Jamie Newman, MD, FACP

Josef Leopold Auenbrugger: the inventor of percussion

Who more appropriate to discover percussion in the human form than a Viennese-trained physician? Josef Leopold Auenbrugger invented the technique of percussing the patient’s chest in 1754, just two years before Wolfgang Amadeus Mozart’s birth in 1756.

The son of an innkeeper, Auenbrugger is said to have tapped wine barrels in his father’s cellar as a boy to find out how full they were. Little would one expect that this percussive background would lead to a medical breakthrough. Later in life he became a composer and wrote an opera for Austrian Empress Marie Theresa.

Auenbrugger described the lung as sounding like a drum with a heavy cloth over it. When the lung is full, stated Auenbrugger, such as in the case of pneumonia, the sound is similar to tapping the fleshy part of the thigh. Auenbrugger practiced these techniques on cadavers. He injected fluid into the pleural cavity and created a science around when and where efforts should be made for its removal.

These observations were published in a small book, now considered a medical classic. Called Inventum Novum, the full English title is A New Discovery that Enables the Physician from the Percussion of the Human Thorax to Detect the Diseases Hidden Within the Chest (and hence, the shorter, more common title).

What is a great story—albeit true—without rejection and shame? His ideas rejected and forced to resign his commission in his current post, Auenbrugger showed understanding of human nature in the following statement: “I have not been unconscious of the dangers I must encounter, since it has always been the fate of those who have illustrated or improved the arts and sciences by their discovery, to be beset by envy, malice, hatred, detraction, and calumny.”

Auenbrugger’s work did eventually rise out of obscurity largely through the exposure of Jean Nicolas Corvisart, Napoleon’s favorite physician. Corvisart, who also influenced René-Théophile-Hyacinthe Laennec, inventor of the stethoscope, led a school of medicine that hoped to correlate the clinical exam to pathologic findings. Corvisart taught the method of percussion to his students and in 1808 translated and published the book with annotations—just a year before Auenbrugger’s death. Ironically, Auenbrugger may not have known about this translation that spread rapidly among the medical community.

To some the physical exam is defunct, supplanted by scans and lab. Two hundred and fifty years later, the technique of percussion is still a cornerstone of the art of the physical exam. Next time you percuss an ascitic abdomen or tap out the level of a pleural effusion, think back to Leopold Auenbrugger, his Inventum Novum, and the birth of the modern physical exam. TH

Josef Leopold Auenbrugger: the inventor of percussion

Who more appropriate to discover percussion in the human form than a Viennese-trained physician? Josef Leopold Auenbrugger invented the technique of percussing the patient’s chest in 1754, just two years before Wolfgang Amadeus Mozart’s birth in 1756.

The son of an innkeeper, Auenbrugger is said to have tapped wine barrels in his father’s cellar as a boy to find out how full they were. Little would one expect that this percussive background would lead to a medical breakthrough. Later in life he became a composer and wrote an opera for Austrian Empress Marie Theresa.

Auenbrugger described the lung as sounding like a drum with a heavy cloth over it. When the lung is full, stated Auenbrugger, such as in the case of pneumonia, the sound is similar to tapping the fleshy part of the thigh. Auenbrugger practiced these techniques on cadavers. He injected fluid into the pleural cavity and created a science around when and where efforts should be made for its removal.

These observations were published in a small book, now considered a medical classic. Called Inventum Novum, the full English title is A New Discovery that Enables the Physician from the Percussion of the Human Thorax to Detect the Diseases Hidden Within the Chest (and hence, the shorter, more common title).

What is a great story—albeit true—without rejection and shame? His ideas rejected and forced to resign his commission in his current post, Auenbrugger showed understanding of human nature in the following statement: “I have not been unconscious of the dangers I must encounter, since it has always been the fate of those who have illustrated or improved the arts and sciences by their discovery, to be beset by envy, malice, hatred, detraction, and calumny.”

Auenbrugger’s work did eventually rise out of obscurity largely through the exposure of Jean Nicolas Corvisart, Napoleon’s favorite physician. Corvisart, who also influenced René-Théophile-Hyacinthe Laennec, inventor of the stethoscope, led a school of medicine that hoped to correlate the clinical exam to pathologic findings. Corvisart taught the method of percussion to his students and in 1808 translated and published the book with annotations—just a year before Auenbrugger’s death. Ironically, Auenbrugger may not have known about this translation that spread rapidly among the medical community.

To some the physical exam is defunct, supplanted by scans and lab. Two hundred and fifty years later, the technique of percussion is still a cornerstone of the art of the physical exam. Next time you percuss an ascitic abdomen or tap out the level of a pleural effusion, think back to Leopold Auenbrugger, his Inventum Novum, and the birth of the modern physical exam. TH

Josef Leopold Auenbrugger: the inventor of percussion

Who more appropriate to discover percussion in the human form than a Viennese-trained physician? Josef Leopold Auenbrugger invented the technique of percussing the patient’s chest in 1754, just two years before Wolfgang Amadeus Mozart’s birth in 1756.

The son of an innkeeper, Auenbrugger is said to have tapped wine barrels in his father’s cellar as a boy to find out how full they were. Little would one expect that this percussive background would lead to a medical breakthrough. Later in life he became a composer and wrote an opera for Austrian Empress Marie Theresa.

Auenbrugger described the lung as sounding like a drum with a heavy cloth over it. When the lung is full, stated Auenbrugger, such as in the case of pneumonia, the sound is similar to tapping the fleshy part of the thigh. Auenbrugger practiced these techniques on cadavers. He injected fluid into the pleural cavity and created a science around when and where efforts should be made for its removal.

These observations were published in a small book, now considered a medical classic. Called Inventum Novum, the full English title is A New Discovery that Enables the Physician from the Percussion of the Human Thorax to Detect the Diseases Hidden Within the Chest (and hence, the shorter, more common title).

What is a great story—albeit true—without rejection and shame? His ideas rejected and forced to resign his commission in his current post, Auenbrugger showed understanding of human nature in the following statement: “I have not been unconscious of the dangers I must encounter, since it has always been the fate of those who have illustrated or improved the arts and sciences by their discovery, to be beset by envy, malice, hatred, detraction, and calumny.”

Auenbrugger’s work did eventually rise out of obscurity largely through the exposure of Jean Nicolas Corvisart, Napoleon’s favorite physician. Corvisart, who also influenced René-Théophile-Hyacinthe Laennec, inventor of the stethoscope, led a school of medicine that hoped to correlate the clinical exam to pathologic findings. Corvisart taught the method of percussion to his students and in 1808 translated and published the book with annotations—just a year before Auenbrugger’s death. Ironically, Auenbrugger may not have known about this translation that spread rapidly among the medical community.

To some the physical exam is defunct, supplanted by scans and lab. Two hundred and fifty years later, the technique of percussion is still a cornerstone of the art of the physical exam. Next time you percuss an ascitic abdomen or tap out the level of a pleural effusion, think back to Leopold Auenbrugger, his Inventum Novum, and the birth of the modern physical exam. TH

This month in “Flashback:” a medical mystery and competition. This following is an actual case described by Theodore Tronchin. Dr. Tronchin routinely made diagnoses without seeing patients and based on descriptions of signs and symptoms included in patients’ letters. This makes this month’s written diagnosis “contest” all the more relevant.

Review Dr. Tronchin’s case below and see if you can make the diagnosis based on the information provided. E-mail your diagnosis to Physician Editor Jamie Newman at newman.james@mayo.edu. The deadline is Tuesday, April 4. We’ll select a winner at random and publish their response in a future issue of The Hospitalist.

The Case

You move to Paris in 1752 to practice medicine. You are consulted on the following case:

A 42-year-old man complains of abdominal pain. Four weeks prior to this visit he noted a gradual onset of diffuse cramping abdominal pain. The illness began with a sensation of generalized weakness, cold sweats, and nausea. He had several episodes of emesis. He was constipated, and his stool was occasionally streaked with blood. He had increased thirst and mild dysuria. He also had a mild, nonproductive cough.

Subsequently, he noted a mild tremor of his hands and occasional difficulty focusing his eyes. In the past few days, he had experienced weakness in his knees and arms (noticeable when he tried to stand from a sitting position) with a mild tingling in his feet but no loss of sensation.

The patient reports no unusual childhood illnesses and has been inoculated against smallpox. He was seen by another provider several weeks ago for gonorrhea. He does not drink alcohol excessively and both of his parents died in a carriage accident.

On exam the patient appeared pale, weak, and tremulous. His pulse was slightly weak but regular. He experienced some soreness to his mouth and gums without loss of teeth. His breath was slightly fetid, his teeth were intact, the gums were tender, and the tongue was coated whitish green. His abdomen was bloated but not tender. His grip was weak as were his legs, though they seemed intact to sensation.

What is your diagnosis? TH

This month in “Flashback:” a medical mystery and competition. This following is an actual case described by Theodore Tronchin. Dr. Tronchin routinely made diagnoses without seeing patients and based on descriptions of signs and symptoms included in patients’ letters. This makes this month’s written diagnosis “contest” all the more relevant.

Review Dr. Tronchin’s case below and see if you can make the diagnosis based on the information provided. E-mail your diagnosis to Physician Editor Jamie Newman at newman.james@mayo.edu. The deadline is Tuesday, April 4. We’ll select a winner at random and publish their response in a future issue of The Hospitalist.

The Case

You move to Paris in 1752 to practice medicine. You are consulted on the following case:

A 42-year-old man complains of abdominal pain. Four weeks prior to this visit he noted a gradual onset of diffuse cramping abdominal pain. The illness began with a sensation of generalized weakness, cold sweats, and nausea. He had several episodes of emesis. He was constipated, and his stool was occasionally streaked with blood. He had increased thirst and mild dysuria. He also had a mild, nonproductive cough.

Subsequently, he noted a mild tremor of his hands and occasional difficulty focusing his eyes. In the past few days, he had experienced weakness in his knees and arms (noticeable when he tried to stand from a sitting position) with a mild tingling in his feet but no loss of sensation.

The patient reports no unusual childhood illnesses and has been inoculated against smallpox. He was seen by another provider several weeks ago for gonorrhea. He does not drink alcohol excessively and both of his parents died in a carriage accident.

On exam the patient appeared pale, weak, and tremulous. His pulse was slightly weak but regular. He experienced some soreness to his mouth and gums without loss of teeth. His breath was slightly fetid, his teeth were intact, the gums were tender, and the tongue was coated whitish green. His abdomen was bloated but not tender. His grip was weak as were his legs, though they seemed intact to sensation.

What is your diagnosis? TH

This month in “Flashback:” a medical mystery and competition. This following is an actual case described by Theodore Tronchin. Dr. Tronchin routinely made diagnoses without seeing patients and based on descriptions of signs and symptoms included in patients’ letters. This makes this month’s written diagnosis “contest” all the more relevant.

Review Dr. Tronchin’s case below and see if you can make the diagnosis based on the information provided. E-mail your diagnosis to Physician Editor Jamie Newman at newman.james@mayo.edu. The deadline is Tuesday, April 4. We’ll select a winner at random and publish their response in a future issue of The Hospitalist.

The Case

You move to Paris in 1752 to practice medicine. You are consulted on the following case:

A 42-year-old man complains of abdominal pain. Four weeks prior to this visit he noted a gradual onset of diffuse cramping abdominal pain. The illness began with a sensation of generalized weakness, cold sweats, and nausea. He had several episodes of emesis. He was constipated, and his stool was occasionally streaked with blood. He had increased thirst and mild dysuria. He also had a mild, nonproductive cough.

Subsequently, he noted a mild tremor of his hands and occasional difficulty focusing his eyes. In the past few days, he had experienced weakness in his knees and arms (noticeable when he tried to stand from a sitting position) with a mild tingling in his feet but no loss of sensation.

The patient reports no unusual childhood illnesses and has been inoculated against smallpox. He was seen by another provider several weeks ago for gonorrhea. He does not drink alcohol excessively and both of his parents died in a carriage accident.

On exam the patient appeared pale, weak, and tremulous. His pulse was slightly weak but regular. He experienced some soreness to his mouth and gums without loss of teeth. His breath was slightly fetid, his teeth were intact, the gums were tender, and the tongue was coated whitish green. His abdomen was bloated but not tender. His grip was weak as were his legs, though they seemed intact to sensation.

What is your diagnosis? TH

Pharmacies have plotted a dynamic course through history, arriving late to North America in relation to other nations. Before the origin of the first true hospital pharmacy, medicinal therapies were often distributed by public officials, heads of households, and religious leaders or sold in drug stores and other free-standing apothecaries. Colonists followed books on self-treatment and methods of cultivating herbs. With the introduction of hospitals came the hospital pharmacy.

Great Britain had long been a glowing example of how pharmacists could prepare, compound, and administer prescriptions ordered by physicians in an organized manner. In contrast, the role of physicians, surgeons, and apothecaries in the British colonies were blurred, each with overlapping responsibilities of caring for patients and treating ailments.

It was not until 1751 after Benjamin Franklin and Dr. Thomas Bond founded the first hospital in the British Colonies—Pennsylvania Hospital in Philadelphia—that the idea for a hospital pharmacy was cultivated in North America. Because the first hospital’s mission was to provide charity for the poor, there initially was resistance to Dr. Bond’s idea of creating an apothecary in the same institution. Colonists feared that it would become costly to those in Philadelphia being served by the hospital. However, with Franklin’s persuading, enough funds were eventually solicited to purchase more than 112 pounds worth of drugs from London. In 1752, these drugs filled shelves in the hospital president’s office in the Pine Building of Pennsylvania Hospital instituting the first “Apothecary’s Shop in the Hospital” in the British colonies.

The first salaried hospital pharmacist, making 15 pounds per year, was Jonathon Roberts who worked until 1755 fulfilling the role of preparing medications requested by physicians. Medical and surgical students were often hired for short tenures in the apothecary to obtain experience in pharmacy or to simply cover their room and board expenses. John Morgan replaced Roberts in May 1755, and he worked for only one year before using that experience as a springboard for stirring up great influence in the future direction of American pharmacy. Morgan went on to become a physician and a vocal advocate for a more distinct separation of professions among physicians, surgeons, and pharmacists in America.

Most of the drugs available in the first American hospital pharmacy could be found in the London Pharmacopoeia of 1650, whereas very few drugs were of North American origin. Contributions from the colonies came primarily from the American Indian traditions that involved the extraction of botanical drugs such as cascara, bloodroot, and jalap. Nearly 170 of these particular preparations used by Indians north of the Rio Grande or their derivatives are still used today.

Other drugs used at the time of the first hospital pharmacy included emetic ipecac, an expectorant made of benzoin known as “Jesuit’s Drops,” antimony in “Plummer’s Pills,” and tincture of lavender (originally referred to as “Palsy Drops” and used to treat muscle spasms and headaches).

The advent of the American Revolution made importing drugs nearly impossible, requiring an increase in the number of patented drugs from North America. The first colonial hospital pharmacy, thanks to the ingenuity and persistence of Benjamin Franklin and Dr. Bond, set the stage for the development and transformation of pharmacies as we know them to today. TH

Nordman is a senior medical student at Penn State University.

Resources

• Bender GA. The First Hospital Pharmacy in Colonial America. In: Great Moments in Pharmacy. Detroit: Northwood Institute Press; 1966:84-87.
• Franklin B. Some Account of the Pennsylvania Hospital. Baltimore: The Johns Hopkins Press; 1954.
• Harris MR, Paracandola J. Images of Hospital Pharmacy in America. Am J Hosp Pharm. Reprint. June 1992.
• Lawall CH. Four Thousand Years of Pharmacy: An Outline History of Pharmacy and the Allied Sciences. Philadelphia: Lippincott; 1927.
• Massengill SE. American Pharmacy. In: A Sketch of Medicine and Pharmacy. Bristol, Tenn.: The S.E. Massengill Company. Chapter XV.
• Osborne GE. Pharmacy in British Colonial America. In: Bender GA, Parascandolam J, eds. American Pharmacy in the Colonial and Revolutionary Periods: A Bicentential Symposium held April 5, 1976. Madison, Wis.: American Institute of Pharmacy; 1977.
• Williams WH. Pharmacists at America’s First Hospital, 1752–1841 [abstract]. Am J Health Sys Pharm. 1976;33:804-804.

Pharmacies have plotted a dynamic course through history, arriving late to North America in relation to other nations. Before the origin of the first true hospital pharmacy, medicinal therapies were often distributed by public officials, heads of households, and religious leaders or sold in drug stores and other free-standing apothecaries. Colonists followed books on self-treatment and methods of cultivating herbs. With the introduction of hospitals came the hospital pharmacy.

Great Britain had long been a glowing example of how pharmacists could prepare, compound, and administer prescriptions ordered by physicians in an organized manner. In contrast, the role of physicians, surgeons, and apothecaries in the British colonies were blurred, each with overlapping responsibilities of caring for patients and treating ailments.

It was not until 1751 after Benjamin Franklin and Dr. Thomas Bond founded the first hospital in the British Colonies—Pennsylvania Hospital in Philadelphia—that the idea for a hospital pharmacy was cultivated in North America. Because the first hospital’s mission was to provide charity for the poor, there initially was resistance to Dr. Bond’s idea of creating an apothecary in the same institution. Colonists feared that it would become costly to those in Philadelphia being served by the hospital. However, with Franklin’s persuading, enough funds were eventually solicited to purchase more than 112 pounds worth of drugs from London. In 1752, these drugs filled shelves in the hospital president’s office in the Pine Building of Pennsylvania Hospital instituting the first “Apothecary’s Shop in the Hospital” in the British colonies.

The first salaried hospital pharmacist, making 15 pounds per year, was Jonathon Roberts who worked until 1755 fulfilling the role of preparing medications requested by physicians. Medical and surgical students were often hired for short tenures in the apothecary to obtain experience in pharmacy or to simply cover their room and board expenses. John Morgan replaced Roberts in May 1755, and he worked for only one year before using that experience as a springboard for stirring up great influence in the future direction of American pharmacy. Morgan went on to become a physician and a vocal advocate for a more distinct separation of professions among physicians, surgeons, and pharmacists in America.

Most of the drugs available in the first American hospital pharmacy could be found in the London Pharmacopoeia of 1650, whereas very few drugs were of North American origin. Contributions from the colonies came primarily from the American Indian traditions that involved the extraction of botanical drugs such as cascara, bloodroot, and jalap. Nearly 170 of these particular preparations used by Indians north of the Rio Grande or their derivatives are still used today.

Other drugs used at the time of the first hospital pharmacy included emetic ipecac, an expectorant made of benzoin known as “Jesuit’s Drops,” antimony in “Plummer’s Pills,” and tincture of lavender (originally referred to as “Palsy Drops” and used to treat muscle spasms and headaches).

The advent of the American Revolution made importing drugs nearly impossible, requiring an increase in the number of patented drugs from North America. The first colonial hospital pharmacy, thanks to the ingenuity and persistence of Benjamin Franklin and Dr. Bond, set the stage for the development and transformation of pharmacies as we know them to today. TH

Nordman is a senior medical student at Penn State University.

Resources

• Bender GA. The First Hospital Pharmacy in Colonial America. In: Great Moments in Pharmacy. Detroit: Northwood Institute Press; 1966:84-87.
• Franklin B. Some Account of the Pennsylvania Hospital. Baltimore: The Johns Hopkins Press; 1954.
• Harris MR, Paracandola J. Images of Hospital Pharmacy in America. Am J Hosp Pharm. Reprint. June 1992.
• Lawall CH. Four Thousand Years of Pharmacy: An Outline History of Pharmacy and the Allied Sciences. Philadelphia: Lippincott; 1927.
• Massengill SE. American Pharmacy. In: A Sketch of Medicine and Pharmacy. Bristol, Tenn.: The S.E. Massengill Company. Chapter XV.
• Osborne GE. Pharmacy in British Colonial America. In: Bender GA, Parascandolam J, eds. American Pharmacy in the Colonial and Revolutionary Periods: A Bicentential Symposium held April 5, 1976. Madison, Wis.: American Institute of Pharmacy; 1977.
• Williams WH. Pharmacists at America’s First Hospital, 1752–1841 [abstract]. Am J Health Sys Pharm. 1976;33:804-804.

Pharmacies have plotted a dynamic course through history, arriving late to North America in relation to other nations. Before the origin of the first true hospital pharmacy, medicinal therapies were often distributed by public officials, heads of households, and religious leaders or sold in drug stores and other free-standing apothecaries. Colonists followed books on self-treatment and methods of cultivating herbs. With the introduction of hospitals came the hospital pharmacy.

Great Britain had long been a glowing example of how pharmacists could prepare, compound, and administer prescriptions ordered by physicians in an organized manner. In contrast, the role of physicians, surgeons, and apothecaries in the British colonies were blurred, each with overlapping responsibilities of caring for patients and treating ailments.

It was not until 1751 after Benjamin Franklin and Dr. Thomas Bond founded the first hospital in the British Colonies—Pennsylvania Hospital in Philadelphia—that the idea for a hospital pharmacy was cultivated in North America. Because the first hospital’s mission was to provide charity for the poor, there initially was resistance to Dr. Bond’s idea of creating an apothecary in the same institution. Colonists feared that it would become costly to those in Philadelphia being served by the hospital. However, with Franklin’s persuading, enough funds were eventually solicited to purchase more than 112 pounds worth of drugs from London. In 1752, these drugs filled shelves in the hospital president’s office in the Pine Building of Pennsylvania Hospital instituting the first “Apothecary’s Shop in the Hospital” in the British colonies.

The first salaried hospital pharmacist, making 15 pounds per year, was Jonathon Roberts who worked until 1755 fulfilling the role of preparing medications requested by physicians. Medical and surgical students were often hired for short tenures in the apothecary to obtain experience in pharmacy or to simply cover their room and board expenses. John Morgan replaced Roberts in May 1755, and he worked for only one year before using that experience as a springboard for stirring up great influence in the future direction of American pharmacy. Morgan went on to become a physician and a vocal advocate for a more distinct separation of professions among physicians, surgeons, and pharmacists in America.

Most of the drugs available in the first American hospital pharmacy could be found in the London Pharmacopoeia of 1650, whereas very few drugs were of North American origin. Contributions from the colonies came primarily from the American Indian traditions that involved the extraction of botanical drugs such as cascara, bloodroot, and jalap. Nearly 170 of these particular preparations used by Indians north of the Rio Grande or their derivatives are still used today.

Other drugs used at the time of the first hospital pharmacy included emetic ipecac, an expectorant made of benzoin known as “Jesuit’s Drops,” antimony in “Plummer’s Pills,” and tincture of lavender (originally referred to as “Palsy Drops” and used to treat muscle spasms and headaches).

The advent of the American Revolution made importing drugs nearly impossible, requiring an increase in the number of patented drugs from North America. The first colonial hospital pharmacy, thanks to the ingenuity and persistence of Benjamin Franklin and Dr. Bond, set the stage for the development and transformation of pharmacies as we know them to today. TH

Nordman is a senior medical student at Penn State University.

Resources

• Bender GA. The First Hospital Pharmacy in Colonial America. In: Great Moments in Pharmacy. Detroit: Northwood Institute Press; 1966:84-87.
• Franklin B. Some Account of the Pennsylvania Hospital. Baltimore: The Johns Hopkins Press; 1954.
• Harris MR, Paracandola J. Images of Hospital Pharmacy in America. Am J Hosp Pharm. Reprint. June 1992.
• Lawall CH. Four Thousand Years of Pharmacy: An Outline History of Pharmacy and the Allied Sciences. Philadelphia: Lippincott; 1927.
• Massengill SE. American Pharmacy. In: A Sketch of Medicine and Pharmacy. Bristol, Tenn.: The S.E. Massengill Company. Chapter XV.
• Osborne GE. Pharmacy in British Colonial America. In: Bender GA, Parascandolam J, eds. American Pharmacy in the Colonial and Revolutionary Periods: A Bicentential Symposium held April 5, 1976. Madison, Wis.: American Institute of Pharmacy; 1977.
• Williams WH. Pharmacists at America’s First Hospital, 1752–1841 [abstract]. Am J Health Sys Pharm. 1976;33:804-804.

It was a dreary cold, December day and I was on call. It had been slow, but that was about to change. An 82-year-old man was admitted to my service with diarrhea, vomiting, fever, and abdominal cramps. He had never had any gastrointestinal problems and was on no medications. The only pertinent history was that his grandson was sick with a similar illness, and his daughter had been sick three days earlier.

Moments later, I received a second call for a preop clearance on a man who had been electrocuted while decorating his house for the holidays. He had fallen and broken his hip. Before I put the phone down the pager went off again—a patient admitted with a glucose level of 820. The light bulb over my head went off: We had entered the Dangerous Season.

What is this season that bodes well for no one? This poorly understood clinical risk factor begins during Halloween and lasts through Christmas, New Year’s, Valentine’s Day, and—in some areas of the country—until Mardi Gras. And now they’re upon us again: the holidays. Our bodies shudder, increasingly deprived of sunlight and oversupplied with calories, as we begin our festive mode.

All Hallow’s Eve: The Dangerous Season starts with Halloween, a pagan ritual. What child would not want to stay up after dark, run around in a mask scaring people, and eat too much candy to commemorate the leprous dead?

Halloween is the most medical of holidays. Many costumes and traditions are related to medicine: Frankenstein’s monster was assembled from body parts obtained by anatomic grave robbers. Mummies are well-preserved corpses, and mummy powder was a traditional remedy for skin ailments for centuries. Vampires may have nutritional deficiencies, and werewolves porphyria. Spider web is a traditional therapy used cutaneously as a styptic and internally for asthma.

For diabetics—especially diabetic children—Halloween is a painful time. In addition, there’s no shortage of pumpkin seed-induced diverticulitis, not to mention the unfortunate periodic occurrence of poisoned candy. According to the American College of Emergency Physicians there’s also a serious increase in risk of injury from collisions with motor vehicles, eye injuries from sharp objects, and burns from flammable costumes.

Other Halloween problems include minor inconveniences such as lost fillings secondary to nougat, falls from trees while removing toilet paper, and the occasional rotten egg to the posterior occiput. In our household there appears to be a higher than usual incidence of emesis and general abdominal pain.

Turkey Day: Next comes Thanksgiving, a seemingly benign day of turkey consumption and family cheer. The greatest danger of this holiday remains Salmonella, though Campylobacter jejuni lurks somewhere nearby. Undercooked turkey is a potent source of this infection, as are uncooked eggs in cookie dough.

The amount of time to properly thaw and cook a whole turkey, for example, is much longer than the standard-size poultry pieces and cuts of meat served year-round. When thawed correctly in the refrigerator or at a temperature of no more than 40 degrees F, a 20-pound turkey requires two to three days to thaw completely. Thawing the turkey completely before cooking is important. Otherwise, the outside of the turkey will be done before the inside.

To check a turkey for doneness, insert a food thermometer into the inner thigh area near the breast of the turkey (but not touching bone). The turkey is done when the temperature reaches 180 degrees F. If the turkey is stuffed, the temperature of the stuffing should be 165 degrees F. It is not unusual for whole families to fall ill after eating the Thanksgiving feast. Salmonella may be found in turkey, gravy, stuffing, pies, and other foods served at the Thanksgiving dinner.

Another danger of turkey consumption is its high L-tryptophan concentration. Excessive turkey consumption may lead to significant sleepiness, which when combined with substantial alcohol intake may lead to traffic accidents or, at minimum, falling asleep in front of the television. Of course Thanksgiving is not a healthy day for turkeys.

Perhaps the safest thing about Thanksgiving day is the cranberry sauce. If you can get real sauce and not canned, jellied sugar, you might prevent a urinary tract infection caused by E. coli by inhibiting the bacterial podocytes’ adherence to your bladder wall.

Christmas: Christmas can be a time of great stress, especially for the non-Christian members of our society, who are deluged with holiday images. There is an increased incident of suicide over the peri-Christmas timeframe, perhaps worsened by seasonal affective disorder, though there is no study showing higher suicide rates in this time period in the north.

For some unclear reason there’s a higher rate of deadly train collisions and other disasters over Christmas. The year 1910 was an especially bad year, with eight accidents in the United States, England, and France on Christmas Eve and Day with a total mortality of 56 lives.

As per Thanksgiving, the same dietary risks exist at Christmas, along with the addition of deadly bacterially infested homemade eggnog (best to drink the pasteurized variety). Fruitcake, a mysterious substance not currently listed on the periodic table, is used most frequently as a doorstop. In a limited survey of holiday revelers none of the subjects had actually ever eaten any. In all fairness to fruitcakes, Dec. 27 is National Fruitcake Day.

The most dangerous part of Christmas, besides paper cuts from wrapping presents and frustration from assembling bicycles, is the venerable Christmas tree. A tradition that likely started in 16th century Germany, Christmas trees only became accepted in the United States in the mid-1840s. Trees are a fire hazard and can fall, injuring children. The biggest problem, though, is electrocution from holiday lights placed on the tree and home.

In 1999 the New Zealand Ministry of Consumer Affairs’ Energy Safety Service warned consumers to cease using certain types of lights because of a danger of electrocution. Metal objects—especially tinsel—from a Christmas tree could come in contact with the adapter and act as a conductor. Perhaps Charlie Brown’s tree was best after all.

Both Hanukkah and Kwanzaa have candle-lighting ceremonies—the menorah and kinara, respectively—and carry an increased risk of burns and fires.

New Year’s and Valentine’s: New Year’s Eve (aka amateur night) is a chance for those who never stay up late drinking to do so. Other than vehicular manslaughter, a major risk of this evening is stray gunfire. The Los Angeles Police Department has launched a Citywide Gunfire Reduction Campaign for New Year’s because this has become a time to shoot guns. The best-known treatment for over-libation is the ever-popular menudo (a Mexican soup made with hominy and tripe—not the boy band).

Saint Valentine’s Day is another Hallmark bonanza, as well as an amateur day for lovers. There are many myths involving this saint. One legend contends that Valentine was a priest who served during the third century in Rome. When Emperor Claudius II decided that single men made better soldiers than those with wives and families, he outlawed marriage for young men—his crop of potential soldiers. Valentine, realizing the injustice of the decree, defied Claudius and continued to perform marriages for young lovers in secret. When Valentine’s actions were discovered, Claudius ordered that he be put to death.

A less likely version is that while in prison Valentine fell in love with a young girl—his jailer’s daughter—who visited him during his confinement. Before his death he allegedly wrote her a letter, which he signed “From your Valentine,” an expression still in use today.

The dangers of Valentine’s Day are so pervasive and hideous it is difficult to write about them all, so I won’t. Let it be said, though, that from herpes to HIV, lipstick on the collar to lymphogranuloma venereum, lust can kill.

In the South, Mardi Gras ends the dangerous season. Eye trauma from flying beads and sightings of flying monkeys are a constant threat. I have been to Mardi Gras, but this is all I can remember of it.

So ’tis the season to be jolly, to spend time with our loved ones, and to bask in the familial hearth. Bah, hum and bug. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, senior associate consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

It was a dreary cold, December day and I was on call. It had been slow, but that was about to change. An 82-year-old man was admitted to my service with diarrhea, vomiting, fever, and abdominal cramps. He had never had any gastrointestinal problems and was on no medications. The only pertinent history was that his grandson was sick with a similar illness, and his daughter had been sick three days earlier.

Moments later, I received a second call for a preop clearance on a man who had been electrocuted while decorating his house for the holidays. He had fallen and broken his hip. Before I put the phone down the pager went off again—a patient admitted with a glucose level of 820. The light bulb over my head went off: We had entered the Dangerous Season.

What is this season that bodes well for no one? This poorly understood clinical risk factor begins during Halloween and lasts through Christmas, New Year’s, Valentine’s Day, and—in some areas of the country—until Mardi Gras. And now they’re upon us again: the holidays. Our bodies shudder, increasingly deprived of sunlight and oversupplied with calories, as we begin our festive mode.

All Hallow’s Eve: The Dangerous Season starts with Halloween, a pagan ritual. What child would not want to stay up after dark, run around in a mask scaring people, and eat too much candy to commemorate the leprous dead?

Halloween is the most medical of holidays. Many costumes and traditions are related to medicine: Frankenstein’s monster was assembled from body parts obtained by anatomic grave robbers. Mummies are well-preserved corpses, and mummy powder was a traditional remedy for skin ailments for centuries. Vampires may have nutritional deficiencies, and werewolves porphyria. Spider web is a traditional therapy used cutaneously as a styptic and internally for asthma.

For diabetics—especially diabetic children—Halloween is a painful time. In addition, there’s no shortage of pumpkin seed-induced diverticulitis, not to mention the unfortunate periodic occurrence of poisoned candy. According to the American College of Emergency Physicians there’s also a serious increase in risk of injury from collisions with motor vehicles, eye injuries from sharp objects, and burns from flammable costumes.

Other Halloween problems include minor inconveniences such as lost fillings secondary to nougat, falls from trees while removing toilet paper, and the occasional rotten egg to the posterior occiput. In our household there appears to be a higher than usual incidence of emesis and general abdominal pain.

Turkey Day: Next comes Thanksgiving, a seemingly benign day of turkey consumption and family cheer. The greatest danger of this holiday remains Salmonella, though Campylobacter jejuni lurks somewhere nearby. Undercooked turkey is a potent source of this infection, as are uncooked eggs in cookie dough.

The amount of time to properly thaw and cook a whole turkey, for example, is much longer than the standard-size poultry pieces and cuts of meat served year-round. When thawed correctly in the refrigerator or at a temperature of no more than 40 degrees F, a 20-pound turkey requires two to three days to thaw completely. Thawing the turkey completely before cooking is important. Otherwise, the outside of the turkey will be done before the inside.

To check a turkey for doneness, insert a food thermometer into the inner thigh area near the breast of the turkey (but not touching bone). The turkey is done when the temperature reaches 180 degrees F. If the turkey is stuffed, the temperature of the stuffing should be 165 degrees F. It is not unusual for whole families to fall ill after eating the Thanksgiving feast. Salmonella may be found in turkey, gravy, stuffing, pies, and other foods served at the Thanksgiving dinner.

Another danger of turkey consumption is its high L-tryptophan concentration. Excessive turkey consumption may lead to significant sleepiness, which when combined with substantial alcohol intake may lead to traffic accidents or, at minimum, falling asleep in front of the television. Of course Thanksgiving is not a healthy day for turkeys.

Perhaps the safest thing about Thanksgiving day is the cranberry sauce. If you can get real sauce and not canned, jellied sugar, you might prevent a urinary tract infection caused by E. coli by inhibiting the bacterial podocytes’ adherence to your bladder wall.

Christmas: Christmas can be a time of great stress, especially for the non-Christian members of our society, who are deluged with holiday images. There is an increased incident of suicide over the peri-Christmas timeframe, perhaps worsened by seasonal affective disorder, though there is no study showing higher suicide rates in this time period in the north.

For some unclear reason there’s a higher rate of deadly train collisions and other disasters over Christmas. The year 1910 was an especially bad year, with eight accidents in the United States, England, and France on Christmas Eve and Day with a total mortality of 56 lives.

As per Thanksgiving, the same dietary risks exist at Christmas, along with the addition of deadly bacterially infested homemade eggnog (best to drink the pasteurized variety). Fruitcake, a mysterious substance not currently listed on the periodic table, is used most frequently as a doorstop. In a limited survey of holiday revelers none of the subjects had actually ever eaten any. In all fairness to fruitcakes, Dec. 27 is National Fruitcake Day.

The most dangerous part of Christmas, besides paper cuts from wrapping presents and frustration from assembling bicycles, is the venerable Christmas tree. A tradition that likely started in 16th century Germany, Christmas trees only became accepted in the United States in the mid-1840s. Trees are a fire hazard and can fall, injuring children. The biggest problem, though, is electrocution from holiday lights placed on the tree and home.

In 1999 the New Zealand Ministry of Consumer Affairs’ Energy Safety Service warned consumers to cease using certain types of lights because of a danger of electrocution. Metal objects—especially tinsel—from a Christmas tree could come in contact with the adapter and act as a conductor. Perhaps Charlie Brown’s tree was best after all.

Both Hanukkah and Kwanzaa have candle-lighting ceremonies—the menorah and kinara, respectively—and carry an increased risk of burns and fires.

New Year’s and Valentine’s: New Year’s Eve (aka amateur night) is a chance for those who never stay up late drinking to do so. Other than vehicular manslaughter, a major risk of this evening is stray gunfire. The Los Angeles Police Department has launched a Citywide Gunfire Reduction Campaign for New Year’s because this has become a time to shoot guns. The best-known treatment for over-libation is the ever-popular menudo (a Mexican soup made with hominy and tripe—not the boy band).

Saint Valentine’s Day is another Hallmark bonanza, as well as an amateur day for lovers. There are many myths involving this saint. One legend contends that Valentine was a priest who served during the third century in Rome. When Emperor Claudius II decided that single men made better soldiers than those with wives and families, he outlawed marriage for young men—his crop of potential soldiers. Valentine, realizing the injustice of the decree, defied Claudius and continued to perform marriages for young lovers in secret. When Valentine’s actions were discovered, Claudius ordered that he be put to death.

A less likely version is that while in prison Valentine fell in love with a young girl—his jailer’s daughter—who visited him during his confinement. Before his death he allegedly wrote her a letter, which he signed “From your Valentine,” an expression still in use today.

The dangers of Valentine’s Day are so pervasive and hideous it is difficult to write about them all, so I won’t. Let it be said, though, that from herpes to HIV, lipstick on the collar to lymphogranuloma venereum, lust can kill.

In the South, Mardi Gras ends the dangerous season. Eye trauma from flying beads and sightings of flying monkeys are a constant threat. I have been to Mardi Gras, but this is all I can remember of it.

So ’tis the season to be jolly, to spend time with our loved ones, and to bask in the familial hearth. Bah, hum and bug. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, senior associate consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

It was a dreary cold, December day and I was on call. It had been slow, but that was about to change. An 82-year-old man was admitted to my service with diarrhea, vomiting, fever, and abdominal cramps. He had never had any gastrointestinal problems and was on no medications. The only pertinent history was that his grandson was sick with a similar illness, and his daughter had been sick three days earlier.

Moments later, I received a second call for a preop clearance on a man who had been electrocuted while decorating his house for the holidays. He had fallen and broken his hip. Before I put the phone down the pager went off again—a patient admitted with a glucose level of 820. The light bulb over my head went off: We had entered the Dangerous Season.

What is this season that bodes well for no one? This poorly understood clinical risk factor begins during Halloween and lasts through Christmas, New Year’s, Valentine’s Day, and—in some areas of the country—until Mardi Gras. And now they’re upon us again: the holidays. Our bodies shudder, increasingly deprived of sunlight and oversupplied with calories, as we begin our festive mode.

All Hallow’s Eve: The Dangerous Season starts with Halloween, a pagan ritual. What child would not want to stay up after dark, run around in a mask scaring people, and eat too much candy to commemorate the leprous dead?

Halloween is the most medical of holidays. Many costumes and traditions are related to medicine: Frankenstein’s monster was assembled from body parts obtained by anatomic grave robbers. Mummies are well-preserved corpses, and mummy powder was a traditional remedy for skin ailments for centuries. Vampires may have nutritional deficiencies, and werewolves porphyria. Spider web is a traditional therapy used cutaneously as a styptic and internally for asthma.

For diabetics—especially diabetic children—Halloween is a painful time. In addition, there’s no shortage of pumpkin seed-induced diverticulitis, not to mention the unfortunate periodic occurrence of poisoned candy. According to the American College of Emergency Physicians there’s also a serious increase in risk of injury from collisions with motor vehicles, eye injuries from sharp objects, and burns from flammable costumes.

Other Halloween problems include minor inconveniences such as lost fillings secondary to nougat, falls from trees while removing toilet paper, and the occasional rotten egg to the posterior occiput. In our household there appears to be a higher than usual incidence of emesis and general abdominal pain.

Turkey Day: Next comes Thanksgiving, a seemingly benign day of turkey consumption and family cheer. The greatest danger of this holiday remains Salmonella, though Campylobacter jejuni lurks somewhere nearby. Undercooked turkey is a potent source of this infection, as are uncooked eggs in cookie dough.

The amount of time to properly thaw and cook a whole turkey, for example, is much longer than the standard-size poultry pieces and cuts of meat served year-round. When thawed correctly in the refrigerator or at a temperature of no more than 40 degrees F, a 20-pound turkey requires two to three days to thaw completely. Thawing the turkey completely before cooking is important. Otherwise, the outside of the turkey will be done before the inside.

To check a turkey for doneness, insert a food thermometer into the inner thigh area near the breast of the turkey (but not touching bone). The turkey is done when the temperature reaches 180 degrees F. If the turkey is stuffed, the temperature of the stuffing should be 165 degrees F. It is not unusual for whole families to fall ill after eating the Thanksgiving feast. Salmonella may be found in turkey, gravy, stuffing, pies, and other foods served at the Thanksgiving dinner.

Another danger of turkey consumption is its high L-tryptophan concentration. Excessive turkey consumption may lead to significant sleepiness, which when combined with substantial alcohol intake may lead to traffic accidents or, at minimum, falling asleep in front of the television. Of course Thanksgiving is not a healthy day for turkeys.

Perhaps the safest thing about Thanksgiving day is the cranberry sauce. If you can get real sauce and not canned, jellied sugar, you might prevent a urinary tract infection caused by E. coli by inhibiting the bacterial podocytes’ adherence to your bladder wall.

Christmas: Christmas can be a time of great stress, especially for the non-Christian members of our society, who are deluged with holiday images. There is an increased incident of suicide over the peri-Christmas timeframe, perhaps worsened by seasonal affective disorder, though there is no study showing higher suicide rates in this time period in the north.

For some unclear reason there’s a higher rate of deadly train collisions and other disasters over Christmas. The year 1910 was an especially bad year, with eight accidents in the United States, England, and France on Christmas Eve and Day with a total mortality of 56 lives.

As per Thanksgiving, the same dietary risks exist at Christmas, along with the addition of deadly bacterially infested homemade eggnog (best to drink the pasteurized variety). Fruitcake, a mysterious substance not currently listed on the periodic table, is used most frequently as a doorstop. In a limited survey of holiday revelers none of the subjects had actually ever eaten any. In all fairness to fruitcakes, Dec. 27 is National Fruitcake Day.

The most dangerous part of Christmas, besides paper cuts from wrapping presents and frustration from assembling bicycles, is the venerable Christmas tree. A tradition that likely started in 16th century Germany, Christmas trees only became accepted in the United States in the mid-1840s. Trees are a fire hazard and can fall, injuring children. The biggest problem, though, is electrocution from holiday lights placed on the tree and home.

In 1999 the New Zealand Ministry of Consumer Affairs’ Energy Safety Service warned consumers to cease using certain types of lights because of a danger of electrocution. Metal objects—especially tinsel—from a Christmas tree could come in contact with the adapter and act as a conductor. Perhaps Charlie Brown’s tree was best after all.

Both Hanukkah and Kwanzaa have candle-lighting ceremonies—the menorah and kinara, respectively—and carry an increased risk of burns and fires.

New Year’s and Valentine’s: New Year’s Eve (aka amateur night) is a chance for those who never stay up late drinking to do so. Other than vehicular manslaughter, a major risk of this evening is stray gunfire. The Los Angeles Police Department has launched a Citywide Gunfire Reduction Campaign for New Year’s because this has become a time to shoot guns. The best-known treatment for over-libation is the ever-popular menudo (a Mexican soup made with hominy and tripe—not the boy band).

Saint Valentine’s Day is another Hallmark bonanza, as well as an amateur day for lovers. There are many myths involving this saint. One legend contends that Valentine was a priest who served during the third century in Rome. When Emperor Claudius II decided that single men made better soldiers than those with wives and families, he outlawed marriage for young men—his crop of potential soldiers. Valentine, realizing the injustice of the decree, defied Claudius and continued to perform marriages for young lovers in secret. When Valentine’s actions were discovered, Claudius ordered that he be put to death.

A less likely version is that while in prison Valentine fell in love with a young girl—his jailer’s daughter—who visited him during his confinement. Before his death he allegedly wrote her a letter, which he signed “From your Valentine,” an expression still in use today.

The dangers of Valentine’s Day are so pervasive and hideous it is difficult to write about them all, so I won’t. Let it be said, though, that from herpes to HIV, lipstick on the collar to lymphogranuloma venereum, lust can kill.

In the South, Mardi Gras ends the dangerous season. Eye trauma from flying beads and sightings of flying monkeys are a constant threat. I have been to Mardi Gras, but this is all I can remember of it.

So ’tis the season to be jolly, to spend time with our loved ones, and to bask in the familial hearth. Bah, hum and bug. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, senior associate consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

The forces of our universe are described and measured by a series of laws and equations known collectively as physics. Though we seem far removed from those halcyon (or Halcion) days of college physics, we exist in a universe still ruled by them. In this instance, our world is the hospital.

Strange vectors of force and difficult-to-fathom principles swirl, causing unanticipated changes in our environment. Using the laws of physics we can attempt to understand these forces.

NEWTON’S FIRST LAW: Newton’s first law is a statement about inertia. An object at rest stays at rest; an object in motion stays in motion unless compelled to change its state by the action of an external force. Byzantine bureaucracies maintain a significant amount of inertia. The expression “that’s the way we’ve always done it here” best summarizes this philosophy.

NEWTON’S SECOND LAW: Newton’s second law examines the force necessary to cause the acceleration of an object in relationship to its mass (F=MA). A moderate amount of force applied to a golf ball may send that object 250 yards—hook right, but the same force applied to a dump truck causes no significant motion.

In the hospital, we often see large expenditures of energy resulting in little movement. This is generally an administrative phenomenon.

NEWTON’S THIRD LAW: For every action there is an equal and opposite reaction. This is an important law in the hospital. The most recent example is the change in residents’ work hours. A seemingly simple issue, residents working too many hours leads to a legislative action and mandated hours. This specific alteration has had unintended consequences and affected numerous other systems. In the case of resident work hours the potential advantages in hours worked has led to a potentially adverse effect on such things as continuity and learning—and an increase in demand for hospitalists.

No system changes can occur without consequences, and the trick is to identify those changes before they occur. Luckily most systems have significant inertia, and only the greatest forces cause major change. It takes massive energy expenditure (i.e., government regulation or resident review boards) to solicit the forces adequate to overcome escape velocity and cause change.

Some forces can cause change not by their sheer energy level, but by their strategic placement. A small forceful tap may split a diamond. A call by a resident’s spouse can cause the downfall of a program. An off-hand comment by a colleague can lead to a disastrous malpractice settlement.

CENTRIFUGAL PSEUDOFORCE: A pseudoforce occurs when one moves in a uniform circular motion. Most of us have observed this phenomenon. When you run around in circles like the proverbial decapitated fowl, little is accomplished despite a sensation of energy expended.

A related principle is Brownian motion: Particles in a gas or fluid collide against each other and the walls of the container causing a random motion. At times the hospitalist’s day may feel that way: active movement but much of it nondirectional.

COPERNICAN PRINCIPLE: The idea, suggested by Copernicus was that the sun—not the earth—is the center of this universe. This is an essential point for hospitalists to remember. We spend hours rounding on our patients. We must always remember that the physician is not the center of the universe for the hospitalized patient. As the name suggests, when we “round” we are the satellite.

CAUSALITY PRINCIPLE: Cause must follow effect. This is a dangerous theory exemplified by the classic post-hoc, prompter hoc: Because I did something, something happened.

When applied to patients, the causality principle can mislead. The fever went down when the antibiotic was started. Coincidence or causality? We hired a hospitalist and our length of stay went down. Coincidence or causality?

THE THEORY OF RELATIVITY: Einstein’s famous equation E=mc2 represents his theory of relativity. This equation represents the relationship between an object’s mass and its energy. Mass is represented by the formula M=DV where D is density and V=volume.

In a hospital setting we see this formula used in a corollary to Einstein’s, called the Theory of Relatives. When entering a patient’s room, one is often confronted with a large number of relatives, spouses, siblings, and the dreaded estranged children. These situations almost always require an increased amount of energy expenditure in communication, consensus building, and time.

As the absolute number (or volume) of family members increases, concurrent with any increased density on the individual members’ part, energy expenditure increases dramatically. This follows the mass equation closely. In situations where the density of an individual family member increases beyond measurable levels, one can enter a Black Hole scenario (see illustration).

BLACK HOLES: A black hole is a region of space-time from which nothing can escape—even light.

A black hole is a region of such extreme density that all energy is sucked into its gravitational field. Once exposed to a black hole situation, the observer may note expected phenomena, including absence of light, loss of energy, extreme fatigue and malaise, and a sensation of hopelessness. This effect can be seen in committee rooms or on the wards.

The only known remedies for this condition are avoidance or going off-service.

THE GIBBS FREE ENERGY EQUATION: The Gibbs free energy equation, G=H-(TS), is a thermodynamic formula and a measure of the conservation of energy. Simply put, the energy of a system is related to the enthalpy (H) or positive creative energy input minus the product of time and entropy, the natural tendency of systems to fall apart.

This effect can be seen in the creation of hospitalist programs.

A hospitalist program is sometimes created by an energetic entrepreneur responding to a vacuum or potential space. A great design leads to a functional program (G). The hospitalist (H) must continually put energy into maintaining the system, otherwise over time (T) entropy (S) takes hold and the system deteriorates. A hospitalist program can’t rely on its initial successful design to survive.

PARTICLE WAVE DUALITY: Quanta are bundles of energy. We see these basic units in the hospital on a nonsubatomic level.

Our admissions seem to come in waves. Our daily workload seems to come in waves as well. Yet the essential quantum of hospital medicine is the patient. RVUs may be 1.33, and LOS 3.2 days, and FTEs 0.8, but I have yet to see a patient-and-a-half in a room.

CRITICAL MASS: Critical mass is the smallest amount of fissionable material necessary to maintain a nuclear chain reaction at a constant level. The term is also used to denote an amount or level needed for a specific result or new action to occur. Happily the hospitalist movement in America has reached that self-sustaining critical mass.

CONCLUSION: As Sir Isaac Newton sat under the proverbial tree and watched a ripe Granny Smith drop on his noggin, little did he know how profoundly he would affect the world of hospital medicine. What goes up must come down. The patient admitted must be discharged. And the editorial started must eventually finish. TH

Jamie Newman, MD, FACP, is physician editor of The Hopitalist, and senior associate consultant, Hospital Internal Medicine and associate professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

The forces of our universe are described and measured by a series of laws and equations known collectively as physics. Though we seem far removed from those halcyon (or Halcion) days of college physics, we exist in a universe still ruled by them. In this instance, our world is the hospital.

Strange vectors of force and difficult-to-fathom principles swirl, causing unanticipated changes in our environment. Using the laws of physics we can attempt to understand these forces.

NEWTON’S FIRST LAW: Newton’s first law is a statement about inertia. An object at rest stays at rest; an object in motion stays in motion unless compelled to change its state by the action of an external force. Byzantine bureaucracies maintain a significant amount of inertia. The expression “that’s the way we’ve always done it here” best summarizes this philosophy.

NEWTON’S SECOND LAW: Newton’s second law examines the force necessary to cause the acceleration of an object in relationship to its mass (F=MA). A moderate amount of force applied to a golf ball may send that object 250 yards—hook right, but the same force applied to a dump truck causes no significant motion.

In the hospital, we often see large expenditures of energy resulting in little movement. This is generally an administrative phenomenon.

NEWTON’S THIRD LAW: For every action there is an equal and opposite reaction. This is an important law in the hospital. The most recent example is the change in residents’ work hours. A seemingly simple issue, residents working too many hours leads to a legislative action and mandated hours. This specific alteration has had unintended consequences and affected numerous other systems. In the case of resident work hours the potential advantages in hours worked has led to a potentially adverse effect on such things as continuity and learning—and an increase in demand for hospitalists.

No system changes can occur without consequences, and the trick is to identify those changes before they occur. Luckily most systems have significant inertia, and only the greatest forces cause major change. It takes massive energy expenditure (i.e., government regulation or resident review boards) to solicit the forces adequate to overcome escape velocity and cause change.

Some forces can cause change not by their sheer energy level, but by their strategic placement. A small forceful tap may split a diamond. A call by a resident’s spouse can cause the downfall of a program. An off-hand comment by a colleague can lead to a disastrous malpractice settlement.

CENTRIFUGAL PSEUDOFORCE: A pseudoforce occurs when one moves in a uniform circular motion. Most of us have observed this phenomenon. When you run around in circles like the proverbial decapitated fowl, little is accomplished despite a sensation of energy expended.

A related principle is Brownian motion: Particles in a gas or fluid collide against each other and the walls of the container causing a random motion. At times the hospitalist’s day may feel that way: active movement but much of it nondirectional.

COPERNICAN PRINCIPLE: The idea, suggested by Copernicus was that the sun—not the earth—is the center of this universe. This is an essential point for hospitalists to remember. We spend hours rounding on our patients. We must always remember that the physician is not the center of the universe for the hospitalized patient. As the name suggests, when we “round” we are the satellite.

CAUSALITY PRINCIPLE: Cause must follow effect. This is a dangerous theory exemplified by the classic post-hoc, prompter hoc: Because I did something, something happened.

When applied to patients, the causality principle can mislead. The fever went down when the antibiotic was started. Coincidence or causality? We hired a hospitalist and our length of stay went down. Coincidence or causality?

THE THEORY OF RELATIVITY: Einstein’s famous equation E=mc2 represents his theory of relativity. This equation represents the relationship between an object’s mass and its energy. Mass is represented by the formula M=DV where D is density and V=volume.

In a hospital setting we see this formula used in a corollary to Einstein’s, called the Theory of Relatives. When entering a patient’s room, one is often confronted with a large number of relatives, spouses, siblings, and the dreaded estranged children. These situations almost always require an increased amount of energy expenditure in communication, consensus building, and time.

As the absolute number (or volume) of family members increases, concurrent with any increased density on the individual members’ part, energy expenditure increases dramatically. This follows the mass equation closely. In situations where the density of an individual family member increases beyond measurable levels, one can enter a Black Hole scenario (see illustration).

BLACK HOLES: A black hole is a region of space-time from which nothing can escape—even light.

A black hole is a region of such extreme density that all energy is sucked into its gravitational field. Once exposed to a black hole situation, the observer may note expected phenomena, including absence of light, loss of energy, extreme fatigue and malaise, and a sensation of hopelessness. This effect can be seen in committee rooms or on the wards.

The only known remedies for this condition are avoidance or going off-service.

THE GIBBS FREE ENERGY EQUATION: The Gibbs free energy equation, G=H-(TS), is a thermodynamic formula and a measure of the conservation of energy. Simply put, the energy of a system is related to the enthalpy (H) or positive creative energy input minus the product of time and entropy, the natural tendency of systems to fall apart.

This effect can be seen in the creation of hospitalist programs.

A hospitalist program is sometimes created by an energetic entrepreneur responding to a vacuum or potential space. A great design leads to a functional program (G). The hospitalist (H) must continually put energy into maintaining the system, otherwise over time (T) entropy (S) takes hold and the system deteriorates. A hospitalist program can’t rely on its initial successful design to survive.

PARTICLE WAVE DUALITY: Quanta are bundles of energy. We see these basic units in the hospital on a nonsubatomic level.

Our admissions seem to come in waves. Our daily workload seems to come in waves as well. Yet the essential quantum of hospital medicine is the patient. RVUs may be 1.33, and LOS 3.2 days, and FTEs 0.8, but I have yet to see a patient-and-a-half in a room.

CRITICAL MASS: Critical mass is the smallest amount of fissionable material necessary to maintain a nuclear chain reaction at a constant level. The term is also used to denote an amount or level needed for a specific result or new action to occur. Happily the hospitalist movement in America has reached that self-sustaining critical mass.

CONCLUSION: As Sir Isaac Newton sat under the proverbial tree and watched a ripe Granny Smith drop on his noggin, little did he know how profoundly he would affect the world of hospital medicine. What goes up must come down. The patient admitted must be discharged. And the editorial started must eventually finish. TH

Jamie Newman, MD, FACP, is physician editor of The Hopitalist, and senior associate consultant, Hospital Internal Medicine and associate professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

The forces of our universe are described and measured by a series of laws and equations known collectively as physics. Though we seem far removed from those halcyon (or Halcion) days of college physics, we exist in a universe still ruled by them. In this instance, our world is the hospital.

Strange vectors of force and difficult-to-fathom principles swirl, causing unanticipated changes in our environment. Using the laws of physics we can attempt to understand these forces.

NEWTON’S FIRST LAW: Newton’s first law is a statement about inertia. An object at rest stays at rest; an object in motion stays in motion unless compelled to change its state by the action of an external force. Byzantine bureaucracies maintain a significant amount of inertia. The expression “that’s the way we’ve always done it here” best summarizes this philosophy.

NEWTON’S SECOND LAW: Newton’s second law examines the force necessary to cause the acceleration of an object in relationship to its mass (F=MA). A moderate amount of force applied to a golf ball may send that object 250 yards—hook right, but the same force applied to a dump truck causes no significant motion.

In the hospital, we often see large expenditures of energy resulting in little movement. This is generally an administrative phenomenon.

NEWTON’S THIRD LAW: For every action there is an equal and opposite reaction. This is an important law in the hospital. The most recent example is the change in residents’ work hours. A seemingly simple issue, residents working too many hours leads to a legislative action and mandated hours. This specific alteration has had unintended consequences and affected numerous other systems. In the case of resident work hours the potential advantages in hours worked has led to a potentially adverse effect on such things as continuity and learning—and an increase in demand for hospitalists.

No system changes can occur without consequences, and the trick is to identify those changes before they occur. Luckily most systems have significant inertia, and only the greatest forces cause major change. It takes massive energy expenditure (i.e., government regulation or resident review boards) to solicit the forces adequate to overcome escape velocity and cause change.

Some forces can cause change not by their sheer energy level, but by their strategic placement. A small forceful tap may split a diamond. A call by a resident’s spouse can cause the downfall of a program. An off-hand comment by a colleague can lead to a disastrous malpractice settlement.

CENTRIFUGAL PSEUDOFORCE: A pseudoforce occurs when one moves in a uniform circular motion. Most of us have observed this phenomenon. When you run around in circles like the proverbial decapitated fowl, little is accomplished despite a sensation of energy expended.

A related principle is Brownian motion: Particles in a gas or fluid collide against each other and the walls of the container causing a random motion. At times the hospitalist’s day may feel that way: active movement but much of it nondirectional.

COPERNICAN PRINCIPLE: The idea, suggested by Copernicus was that the sun—not the earth—is the center of this universe. This is an essential point for hospitalists to remember. We spend hours rounding on our patients. We must always remember that the physician is not the center of the universe for the hospitalized patient. As the name suggests, when we “round” we are the satellite.

CAUSALITY PRINCIPLE: Cause must follow effect. This is a dangerous theory exemplified by the classic post-hoc, prompter hoc: Because I did something, something happened.

When applied to patients, the causality principle can mislead. The fever went down when the antibiotic was started. Coincidence or causality? We hired a hospitalist and our length of stay went down. Coincidence or causality?

THE THEORY OF RELATIVITY: Einstein’s famous equation E=mc2 represents his theory of relativity. This equation represents the relationship between an object’s mass and its energy. Mass is represented by the formula M=DV where D is density and V=volume.

In a hospital setting we see this formula used in a corollary to Einstein’s, called the Theory of Relatives. When entering a patient’s room, one is often confronted with a large number of relatives, spouses, siblings, and the dreaded estranged children. These situations almost always require an increased amount of energy expenditure in communication, consensus building, and time.

As the absolute number (or volume) of family members increases, concurrent with any increased density on the individual members’ part, energy expenditure increases dramatically. This follows the mass equation closely. In situations where the density of an individual family member increases beyond measurable levels, one can enter a Black Hole scenario (see illustration).

BLACK HOLES: A black hole is a region of space-time from which nothing can escape—even light.

A black hole is a region of such extreme density that all energy is sucked into its gravitational field. Once exposed to a black hole situation, the observer may note expected phenomena, including absence of light, loss of energy, extreme fatigue and malaise, and a sensation of hopelessness. This effect can be seen in committee rooms or on the wards.

The only known remedies for this condition are avoidance or going off-service.

THE GIBBS FREE ENERGY EQUATION: The Gibbs free energy equation, G=H-(TS), is a thermodynamic formula and a measure of the conservation of energy. Simply put, the energy of a system is related to the enthalpy (H) or positive creative energy input minus the product of time and entropy, the natural tendency of systems to fall apart.

This effect can be seen in the creation of hospitalist programs.

A hospitalist program is sometimes created by an energetic entrepreneur responding to a vacuum or potential space. A great design leads to a functional program (G). The hospitalist (H) must continually put energy into maintaining the system, otherwise over time (T) entropy (S) takes hold and the system deteriorates. A hospitalist program can’t rely on its initial successful design to survive.

PARTICLE WAVE DUALITY: Quanta are bundles of energy. We see these basic units in the hospital on a nonsubatomic level.

Our admissions seem to come in waves. Our daily workload seems to come in waves as well. Yet the essential quantum of hospital medicine is the patient. RVUs may be 1.33, and LOS 3.2 days, and FTEs 0.8, but I have yet to see a patient-and-a-half in a room.

CRITICAL MASS: Critical mass is the smallest amount of fissionable material necessary to maintain a nuclear chain reaction at a constant level. The term is also used to denote an amount or level needed for a specific result or new action to occur. Happily the hospitalist movement in America has reached that self-sustaining critical mass.

CONCLUSION: As Sir Isaac Newton sat under the proverbial tree and watched a ripe Granny Smith drop on his noggin, little did he know how profoundly he would affect the world of hospital medicine. What goes up must come down. The patient admitted must be discharged. And the editorial started must eventually finish. TH

Jamie Newman, MD, FACP, is physician editor of The Hopitalist, and senior associate consultant, Hospital Internal Medicine and associate professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

I was in my office perusing patient records when I got the call. I’d been selected to be the new Physician Editor of The Hospitalist. I felt surprised—and excited. Then, harsh reality set in: My first deadline was only three weeks away. I checked my pulse—117 and irregularly irregular, good. I brewed some foxglove tea, chewed on some willow bark, and prepared to work.

Deja Vu

I found myself experiencing an unusual sensation. What was the emotion I was feeling? A fine mixture of dread and excitement, with an overlay of angst. I’d had this sensation before, but when?

I looked at the May issue of The Hospitalist. How was I going to continue to produce a quality publication—and improve upon it? The people who had supported my selection as editor were counting on me; my mom was counting on me. Heck, even I was even counting on me.

I drew a blank. Where would I go with this? That’s when it hit me: the sense of being in a situation that I wanted, only to discover I wasn’t ready. The tidal forces of time and pressure descended upon me.

In a flash I knew what was happening. I was suffering from delayed post-traumatic residency syndrome. It was 1985, and I was back in Houston’s old Ben Taub Hospital. (Reminiscing is a sure sign of early senescence.) I was the intern coming on service, a very busy general medicine service. Among my new patients, I had to pick up an elderly gentleman who had been ill for years and who had been in the hospital for more than a month. His chart was missing, he was unresponsive, and his family was AWOL.

My beeper kept going off. There was a code on the other side of the hospital, and the ED was calling. Should I give the patient heparin? How do I dose it? Should I give antibiotics and, if so, which ones? Should I draw blood cultures? My circuits totally overloaded.

My resident came to my rescue, with a cup of coffee and good advice: Settle down, find the old records, obtain a history, and perform a physical exam before I even thought about therapeutic intervention.

This was exactly what I needed to do as physician editor. I turned to my current resident-equivalent, in this case Lisa Dionne from John Wiley & Sons—the editorial Yang to my Yin. She gave me the same advice my resident had decades before: Get the back issues of The Hospitalist from SHM, see where it was going, where it had been, learn the terminology, and get organized. Luckily the SHM staff is a lot more responsive then the medical records department at Ben Taub was.

Then, as with any patient, I had to ask some basic questions. What initial symptoms caused the development of The Hospitalist? How long had the publication been present? What made it better, and what made it worse? Was it progressing or was it unchanged? Was I having chest pain? What was SHM, and why did it exist? What did a hospitalist want to read? What was a hospitalist, and why would anyone want to be one?

Why I’m a Hospitalist

That final question seemed the heart of my issue. I pondered what forces drove me to become a hospitalist and why I enjoyed it so much.

When I finished my residency I went into private practice. Like most residents of the time I was totally unprepared for ambulatory care. I could run a code, knew all the latest diagnostic tests, and could even quote a few articles.

But the first time I saw a young man with chronic back pain who wanted to go on disability, or an elderly lady with osteoporosis and breast cancer who wondered if she could take quinine for leg cramps, I was lost. It only took a decade or two for me to feel vaguely competent. Meantime I did some hard time in the hospital, but my focus shifted tectonically toward the outpatient. When my running partner Mitchell Wilson decided to start one of the early hospitalist programs (at the University of Texas) my hospital time ever more rapidly receded.

At the same time, the forces of capitalism were at work: IPAs and IPOs, practice management groups, university expansions and contractions, hospital closings. This was the new shifting sand (or shifting dullness) of medical practice. I was ready for a change, but could I give up my comfortably cluttered office, my established, fairly well-tuned patients, my six-year-old National Geographic magazines in the waiting room? Would going back to the hospital feel like being a resident again? There was only one way to find out.

I said goodbye to the beach and the fire ants, loaded my truck like Jed Clampett, and moved to Rochester—Minn., that is—frozen tundra, lots of geese. Under the auspices of Jeanne Huddleston and the Mayo Clinic Inpatient Internal Medicine Team, I joined the world of hospitalists.

New Beginnings

My first impression of life as a hospitalist was that I was cold. Frigid really. Of course it was winter in Minnesota, so I guess I should have expected that. I rapidly discovered that it was a lot nicer being a member of the consulting staff than a member of the house staff. In some ways I felt like an intern again. It was difficult to believe, but hospital medicine had changed over the last decade or two; however, the patients hadn’t.

I was armed with acceptable history taking and exam skills. I had a superb support system in the nurse practitioners and physician assistants who carried my load the first few weeks. My colleagues were supportive. I muddled through and, after several years, felt like I was back to my baseline level of moderate competence.

Though my story is immensely fascinating (to me) from an autobiographical standpoint, does it answer the question of why I enjoy being a hospitalist? Usually people ask me, “What is a hospitalist?” I usually explain that I’m an internist—not an intern—though some days I feel like the latter. The taxonomy of hospitalists is fairly diverse. Some of us come straight from residency, for others it’s the resolution of a mid-career crisis.

One of my favorite things about being a hospitalist is the control I have over my schedule. As an outpatient doctor I had a timetable to keep based on the waiting patient. If I got behind, waxed conversational, or got involved with a family, my day was ruined. Patients got mad at me; my nurses were aggravated.

In the hospital, I have a body of work I must do each day. It’s predictably unpredictable at the beginning of the shift. I have a certain number of patients to see, discharge, and admit. I risk acute medical emergencies, unexpected families who want an update on their mother’s condition, and similar hospitalist activities of daily life (aka HADLs). The volume of work is variable: Some days are difficult, some aren’t. The complexity of cases is stimulating and makes continued learning a necessity. Instead of being isolated in an office I interact with other physicians and staff. The most stimulating aspect I experience is the sensation that hospital medicine is an evolving field and there are hundreds of dedicated colleagues out there trying to make it better.

My goal as physician editor is to work with SHM members to continue to produce a great source of hospitalist information. The Hospitalist readers include internists, family practitioners, pediatricians, nurse practitioners, and physician assistants. They also comprise administrators, businesspeople, and legislators. I perceive important topics to involve medical management, education, communication, economics, government regulation, ethics, and palliative care, as well as the activities of our society, chapters, and members.

With the team from John Wiley & Sons and the support of SHM administration and the members, I hope to accomplish this task. My patient all those years ago survived and left the hospital. I only can hope that The Hospitalist will thrive as well. TH

Jamie Newman, MD, FACP, is senior associate consultant, Hospital Internal Medicine, associate professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

I was in my office perusing patient records when I got the call. I’d been selected to be the new Physician Editor of The Hospitalist. I felt surprised—and excited. Then, harsh reality set in: My first deadline was only three weeks away. I checked my pulse—117 and irregularly irregular, good. I brewed some foxglove tea, chewed on some willow bark, and prepared to work.

Deja Vu

I found myself experiencing an unusual sensation. What was the emotion I was feeling? A fine mixture of dread and excitement, with an overlay of angst. I’d had this sensation before, but when?

I looked at the May issue of The Hospitalist. How was I going to continue to produce a quality publication—and improve upon it? The people who had supported my selection as editor were counting on me; my mom was counting on me. Heck, even I was even counting on me.

I drew a blank. Where would I go with this? That’s when it hit me: the sense of being in a situation that I wanted, only to discover I wasn’t ready. The tidal forces of time and pressure descended upon me.

In a flash I knew what was happening. I was suffering from delayed post-traumatic residency syndrome. It was 1985, and I was back in Houston’s old Ben Taub Hospital. (Reminiscing is a sure sign of early senescence.) I was the intern coming on service, a very busy general medicine service. Among my new patients, I had to pick up an elderly gentleman who had been ill for years and who had been in the hospital for more than a month. His chart was missing, he was unresponsive, and his family was AWOL.

My beeper kept going off. There was a code on the other side of the hospital, and the ED was calling. Should I give the patient heparin? How do I dose it? Should I give antibiotics and, if so, which ones? Should I draw blood cultures? My circuits totally overloaded.

My resident came to my rescue, with a cup of coffee and good advice: Settle down, find the old records, obtain a history, and perform a physical exam before I even thought about therapeutic intervention.

This was exactly what I needed to do as physician editor. I turned to my current resident-equivalent, in this case Lisa Dionne from John Wiley & Sons—the editorial Yang to my Yin. She gave me the same advice my resident had decades before: Get the back issues of The Hospitalist from SHM, see where it was going, where it had been, learn the terminology, and get organized. Luckily the SHM staff is a lot more responsive then the medical records department at Ben Taub was.

Then, as with any patient, I had to ask some basic questions. What initial symptoms caused the development of The Hospitalist? How long had the publication been present? What made it better, and what made it worse? Was it progressing or was it unchanged? Was I having chest pain? What was SHM, and why did it exist? What did a hospitalist want to read? What was a hospitalist, and why would anyone want to be one?

Why I’m a Hospitalist

That final question seemed the heart of my issue. I pondered what forces drove me to become a hospitalist and why I enjoyed it so much.

When I finished my residency I went into private practice. Like most residents of the time I was totally unprepared for ambulatory care. I could run a code, knew all the latest diagnostic tests, and could even quote a few articles.

But the first time I saw a young man with chronic back pain who wanted to go on disability, or an elderly lady with osteoporosis and breast cancer who wondered if she could take quinine for leg cramps, I was lost. It only took a decade or two for me to feel vaguely competent. Meantime I did some hard time in the hospital, but my focus shifted tectonically toward the outpatient. When my running partner Mitchell Wilson decided to start one of the early hospitalist programs (at the University of Texas) my hospital time ever more rapidly receded.

At the same time, the forces of capitalism were at work: IPAs and IPOs, practice management groups, university expansions and contractions, hospital closings. This was the new shifting sand (or shifting dullness) of medical practice. I was ready for a change, but could I give up my comfortably cluttered office, my established, fairly well-tuned patients, my six-year-old National Geographic magazines in the waiting room? Would going back to the hospital feel like being a resident again? There was only one way to find out.

I said goodbye to the beach and the fire ants, loaded my truck like Jed Clampett, and moved to Rochester—Minn., that is—frozen tundra, lots of geese. Under the auspices of Jeanne Huddleston and the Mayo Clinic Inpatient Internal Medicine Team, I joined the world of hospitalists.

New Beginnings

My first impression of life as a hospitalist was that I was cold. Frigid really. Of course it was winter in Minnesota, so I guess I should have expected that. I rapidly discovered that it was a lot nicer being a member of the consulting staff than a member of the house staff. In some ways I felt like an intern again. It was difficult to believe, but hospital medicine had changed over the last decade or two; however, the patients hadn’t.

I was armed with acceptable history taking and exam skills. I had a superb support system in the nurse practitioners and physician assistants who carried my load the first few weeks. My colleagues were supportive. I muddled through and, after several years, felt like I was back to my baseline level of moderate competence.

Though my story is immensely fascinating (to me) from an autobiographical standpoint, does it answer the question of why I enjoy being a hospitalist? Usually people ask me, “What is a hospitalist?” I usually explain that I’m an internist—not an intern—though some days I feel like the latter. The taxonomy of hospitalists is fairly diverse. Some of us come straight from residency, for others it’s the resolution of a mid-career crisis.

One of my favorite things about being a hospitalist is the control I have over my schedule. As an outpatient doctor I had a timetable to keep based on the waiting patient. If I got behind, waxed conversational, or got involved with a family, my day was ruined. Patients got mad at me; my nurses were aggravated.

In the hospital, I have a body of work I must do each day. It’s predictably unpredictable at the beginning of the shift. I have a certain number of patients to see, discharge, and admit. I risk acute medical emergencies, unexpected families who want an update on their mother’s condition, and similar hospitalist activities of daily life (aka HADLs). The volume of work is variable: Some days are difficult, some aren’t. The complexity of cases is stimulating and makes continued learning a necessity. Instead of being isolated in an office I interact with other physicians and staff. The most stimulating aspect I experience is the sensation that hospital medicine is an evolving field and there are hundreds of dedicated colleagues out there trying to make it better.

My goal as physician editor is to work with SHM members to continue to produce a great source of hospitalist information. The Hospitalist readers include internists, family practitioners, pediatricians, nurse practitioners, and physician assistants. They also comprise administrators, businesspeople, and legislators. I perceive important topics to involve medical management, education, communication, economics, government regulation, ethics, and palliative care, as well as the activities of our society, chapters, and members.

With the team from John Wiley & Sons and the support of SHM administration and the members, I hope to accomplish this task. My patient all those years ago survived and left the hospital. I only can hope that The Hospitalist will thrive as well. TH

Jamie Newman, MD, FACP, is senior associate consultant, Hospital Internal Medicine, associate professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

I was in my office perusing patient records when I got the call. I’d been selected to be the new Physician Editor of The Hospitalist. I felt surprised—and excited. Then, harsh reality set in: My first deadline was only three weeks away. I checked my pulse—117 and irregularly irregular, good. I brewed some foxglove tea, chewed on some willow bark, and prepared to work.

Deja Vu

I found myself experiencing an unusual sensation. What was the emotion I was feeling? A fine mixture of dread and excitement, with an overlay of angst. I’d had this sensation before, but when?

I looked at the May issue of The Hospitalist. How was I going to continue to produce a quality publication—and improve upon it? The people who had supported my selection as editor were counting on me; my mom was counting on me. Heck, even I was even counting on me.

I drew a blank. Where would I go with this? That’s when it hit me: the sense of being in a situation that I wanted, only to discover I wasn’t ready. The tidal forces of time and pressure descended upon me.

In a flash I knew what was happening. I was suffering from delayed post-traumatic residency syndrome. It was 1985, and I was back in Houston’s old Ben Taub Hospital. (Reminiscing is a sure sign of early senescence.) I was the intern coming on service, a very busy general medicine service. Among my new patients, I had to pick up an elderly gentleman who had been ill for years and who had been in the hospital for more than a month. His chart was missing, he was unresponsive, and his family was AWOL.

My beeper kept going off. There was a code on the other side of the hospital, and the ED was calling. Should I give the patient heparin? How do I dose it? Should I give antibiotics and, if so, which ones? Should I draw blood cultures? My circuits totally overloaded.

My resident came to my rescue, with a cup of coffee and good advice: Settle down, find the old records, obtain a history, and perform a physical exam before I even thought about therapeutic intervention.

This was exactly what I needed to do as physician editor. I turned to my current resident-equivalent, in this case Lisa Dionne from John Wiley & Sons—the editorial Yang to my Yin. She gave me the same advice my resident had decades before: Get the back issues of The Hospitalist from SHM, see where it was going, where it had been, learn the terminology, and get organized. Luckily the SHM staff is a lot more responsive then the medical records department at Ben Taub was.

Then, as with any patient, I had to ask some basic questions. What initial symptoms caused the development of The Hospitalist? How long had the publication been present? What made it better, and what made it worse? Was it progressing or was it unchanged? Was I having chest pain? What was SHM, and why did it exist? What did a hospitalist want to read? What was a hospitalist, and why would anyone want to be one?

Why I’m a Hospitalist

That final question seemed the heart of my issue. I pondered what forces drove me to become a hospitalist and why I enjoyed it so much.

When I finished my residency I went into private practice. Like most residents of the time I was totally unprepared for ambulatory care. I could run a code, knew all the latest diagnostic tests, and could even quote a few articles.

But the first time I saw a young man with chronic back pain who wanted to go on disability, or an elderly lady with osteoporosis and breast cancer who wondered if she could take quinine for leg cramps, I was lost. It only took a decade or two for me to feel vaguely competent. Meantime I did some hard time in the hospital, but my focus shifted tectonically toward the outpatient. When my running partner Mitchell Wilson decided to start one of the early hospitalist programs (at the University of Texas) my hospital time ever more rapidly receded.

At the same time, the forces of capitalism were at work: IPAs and IPOs, practice management groups, university expansions and contractions, hospital closings. This was the new shifting sand (or shifting dullness) of medical practice. I was ready for a change, but could I give up my comfortably cluttered office, my established, fairly well-tuned patients, my six-year-old National Geographic magazines in the waiting room? Would going back to the hospital feel like being a resident again? There was only one way to find out.

I said goodbye to the beach and the fire ants, loaded my truck like Jed Clampett, and moved to Rochester—Minn., that is—frozen tundra, lots of geese. Under the auspices of Jeanne Huddleston and the Mayo Clinic Inpatient Internal Medicine Team, I joined the world of hospitalists.

New Beginnings

My first impression of life as a hospitalist was that I was cold. Frigid really. Of course it was winter in Minnesota, so I guess I should have expected that. I rapidly discovered that it was a lot nicer being a member of the consulting staff than a member of the house staff. In some ways I felt like an intern again. It was difficult to believe, but hospital medicine had changed over the last decade or two; however, the patients hadn’t.

I was armed with acceptable history taking and exam skills. I had a superb support system in the nurse practitioners and physician assistants who carried my load the first few weeks. My colleagues were supportive. I muddled through and, after several years, felt like I was back to my baseline level of moderate competence.

Though my story is immensely fascinating (to me) from an autobiographical standpoint, does it answer the question of why I enjoy being a hospitalist? Usually people ask me, “What is a hospitalist?” I usually explain that I’m an internist—not an intern—though some days I feel like the latter. The taxonomy of hospitalists is fairly diverse. Some of us come straight from residency, for others it’s the resolution of a mid-career crisis.

One of my favorite things about being a hospitalist is the control I have over my schedule. As an outpatient doctor I had a timetable to keep based on the waiting patient. If I got behind, waxed conversational, or got involved with a family, my day was ruined. Patients got mad at me; my nurses were aggravated.

In the hospital, I have a body of work I must do each day. It’s predictably unpredictable at the beginning of the shift. I have a certain number of patients to see, discharge, and admit. I risk acute medical emergencies, unexpected families who want an update on their mother’s condition, and similar hospitalist activities of daily life (aka HADLs). The volume of work is variable: Some days are difficult, some aren’t. The complexity of cases is stimulating and makes continued learning a necessity. Instead of being isolated in an office I interact with other physicians and staff. The most stimulating aspect I experience is the sensation that hospital medicine is an evolving field and there are hundreds of dedicated colleagues out there trying to make it better.

My goal as physician editor is to work with SHM members to continue to produce a great source of hospitalist information. The Hospitalist readers include internists, family practitioners, pediatricians, nurse practitioners, and physician assistants. They also comprise administrators, businesspeople, and legislators. I perceive important topics to involve medical management, education, communication, economics, government regulation, ethics, and palliative care, as well as the activities of our society, chapters, and members.

With the team from John Wiley & Sons and the support of SHM administration and the members, I hope to accomplish this task. My patient all those years ago survived and left the hospital. I only can hope that The Hospitalist will thrive as well. TH

Jamie Newman, MD, FACP, is senior associate consultant, Hospital Internal Medicine, associate professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.