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June 22nd, 2011
01:00 PM ET
Why you should never go to the hospital in July
Anthony Youn, M.D., is a plastic surgeon in Metro Detroit. He is the author of “In Stitches,” a humorous memoir about growing up Asian American and becoming a doctor. Do not get sick in July. Why? You might die. A 2011 study published by the Journal of General Internal Medicine reported a 10% spike in teaching hospital deaths during the month of July due to medical errors. We call this spike “The July Effect” and we attribute it to the influx of new interns and residents. Typically, medical students graduate in June and begin their first year of residency training — internship — in July. This group of eager new interns invades the hospital to learn, care for patients, and make medical decisions. One problem. They don’t know what they’re doing. Like most interns, I arrived with four years of medical school under my belt, an M.D. after my name, and virtually no practical knowledge of medicine. Although I wore the long white coat of a doctor, I kept my pockets packed with condensed medical manuals that we called our “peripheral brains” to make up for the lack of knowledge held in my actual brain. Thank God for these manuals. Otherwise I would have been part of “The July Effect.” My first night on call. I walk down a dimly lit hallway toward my call room, the only sound the intermittent beeping of a heart monitor. Suddenly, a loud siren rings overhead. A nurse rushes out of a room right in front of me. “Call a code!” she yells to a secretary. The nurse looks in my direction and asks, “You’re a resident, right? I need you to run this code!” I look left, right, and behind me. Gulp. She’s talking to me. “OK,” I say, hoping that she hasn’t noticed that my voice has leaped an octave. The truth is, I’ve just finished orientation, which included a course in Advanced Cardiac Life Support, but I have not spent a minute reviewing the manual. Confession: I’m not feeling all that confident. I rushed with the nurse into the patient’s room. I see on the cardiac monitor that the patient is in ventricular fibrillation, the heart rhythm that immediately precedes death. Squeezing an oxygen mask, a nurse stands above the patient’s head. A second nurse runs medications into an IV. “What should we do, doctor?” My mind goes blank. I have absolutely no idea. I pull out my “peripheral brain,” flip to the section on “ventricular fibrillation.” Aha! Got the treatment. Cardioversion - commonly called electric shocks. [By cardioversion, I'm using a general term for restoring a heart to its correct rhythm. ] “Get me the paddles!” I say, my voice rising. The nurse shoves the paddles into my hands and sets the power to the appropriate level. “Clear!” I yell, and place the paddles on the patient’s chest. “STOP!” the nurse screams. She grabs my hands and moves the paddles to a different spot on the patient’s chest. One more second and I would have shocked his liver. “Clear!” I yell again, and press the defibrillation button. The patient jerks slightly and for an instant the heart monitor goes wild. Then it completely stops. We stand still, staring at the monitor for what seems like minutes, awaiting his new cardiac rhythm. Beep… beep… beep. Normal. He’s saved. I let out a breath of relief. Within seconds, several residents enter the room and take over for me. I gladly step aside. I go back to my call room, both exhilarated that I’ve saved a patient’s life and freaking out that I nearly made a mistake would have cost it. I’ve learned my lesson. I pull out my heart book and study it cover-to-cover until dawn. 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. soundoff (2,421 Responses)« Previous 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 Next »Leave a Reply to xem.vn
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I had wondered about the quality of care during the July vacation month, but know for sure that the WORST time to be hospitalized is during the Christmas and New years season. You will get second or third string staff and not much of that either. My daughter had surgery some years ago during Christmas week and I was asked to stay 24 hours a day to help care for her. There was only one nurse working on the floor at night. Never, never schedule surgery around the time of a major holiday!
Both of my grandmothers died within days of each other (years apart, but still). This was within three days of Christmas. I wholeheartedly believe this to be a contributing factor.
sorry to say my dad was admitted to a very well-respected teaching hospital (you would all recognize the name) the first week of july, 2003 and began throwing clots after a bronchoscopy. he had seen various specialists during his short stay, but once he was in icu no one seemed to be the primary/attending. at the mercy of new residents, the orders for "no intubation" became interpreted as "no medical intervention" and my mother and brother essentially watched him suffocate to death as the staff ratcheted up the morphine dose. no clot busters, no diurectics, etc. my mother was overwhelmed by the decision-making processes and by the time my brother could get there (a clinically-trained pharm d), it was too late. many times we tho't of pulling dad's chart and reviewing the time line so other families would not encounter this same train wreck. ultimately we are at peace with our dad because the alternative was probably a long demise with lung cancer. we wonder sometimes how often orders are misinterpreted. it takes a very educated and vigilant (yet gracious) family to oversee health care. thank god we know we will see my dad again in heaven. none of us can really control the future, so keep short accounts and make the most of your relationships.
You're probably right Jen, the staffing of the hospital factored into both grandma's deaths. Forget about age, medical conditions, overall health ect.....As a medical professional I see this all too much. Family members aren't ready to let the patient go and they hold on to life support for weeks untill the body finally gives in. Staffing does drop during these holidays in direct porportion to hospital census. Usually no elective surgeries during this time and we work to get patients home and out of the hospital around these times.
how horrible they expected you to actually CARE for your daughter....
I lost a relative during Christmas and timing had everything to do with it. They delayed treatment for a block carotid artery until the doctor returned from a fishing trip in South America. They said our relative would be fine with blood thinners until then. But he died of the blockage. We didn't have anyone who is in the medical world in our family so we failed to get good advice. Had we known what we know now, we would have transported him by air ambulance to another hospital with a level 1 trauma center. So if you ever have a bad medical condition you may want to remember to always go to a trauma center and not just a local ER. It will be the difference between life and death.
@JaneDoe – Not for nothing, but many times having a family member with you in the hospital may be the difference between life and death. Or to minimize the chance for other mistakes
There is no "second or third string staff". Sorry, it just doesn't exist. Holidays are rotated in every unit I've ever worked in. It's the same staff every day of the year. It's nice to try to blame bad things on people, but the fact of the matter is, if someone is going to die on Christmas, they're going to die on Christmas.
You are probably right Jean. I went to the emergency room early Christmas morning, was misdiagnosed and sent home. Thank God I say another doctor in a few days and found out that I needed surgery asap and had it been put off for another week, I may have died. You definitely have to be proactive when it comes to your health or the health of your loved ones. Long ago I refused to go to any doctor right out of med school. I only choose older doctors with a fairly long and good track record. Experience is the best teacher in any field.
Cheez Maggie..........Those older experienced doctors you saw long ago.....were they born as MD's?
Joe that was a dumb reply. Whenever I have had the occasion to see a specialist, I choose to select one that is older because I prefer an older doctor with more experience. You can trust your life to whomever you choose. It's a free country. Does it make you feel big to patronize people who don't see things the same way you do?
My, what a bunch of armchair quarterbacks we have. While it's true that in July you are likely to encounter an intern that is quite nervous and not sure what they are doing, but interns are NOT left on call unsupervised. There is always a senior resident or staff physician reviewing everything they do and just like in this story, the nurses are used to this and will speak up if something looks dreadfully wrong. It's a big joke among members of the medical profession that you wouldn't want to get sick in July, but other than fumbling of instruments and perhaps some stuttering you are unlikely to know the difference between the new guy and the one who has been their three years.
That's all good in theory, but in reality the senior resident of attending are not at all always readily available. The nurses are the best bet, and not going to a teaching hospital (where it's impossible to get healing rest) is even better.
I was about to take you seriously, but then realized that you can't even manage to use the correct context of "there."
The obvious question, to what do you attribute the July spike in deaths due to medical errors?
I have lived in Boston most of my life, have had some of the 'best' doctors in the world, and they have still made crucial mistakes( which they have admitted to). There is a funny phenomenon that occurs when otherwise strong personal advocates come into contact with the 'best'; there is a tendency to accept what is said by our doctors, more easily then we might usually do, because we are swayed by reputation(s). Do any of you remember when the interns weren't even paid ?! Having said all that, I always though it was the end of June to watch out for-thanks for the update!!
Did you just say that they admitted to a mistake? Those doctors are quite good indeed!
Just read the New England Journal of Medicine..."accidental" deaths occur from hospital and doctors errors more often than the medical profession will ever admit to. (lawsuit material) It's the third leading cause of death in the US. They already tried to kill me once...post op bacterial pneumonia...so I'll just stay home and take my chances. They already killed my best friend. She went in for a migraine, was put on a morphine drip and left unattended for hours. She never regained consciousness. The doctor did admit is was her own fault. No lawsuit was ever filed by the family. I guess the hardest thing for me is that most doctors think they're god by their words and actions. They often intimidate their patients with their knowledge and power, because god forbid that they're ever wrong! (They're actually the only profession that can legally kill someone and get away with it.) Perhaps if they'd admit their fault and be more compassionate, patients would be more forgiving. What ever happened to the oath of "first do no harm"?
Please, take your chances outside of the hospital. The best bet for our species is that people as stupid as you do not reproduce.
I would put serious money down that Doctors never set out to do harm. Must be difficult in a job where you have to do bat 1000 everyday, no such thing as being human.
your post-op pneumonia was probably caused by you not getting your lazy ass up out of bed soon enough after surgery, and guaranteed your intern wrote the order that you should be up, because that's standard.
Wow the doctor even admitted she was wrong! Yet you say doctors should "be more honest!" You sir are on a revenge trip. You won't be satisfied until you see the doctor as a beggar on the street. Try to go through medical school and residency. Then make an error as an attending and state it is a mistake to the family (cause it will happen because doctors are human). There will always be a patient or family member tearing you a new one no matter how sorry you are!
If doctors truly think they are gods, then perhaps the patients are to blame. Let's face it. We expect doctors to be perfect. When they are not, we complain. And when they are and then act as if they can do no wrong, we complain too. Perhaps this is using a bit of hyperbole, but every time a doctor makes a decision on a course of treatment or on what drugs to give a patient, they are risking a malpractice suit. Having worked in the data analytics end of health care for the last decade, I see time and time again where suits are filed because, despite the doctor using their best judgment given the information at hand, the patient had a bad reaction. This is not negligence, folks. It is just a bad outcome. But there are too many people out there who think that a bad outcome is fodder for a lawsuit...
Bottom line... doctors are human beings just like any of us. The only problem is that they are EXPECTED to be god-like. Remember that the next time you want to complain about a doctor acting like a diety.
I agree with Mike. If you believe doctors are just a group of arrogant murderers, then don't ever go to them for help. What a jerk...
Maybe you should just avoid hospitals altogether if you hate them so much. It will be good for you and the "arrogant doctors" you think you are too good for.
My comment is in response to the comment "Concerned Doc" made stating, "I have been a surgeon for 25 years and have never heard of a surgeon not showing up due to vacation." A friend of mine has ulcerative colitis and after several different treatment attempts to control the disease, a specialist at the University of Chicago hospital made the decision that my friend should have, what I believe is called, an ileo-pouch procedure done. I'm not a doctor, so I can't specifically outline what this entails, but I can tell you from my friend's experience that it is a three part surgery, with a recovery period of 10 weeks between each surgery. The first surgery was scheduled for the beginning of March, after that surgery, they scheduled the next surgery for the end of May. My friend just had his follow up appointment and called to schedule his third and final surgery. When he called to schedule the appointment, he was told that his doctor will not be available to do the third surgery because he will be on vacation during the months of July and August, and as such, my friend had to schedule his surgery with a different doctor, despite the fact that he has been working with the first doctor since November. I'm sure that the doctor he has scheduled the final procedure with is perfectly capable, especially given that it is the "easiest" of all three procedures, but it would have been nice for the original doctor to have been honest and up front about his vacation plans when they first addressed the issue of surgery - how long it would take, approximately when each surgery would take place, etc. Seems to me that, yes, indeed, "Concerned Doc", the doctor is "not showing up due to vacation."
I'm a surgeon. I take vacations just like anyone else. Is that a crime? I've never heard of any surgeon taking 2 months off. At most, I will take a week off.
There are good nurses and bad nurses... just as there are good docs and bad docs... not denying that.
I believe that there are more mistakes in July. Most are caught by more senior residents and staff physicians, but not all. I think as a whole, the medical field is getting better at catching and reducing complications. We are scrutinizing outcomes a whole lot more and looking at how hospitals are doing, and even how each physician is doing.
to unowhoitsme.... postop bacterial pneumonia is not a fault of the physician/surgeon. It can happen after surgery. You can reduce your chances by coughing and deep breathing, early ambulation after surgery... but even so, you can still get it. Especially if you smoke or have pre-existing lung conditions (copd or emphysema). So don't blame your doc... get over it.
I address my comment to the doc who commented in regard to the above post. I have had about 14 major surgeries in my life - and in general have had good outcomes, with one exception - a hip replacement where the doc first broke my femur at the head when driving in part of the appliance, and the other a four part spiral fracture done by his pa when trying to put the leg back in the socket. But my problems almost always occur with hospital staff, especially our local hospital. They only go by the rules when there is an accreditation team coming, and then go back to their blatant errors as soon as they get recertified - and pat themselves on the back. And, yes, teaching hospitals are the worst for all of the reasons previously mentioned. Unfortunately, I live in West Virginia - where, if you need any kind of specialized treatment, you must go to Morgantown to the University Hospital. One complex that tries to meet the needs of the population of an entire state. If I have to have surgery there, I demand that my surgeon actually performs the surgery, not an intern or a resident. If they refuse, I will not have the surgery. Finally, we all need to become informed consumers of medical care. Do your research ahead of time for all medical problems - especially when being prescribed a new drug. Trust yourself as you are your ultimate defense against medical errors.
isn't there supposed to be a chain of command in a hospital. I'm not a medical professional but i always assumed the doc was in charge and the nurse took the orders. doesn't it take like 10 yrs to become an actual doc vs. like 2 to become a nurse? just saying, the amnt of education pretty clearly defines who's should be making the calls and that all these nurses on here should stop complaining and fall into line
There is a chain of command, and doctors and nurses each have their own hierarchies. While there is a lot of training involved in being a doctor, nurses very often have much more practical knowledge than first-year interns. As an intern, you'd be stupid not to listen to a nurse, even though you technically write the orders.
NotaDoc I am not a nurse either but my sister is. She has a four year bachelor's degree in nursing plus two more years for her master's degree in Nursing. The stories she and her well-educated, highly experienced friends tell about the incompetent, arrogant doctors they have to deal with on a daily basis is hair raising. She also teaches classes at a private college. I got the chance to see what she was talking about first hand when I did my master's degree field work at an emergency room. So NotaDoc, be careful, your ignorance is showing.
It's the nurses who are with you 24/7. I may not hold a doctorate, but I'm the one who's going to stay at your bedside after you've had open heart surgery, or were hit by a car, or swallowed a bottle full of pills. I'm going to skip my breaks and my lunch, so that I can wash off your sweat, cleanse your wounds, and give you that needed dose of pain medication. I'm going to perform advanced cardiac life support when your heart stops beating or you stop breathing. I'm going to make sure that all those medications the doctor ordered, are safe for you. I may not hold a doctorate, but I'm going to do my best to keep you alive.
I find your comments insulting and ignorant.
Wow, you are so ignorant. I have a 6 year SICU nursing experience at a huge teaching hospital, plus a 4 year degree. I will NEVER accept an order from a physician, especially an intern, that I do not believe is the correct action to take without politely asking them to consult with a resident, fellow and so, on. I have a license at stake and will not jeopardize it. I am not an MD's servant. My main focus as an RN is to be a patient advocate. In the real world, I am part of a great team in which we respect everyone's position and purpose within the team. We have the checks and balances and it begins with the lowly undereducated bedside RN that's working their butt off to save your family members life in an ICU during a hectic 12 hr shift.
As for Christmas time...best time to go the the hospital. Census is at all time low and the nurses working there are a lot of the time most senior and high quality. They want to be there to get the holiday pay of 1 1/2 to 2 1/2 times the normal rate.
Good advice but even better advice is to avoid hospitals altogether if you can!
Maybe we should let these nurses in charge instead. I used to volunteer at hospitals as a kid, the nurses did most of the patient interaction and usually corrected doctors mistakes as well. Part of the reason health care in the US is so expensive is we let doctors set their salaries and then pay them, rather than doing the opposite. Instead of funding medicare and medicaid with taxpayer money and then paying it to the doctors, why doesn't the government hire doctors directly and pay them a salary?
Primary care physicians on average make $175k and whine about how poor they are. They are the LOWEST paid doctor. Everyone else makes a lot more. Meanwhile they like to pretend healthcare is more expensive because of some lawyer making $50k a year managed to make them cough up some cash for chopping some guy's arm off. Rationally speaking, the person making $175k a year is more responsible for higher cost than the guy making $50k. If ambulance chasers actually made as much money as doctors claimed, they'd all retire after one case.
"why doesn't the government hire doctors directly and pay them a salary?" Ever heard of the VA hospital? They are the most overpaid and lazy docs in America, and they're gov't hired physicians. Having doctors as gov't employees will only add to the healthcare cost. You have no knowledge of the medical system, Medicare or Medicaid. If you did, you'd make more intelligent comments.
Umm 175k is low when you have nearly 400k debt and work 60 hours a week and have spent over a decade of doing higher education. Also nurses are a key part of the team, but they are not prepared for diagnostics and immunology at all. It takes a doctor to understand vital immunology and a strong grasp of pathology to work the team forward!
Wow. Your ignorance regarding anything in the medical field is astounding. Most people who don't know anything about a topic tend to keep their mouth shut, but you throw out words and numbers like it's factual information, when in reality, it couldn't be further from the truth. First, if you would like to see what would happen if you let nurses take over the primary role in care for a patient, I suggest you volunteer to be the first. I don't even know any nurses that they themselves think it would be a good idea for a nurse to assume that role. I love how your opinion is formed by your experiences volunteering as a child, however many years ago that was, but I'm sure you had no context whatsoever in which to understand what you saw. Second, doctors' salaries are a very small part of health care spending in this country. If you cut all doctors' pay by 50%, that would cut our health care budget by 5%. Third, you overestimated the amount that primary care doctors make on average by about 40%. I'm not saying that $125k is a measly sum, but when you consider that many students' debt coming out of medical school is double that, it puts things into perspective. Fourth, if you know a personal injury lawyer that makes $50k/yr, he/she must not be very good. A good friend of mine's father is one and makes multiple millions a year. Besides, the issue is not how much the lawyer does or does not make, but how much extra money is used on unnecessary tests/procedures out of fear of being sued. Please educate yourself on the issues, or at least AN issue, before commenting.
Doctors make $175K a year because first of all they had to pay for 10 years of school. Second of all they had to get a 3.8GPA in their undergraduate, pass very difficult classes etc. If doctors made $60K a year people with a 3.8GPA would go into engineering because with an engineering degree you'll make that much at the age of 22 instead of 34 and with a 3.1 GPA instead of 3.8. Its very difficult to become a doctor, and the high pay is there as a reward for the risk. Suffice to say, if doctors didn't make a lot of money, nobody would be a doctor.
Actually if all doctors worked for free this year than it would only save ~8% of the budget. It's not even worth attacking doctors salaries as it will bring no effect except drive away capable persons from medicine, then again... I think you're crazy if you do an M.D or D.O. Just do a PA in 3 and avoid dealing with all this crap and malpractice.
Excuse me, engineers often graduate with over a 3.1 GPA. I know you want to make it sound like doctors are smarter, but many engineers are very bright, just chose a different profession.
As a nurse your comments infuriate me. I work at a level 1 trauma center and to save live the nurses and MDs have to work together, yeah ive caught miskates made by interns and even some of the higher ups. Your comment about how nurses should be incharge would be like sending the engineers of the space shuttle up in space instead of the astronauts, sure they know a lot about how the mission should take place and they are a part of it, but they do not have the training to fly the ship. Also most interns make less than nurse. If you want to complain about their salaries you should look into how much they spend on malpractice insurance then maybe you would see were the money goes. As was stated before, having to have a batting average of 1000 everyday is impossible, when you make it through med school and your residency without making a mistake come back here and tell us. Many people dont realize we (medical professionals) have to deal with people on the worst day of their lives and also deal with the family, oh and not to mention THEY SAVE LIVES thats why they get paid so much!
I turned down a ticket to a name med school to go through my Grad program in Biology. If I had wanted to be a MD or DO I would have been.
The doctors who do the most critical work – family practice, ER, and internal medicine – are NOT that highly paid, which is unfair. The specialties of plastic surgery, cardiology, anesthesiology, pathology, and radiology are the hardest to get in to, not because they are more difficult, but because they offer the best pay and work hours after training. That's why the MDs with the best test scores gravitate towards those fields. The problem is, insurance companies and Medicare will pay more for a PROCEDURE like a nuclear stress test, or CT scan, or pathology report, or surgery, than they will for TREATMENT like non-generic (i.e. effective and not side-effect ridden) medication, patient teaching, and simple screening tests to prevent problems.
Surgeons (if they are good) are well-paid and deserve it. Their job requires long hours, intense knowledge of anatomy and physiology, and an artistic manual dexterity. I know this because I have worked in the OR and watched many surgeries. This isn't to say that some of them aren't **swipes who treat others like crap, close wounds without removing a sponge, and dump the "grunt work" on nurses, but most of them are saving and improving the lives of patients.
I have had the opportunity to practice in the ER in multiple (non third world) countries. There are training programs everywhere because doctors cannot learn to practice medicine without learning from their peers. This is the same with every medical profession including EMTs, nurses, medical techs, phlebotomists, etc. When I was in New Zealand working in an ER with other registrars (the same as residents in the US), they have very little supervision. In ER training programs here in the US, there is a supervising resident and an attending by your side for every critical patient. The attending physician sees EVERY patient that you see. At my county resident program, at a very busy (>130,000 ER visits per year) hospital, July comes and goes every year. There is no change in patient care except for the fact that all the residents, interns, and attendings are more careful of how they take care of patients. You may have to wait longer in the Emergency Department, but ultimately, you will still get great care. The patients that come to our ER are THANKFUL for the whole ER staff including nurses because we help people who normally would not be getting good care. There are extra frustrations such as telling your history of present illness multiple times as you have to tell the intern, the resident, and then the attending (and then when you get admitted you go through the same thing again with the medicine or surgery residents). But ultimately, you have more than one mind trying to figure out your best plan of care for your illness. This works to the benefit of the patient.
In New Zealand, the registrars (residents), do not have ANY supervision at night. You have someone that isn't even training in Emergency Medicine treating you in the emergency department 1 month out of medical school. There is no attending watching over them. That is just one of the benefits of the US training programs. There are always ways to fix medical care in the US, but it is not easy. This is the best we can do today!
Thankfully I had read The House of God prior to my intern year. Many of the Laws of the House of God helped me provide most excellent care for my patients. Laws such as "Age + BUN = Lasix dose" and "at a cardiac arrest, the first procedure is to take your own pulse" saved many a life. But the law I hold dearest to my heart these many years later is "the delivery of medical care is to do as much nothing as possible." If only all doctors held up this law, the cost of medicine would be a lot less.
As we call it in our division, "active inaction."
Best book ever! I need to read that again very soon. GOMER!!
Great book. Unfortunately, most "unnecessary" tests ordered and procedures done are to protect the doctor from lawsuits, NOT because they are medically needed. This is a big part of the huge cost of healthcare – appeasing lawyers who say "well, did you check for EVERYTHING?"
Frankly, these days the hospital is no place to be sick. The insurances want you out 5 mins before you've gotten into a bed, the doctors don't even have much say anymore as to how you'll be treated, everyone has a "care map" which is the "gold standard" but doesn't take into account individuals. Nurses have more paper work/bureaurcracy and machines to deal with so who gets to see a patient? You need to make sure you have a person of sound mind and body who will stay with you at all times as an advocate.
I am a little too drunk to pontificate. Stay out the hospital all the time. You ain't special, your chest pains is gas from too many ribs. Hey woman monistat, advil, and a heating pad is a helluva thing. Then stop the madness and pay attention and you will know when show up for the best in US healthcare.
My head hurts after reading that
Hi everyone! It's Dr. Youn, the author of this post. In the interests of accuracy, I've changed the term "cardioversion" to "defibrillation."
No, a nurse must have changed it.
Nerd.
thanks, dr. youn, for your honest article. if interested, see my longer response towards the top. we are a family of health professionals and still lost my dad in a teaching hospital back in 2003 because we could not be in the right place at the right time. my brother the pharm d said it was probably a july effect.
In the interest of accuracy, Dr. Youn, you should have this article retracted. In my opinion, you're doing a disservice to the medical community and to patients.
While I believe there is some component of the July effect in teaching hospitals, I also believe the public should be reassured that the hospital's patients are still being managed by experienced attending physicians. This article leads the average lay person to believe that July = complete pandemonium in the hospital with greenhorns running around like chickens with their heads cut off.
In the university hospital in which I work, the intern is always low man on the totem pole, as he/she should be. I know that if my intern gives me an order that doesn't make sense, I can 1)question him about it, 2)call the senior resident, who is also inhouse even in the middle of the night, 3)page the attending physician, who may be home asleep, but is still ultimately in charge.
So, stop being an alarmist and retract this ignorant article!!
Instead of changing a word, or retracting the article as suggested, how about surrendering your medical license.
In order to get your R.N. (Registered Nurse) degree it takes four or more years to get the Bachelors Degree from an accredited university. Often the nurse will know more than the doctor about her ward and her patients because she deals with these issues regularly from day to day and week to week.
Some of the nurses have a Masters degree which usually takes another two years. So we aren't talking about ignoramuses here. They are professionals with a vast amount of knowledge and experience.
Many doctors treat them as such and the ones that don't should be ashamed of themselves.
This is at least the 3rd post on this thread that has stated how nurses have this 4-year degree, and MAYBE another 2-year Masters', and therefore they have extensive training that rivals doctors' training. The problem with this argument? Doctors also have a 4-year bachelors' degree before they can even apply to medical school. Then, they go to another 4 years of medical school. Following that, they go to between 3 and 7 years of residency training, and possibly fellowship training after that. The interns in this story are at the start of the residency years, so have already had 8 years to the nurses' 4 years.
That said, I agree that the nurses who have additional clinical experience do sometimes know more, and they many at least have the calm confidence in a code setting that a new intern may not have. Should the nurse in this story have told the intern to put the paddles in the correct place? Of course. Speaking up in the face of an obvious error is absolutely the right thing to do. But to argue that 4 years of college is somehow equivalent to 4 years + 4 years (+ residency) is kind of flawed.
My experience was similar to what Patricia reported. I was "smart" – I knew about the July effect and scheduled my hysterectomy for early June. Figured I'd get the best and most experienced, right? Well that was great, except that my 30 years experienced doc at a top New York hospital botched the close, and the whole thing opened up on...you guessed it – July 2nd. What followed was a horror show. I was readmitted on July 2 and NO ONE knew what they were doing. Not just the new interns, but the new resident and new fellows who didn't know their way around the hospital, who was in charge of what, and how to navigate the bureaucracy. The nurses were overwhelmed, they were VERY PUT OUT when I questioned what was going into my IV, because no one had discussed it with me. They had to walk back and forth to my room twice when they didn't "need" to. By August, I'd fired that doctor and that hospital, and was admitted to another hospital where the doctor in charge of my case had assembled a permanent team that finally fixed me. That took all of two days.
So yeah, avoid hospitals in July.
This article does not help anyone it just sets up an uncecessary anxiety for nothing.
I think the above comment and others like it prove that is not the case. Watch out!
This Doctor is an Ass...just like the rest of them. If any member of the healthcare team pulled out a manual during a code...especially the Physician...that person would have been thrown out of the room. The Nurses are the one's that saved the patient's life, not this Doctor. Doctors get all the glory....Nurses do all the work!!!
Get over yourself and do what you're told. They're called "order" for a reason.
No one is claiming that the nurses didn't help to save this patient's, and many other patients', life. But please don't claim that doctors come in with no work and claim all the glory while the nurses do all the work. That's just ignorance. And tell me how many nurses have been sued for malpractice while you complain about the attention that physicians get.
The best care combines the theoretical knowledge of a physician (and physical skills of surgeons) and the practical knowledge of a nurse (as well as other members of the health care team). They are complementary pieces.
no he's not an azz. He's telling everyone to avoid the hospital in july because of his own experience as the new intern. I'm sure he's an experienced surgeon by now, but at least he's being honest.
Plenty of people carry code cards and use them regularly, especially when starting out. I'd be more worried if he *didn't* have the card with him.
Kind of an obnoxious commentary coming from a fellow physician. Medical training is already challenging enough without having articles written by physicians on why people shouldn't be go to a hospital in July. I am sorry that the author trained at a program that put him such an unusual position on his first day. All residency programs have senior residents and attending physicians to guide new interns as they continue to gain proficiency. It would have been nice if the author could have utilized this opportunity to educate the public about how medical education works instead of painting our new physicians as being relatively incompetent.
Totally agree with you. This guy is not helping us.
The fact remains that medical mistakes spike in July. Some proportion of that spike is likely due to newbies (in the intern, senior resident, fellow, and often attending role). Therefore, it stands to reason that if one is having an elective procedure they should think twice about heading to the hospital in July.
That being said, all of us MD's are yelled at so often that I don't think people worrying about the July effect are going to add much to our burden.
I had thumb surgery on July 9. When I woke up I found my nose attached to my thumb.. and then I went to touch my nose on my face, and it was there too!! Afterwards, I found out this was a "Teaching" Hospital, also I found out it was a 'magician's' hospital. Then I found out that the janitor performed my surgery. If I would have known this I never would have had thumb surgery in July..
Hooray for a doctor (the author) who recognizes he doesn't know everything. Unfortunately, he's in the minority. I work in a hospital and the new doctors there are the most arrogant snobs in the place.
This article is bothersome on so many levels that I barely know where to begin. This article unfortunately paints interns and residents in a very negative light. While interns and residents don't have the wealth of knowledge that their attending physicians do, they have spent the last eight (or more) years of their lives trying to master volumes of information on medicine and patient care. Good interns and medical students know when to ask for help from their attendings and from the nurses. Medical students, interns, and residents deserve to be treated with respect (providing that they are respectful to their patients as well).
For those who think doctors make too much money-Medical school, residency, private practice, and life as a doctor is no cake walk. Only a few of us are cut out for the job, and we work damn hard to get here. 4 years of undergrad, 1 year for a master's degree, 4 years of medical school, 5+ years of residency, one divorce and 230K dollars in student loans later I can call myself doctor. I think I've earned my 200K per year. Most of us won't make millions. In fact most of us will struggle to pay our overheads and stay in business practicing medicine just because we love to help people.
Add in the malpractice insurance doctors are required to pay, that 200,000 gets smaller.
$400K in debt here. Not including a nearly maxed out credit card due to interviews, and flying and relocating. My car has 192K miles on it, AC barely works (and I'm living in the South), bumper about to fall off. Facing 8 years of indentured servitude making less than minimum wage while interest accrues. Glad to see someone who feels the burden too!
I think you got it wrong. He paints interns are real people and accurately states that interns do not have enough experience and sometimes it's a potential problem if the senior residents are not close by. It's a little self deprecating humor that apparently you don't get.
"Only a few of us are cut out for the job, and we work damn hard to get here. 4 years of undergrad, 1 year for a master's degree, 4 years of medical school, 5+ years of residency, one divorce and 230K dollars in student loans later I can call myself doctor. I think I've earned my 200K per year. "
Oh, aren't you just the special one...one of the "few of us who are cut out for the job"...without a clue how myopic, self-centered, delusional, and arrogant that statement is.
Jeffison, that's no overstatement. Do you know how many people say they are pre-med when they begin college? Do you have any clue how many change majors before they even finish chemistry? Do you have slightest idea how many applicants are never admitted to even 1 medical school out of dozens they may apply to? Go out and try it some time, then come back and say it was a piece of cake.
Facts:
0.1% of the world population are doctors.
15% of americans older than 25 have a bachelors.
about 6% of graduating college students try to get into medical school.
about half will get in.
0.37% of americans older than 25 hold a medical doctorate.
I told you that to tell you this. I know education is more a measure of knowledge than it is intelligence and I know they are not the same but they correlate. Also, I know that there are a lot very smart people doing other jobs. So its my guess that even the dumbest doctor has to be at least in the top 10% of the population with regards to intelligence. So whats my point:
There are so few doctors that it must either suck to be one or it must be hard as &%$# to be one. The answer is both. So since most people (99.63%) either can't or don't want to be one STOP COMPLAINING ABOUT HOW MUCH THEY MAKE! Its a lot less than you think(A store manager at Publix and a pediatrician make about the same).
Lastly, before you decide to start judging that "idiot" intern, remember, there is probably a 90% chance that he/she is smarter than you.
I think the "delusion" is to think anyone can be a doctor.
I do not agree with this doctor, he is a surgeon and yes, usually surgeons do not know much. Not all hospitals work with residents and even in the hospitals that have residents, not all patients are resident covered and they are always supervised by a second year resident and by the attending physician whose license is on the line with every single case.
Haters are going to hate...
I'm a surgeon at an academic hospital.
I wouldn't want to be hospitalized in July.
Some advice:
It's always good practice to be prepared (have a list of your medications/dosing, copies of your medical records) before seeing your physician. Don't assume that they will already have everything listed. Write your questions down and ask. Also, it is good to bring a friend or family member with you that may have a different perspective (esp if they are in the medical field). If your spouse is a physician or lawyer, I would mention it. I think physicians are more cautious after hearing this.
Do research ahead of time regarding your symptoms or condition. There is an abundance of information on the internet. I think the more informed you are, the better. Also, you can ask directed questions.
Don't go to your physician with a whole laundry list of complaints. Pick the most important 1 or 2... after that, docs start to lose attention.
thanks for mentioning this. I didn't learn until recently that doctors put on their best behaviors when they learnt that the patient knows someone in the medical field. When my spouse got sick and had to go to ICU, his cousin who was a resident in the same field that he required surgery for, sat by him for several days. Other than him being nice, I later found out from another friend who works in the hospital that his presence bumped my spouse up to "VIP" level even though he doesn't work there or knows anyone there.
Sad but true. Most MDs in the hospital are so overwhelmed with work that they can only focus on "top priorities" like #1 and #2. Also, having a family member or friend in the medical field as your patient advocate does help tremedously. Lawyers not so much.
While it is true that hoards of new, inexperienced interns start in July, I do not feel "The July Effect" is due to interns. For the most part, interns are well supervised by higher level residents and attendings. I believe that this phenomenon is more likely the result of higher level residents. Once July 1 rolls around, residents and intern are promoted to the next year, and are given a higher level of responsibility. Having 1 or 2 years of training under their belts, these residents often become over-confident in their abilities, and that is the most dangerous type of resident. I also feel that newly graduated attendings contribute to this statistic, as they now lack the supervision that they previously had, and may also suffer from over-confidence. Most interns are smart enough to know that they know nothing, and are very cautious in their patient care. Nurses also watch these interns like a hawk, but are more lax in their questioning of junior and senior residents and attendings. In my experience, interns are much more dangerous in September. It is about this time that interns have had just enough experience to think that they know what they are doing, attendings and residents become more confident in their abilities and offer less supervision, and nurses also become more comfortable with their orders, a truly deadly combination. But this is just one physicians opinion.
Interesting theory. Someone should do a clinical study on this – but the AMA would never allow that, now would it?
Fear monger much CNN?
I'm an RN who is quite used to the July onslaught of new docs. However, last year on July 1, I was admitted with chest pain to a well-known teaching hospital. The care was horrible. The attention I got was horrible. Never again. I'd rather die than have to put up with such sub-standard care and utter chaos. The problem basically was that there was no communication between teams of doctors. I did receive an apology from the Head of the Hospital.
What the author failed to mention is that HE IS ONLY TALKING ABOUT TEACHING HOSPITALS. Multiple studies have shown that, on the whole, THE CARE AT TEACHING HOSPITALS IS BETTER THAN OTHER HOSPITALS. So what he is really saying is that the care at the best hospitals is a little less good that it usually is during the month of July.
Better to receive inexperienced evidence-based medicine than experienced, completely made-up medicine, I suppose? Not that private hospitals do made-up medicine but certainly there's a bit more of a wild west atmosphere in the private hospital settings. Which is fine if you just need your appendix out, but if you have some rarer ailment I'd still go to a teaching hospital in July.
I agree completely with CardMD and Ken. I will never go anywhere other than a teaching hospital. The new interns may not know much, but what they do know is new.
Absolutely correct. Many "old school" doctors practice based on their own anecdotal evidence and personal (if unconcious) beliefs, NOT clinically-proven double-blind randomized trials. It's like gambling in Vegas.
I have worked in laboratory medicine for more than 30 years, in large and small hospitals. Currently, I work in a Level I trauma center and "don't get out much". However, I've seen amazingly good and bad things in 30 years. There is a reason that they say Medicine is more an art, than a science. I've seen doctors and nurses miss the obvious many times over. Many nurses lack a basic understanding of the scientific aspect of their jobs. And many physicians are too busy wielding power and chasing the dollar. There is too much waste and too little responsibility. Information systems are out-dated and care-givers are too busy to take the time to learn how to use them anyway. Administrators and managers manage by consensus because they lack the back bone to make a decision. I have been fortunate to periodically work with people that I thought trust-worthy but for the most part, going to any hospital is a gamble because you may or may not get appropriate care. IF patient care is truely our #1 priority, then each of us need to be more diligent in the performance of our jobs.
When you say "nurses" – who are you referring to? I have heard people call themselves "nurse" when they have anything from a 6-week medical assistant's training to a 2-year "licensed practical nurse" degree. However, if these are RNs who graduated with a bachelor's degree and are keeping up on continuing education, they should not be that clueless.
ALWAYS ask if your surgeon/dr is going on vacation after your surgery date! if he is, reschedule for when he comes back.
Even if he is "only going to be gone that weekend". I had my Hysterectomy on a Fri. The intern that was left in charge didn't bother to open my records to see what my baseline narcotic dose was (it was on the top page of my records when I opened them to check), so I was stuck dealing with some idiot kid, with no one overseeing her, only being willing to give me 60% of my BASELINE pain meds post op. When my Dr got back I told him that they had best keep her out of my sight or she would be taking flying lessons free of charge out a 5th floor window.
I'm actually about to begin residency this upcoming Friday. Yeah, it's scary. Yeah, I am more prone to make an error than probably years later down the line after some experience under my belt. But if there's one thing that gets drilled in our heads throughout medical school and through orientation for residency, and through residency, it's "DO NOT A HERO." CALL someone if anything happens. And we do. I can certainly speak for many of my colleagues that we say with utmost confidence that we know very little.
err I mean "DO NOT BE A HERO". First mistake already!
haha, Brando, you got that first mistake out of the way already. Now go re-study all of your books cover-to-cover before Friday!
Good luck!
... explains why my mom died after a series of really bad decisions made by at least 4 or 5 doctors in July 2 years ago.
I am so glad my local hospital of choice is not a teaching hospital.
Larry everyone has to learn somewhere and it's people like you that stunt learning...just think that doctor that is treating you was a resident just a short time ago
The author of this article fails to mention that iatrogenesis (medically-induced illness) was declared a pandemic in the U.S. by the CDC (Center for Disease Control) two decades ago and it's only gotten worse since. Over half of all illness and illness-related deaths are now caused by medical intervention, and it increases every year..
Can you please cite your reference for this radical statement? If it's true, I'd like to check it out.
Having been a nurse in the ICU, I am quite familiar with the dreaded month of July! It is challenging for all the staff, particularly when you encounter residents that HATE the unit and have no intention of even remotely persuing a career in intensive care medicine. At first, nurses make polite "suggestions" as to what orders should be written, and then become more persistent and perhaps even by-pass the new resident to consult with a more senior resident. Luckily, these new residents are surrounded by ancillary staff that are experienced and safe. As for the comments regarding the holidays... the staff reflects the unit census. It often seems as if individuals "ignore" their symptoms (i.e. chest pain, severe headache) due to holiday festivities. There should be no lack of staff, as they are required to rotate through the holiday shifts. New Years Eve is NUTS with all the traumas, fyi!!!
I can't even get a doctor's appointment in July because they're all on vacation!
First of all you do not cardiovert V-Fib, you defibrillate – a major difference in ACLS and on the settings of a machine. It does not restore the rhythm of the heart, it stops it and may allow for the normal automated cells of the heart to take over. This does not always occur.
Thank you Dr. Youn for a great article! As a RN at a teaching oncology hospital it is so wonderful to hear you speak highly of nurses and help new residents understand that if we all work as a team we will be much more effective in saving lives! A lot of our new residents do not think of nurses as resources but we really can be helpful!
I think October is really the worst month. I had to go to the emergency room on Halloween, and all the nurses were in costumes, I thought I was in the nut house and not a professional hospital.
I find it funny that there's nothing but btching and moaning here about hospitals yet no one proposes any solution. Should we just go ahead abolish teaching residents so no there will be no "newbies" ever? Perhaps we can bring back the old indentured servitude system back in the 1800's that was in place. Or we can entertain the idea that physicians can no longer retire and work til they die? It's called turnover. They have this in any profession that sees crops of new recruits at a particular time of year. Armchair quarterbacking is great. I've tried it and it definitely makes me feel like I am part of the solution. But like a hen house during a thunderstorm, it's just a bunch of squawking. So readers, I'd like to go ahead and ask- how would YOU solve it?
Solve it by not allowing any intern's order to be followed until it is approved by the attending physician, that's how. That way he/she learns without the patient suffering the consequences of the intern's lack of experience.
This is a hilarious article. Thanks for writing such a light hearted but honest opinion piece.
After 4 years of medical school you did not learn how to use a defibrillator? What the hell are they teaching you in medical school? How to fix a hangnail?
I think the doctors should have said "WE saved a life..." not "I saved a life.." forgetting the nurses are we??
weird thing is in all my years i've never heard a doctor say he/she saves lives, i've only heard that statement from nurses
It's been just over 10 years since I graduated medical school and 2 years since I finished training. A couple of points 1) most of the 6000 hospitals in the US are not teaching hospitals so this discussion is not germane to most hospitalizations. 2) Everyone from nurses to senior attending docs are aware that the fellows, residents and interns are new and therefore are more vigilant 3) I'd be more scared of a resident who's already checked out with a bad case of senioritis (March to June) than a scared intern who fastidiously checks all his little check boxes (July to October).
Why do we have the same article every year?
There is a bit of misstatement in this piece: the intern did not save the patients life – the nurse did by telling the intern what and how. She saved the interns hide as well.
Errors will always occur, even in medicine, that is part of being human. Your loved ones will die, that is also part of being human. We live in a fantasy if we don't expect that. What we as physicians and surgeons are trying to do is prevent both of those things, or at least delay them as long as possible. Trust me, that NO ONE on this blog ever wants to know what it feels like to watch someone die in front of you because you can't fix them, let alone because of an error. Want to avoid a medical error... take care of yourself. Stop eating fried fatty foods, stop sitting lazily on your couch. Stop thinking you can do anything to your body and we'll fix it or if we can't... you'll just sue us. Minimize the variables that make it harder to treat you!!! I work 80 hours a week because by law that is all I am allowed in the hospital. I make $7 an hour and have been in graduate school now (college, med school, research and residency) for 13 years trying to learn everything I can to help save people's lives, but am instead met with contempt from patients and if they don't get the pain medication they want then I get "I'm going to talk to my lawyer." We are all trying to make YOU BETTER. The only people who are not dedicating their lives to trying to fix this problem are medical professionals that go into careers to make money... like dermatologists and cosmetic (i.e. plastic) surgeons.
did you actually calculate the 7 dollars an hour or just make that up... Even if you work the max 80 hrs every week (including your cush elective rotation) x50 weeks is 4000 hours. There is not a single PGY 1 program paying only 28K.
I agree that the public needs to take better care of themselves, they also need to learn more about their health. They have become far to trusting in a system that is rife with profiteering. While I applaud your decision to follow a career in medicine, I must point out that it is rapidly loosing it's nobility. I have often heard complaint from providers regarding the drug seekers that you have mentioned. One solution would be to make those drugs available without a prescription. Many laboratory tests should also be available without a doctor's order. In addition, Pathologists need to stop charging a fee for that lab work that they do not even look at. I get really tired of those guys making more off of my work than I do, then asking my advice.
I was admitted in the (top of its class in our town) hospital due to hyperacidity. It was so severe caused me not only heartburn but also muscle cramps. After some (few) lab tests my attending physician administered some meds and I feel relieved. I even asked her if I could go home that day or the next day but she told me that I have to stay for a week because I have to finish 6 shots (of med) through IV to totally minimize the acid secretion. Thinking that it was the best for me, so I argue no more.
In the next day, a nurse/intern came to give me some meds. But a few minutes after, I felt something was wrong. I felt that my stomach crumbles so I went to the CR, but it gone worst that something is squezzing inside of me that I sweated all over my body and stayed inside the CR for one or a couple of hours. It only did cease after it seems that I discharged and sweated everything out.
I was thinking then that perhaps, it was only the effect of the medication; that it was acid that I discharged and sweated-out. But in the next day, same thing happen to me and it's getting worst that in the 4th day that I thought that I would die. Hence, in the 5th day, I asked the nurse/intern what kind of drug she have been given to me and told her to stop it. She insisted but my decision was firm of stopping it or I'll die.
In less than an hour, my attending came and was very upset of what I did without her consent. She told me that I should not have done it because she was the one in-charge and answerable to whatever happens to me and most of all (as my doctor) she knows what's best for me.
I told her I'm sorry and I don't mean to disrespect her as my doctor. Also, I told her that all she said was (technically) right but the fact was I was the one carries my body and told everything I've been through with after every shots of the med and I felt that I would die if I don't have it stop.
She could hardly believe when she heard it and tried to explain to the use of the med, but when she mentioned the name I interferred an told her that it was not the one mentioned by the nurse/intern. I told her that the nurse said it was PEPSIDEN, not H2BLOCK. When she heard it, she seemed so shock. She said that she have to confirm it but mumbled: "why the hell they gave you PEPSIDEN!"
After an hour or two, a (resident) doctor came and converse and (seems like) was trying to comfort me and told me that she have to give me one shot, she told me that the drug was quite expensive but I don't have to worry coz they'll not charge it in the bill and if I fell okay I could go home anytime. I felt better that took-off my dextrose and was able to roam around the hospital.
Then my attention was caught by some people weeping out loud in one room. I learned that a patient died and the cause was allergic asthma gone worst. I learned further that the patient was showing discomfort and seizures after every shot of the meds and the worst and the last one was in the morning, more or less the same time I decided to stop my medication.
I immediately went to the nurse's station to have them prepare my release papers so that I could check out and go home as soon as possible.
Therafter, I said to myself, that as much as possible, I will allow neither myself nor my love ones to be admitted in the hospital. However, when deemed necessary, I will but NEVER again to that "so called" first class hospital.
Why did you wait until the 5th dose to speak up? See? That's part of the problem. Patients don't speak up. They don't ask questions. They just take it because the doctor said this is what is needed. No doubt, mistakes are made in hospitals everyday. But if you thought something was wrong, YOU should have said something. You have to be your own advocate!!
Great. I have a huge reverse shoulder replacement scheduled for July at a teaching hospital in California.
Don't worry. Now that you're aware, you can advocate for yourself. Ask lots of questions.
Yes, I've heard of the July effect. Fortunately, I never made any errors in my internship (at least not any that I was aware of) *whew* - it's an intern's worst nightmare. I also know that by 2nd year medical school I knew the proper positioning of defib paddles....yikes :S