Avoid the Hospital in July

Why? New doctors and nurses report to work for the first time, eager to "practice" medicine on you

July is here so you might want to avoid the hospital if at all possible.

Conventional wisdom has long held that the quality of care in hospitals plummets during the month of July. But now a new study published in the Annals of Internal Medicine on July 11 confirms that suspicion. Why is July so problematic?

Because on or around July 1, fresh, inexperienced interns, residents, nurses and other new health care workers first report to work at many of the nation’s hospitals, eager to start practicing medicine — on you.

In medical circles it’s known as the “July effect.”

The new study reviewed data from 39 previous studies that tracked health results in teaching hospitals — including death rates and complications from medical procedures. The best designed and largest studies, the authors found, showed mortality rates increase 4 to 12 percent in July and revealed that many patients remain in the hospital longer, spend more time in surgery and have higher hospital charges in July than in other months.

John Young, M.D., psychiatrist with the University of California San Francisco and co-author of the study, said the “July effect” occurs when new trainees replace experienced physicians. The new doctors have little experience caring for patients, often aren’t well supervised and don’t yet know the hospital system.

Even before this latest research, experts have been wary of July.

“You may get more personal attention, but the skill level isn’t there,” explains veteran physician David Sherer, M.D., past director of risk management for a large insurance provider and coauthor of Dr. David Sherer’s Hospital Survival Guide. “You have newcomers arriving at hospitals — often placed in a sink-or-swim situation — and they don’t know where anything is or how anything is done. July is not the time to have elective surgery or another procedure that could be postponed.”

As a group, these physicians-in-training are “universally supervised,” says Christopher Landrigan, M.D., who teaches at Harvard Medical School and oversees residents at Children’s Hospital Boston. But individually, “from day one, residents are writing medication orders and doing certain procedures and diagnostic tests with relatively little direct supervision, so there’s always an opportunity for something to slip through the safety net.”

That’s not to say that midsummer is the only time for potential problems. After all, some 100,000 Americans die from hospital medical errors each year — thousands every month. “But there is good evidence that errors are somewhat more common when residents first begin to work,” notes Landrigan.

Most studies exploring the July effect focused on seasonal error rates at specific hospitals. But some research in the past few years indicated that, indeed, more medical errors of various types occur in July and early August than other months — especially at teaching hospitals, which train medical interns and residents and are connected with medical schools. July also is a popular month for others, fresh from college, to begin their health care careers at all types of facilities–including nurses, pharmacists and health technicians and therapists.

Last year a large study examined the July effect on a national level — with an alarming finding.

After analyzing more than 62 million death certificates issued across the country from 1979 to 2006, researchers found that fatal medication errors consistently spiked in July by about 10 percent — but only in U.S. counties with many teaching hospitals — and then subsided in August to levels on par with other months. Yet there was no measurable increase in counties with facilities that don’t employ residents, such as community hospitals.

“We were looking for all causes of death occurring in hospitals,” explains study leader David P. Phillips of the University of California, San Diego, whose research was recently published online in the Journal of General Internal Medicine, “and found no increase in death from surgical errors, hospital-acquired infection or other causes in any type of facility — only in fatal medication errors at teaching hospitals.”

His theory: “With surgery, you have a whole team of people working together, so there’s a lot of redundant checking. But residents prescribe or hand out medication alone.”

Still, others say there are other concerns in July beyond the possibility of getting the wrong medication or the wrong dose.

“Whether it’s assisting in surgery or giving an intravenous line, there’s a necessary learning curve that occurs over time,” says Sherer, a practicing anesthesiologist near Washington, D.C. “I’ve seen it myself: The success rate for first-time IVs is not there among new residents and nurses.” Central-line infection rates, which occur from improperly placed IVs, account for nearly 30,000 hospital deaths a year.

How to Protect Yourself From the "July Effect"
Actually, these tips are useful anytime you're admitted to a hospital.

1.Bring your own health records (including a “Personal Medication Record”).
2.Ask a friend, relative or other health advocate to stay with you.
3.To lessen the chance of mix-ups, state your name to anyone providing you with care.
4.Know the name of the doctor who is ultimately in charge of your care.

Sid Kirchheimer writes about health and consumer issues.