With Medical Errors, is the “July Effect” Fact or Fiction?

by Godfrey Onime

Tired resident
From Well-Being Index

At the physicians’ lounge recently, a colleague asked me, “How are the new interns? Aren’t you glad another July is over?”

I told him that our new class of first-year medical residents, or interns as they are commonly called, seemed quite strong. As for his celebratory comments about the vanquishing of July, I knew what he meant. After all, a common sage in American teaching hospitals is, “Don’t get sick in July.” The reason for this sentiment is because that’s when most of the doctors are the most green, or inexperienced.

It happens that when we consider medical errors, the level of experience of a doctor or other healthcare providers — as with any profession for that matter — is quite important. Less experience often equals more mistakes – from writing to accounting to carpentry. These screwups can become learning opportunities for these professionals. But medicine is different. Often, people die.

The so-called July effect in American teaching hospitals is one example of how inexperience can come to bear in the vexing world of medical errors. For one, July 1st or thereabout is the date when fresh medical school graduates transform into new interns, ready to practice — on you. That’s when they begin to zig-zag about the hospitals at frenzied paces in their yet shinny, starched white coats and introducing themselves as Dr. Superman (or woman). To truly understand the forces at play here, let’s for a moment get into the head of the new intern.

To snatch their top residency spots, these interns had written wonderful personal essays and got glowing letters of recommendation. They had even, during the residency interviews, explained away any semblance of blemishes in their files, or contextualized any poor grades on their medical schools’ transcripts or standardized test scores.

“I was sick on the day of the test but decided to take it anyway. Heavens knows I’ve learned my lessons.”

“My grandfather had died.”

“I could not do any last-minute reviews of the study materials, because the dog ate my laptop.”

The new medical interns are ecstatic that they got the residency spot and are eager to prove themselves. They are terrified to ask questions for fear of being considered unintelligent, and they fail to ask for help for fear of being thought incompetent — or worse, lazy.

I should know these things; I was an intern once, too.

And so, like myself and the hundreds of thousands of interns before them, these beginning residents do something stupid, miss important clues. And so when they do not kill patients, they risk hurting them.

In a blog post in The Anesthesia Consultant, Richard Novak, MD, an Adjunct Clinical Professor of Anesthesiology, Perioperative and Pain Medicine at Stanford University, recounted a quite telling experience. 

“On July 1st of the first day of my anesthesia residency,” he wrote, “I reported at 0630 hours to the San Jose, California county hospital where I was assigned. I walked into the operating room and stared at the collection of anesthesia apparatus with complete bewilderment. I had no idea how the patient would even be connected to the anesthesia machine.”

How could he know? He had not been oriented to the machines and yet was expected to start work on that day. As it turned out, he had arrived early, ahead of the technicians who stocked the operating rooms, and the hoses had not yet been connected to the machines. 

Soon enough it was time to put their first patient to sleep. Before proceeding, Novak’s supervising faculty anesthesiologist uttered the biggest understatement, “I don’t think the operating room is a good place to learn in the beginning.” 

No kidding! 

The supervising physician then proceeded with injecting sodium pentothal into the patient’s IV and placing the breathing tube into the windpipe. Then he connected the patient to the anesthesia machine. Soon the patient was fast asleep and the surgery began. 

But that was when Novak’s anguish truly started because after ten minutes, the supervising attending Anesthesiologist left to pursue other duties. As Novak reports, “I was alone, under-informed, and full of dread.”

I can only imagine! What if something had gone wrong? Unfortunately, those are the type of sink-or-swim situations that inexperienced interns can find themselves. To compound issues, Novak reports being on call that first night and spent twenty-four hours in the hospital battling case after case until six the next morning.

Not surprising, that 24 hours alone was riddled with one mistake after another. As he tells it, “When I left the hospital I had some rudimentary knowledge of how an anesthetic was done, but I’d failed to successfully place a breathing tube into any patient’s windpipe myself—a faculty member had to do every procedure for me.” As if those were not trying enough, Novak would further recount another experience, which happened after a surgery and he had to stop anesthesia, “I turned off the isoflurane (the predominant gas anesthetic at the time), switched off the ventilator, and waited, wondering why the patient wasn’t waking up.” He would soon enough learn that the isoflurane had no way of escaping the patient’s lungs or brain unless the ventilator is kept on and the patient’s lungs continued to be ventilated.

Of course, the July interns are far from the only cases of inexperience that put hospitalized patients at risk. As it turns out, these trainees are usually supervised. Even with the scenarios which Dr. Novak described, an attending anesthesiologist was never very far away, including during his night call when he could not intubate a patient and a more experienced attending physician helped him.

Predictably, there has been much debate as to the credibility of the so-called July effect–the inexperienced, error-prone interns dashing dangerously about our hospitals. Various research studies have tackled the question and their answers have been no and yes. One study examined 10 years of data on patients undergoing neurosurgery. 

It found that the month of July was no more dangerous than the others, say June or August. But other investigations have found differently–that July patients do indeed fare worse. Research published in the Journal of General Internal Medicine found a 10% increase in fatal medication errors in July, ostensibly due in part to changes resulting from the arrival of the new medical residents. In another study of patients undergoing surgery for spine-related cancer, July patients were more than twice as likely to have a surgical complication and 81% more likely to die, compared with August or June patients. A systematic review of all the research done on the topic has tried to break the tie. They found that many of the studies showing no July effect looked at too few cases and were not as rigorously conducted. On the other hand, the bigger and better-conducted studies tended to find that July is truly a more dangerous and error-prone month in teaching hospitals.

Whether the July effect is a myth or not, it’s hard to imagine that the competence of a beginning medical resident on July 1st can compare with that same physician a year later, on June 30th. In fact, the problem of inexperience in teaching hospitals goes way beyond medical school graduates becoming brand new interns. The old interns also move on to become second years, where, in specialties such as internal medicine, they are now in supervisory, junior residents’ roles. Of course, they would have to adjust to these new responsibilities themselves by the beginning of the new academic year. Add to that the fact that in specialties such as internal medicine, family medicine, and pediatrics, third-year residents who had become the most experienced residents have just graduated and left en-masse by the end of June, now happily replaced by the new interns.

Even so, it would be foolhardy to blame all the errors in medicine– or most of it, for that matter–on the July phenomenon. Hospitals simply can be a dangerous place. Unfortunately, virtually every one of us would someday find ourselves or loved ones seeking care at the hospital–or other health facilities–be it in July or not. To minimize our chances of falling victims to medical errors during such times, some experts have made several recommendations.

  • Always take along a list of current medications, and make sure your records are updated accordingly
  • Be quick to ask questions if you have any concerns about a medication or medical procedure
  • If you are unsure about a diagnosis or treatment recommendation, never hesitate to seek a second opinion. If you are being seen by a resident, physician assistant, or nurse practitioner, ask to speak with their supervising physicians.
  • Of course, we should also take it upon ourselves to help our loved ones who are unable to do these things for themselves remain vigilant.

 July or not, when it comes to preventing medical errors in our hospitals or other healthcare situations, we all owe it to ourselves to always be attentive and diligent in asking questions and understanding what’s being done to us.

As for my colleague who had sounded the celebratory note about the end of July, I reminded him that to prevent medical errors, doctors must never relent — both in our own diligence in caring for patients and in supervising our residents. It may sound cliché, I added, but lives depend on us.

My colleague looked at me as if to suggest I needed a chill pill, but he simply answered, “But of course.”