possible for a larger percentage of the population to access the healthcare system.7 According to the authors, this has resulted in increased hospital admissions (35% in the decade since the introduction of national health insurance), resulting in a shortage of Hospital Medicine physicians and hospital beds.7 Compounding the stressors on this system is that the diagnosis related group (DRG) reimbursement model, similar to the American DRG reimbursement model, will soon take effect in Taiwan. As a result, our colleagues in Taiwan are experiencing issues commonly faced by mature hospitalist programs in the US: increased needs in efficiency to improve patient flow and decrease emergency room overcrowding and LOS; and concerns with safe discharges of high‐risk patients while ensuring outpatient follow‐up. This is a scenario with which US hospitalists are all too familiar.

The next step for Taiwan might be to implement a culturally specific patient education program regarding the discharge process. The first step would be a needs assessment survey of patients in Taiwan, inquiring about concerns regarding readiness for discharge. They might inquire about patient beliefs regarding understanding indications for inpatient hospitalization versus discharge to home, home with home services, or skilled nursing facilities. They might be able to drill down to the root cause of refusal to be discharged home. These data could help our colleagues in Taiwan create their own discharge program to drive down LOS closer to that of the US and other Western countries, in order to reap financial benefits and improve resource utilization.

What do we know about the growth of Hospital Medicine around the world? The Society of Hospital Medicine (SHM) reports international members from 26 countries around the world. In North America, SHM members are found in the US, Canada, and Bermuda. In Europe, SHM members are found in England, Ireland, Scotland, Spain, Belgium, Portugal, Italy, and Germany. In South America, SHM members are found in Brazil, Chile, Colombia, and Argentina. In Asia and the Middle East, SHM has members in Saudi Arabia, Israel, United Arab Emirates, Pakistan, Japan, China, the Philippines, and Singapore. In Oceania, SHM has members in Australia, and New Zealand. In Africa, 1 SHM member is from Nigeria (Society of Hospital Medicine Data, 2011). In fact, the International Hospitalists Section of SHM is 1 of only 2 sections that the Society recognizes.

Hospitalists are organizing themselves abroad as well. In Canada, the Canadian Society of Hospital Medicine was founded in 2001 and has had 8 national conferences to date.8 There are roughly 1,000 Canadian hospitalists (Wilton D, personal communication, 2011). Whereas most US hospitalists are internists or pediatricians, in Canada, most hospitalists are family physicians. In the US, hospitalists are more likely to perform the following services: consultation, intensive care unit patient care, rapid response team service, surgical comanagement, and evening on‐site coverage. Canadian hospitalists are more likely to provide pediatric care and psychiatry inpatient comanagement.9

In the UK, the professional organization of physicians most similar to US hospitalists, acute physicians, is called SAM (The Society for Acute Medicine). It was founded in 2000.10 In the UK, general practitioners (GPs) never care for inpatients; at the time, GPs referred all admissions to organ‐specific specialists (eg, cardiologists). Acute medicine was created due to the realization that medical inpatients were too complex to have specialists managing them. Training programs were set up circa 2003 to create this specialty and address this need. Acute physicians staff geographically localized acute medicine units near emergency departments. These patients stay 1 to 3 days in an effort to concentrate services and resources to these patients, to prevent longer stays once fully admitted (Smith R, personal communication, April 23, 2011). Acute medicine units in the UK, Ireland, and Australia have led to positive benefits on patient outcomes. A review article by Scott and colleagues revealed reductions in LOS, inpatient mortality, and emergency department LOS, without increased 30‐day readmission rates. They found increased staff and patient satisfaction, and more medical patients discharged directly to home from acute medical units.11 The development of acute medicine in Australia and New Zealand began around 2005 and derives from the geographic localization of the UK model. Whereas the UK model has a focus on the first 72 hours of hospitalization, the model in Australia and New Zealand is more similar to the US model of following patients through their entire admission.12 Unlike the UK, Australia does not have dedicated acute medicine training programs.

PASHA, the Pan‐American Society of Hospitalists, is a loose affiliation of hospitalists largely in South America, linking with their North American colleagues. PASHA grew out of SOBRAMH, Sociedade Brasileira de Medicina Hospitalarthe first Hospital Medicine Society in South America, tracing its roots to 2004. To date, PASHA has had 1 international conference, but there have been 2 national conferences each in Brazil and Chile, and 1 in Colombia. The concept and advantages of Hospital Medicine have been presented at a conference in Panama. Argentina has its first Hospital Medicine Congress scheduled for September 2011, in concert with PASHA.

Two Hospital Medicine programs abroad deserve special mention. Both started in 2005 and have instituted the full hospitalist package, including multiple evidence‐based order sets at both sites (eg, deep vein thrombosis [DVT] prophylaxis and hyperglycemia management). At the Pontificia Universidad Catlica in Santiago, Chile, they have been awarded national grants to study hyperglycemia in hospitalized patients, and they have sent their faculty to the US for additional training in patient safety, quality improvement, leadership, and medical informatics. They have succeeded in decreasing LOS and improved the exam grades of their learners. Their faculty has published in national journals and is now beginning to submit their work for publication in US‐based journals (Rojas L, personal communication, April 22, 2011). The Clnica Universidad de Navarra (CUN) in Pamplona, Spain is a Joint Commission certified facility with a full electronic medical record. Hospitalists there are looking at ways in which hospitalist‐staffed intermediate care units can benefit patient outcomes. Additionally, they have comanagement arrangements with nearly all surgical subspecialties. The Management of the Hospitalized Patient symposium was organized by CUN hospitalists in 2007the first Hospital Medicine Congress, to our knowledge, in continental Europe. At any one time, 30% of all residents in all specialties rotate with CUN hospitalists (Lucena F, personal communication, April 22, 2011).

The specialty of Hospital Medicine is truly global. Our colleagues around the world employing the hospitalist model of care are now producing outcomes similar to the published models in North America and to the acute medicine models in Europe and Australia. According to the Society of Hospital Medicine, there are over 30,000 hospitalists in the US. There could be well over 50,000 hospitalists around the world. In 5 years, the world may have 100,000 hospitalists. The same drivers are fueling the growth of Hospital Medicine around the world. The evidence is building that the hospitalist model of care has financial and quality benefits that transcend borders. We forecast that the hospitalist model of care will become an increasingly larger part of the solution around the world to fix these international healthcare systems.

In the 15 years since Wachter and Goldman coined the term hospitalists, the specialty of Hospital Medicine grew faster than any other in the history of American medicine.1 The early drivers for growth were largely economic: There were significant reductions in resource use, with a 13% decrease in hospital costs and a 16% decrease in hospital lengths of stay (LOS).2 Hospitalist clinician‐educators increased the satisfaction of residents and medical students in academic settings.2 Patient satisfaction and hospital mortality did not suffer.2

Recent growth of Hospital Medicine revolves around 3 drivers: 1) improving quality and safety of hospitalized patientsowing in large part to the Institute of Medicine's 2 compelling reports, To Err Is Human3 and Crossing the Quality Chasm4; 2) hospitalist and specialist (surgeon) comanagement; and 3) the effects of duty hours restrictions imposed by the Accreditation Council for Graduate Medical Education affecting United States (US) teaching hospitals.5

In this issue of the Journal of Hospital Medicine, Shu and colleagues6 report on the performance of a hospitalist program in Taiwan. To the best of our knowledge, this report from Asia is the first published report of a successful hospitalist model with measurable patient outcomes outside of North America. Specifically, over a year, the authors found that patients admitted by hospitalists had a shorter LOS and lower cost per case, with no difference in in‐hospital mortality and 30‐day readmission. These results were obtained despite the fact that the cohort of patients admitted to the hospitalist team was older, sicker, and had worse functional capacity. Additionally, the patients admitted to the hospitalist team, and who died during hospitalization, were more likely to have a do‐not‐resuscitate (DNR) order signed, when compared with those patients admitted to the general internal medicine teaching service. Comparing LOS with North America may be problematic. As Shu and colleagues6 point out, there are cultural and economic issues that affect the behavior of patients and physicians in Taiwan.

The healthcare system in Taiwan has similarities to the healthcare systems in the United Kingdom (UK) and the US. In 1995, Taiwan implemented a national health insurance system. The UK has had a National Health Service for many years that provides most services for free. The Taiwanese system requires modest copayments for services. The implementation of the national health insurance system in Taiwan increased healthcare access from 57% of the population to 98%.7 The increase in insurance across the population with modest copayments has made it possible for a larger percentage of the population to access the healthcare system.7 According to the authors, this has resulted in increased hospital admissions (35% in the decade since the introduction of national health insurance), resulting in a shortage of Hospital Medicine physicians and hospital beds.7 Compounding the stressors on this system is that the diagnosis related group (DRG) reimbursement model, similar to the American DRG reimbursement model, will soon take effect in Taiwan. As a result, our colleagues in Taiwan are experiencing issues commonly faced by mature hospitalist programs in the US: increased needs in efficiency to improve patient flow and decrease emergency room overcrowding and LOS; and concerns with safe discharges of high‐risk patients while ensuring outpatient follow‐up. This is a scenario with which US hospitalists are all too familiar.

The next step for Taiwan might be to implement a culturally specific patient education program regarding the discharge process. The first step would be a needs assessment survey of patients in Taiwan, inquiring about concerns regarding readiness for discharge. They might inquire about patient beliefs regarding understanding indications for inpatient hospitalization versus discharge to home, home with home services, or skilled nursing facilities. They might be able to drill down to the root cause of refusal to be discharged home. These data could help our colleagues in Taiwan create their own discharge program to drive down LOS closer to that of the US and other Western countries, in order to reap financial benefits and improve resource utilization.

What do we know about the growth of Hospital Medicine around the world? The Society of Hospital Medicine (SHM) reports international members from 26 countries around the world. In North America, SHM members are found in the US, Canada, and Bermuda. In Europe, SHM members are found in England, Ireland, Scotland, Spain, Belgium, Portugal, Italy, and Germany. In South America, SHM members are found in Brazil, Chile, Colombia, and Argentina. In Asia and the Middle East, SHM has members in Saudi Arabia, Israel, United Arab Emirates, Pakistan, Japan, China, the Philippines, and Singapore. In Oceania, SHM has members in Australia, and New Zealand. In Africa, 1 SHM member is from Nigeria (Society of Hospital Medicine Data, 2011). In fact, the International Hospitalists Section of SHM is 1 of only 2 sections that the Society recognizes.

Hospitalists are organizing themselves abroad as well. In Canada, the Canadian Society of Hospital Medicine was founded in 2001 and has had 8 national conferences to date.8 There are roughly 1,000 Canadian hospitalists (Wilton D, personal communication, 2011). Whereas most US hospitalists are internists or pediatricians, in Canada, most hospitalists are family physicians. In the US, hospitalists are more likely to perform the following services: consultation, intensive care unit patient care, rapid response team service, surgical comanagement, and evening on‐site coverage. Canadian hospitalists are more likely to provide pediatric care and psychiatry inpatient comanagement.9

In the UK, the professional organization of physicians most similar to US hospitalists, acute physicians, is called SAM (The Society for Acute Medicine). It was founded in 2000.10 In the UK, general practitioners (GPs) never care for inpatients; at the time, GPs referred all admissions to organ‐specific specialists (eg, cardiologists). Acute medicine was created due to the realization that medical inpatients were too complex to have specialists managing them. Training programs were set up circa 2003 to create this specialty and address this need. Acute physicians staff geographically localized acute medicine units near emergency departments. These patients stay 1 to 3 days in an effort to concentrate services and resources to these patients, to prevent longer stays once fully admitted (Smith R, personal communication, April 23, 2011). Acute medicine units in the UK, Ireland, and Australia have led to positive benefits on patient outcomes. A review article by Scott and colleagues revealed reductions in LOS, inpatient mortality, and emergency department LOS, without increased 30‐day readmission rates. They found increased staff and patient satisfaction, and more medical patients discharged directly to home from acute medical units.11 The development of acute medicine in Australia and New Zealand began around 2005 and derives from the geographic localization of the UK model. Whereas the UK model has a focus on the first 72 hours of hospitalization, the model in Australia and New Zealand is more similar to the US model of following patients through their entire admission.12 Unlike the UK, Australia does not have dedicated acute medicine training programs.

PASHA, the Pan‐American Society of Hospitalists, is a loose affiliation of hospitalists largely in South America, linking with their North American colleagues. PASHA grew out of SOBRAMH, Sociedade Brasileira de Medicina Hospitalarthe first Hospital Medicine Society in South America, tracing its roots to 2004. To date, PASHA has had 1 international conference, but there have been 2 national conferences each in Brazil and Chile, and 1 in Colombia. The concept and advantages of Hospital Medicine have been presented at a conference in Panama. Argentina has its first Hospital Medicine Congress scheduled for September 2011, in concert with PASHA.

Two Hospital Medicine programs abroad deserve special mention. Both started in 2005 and have instituted the full hospitalist package, including multiple evidence‐based order sets at both sites (eg, deep vein thrombosis [DVT] prophylaxis and hyperglycemia management). At the Pontificia Universidad Catlica in Santiago, Chile, they have been awarded national grants to study hyperglycemia in hospitalized patients, and they have sent their faculty to the US for additional training in patient safety, quality improvement, leadership, and medical informatics. They have succeeded in decreasing LOS and improved the exam grades of their learners. Their faculty has published in national journals and is now beginning to submit their work for publication in US‐based journals (Rojas L, personal communication, April 22, 2011). The Clnica Universidad de Navarra (CUN) in Pamplona, Spain is a Joint Commission certified facility with a full electronic medical record. Hospitalists there are looking at ways in which hospitalist‐staffed intermediate care units can benefit patient outcomes. Additionally, they have comanagement arrangements with nearly all surgical subspecialties. The Management of the Hospitalized Patient symposium was organized by CUN hospitalists in 2007the first Hospital Medicine Congress, to our knowledge, in continental Europe. At any one time, 30% of all residents in all specialties rotate with CUN hospitalists (Lucena F, personal communication, April 22, 2011).

The specialty of Hospital Medicine is truly global. Our colleagues around the world employing the hospitalist model of care are now producing outcomes similar to the published models in North America and to the acute medicine models in Europe and Australia. According to the Society of Hospital Medicine, there are over 30,000 hospitalists in the US. There could be well over 50,000 hospitalists around the world. In 5 years, the world may have 100,000 hospitalists. The same drivers are fueling the growth of Hospital Medicine around the world. The evidence is building that the hospitalist model of care has financial and quality benefits that transcend borders. We forecast that the hospitalist model of care will become an increasingly larger part of the solution around the world to fix these international healthcare systems.

In personal terms, all Americans are connected by recollections of the experience. 97% can remember exactly where they were or what they were doing the moment they heard about the attacks. (Pew Research survey, September 5, 2002)

The classic flashbulb memories of our parents' generation, who were young adults in the 1960s, were the assassinations of Martin Luther King and President John Kennedy. In the same way, the 9/11 attacks seem destined to endure as our generation's flashbulb memory, with the Space Shuttle Challenger explosion a distant second for those of us on the far side of age 40. Few of us are likely to ever forget the grief, anger, and confusion of September 11, 2001 and the days that followed, and it seems appropriate 10 years later to remember those who died that day, and to reflect on the lessons we learnedor should have. As hospitalists, we are at least somewhat familiar with the tragic and senseless loss of life that day, as the terrorist attacks were in a sense a reflection, writ large, of the unexpected and inexplicable deaths we have all been a part of: the healthy young woman exsanguinating from DIC in the immediate postpartum period, the preschool teacher rapidly succumbing to pneumococcal meningitis, the young adult dying of acute leukemia or necrotizing fasciitis.

On September 11, 2001, one of us (B.J.H.) was 2 years out of residency and in private practice near San Francisco.

For the other of us (J.C.P.), the news came in a patient's room during rounds.

What lessons should we take away from the 9/11 tragedy a decade later, and indeed from our work with our patients? Certainly that mass casualties and disaster preparedness are an unfortunate fact of life in the 21st century, and that hospitalists have a responsibility to engage with our institutions in preparing for these eventualities. Possibly that life is uncertain and, at best, goes by much more quickly than any of us could have imagined when we embarked on our medical training. In the end, that our lives are measured primarily not by the number of years we live, but by how we live them, and the lives that we touch along the way.

Once a year, we pause to remember the nearly 3000 individuals who lost their lives on 9/11. As hospitalists, we practice a profession that demands a great deal from us and encourages workaholism; perhaps the 10th anniversary of those heinous acts should make each of us, as we remember the lives touched most directly by the attacks on the World Trade Center, the Pentagon, and United Flight 93, also pause to consider our work‐life balance, and to ensure that we are reserving sufficient quality time for our families and friends, as well as for activities that renew and enrich us.

In personal terms, all Americans are connected by recollections of the experience. 97% can remember exactly where they were or what they were doing the moment they heard about the attacks. (Pew Research survey, September 5, 2002)

The classic flashbulb memories of our parents' generation, who were young adults in the 1960s, were the assassinations of Martin Luther King and President John Kennedy. In the same way, the 9/11 attacks seem destined to endure as our generation's flashbulb memory, with the Space Shuttle Challenger explosion a distant second for those of us on the far side of age 40. Few of us are likely to ever forget the grief, anger, and confusion of September 11, 2001 and the days that followed, and it seems appropriate 10 years later to remember those who died that day, and to reflect on the lessons we learnedor should have. As hospitalists, we are at least somewhat familiar with the tragic and senseless loss of life that day, as the terrorist attacks were in a sense a reflection, writ large, of the unexpected and inexplicable deaths we have all been a part of: the healthy young woman exsanguinating from DIC in the immediate postpartum period, the preschool teacher rapidly succumbing to pneumococcal meningitis, the young adult dying of acute leukemia or necrotizing fasciitis.

On September 11, 2001, one of us (B.J.H.) was 2 years out of residency and in private practice near San Francisco.

For the other of us (J.C.P.), the news came in a patient's room during rounds.

What lessons should we take away from the 9/11 tragedy a decade later, and indeed from our work with our patients? Certainly that mass casualties and disaster preparedness are an unfortunate fact of life in the 21st century, and that hospitalists have a responsibility to engage with our institutions in preparing for these eventualities. Possibly that life is uncertain and, at best, goes by much more quickly than any of us could have imagined when we embarked on our medical training. In the end, that our lives are measured primarily not by the number of years we live, but by how we live them, and the lives that we touch along the way.

Once a year, we pause to remember the nearly 3000 individuals who lost their lives on 9/11. As hospitalists, we practice a profession that demands a great deal from us and encourages workaholism; perhaps the 10th anniversary of those heinous acts should make each of us, as we remember the lives touched most directly by the attacks on the World Trade Center, the Pentagon, and United Flight 93, also pause to consider our work‐life balance, and to ensure that we are reserving sufficient quality time for our families and friends, as well as for activities that renew and enrich us.

In personal terms, all Americans are connected by recollections of the experience. 97% can remember exactly where they were or what they were doing the moment they heard about the attacks. (Pew Research survey, September 5, 2002)

The classic flashbulb memories of our parents' generation, who were young adults in the 1960s, were the assassinations of Martin Luther King and President John Kennedy. In the same way, the 9/11 attacks seem destined to endure as our generation's flashbulb memory, with the Space Shuttle Challenger explosion a distant second for those of us on the far side of age 40. Few of us are likely to ever forget the grief, anger, and confusion of September 11, 2001 and the days that followed, and it seems appropriate 10 years later to remember those who died that day, and to reflect on the lessons we learnedor should have. As hospitalists, we are at least somewhat familiar with the tragic and senseless loss of life that day, as the terrorist attacks were in a sense a reflection, writ large, of the unexpected and inexplicable deaths we have all been a part of: the healthy young woman exsanguinating from DIC in the immediate postpartum period, the preschool teacher rapidly succumbing to pneumococcal meningitis, the young adult dying of acute leukemia or necrotizing fasciitis.

On September 11, 2001, one of us (B.J.H.) was 2 years out of residency and in private practice near San Francisco.

For the other of us (J.C.P.), the news came in a patient's room during rounds.

What lessons should we take away from the 9/11 tragedy a decade later, and indeed from our work with our patients? Certainly that mass casualties and disaster preparedness are an unfortunate fact of life in the 21st century, and that hospitalists have a responsibility to engage with our institutions in preparing for these eventualities. Possibly that life is uncertain and, at best, goes by much more quickly than any of us could have imagined when we embarked on our medical training. In the end, that our lives are measured primarily not by the number of years we live, but by how we live them, and the lives that we touch along the way.

Once a year, we pause to remember the nearly 3000 individuals who lost their lives on 9/11. As hospitalists, we practice a profession that demands a great deal from us and encourages workaholism; perhaps the 10th anniversary of those heinous acts should make each of us, as we remember the lives touched most directly by the attacks on the World Trade Center, the Pentagon, and United Flight 93, also pause to consider our work‐life balance, and to ensure that we are reserving sufficient quality time for our families and friends, as well as for activities that renew and enrich us.

In November 2010, the National Heart, Lung, and Blood Institute celebrated the 100th year anniversary of the discovery of sickle cell disease (SCD) in the United States by hosting the Herrick Symposium. Despite progress in the past 100 years, there is just one treatment available (hydroxyurea) and, while SCD is no longer considered only a disease of children, patients' life spans remain severely shortened (42 and 48 years, respectively, for males and females).1 With restrictions in residency hours and hospitals efforts to contain costs, hospitalists are increasingly being called upon to manage inpatient care for adults with SCD during their hospitalization. With the Centers for Medicare and Medicaid Services' recent plans to penalize hospitals with 30‐day readmission rates in excess of expected, hospitalists should address the challenges they face in providing care to adults with SCD and identify strategies to successfully meet them.

In this issue of the Journal of Hospital Medicine, Carroll and colleagues examined data from the California State Inpatient Database provided by the Healthcare Cost and Utilization Project (HCUP) for persons with International Classification of Diseases, Ninth Revision (ICD‐9) codes for SCD.2 They characterized patterns of hospital use during a 4‐year study period. Records for all patients, age 13 and older, with an admission for an SCD ICD‐9related cause were included. Patients with 4 or more hospitalizations in a 12‐month period were classified as having high hospital utilization, and 25% of the 1879 different patients evaluated fell into this category. A general perception exists that most persons with SCD have high hospital utilization, but data from Carroll et al. challenge this perception.2

While 1 in 4 patients in the cohort had high hospital utilization, why were not even more able to stay out of the hospital? Characteristics of these high utilizers shed light on contributing factors. Many patients died in the hospital (6.6%), consistent with research by others who also demonstrated the high risk of death associated with rehospitalization among patients with SCD.3, 4 In a prospective cohort study of 71 adults with either 70 hospital days or 6 admissions in a 12‐month period, 15% of the cohort died within a 24‐month study period.3 Patients with the highest number of hospital days, and those suffering from depression, were at highest risk of death. A separate prospective, longitudinal, 4‐year cohort study of adults with sickle cell anemia found an overall mortality of 14%.4 Mortality for those readmitted within 1 week of a painful crisis was 20%, compared to 11% for others in the cohort. High hospitalization use and hospital readmissions should be seen as worrisome markers of high risk for death, and patients should be carefully evaluated for life‐threatening complications, and not assumed to be purely drug seeking.

Why do some patients with SCD experience high readmission rates and mortality? Such patients with frequent hospitalizations have been found, in fact, to be sicker, and Carroll's research confirms that high utilizers were more likely to have comorbidities (acute chest syndrome, aseptic necrosis, renal disease) and complications (sepsis, pneumonia, pulmonary embolus, diabetes, mood disorders, and cocaine and alcohol use).2 Fortunately, high utilization appears to moderate over time for most patients, but those with persistent high utilization were more likely to have sepsis and mood disorders. Aisiku and colleagues studied a cohort of adults with SCD, in Virginia, in which emergency department (ED) utilization provided additional evidence for the association of high utilization with worse outcomes.5 Patients with 3 or more ED visits in 1 year were found to have lower hematocrits and higher white blood cell counts, to require more blood transfusions, and to report more pain, more pain days, more pain crises, and a worse quality of life. It is clear that patients with high hospital utilization are sicker and at an increased risk of death. While enlightening, this data does not tell the entire story.

Most admissions for patients with SCD begin with a vaso‐occlusive crisis, and frequently other complications may develop. Smith et al. provided the first prospectively collected data documenting that these patients reported pain on more than 54% of days, and many experience pain daily, yet infrequently access healthcare services.6 Hospitalists should appreciate that chronic pain is common for many adults with SCD. Pain management in this patient population is complex and often challenging, requiring high doses of opioids. In this current issue of the Journal, Smith and colleagues have contributed an excellent overview of how to manage pain in adults with SCD.7 The review specifically addresses some of the most challenging aspects of pain management in the hospital setting. Unfortunately, healthcare providers too frequently perceive patients as addicted to narcotics and abusing them, despite clear evidence that patients with SCD suffer from chronic pain. The consequent crisis of trust between the patient and provider commonly leads to inadequate treatment of pain and subsequent self‐discharge. Haywood and colleagues compared trust levels in adults with SCD and a history of sudden self‐discharge (ie, leaving against medical advice [AMA]) to those without such a history.8 Patients with a history of self‐discharge reported lower levels of trust of the medical staff and more negative interpersonal experiences. In a separate investigation, researchers compared scores on the Picker Patient Experience Questionnaire between a cohort of adults with SCD and national norms.9 Patients with SCD scored lower on 9 of 12 items. More specifically, 86% of respondents reported having insufficient involvement in decisions about care and treatment, and 50% reported staff did not do enough to control pain. Sadly, it appears the health system overall has undertreated and mismanaged patients with SCD suffering from pain crises.

Hospitalists face many challenges when managing care for adults with such a complex disease associated with high mortality, severe pain, and often a high readmission rate. The complexity of SCD calls for a comprehensive approach, and the need for each patient to have a clearly identified medical home.10 The hospital, emergency department, and hospitalist cannot and should not serve this role. Recently, Lindquist and Baker proposed a framework to understand and prevent hospital readmissions.11 They recommend optimizing the interfaces of transitional care among the patient, hospitalist, and primary care physician (PCP). By applying this framework of care, hospitalists must identify a PCP and provider with SCD expertise for follow‐up. Clear communication between the PCP, sickle cell expert, and hospitalist can be used to facilitate inpatient and emergency department care, and avoid inconsistent care that fosters mistrust. Individualized and consistent analgesic protocols established by outpatient providers, in collaboration with the patient, are more likely to deliver effective care, compared to variable attempts by whatever hospitalist happens to admit the patient.

Working with physicians expert in the care of patients with SCD, hospitalists might also identify patients who may benefit from hydroxyurea (HU) therapy. Despite clear evidence of HU's multiple salutary effects (decreased number of painful crises and need for hospital admissions, reduced number of blood transfusions and frequency of acute chest syndrome, and an overall benefit in mortality),12, 13 it remains underprescribed.14 In an analysis of a Medicaid managed care organization database in Maryland, 85% of patients never refilled a HU prescription. Moreover, patients with the highest rate of refills had the lowest number of hospital admissions and cost of care. Based on the evidence, hospitalists should screen all patients to determine whether or not HU has been prescribed, and if not, patients should be carefully assessed to determine if they are candidates for this effective therapy with communication to the patient's PCP and SCD expert.

Carroll's analysis confirms that patients with sickle cell disease frequently admitted to hospital (high utilizers) suffer a heavier burden of their illness and are at remarkably high risk of further morbidity and mortality.2 Though admissions are usually for acute pain crises, these high utilizers also suffer greater risk of hematologic, cardiovascular, infectious, orthopedic, and psychiatric complications. The common psychiatric issues, including both mood disorders and substance abuse, emphasize the need for a multidisciplinary team of care providers to provide a comprehensive bio‐psycho‐social assessment of all patients with SCD who experience high hospital utilization. These patients will also benefit from system improvements that integrate and coordinate care across inpatient, outpatient, emergency department, and patient homes. Hospitalists are well positioned to engage in this model of care, as well as develop and improve processes to ensure seamless transitions across the various settings of care delivery. It is also crucial that hospitalists are engaged in research needed to better identify and understand risk factors that lead to high utilization. Only through collaborative efforts can we hope to solve the conundrum of frequently hospitalized patients with sickle cell pain crises.

In November 2010, the National Heart, Lung, and Blood Institute celebrated the 100th year anniversary of the discovery of sickle cell disease (SCD) in the United States by hosting the Herrick Symposium. Despite progress in the past 100 years, there is just one treatment available (hydroxyurea) and, while SCD is no longer considered only a disease of children, patients' life spans remain severely shortened (42 and 48 years, respectively, for males and females).1 With restrictions in residency hours and hospitals efforts to contain costs, hospitalists are increasingly being called upon to manage inpatient care for adults with SCD during their hospitalization. With the Centers for Medicare and Medicaid Services' recent plans to penalize hospitals with 30‐day readmission rates in excess of expected, hospitalists should address the challenges they face in providing care to adults with SCD and identify strategies to successfully meet them.

In this issue of the Journal of Hospital Medicine, Carroll and colleagues examined data from the California State Inpatient Database provided by the Healthcare Cost and Utilization Project (HCUP) for persons with International Classification of Diseases, Ninth Revision (ICD‐9) codes for SCD.2 They characterized patterns of hospital use during a 4‐year study period. Records for all patients, age 13 and older, with an admission for an SCD ICD‐9related cause were included. Patients with 4 or more hospitalizations in a 12‐month period were classified as having high hospital utilization, and 25% of the 1879 different patients evaluated fell into this category. A general perception exists that most persons with SCD have high hospital utilization, but data from Carroll et al. challenge this perception.2

While 1 in 4 patients in the cohort had high hospital utilization, why were not even more able to stay out of the hospital? Characteristics of these high utilizers shed light on contributing factors. Many patients died in the hospital (6.6%), consistent with research by others who also demonstrated the high risk of death associated with rehospitalization among patients with SCD.3, 4 In a prospective cohort study of 71 adults with either 70 hospital days or 6 admissions in a 12‐month period, 15% of the cohort died within a 24‐month study period.3 Patients with the highest number of hospital days, and those suffering from depression, were at highest risk of death. A separate prospective, longitudinal, 4‐year cohort study of adults with sickle cell anemia found an overall mortality of 14%.4 Mortality for those readmitted within 1 week of a painful crisis was 20%, compared to 11% for others in the cohort. High hospitalization use and hospital readmissions should be seen as worrisome markers of high risk for death, and patients should be carefully evaluated for life‐threatening complications, and not assumed to be purely drug seeking.

Why do some patients with SCD experience high readmission rates and mortality? Such patients with frequent hospitalizations have been found, in fact, to be sicker, and Carroll's research confirms that high utilizers were more likely to have comorbidities (acute chest syndrome, aseptic necrosis, renal disease) and complications (sepsis, pneumonia, pulmonary embolus, diabetes, mood disorders, and cocaine and alcohol use).2 Fortunately, high utilization appears to moderate over time for most patients, but those with persistent high utilization were more likely to have sepsis and mood disorders. Aisiku and colleagues studied a cohort of adults with SCD, in Virginia, in which emergency department (ED) utilization provided additional evidence for the association of high utilization with worse outcomes.5 Patients with 3 or more ED visits in 1 year were found to have lower hematocrits and higher white blood cell counts, to require more blood transfusions, and to report more pain, more pain days, more pain crises, and a worse quality of life. It is clear that patients with high hospital utilization are sicker and at an increased risk of death. While enlightening, this data does not tell the entire story.

Most admissions for patients with SCD begin with a vaso‐occlusive crisis, and frequently other complications may develop. Smith et al. provided the first prospectively collected data documenting that these patients reported pain on more than 54% of days, and many experience pain daily, yet infrequently access healthcare services.6 Hospitalists should appreciate that chronic pain is common for many adults with SCD. Pain management in this patient population is complex and often challenging, requiring high doses of opioids. In this current issue of the Journal, Smith and colleagues have contributed an excellent overview of how to manage pain in adults with SCD.7 The review specifically addresses some of the most challenging aspects of pain management in the hospital setting. Unfortunately, healthcare providers too frequently perceive patients as addicted to narcotics and abusing them, despite clear evidence that patients with SCD suffer from chronic pain. The consequent crisis of trust between the patient and provider commonly leads to inadequate treatment of pain and subsequent self‐discharge. Haywood and colleagues compared trust levels in adults with SCD and a history of sudden self‐discharge (ie, leaving against medical advice [AMA]) to those without such a history.8 Patients with a history of self‐discharge reported lower levels of trust of the medical staff and more negative interpersonal experiences. In a separate investigation, researchers compared scores on the Picker Patient Experience Questionnaire between a cohort of adults with SCD and national norms.9 Patients with SCD scored lower on 9 of 12 items. More specifically, 86% of respondents reported having insufficient involvement in decisions about care and treatment, and 50% reported staff did not do enough to control pain. Sadly, it appears the health system overall has undertreated and mismanaged patients with SCD suffering from pain crises.

Hospitalists face many challenges when managing care for adults with such a complex disease associated with high mortality, severe pain, and often a high readmission rate. The complexity of SCD calls for a comprehensive approach, and the need for each patient to have a clearly identified medical home.10 The hospital, emergency department, and hospitalist cannot and should not serve this role. Recently, Lindquist and Baker proposed a framework to understand and prevent hospital readmissions.11 They recommend optimizing the interfaces of transitional care among the patient, hospitalist, and primary care physician (PCP). By applying this framework of care, hospitalists must identify a PCP and provider with SCD expertise for follow‐up. Clear communication between the PCP, sickle cell expert, and hospitalist can be used to facilitate inpatient and emergency department care, and avoid inconsistent care that fosters mistrust. Individualized and consistent analgesic protocols established by outpatient providers, in collaboration with the patient, are more likely to deliver effective care, compared to variable attempts by whatever hospitalist happens to admit the patient.

Working with physicians expert in the care of patients with SCD, hospitalists might also identify patients who may benefit from hydroxyurea (HU) therapy. Despite clear evidence of HU's multiple salutary effects (decreased number of painful crises and need for hospital admissions, reduced number of blood transfusions and frequency of acute chest syndrome, and an overall benefit in mortality),12, 13 it remains underprescribed.14 In an analysis of a Medicaid managed care organization database in Maryland, 85% of patients never refilled a HU prescription. Moreover, patients with the highest rate of refills had the lowest number of hospital admissions and cost of care. Based on the evidence, hospitalists should screen all patients to determine whether or not HU has been prescribed, and if not, patients should be carefully assessed to determine if they are candidates for this effective therapy with communication to the patient's PCP and SCD expert.

Carroll's analysis confirms that patients with sickle cell disease frequently admitted to hospital (high utilizers) suffer a heavier burden of their illness and are at remarkably high risk of further morbidity and mortality.2 Though admissions are usually for acute pain crises, these high utilizers also suffer greater risk of hematologic, cardiovascular, infectious, orthopedic, and psychiatric complications. The common psychiatric issues, including both mood disorders and substance abuse, emphasize the need for a multidisciplinary team of care providers to provide a comprehensive bio‐psycho‐social assessment of all patients with SCD who experience high hospital utilization. These patients will also benefit from system improvements that integrate and coordinate care across inpatient, outpatient, emergency department, and patient homes. Hospitalists are well positioned to engage in this model of care, as well as develop and improve processes to ensure seamless transitions across the various settings of care delivery. It is also crucial that hospitalists are engaged in research needed to better identify and understand risk factors that lead to high utilization. Only through collaborative efforts can we hope to solve the conundrum of frequently hospitalized patients with sickle cell pain crises.

In November 2010, the National Heart, Lung, and Blood Institute celebrated the 100th year anniversary of the discovery of sickle cell disease (SCD) in the United States by hosting the Herrick Symposium. Despite progress in the past 100 years, there is just one treatment available (hydroxyurea) and, while SCD is no longer considered only a disease of children, patients' life spans remain severely shortened (42 and 48 years, respectively, for males and females).1 With restrictions in residency hours and hospitals efforts to contain costs, hospitalists are increasingly being called upon to manage inpatient care for adults with SCD during their hospitalization. With the Centers for Medicare and Medicaid Services' recent plans to penalize hospitals with 30‐day readmission rates in excess of expected, hospitalists should address the challenges they face in providing care to adults with SCD and identify strategies to successfully meet them.

In this issue of the Journal of Hospital Medicine, Carroll and colleagues examined data from the California State Inpatient Database provided by the Healthcare Cost and Utilization Project (HCUP) for persons with International Classification of Diseases, Ninth Revision (ICD‐9) codes for SCD.2 They characterized patterns of hospital use during a 4‐year study period. Records for all patients, age 13 and older, with an admission for an SCD ICD‐9related cause were included. Patients with 4 or more hospitalizations in a 12‐month period were classified as having high hospital utilization, and 25% of the 1879 different patients evaluated fell into this category. A general perception exists that most persons with SCD have high hospital utilization, but data from Carroll et al. challenge this perception.2

While 1 in 4 patients in the cohort had high hospital utilization, why were not even more able to stay out of the hospital? Characteristics of these high utilizers shed light on contributing factors. Many patients died in the hospital (6.6%), consistent with research by others who also demonstrated the high risk of death associated with rehospitalization among patients with SCD.3, 4 In a prospective cohort study of 71 adults with either 70 hospital days or 6 admissions in a 12‐month period, 15% of the cohort died within a 24‐month study period.3 Patients with the highest number of hospital days, and those suffering from depression, were at highest risk of death. A separate prospective, longitudinal, 4‐year cohort study of adults with sickle cell anemia found an overall mortality of 14%.4 Mortality for those readmitted within 1 week of a painful crisis was 20%, compared to 11% for others in the cohort. High hospitalization use and hospital readmissions should be seen as worrisome markers of high risk for death, and patients should be carefully evaluated for life‐threatening complications, and not assumed to be purely drug seeking.

Why do some patients with SCD experience high readmission rates and mortality? Such patients with frequent hospitalizations have been found, in fact, to be sicker, and Carroll's research confirms that high utilizers were more likely to have comorbidities (acute chest syndrome, aseptic necrosis, renal disease) and complications (sepsis, pneumonia, pulmonary embolus, diabetes, mood disorders, and cocaine and alcohol use).2 Fortunately, high utilization appears to moderate over time for most patients, but those with persistent high utilization were more likely to have sepsis and mood disorders. Aisiku and colleagues studied a cohort of adults with SCD, in Virginia, in which emergency department (ED) utilization provided additional evidence for the association of high utilization with worse outcomes.5 Patients with 3 or more ED visits in 1 year were found to have lower hematocrits and higher white blood cell counts, to require more blood transfusions, and to report more pain, more pain days, more pain crises, and a worse quality of life. It is clear that patients with high hospital utilization are sicker and at an increased risk of death. While enlightening, this data does not tell the entire story.

Most admissions for patients with SCD begin with a vaso‐occlusive crisis, and frequently other complications may develop. Smith et al. provided the first prospectively collected data documenting that these patients reported pain on more than 54% of days, and many experience pain daily, yet infrequently access healthcare services.6 Hospitalists should appreciate that chronic pain is common for many adults with SCD. Pain management in this patient population is complex and often challenging, requiring high doses of opioids. In this current issue of the Journal, Smith and colleagues have contributed an excellent overview of how to manage pain in adults with SCD.7 The review specifically addresses some of the most challenging aspects of pain management in the hospital setting. Unfortunately, healthcare providers too frequently perceive patients as addicted to narcotics and abusing them, despite clear evidence that patients with SCD suffer from chronic pain. The consequent crisis of trust between the patient and provider commonly leads to inadequate treatment of pain and subsequent self‐discharge. Haywood and colleagues compared trust levels in adults with SCD and a history of sudden self‐discharge (ie, leaving against medical advice [AMA]) to those without such a history.8 Patients with a history of self‐discharge reported lower levels of trust of the medical staff and more negative interpersonal experiences. In a separate investigation, researchers compared scores on the Picker Patient Experience Questionnaire between a cohort of adults with SCD and national norms.9 Patients with SCD scored lower on 9 of 12 items. More specifically, 86% of respondents reported having insufficient involvement in decisions about care and treatment, and 50% reported staff did not do enough to control pain. Sadly, it appears the health system overall has undertreated and mismanaged patients with SCD suffering from pain crises.

Hospitalists face many challenges when managing care for adults with such a complex disease associated with high mortality, severe pain, and often a high readmission rate. The complexity of SCD calls for a comprehensive approach, and the need for each patient to have a clearly identified medical home.10 The hospital, emergency department, and hospitalist cannot and should not serve this role. Recently, Lindquist and Baker proposed a framework to understand and prevent hospital readmissions.11 They recommend optimizing the interfaces of transitional care among the patient, hospitalist, and primary care physician (PCP). By applying this framework of care, hospitalists must identify a PCP and provider with SCD expertise for follow‐up. Clear communication between the PCP, sickle cell expert, and hospitalist can be used to facilitate inpatient and emergency department care, and avoid inconsistent care that fosters mistrust. Individualized and consistent analgesic protocols established by outpatient providers, in collaboration with the patient, are more likely to deliver effective care, compared to variable attempts by whatever hospitalist happens to admit the patient.

Working with physicians expert in the care of patients with SCD, hospitalists might also identify patients who may benefit from hydroxyurea (HU) therapy. Despite clear evidence of HU's multiple salutary effects (decreased number of painful crises and need for hospital admissions, reduced number of blood transfusions and frequency of acute chest syndrome, and an overall benefit in mortality),12, 13 it remains underprescribed.14 In an analysis of a Medicaid managed care organization database in Maryland, 85% of patients never refilled a HU prescription. Moreover, patients with the highest rate of refills had the lowest number of hospital admissions and cost of care. Based on the evidence, hospitalists should screen all patients to determine whether or not HU has been prescribed, and if not, patients should be carefully assessed to determine if they are candidates for this effective therapy with communication to the patient's PCP and SCD expert.

Carroll's analysis confirms that patients with sickle cell disease frequently admitted to hospital (high utilizers) suffer a heavier burden of their illness and are at remarkably high risk of further morbidity and mortality.2 Though admissions are usually for acute pain crises, these high utilizers also suffer greater risk of hematologic, cardiovascular, infectious, orthopedic, and psychiatric complications. The common psychiatric issues, including both mood disorders and substance abuse, emphasize the need for a multidisciplinary team of care providers to provide a comprehensive bio‐psycho‐social assessment of all patients with SCD who experience high hospital utilization. These patients will also benefit from system improvements that integrate and coordinate care across inpatient, outpatient, emergency department, and patient homes. Hospitalists are well positioned to engage in this model of care, as well as develop and improve processes to ensure seamless transitions across the various settings of care delivery. It is also crucial that hospitalists are engaged in research needed to better identify and understand risk factors that lead to high utilization. Only through collaborative efforts can we hope to solve the conundrum of frequently hospitalized patients with sickle cell pain crises.

An old man and a young boy walk along a beach, with the old man throwing stranded starfish back into the ocean. The boy asks, Why bother tossing them back when you know they'll just keep washing up? To which the old man replies, after casting another starfish into the water, Because it matters to that one.

The Starfish Story, based upon an essay by Loren Eiseley

Most patients seem not to notice it. Occasionally I'll have a patient who, with comedic license, overlooks the stipples and wavy edges and jokingly asks, What are you, a 1‐star general?

I'm referring to the gold starfish pin I wear on the left lapel of my white coat. Where I trained, all Medicine interns receive one on the first day of internship, in tribute of the much‐celebrated story above. The purpose of the pin is simple: to remind us that no matter how tired, frustrated, or overwhelmed we sometimes feel in medicine, we can always make a difference in the life of the patient in front of us.

The older I get the more I've come to appreciate that the starfish tale ‐ inspiring as it is ‐ reminds us of only half the story. As we all know, patients don't exist in isolation. They have brothers and sisters, mothers and fathers, sons and daughters, friends and lovers. In the middle of the night, or from under a pile of paperwork, it can be even harder to remember that what we as healthcare professionals do for our patients matters to these people, too. For this latter reminder, I turn to my hospital chapel.

For those who know me this might come as a surprise. I'm spiritual, but not very religious, and while I often reflect on what's going on in my life or the lives of my loved ones, I usually don't feel the need to go to a sanctuary to do it. I'm not sure why I visited the chapel that first time.

Located behind 2 unadorned double doors off the main hallway, my hospital chapel looks from the outside like any other room in the building. Similarly, on the inside it looks like any other chapel ‐ dimly lit, with an altar, a Bible, pews, and an electric organ. What makes this space special for me is the volume that rests on a podium opposite the altar, under a bright fluorescent lamp and a sign that reads, This book is for your prayer requests. Please write down whatever helps you.

On the days when I feel overwhelmed with patient care, in addition to glancing at the starfish pin on my lapel I think of the prayer request book. Open for all to read, the book is a place where people can share their hopes and fears, about themselves or loved ones, with others who may or may not be complete strangers. Most people write about ill loved ones. What they have to say is profoundly moving and can only be done justice in their own words (with names and other details altered to protect confidentiality).

Some people write about letting go, about redirecting care from attempts at cure to comfort. Their anguish, like the indentation from their pen, is palpable. Dear God, our mom is almost 91 years old, says one person. She's been sick and hospitalized about 7 times or so. We really don't want her to leave us, but[w]e know she has had enough pain and wants to join our dad. Another person reflects, Dear God, my sister Pat is on the 4th floor. I know today I will take her off the vent. Please take her hand. Show her the way if that's Your will.

Others write about specific procedures or illnesses. In the jagged hand of a 10‐year‐old, a child prays for my mother, Mary, because she is getting a spinal tap right now and I want her to get well, which he then signs with a large heart and Love you, Mom. Someone else writes, Dear God, I need Your healing touch for my dad, who has lung cancer. Then, as if an afterthought, Also for me, because I have to have a colonoscopy this weekend.

Although many of the entries are addressed to God, a considerable number are directed toward anyone reading the book. Please pray for my dad, implores one person in an earnest hand. He was in a bad accident. I just want him to get better. He makes everything better. I just want my dad back. Is that selfish? Please pray for him. One of the most heart‐wrenching requests is from a new mother hoping for a second chance: My newborn son is here in the NICU. Please pray he is alrightand that they (the social workers) give me the next 18 or so years to make up for what I've done to him. Please, I want another chance to be the good mother I know he needs.

Every few months, the prayer request book fills up with hopes and fears just like these, including ‐ if it's not refreshed quickly enough ‐ the inside of the front and back cover. More meaningful than anything I could ever pin to my white coat, each entry is a powerful reminder of how we as healthcare providers affect more than just our patients. Indeed, for better or for worse, the stakes are much higher than that. What we do also matters to the people to whom our patients matter.

The people who penned the preceding entries are among those I see walking down the hall, riding with me in the elevator, standing in line next to me in the cafeteria, and sitting at my patients' bedsides. They could be anyone, and so they are everyone. In honor of them all I share this entry of my own: Thank you for opening up your hearts. Thank you for helping me remember how privileged I am to be a physician, and how, through helping one, I help more than one.

An old man and a young boy walk along a beach, with the old man throwing stranded starfish back into the ocean. The boy asks, Why bother tossing them back when you know they'll just keep washing up? To which the old man replies, after casting another starfish into the water, Because it matters to that one.

The Starfish Story, based upon an essay by Loren Eiseley

Most patients seem not to notice it. Occasionally I'll have a patient who, with comedic license, overlooks the stipples and wavy edges and jokingly asks, What are you, a 1‐star general?

I'm referring to the gold starfish pin I wear on the left lapel of my white coat. Where I trained, all Medicine interns receive one on the first day of internship, in tribute of the much‐celebrated story above. The purpose of the pin is simple: to remind us that no matter how tired, frustrated, or overwhelmed we sometimes feel in medicine, we can always make a difference in the life of the patient in front of us.

The older I get the more I've come to appreciate that the starfish tale ‐ inspiring as it is ‐ reminds us of only half the story. As we all know, patients don't exist in isolation. They have brothers and sisters, mothers and fathers, sons and daughters, friends and lovers. In the middle of the night, or from under a pile of paperwork, it can be even harder to remember that what we as healthcare professionals do for our patients matters to these people, too. For this latter reminder, I turn to my hospital chapel.

For those who know me this might come as a surprise. I'm spiritual, but not very religious, and while I often reflect on what's going on in my life or the lives of my loved ones, I usually don't feel the need to go to a sanctuary to do it. I'm not sure why I visited the chapel that first time.

Located behind 2 unadorned double doors off the main hallway, my hospital chapel looks from the outside like any other room in the building. Similarly, on the inside it looks like any other chapel ‐ dimly lit, with an altar, a Bible, pews, and an electric organ. What makes this space special for me is the volume that rests on a podium opposite the altar, under a bright fluorescent lamp and a sign that reads, This book is for your prayer requests. Please write down whatever helps you.

On the days when I feel overwhelmed with patient care, in addition to glancing at the starfish pin on my lapel I think of the prayer request book. Open for all to read, the book is a place where people can share their hopes and fears, about themselves or loved ones, with others who may or may not be complete strangers. Most people write about ill loved ones. What they have to say is profoundly moving and can only be done justice in their own words (with names and other details altered to protect confidentiality).

Some people write about letting go, about redirecting care from attempts at cure to comfort. Their anguish, like the indentation from their pen, is palpable. Dear God, our mom is almost 91 years old, says one person. She's been sick and hospitalized about 7 times or so. We really don't want her to leave us, but[w]e know she has had enough pain and wants to join our dad. Another person reflects, Dear God, my sister Pat is on the 4th floor. I know today I will take her off the vent. Please take her hand. Show her the way if that's Your will.

Others write about specific procedures or illnesses. In the jagged hand of a 10‐year‐old, a child prays for my mother, Mary, because she is getting a spinal tap right now and I want her to get well, which he then signs with a large heart and Love you, Mom. Someone else writes, Dear God, I need Your healing touch for my dad, who has lung cancer. Then, as if an afterthought, Also for me, because I have to have a colonoscopy this weekend.

Although many of the entries are addressed to God, a considerable number are directed toward anyone reading the book. Please pray for my dad, implores one person in an earnest hand. He was in a bad accident. I just want him to get better. He makes everything better. I just want my dad back. Is that selfish? Please pray for him. One of the most heart‐wrenching requests is from a new mother hoping for a second chance: My newborn son is here in the NICU. Please pray he is alrightand that they (the social workers) give me the next 18 or so years to make up for what I've done to him. Please, I want another chance to be the good mother I know he needs.

Every few months, the prayer request book fills up with hopes and fears just like these, including ‐ if it's not refreshed quickly enough ‐ the inside of the front and back cover. More meaningful than anything I could ever pin to my white coat, each entry is a powerful reminder of how we as healthcare providers affect more than just our patients. Indeed, for better or for worse, the stakes are much higher than that. What we do also matters to the people to whom our patients matter.

The people who penned the preceding entries are among those I see walking down the hall, riding with me in the elevator, standing in line next to me in the cafeteria, and sitting at my patients' bedsides. They could be anyone, and so they are everyone. In honor of them all I share this entry of my own: Thank you for opening up your hearts. Thank you for helping me remember how privileged I am to be a physician, and how, through helping one, I help more than one.

An old man and a young boy walk along a beach, with the old man throwing stranded starfish back into the ocean. The boy asks, Why bother tossing them back when you know they'll just keep washing up? To which the old man replies, after casting another starfish into the water, Because it matters to that one.

The Starfish Story, based upon an essay by Loren Eiseley

Most patients seem not to notice it. Occasionally I'll have a patient who, with comedic license, overlooks the stipples and wavy edges and jokingly asks, What are you, a 1‐star general?

I'm referring to the gold starfish pin I wear on the left lapel of my white coat. Where I trained, all Medicine interns receive one on the first day of internship, in tribute of the much‐celebrated story above. The purpose of the pin is simple: to remind us that no matter how tired, frustrated, or overwhelmed we sometimes feel in medicine, we can always make a difference in the life of the patient in front of us.

The older I get the more I've come to appreciate that the starfish tale ‐ inspiring as it is ‐ reminds us of only half the story. As we all know, patients don't exist in isolation. They have brothers and sisters, mothers and fathers, sons and daughters, friends and lovers. In the middle of the night, or from under a pile of paperwork, it can be even harder to remember that what we as healthcare professionals do for our patients matters to these people, too. For this latter reminder, I turn to my hospital chapel.

For those who know me this might come as a surprise. I'm spiritual, but not very religious, and while I often reflect on what's going on in my life or the lives of my loved ones, I usually don't feel the need to go to a sanctuary to do it. I'm not sure why I visited the chapel that first time.

Located behind 2 unadorned double doors off the main hallway, my hospital chapel looks from the outside like any other room in the building. Similarly, on the inside it looks like any other chapel ‐ dimly lit, with an altar, a Bible, pews, and an electric organ. What makes this space special for me is the volume that rests on a podium opposite the altar, under a bright fluorescent lamp and a sign that reads, This book is for your prayer requests. Please write down whatever helps you.

On the days when I feel overwhelmed with patient care, in addition to glancing at the starfish pin on my lapel I think of the prayer request book. Open for all to read, the book is a place where people can share their hopes and fears, about themselves or loved ones, with others who may or may not be complete strangers. Most people write about ill loved ones. What they have to say is profoundly moving and can only be done justice in their own words (with names and other details altered to protect confidentiality).

Some people write about letting go, about redirecting care from attempts at cure to comfort. Their anguish, like the indentation from their pen, is palpable. Dear God, our mom is almost 91 years old, says one person. She's been sick and hospitalized about 7 times or so. We really don't want her to leave us, but[w]e know she has had enough pain and wants to join our dad. Another person reflects, Dear God, my sister Pat is on the 4th floor. I know today I will take her off the vent. Please take her hand. Show her the way if that's Your will.

Others write about specific procedures or illnesses. In the jagged hand of a 10‐year‐old, a child prays for my mother, Mary, because she is getting a spinal tap right now and I want her to get well, which he then signs with a large heart and Love you, Mom. Someone else writes, Dear God, I need Your healing touch for my dad, who has lung cancer. Then, as if an afterthought, Also for me, because I have to have a colonoscopy this weekend.

Although many of the entries are addressed to God, a considerable number are directed toward anyone reading the book. Please pray for my dad, implores one person in an earnest hand. He was in a bad accident. I just want him to get better. He makes everything better. I just want my dad back. Is that selfish? Please pray for him. One of the most heart‐wrenching requests is from a new mother hoping for a second chance: My newborn son is here in the NICU. Please pray he is alrightand that they (the social workers) give me the next 18 or so years to make up for what I've done to him. Please, I want another chance to be the good mother I know he needs.

Every few months, the prayer request book fills up with hopes and fears just like these, including ‐ if it's not refreshed quickly enough ‐ the inside of the front and back cover. More meaningful than anything I could ever pin to my white coat, each entry is a powerful reminder of how we as healthcare providers affect more than just our patients. Indeed, for better or for worse, the stakes are much higher than that. What we do also matters to the people to whom our patients matter.

The people who penned the preceding entries are among those I see walking down the hall, riding with me in the elevator, standing in line next to me in the cafeteria, and sitting at my patients' bedsides. They could be anyone, and so they are everyone. In honor of them all I share this entry of my own: Thank you for opening up your hearts. Thank you for helping me remember how privileged I am to be a physician, and how, through helping one, I help more than one.