Ellis Knight, MD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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