As noted by Flansbaum and colleagues, we still have much to learn about hospital medicine as an academic career, especially with regards to teaching and burnout. The University of California, San Francisco, academic hospitalist model emphasizes the concurrent roles of both teaching-attending and physician-of-record for essentially all patients on a ward team (1). Given this key role in education as well as clinical care, burnout would have an academic impact extending well beyond the job satisfaction of the individual hospitalist. Because of these high stakes for our entire program, we believe that 6 months of acute care inpatient work is the absolute maximum for an academic hospitalist with concurrent inpatient teaching-attending responsibilities.

In this academic model, the limitation of inpatient "systole" to 4 to 6 months puts substantial pressure on the individual and the system to find meaningful, remunerative activities for the remaining months of "diastole." For some of our hospitalists, diastole includes a significant role as an ambulatory clinician and clinical teacher. For many others, however, diastole focuses on leadership of key teaching programs, inpatient consultation, a hospital administrative role, or funded research. Much like the cardiac cycle, hospitalist diastole is an active process that uses substantial energy, although less intensively than during systole.

Chronic tachycardia produces a cardiomyopathy that is due to catecholamine overstimulation and is exacerbated by inadequate diastole. Cardiomyopathy is often complicated by diastolic dysfunction as well as systolic dysfunction. In my opinion, the durability of hospitalist careers, and hence our ability to attract and retain outstanding physicians to such careers, will be partly related to solving the challenge of systolic load but will be even more dependent on diastole's duration, sustainability, value, and remuneration.