The last few years, each June, there have been numerous discussions, studies, articles, blogs, news reports, and stories about “The July Effect” in medicine. Last May, the Journal of Internal General Medicine published a study titled A July Spike in Fatal Medication Errors: A Possible Effect of New Medical Residents. This study continues to be referred to today. As I read it, I was looking for all possible ways to debunk, question, or find holes in the data review. The study reviewed death certificates in counties across the country and found a spike in deaths caused by fatal medication errors in counties with teaching hospitals vs. counties with non-teaching hospitals. The data examined was from 1979-2006 and was broken down per month, teaching hospital county vs. non teaching hospital county. My first initial thought on this data: medicine and health care changed dramatically in that time frame and across those decades-which makes my review of this data very critical. I would be interested to know fatal medication errors at teaching hospitals in blocks of years 1979-1989, 1990-2000, 2001-2006. The differences in resident training, nursing practice, and hospital treatment is dramatically different as we move through those blocks of years. In 2003/2004 Medical resident work week hours became limited to 80 hours per week, this July 1st year residents (R1) will now be limited to 16 hour shifts. In 1979 many IV and critical care medications were only administered by doctors, now nurses administer almost every medication. Medication safety and patient identification has completely changed in that amount of time as well, especially over the last 5 years as technology has blossomed (Drug infusion pumps weren’t even invented until the mid 1970’s and their use wasn’t common practice until much later). The last five years aren’t even included in the data set and technology and institutional practice has continued to grow and change. Because of this it is difficult for me to agree with the conclusion of this study that:
the July Effect is a significant public health problem.
This effect is also discussed in news articles and blogs. Most recently on the CNN Health blog Dr. Youn wrote an editorial titled “Why you should never go to the hospital in July“? His story, I believe, is mostly anecdotal and would be best suited for TV. As a patient code occurs a nurse pulling just any resident into the room to run a code just doesn’t happen. You need either the resident in charge of the patient or like at my hospital the resident in charge of the patient needs to be at the bedside, the chief medical resident runs the code, and the anesthesiology resident intubates; though until they show up, as the bedside nurse, I’m in charge.
My concern with these studies, articles, and writings is that it gives way more power to the success and failures of medical residents that have just started their careers, than the treatment of the medical team as a whole. The reality of hospital culture in July is so different from the picture that is painted by the stories that are told.
At teaching facilities all over the country, medical students graduate and start their residency rotations, residents all move up a rung on the experience ladder and begin teaching and assuming new roles, medical and surgical fellows begin their specializations, and new attending physicians assume their role of leading the team: all at the end of June/beginning of July. It is a major time of transition. However what is not mentioned is that transition continues throughout the year. Attendings rotate on and off service every 1-2 weeks, residents rotate specialties every month. The nurses at the bedside are the fixture to the health care team. We are there to see these changes and rotations happen weekly. We are there in January, we are there in June, and we are still there in July. We are the leaders and resources on how care is directed on our units. Residents that are new to the hospital and specifically in my instance, to practice in the ICU, understand the knowledge and experience that we as nurses bring to the table and to safe patient care. (They ask us a lot of questions)
I read Dr. Youn’s editorial on the CNN Health blog a few days ago and that very night I worked in the ICU with Amy (obviously not her real name), an R1 on her first night of call on the ICU service. My patient had a few minor condition changes that needed to be tweaked with medications and changes to the ventilator. I paged her and when she called back, I explained the situation and the changes to my patient’s condition. I discussed and clarified my concerns and the solutions that I thought were reasonable a few times to her on the phone. She wasn’t quite sure about her understanding of the problems and concerns I was calling her with, but she told me she would talk to her chief and call me back. I said fine. If it had been a true emergency I would have insisted they come see this patient right away, however there really isn’t anytime like the present for a learning opportunity. I appreciated Amy acknowledging the fact that she didn’t really understand the problem or what to do to fix it. I completely respect that when she found herself smack-dab in the middle of a learning opportunity she grabbed it.
This is the truest representative story about the transitions that occur in teaching hospitals across the country. As an ICU nurse I call the doctor to discuss changes in my patient’s condition. They prescribe changes to medication and treatments based on the patients needs. No one works completely autonomously anymore. As a nurse, I’m in constant conversation with the ICU team about the care of my patient. While I call the R1, they have a responsibility to consult with their more senior leadership as to what is the most appropriate treatment for the patient in this situation. On a daily basis, we round as a team and discuss the patient with the attending present, the resident on call overnight, the resident that will be on call that night, the nurse, the respiratory therapist, the pharmacist, and the nutritionist.
Most hospitals have gone the way of interdisciplinary care and teamwork efforts to treat and care for patients. There is never an instant when a brand new doctor should be on the spot for the medications they prescribe, the treatments that need to be ordered. Interdisciplinary teamwork in hospitals, I believe, makes teaching hospitals one of the safest places to be a patient. If I have a concern about the medication that is prescribed or a test or treatment that is ordered for my patient, I have the responsibility to question it. There is a lengthy medical chain of command that I as a nurse can go up, leading directly to the attending. It is the growing expectation for the safety of the patient, that as nurses, we question everything.
I write very confidently that the burgeoning growth of interdisciplinary teamwork makes teaching hospitals one of the safest and best places to be a patient. The influx of new medical and nursing leadership leads to new innovation and new thought processes. While it can be challenging to be a patient (and a nurse) in an organization with physicians that are constantly new, constantly changing, and constantly coming around the unit in big groups to interrupt report and dishevel your patient’s bed and dressings….(well nurses probably care about that last one more than patients). Being on the edge of innovation and working with physicians that are willing to try new techniques and new procedures to save a patient’s life, is of a value that is impossible to quantify. I have a true respect for the forward thinking and innovation in medical care that comes with always having new medical and nursing providers bringing new research ideas into practice; always working toward improving the quality of patient care.
While working or being cared for by new residents can be challenging. The ideas, knowledge, and fresh insights are important to the future of safe practice and being on the cutting edge in health care.
I will agree with the final part of Dr. Youn’s editorial:
Everyone – even doctors, especially doctors – have to learn and train in order to become proficient. Interns start out as rookies, not seasoned veterans. Experience takes time.
So if you have to go to a hospital in July, treat the new interns with patience and respect.
Then check with your nurse to make sure they know what they’re doing.