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Don't Get Sick in July

Thomasrobey72x721Thomas Robey -- There's a proverb often spoken around academic medical centers this time of year: "Don't get sick in July."

Why? July is when the medical new year occurs. It's when interns appear on the scene. Young attendings often take their first jobs at this time. Chief residents are getting used to their new digs. Third year students are deer in the headlights; fourth years feel invincible. At every rung of the medical hierarchy, there's a new guy. The surgery R2 is running her first trauma code in the ER. The senior resident all of a sudden has 2-5 other people reporting to him. There's new paperwork, there are hundreds of new phone numbers –- even new sleep schedules. Not to mention the responsibility.

The theory behind the July warning is that with the guard changing, also goes the skill of care. More mistakes are made, diagnosis takes longer, healthcare is a little less... careful. Last year, as one of the deer-in-the-headlights students, I bought into this idea: I told family to stay away from procedures in July.

But things have changed. I think there's another story here.

That R2 leading the trauma code? She just helped teach the interns the ATLS course, she participated in 200 codes last year, she even practiced barking orders to her dog last month to develop that voice of confidence. Sure, she's scared... but she read the manual 23 times. She's terrified of making a mistake, but that fear heightens her observational skill, and polishes her decision-making process.

And the new senior resident on the ward team? Last year he worked under nine different R2s and R3s. He's been making mental notes. "I like how Dr. Schroff involved the medical students in care." "Dr. Wright had an efficient system of collecting information for discharge summaries." "Dr. Miller was intolerable on rounds because of her endless questions (but they helped in the team room)." This new senior may not have his system quite in place, but he makes up for it with his freshness and enthusiasm.

And what about the deer-in-the-headlights category? (Interns and third year students: that's you!) It will take longer to make the diagnosis, you will carry fewer patients, and you will get things wrong. After I realized as an M3 that the work gets done without me there, it helped me fit into the team better. The intern had already figured out what to write and sometimes took care of it before I could come up with a differential or treatment plan, and that was for the good of the patient. Early on, you hope for an intern who helps you figure it out with her; you won't learn by being told the answer! Likewise, every intern has that superstar of a senior backing her up. Even higher on the rung is the attentive attending. In times of transition, the medical hierarchy pays off.

So is it safe to be a patient in an academic medical center in July? I think it's safer than in June... I'd rather have a little extra adrenaline pumping through my team's blood than the residue of burnout and the debris of casual care.

July 10, 2008 in Thomas Robey | Permalink

Comments

As an M3, I definitely feel like a deer in the headlights at times!

I once read a study (can't seem to find it right now), that actually looked at the various stats to see if this old myth was true. They didn't find anything statistically significant, so maybe your theory holds water!

Posted by: Kendra | Jul 10, 2008 3:38:02 PM

Four years ago, I had a six-day July inpatient stay for MRSA (methecillin resistant staph aureus) which began in the ER and finished up with surgery and an open ten-inch long by 6 inch deep incision. I was one sick puppy! The ER resident diagnosed me in about ten minutes (this was when MRSA was rare in our area), a surgery resident noticed and that I was crying probably because I hadn't had any pain medication (it had been ordered but not delivered) and fixed me up with a nice pump, and the surgery intern, who had been in my state for all of three days, noticed that my bed wasn't plugged in so I couldn't call for help or to go to the bathroom. So, although I have a very small sample of cases (1), I believe your theory about new being better than burned out.

My own guess is that I had such a scary ride because I came in on July 4, when vacation season begins here, since temperatures regularly top 100 degrees in July. It was very obvious that the regular staff was short-handed, short-tempered, over-stretched and in general pretty ineffective. Only the house-staff was full strength, and the bunny in the headlights effect made them pay good attention.
I was proud of them after I got over my hospital-in-July PTSD. Oh yeah, my surgeon was good too but she left for her vacation in Paris when I was one day post-op.

So I'd still recommend avoiding the inpatient experience in July, but not because of new residents.

Posted by: anne vinsel | Jul 15, 2008 7:54:45 PM

Some people don't think the July Effect is a myth. Specifically some doctors.

Dr. Jerome Groopman (writer of 3 books on doctor-patient relationships) relates what he calls a nightmare when his son had a medical emergency in July..."which every doctor knows is the worst of all months to go to a teaching hospital. There's a very morbid joke (among doctors): don't get sick on July 4 weekend."

His story was in Time Magazine in an article titled: "What Scares Doctors? Being the Patient" - How to Survive July.

http://www.time.com/time/magazine/article/0,9171,1186553-6,00.html

Posted by: R2UCLA | Jul 17, 2008 11:42:46 AM

i don't know if it is because of the time of year or because the health system is incredibly understaffed and underfunded but i have to say that july has been a personal nightmare for me of late.

currently i have my best friend in hospital - who after 2 ed trips and eventually being admitted has still not been diagnosed after 10 days. it took 2 days to get a head ct when they thought she might have had a stroke and then she spent a day on a procedure table in the ed waiting to get into a proper bed.

the worst part is we know exactly what is wrong with her but because we haven't got an MD - no one will listen. i am first year med and she is third year nursing.

all that said, i have to say that the interns/junior residents we have been dealing with have actually been agreeing completely with our diagnosis and have been fantastic. it is the registrars/attendings that have been useless! 4 days wait to get a consult with a 2nd year resident who just upped her morphine dosage ... what a joke!

Posted by: amy | Jul 24, 2008 6:40:57 AM

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