July is a difficult month in the hospital. I have said a lot of goodbyes, to residents, to medical students and to scribes. Scribes are undergraduates and recent college grads who write our charts for us. Our new electronic medical record makes it nearly impossible to see patients and chart effectively, so we have trained scribes to chart on the computer while we see patients. It’s a fair trade-off. Most of the scribes are off to medical school and it is likely I will see some of them again on the wards, in the ER or when they return for residency.
Some of the residents have been with me since their first year of medical school all the way through their residencies, so saying goodbye carries a weight.
The goodbyes are not what make July a difficult month, though; it is the hellos. The eager idealism of the new interns is overwhelming to my jaded soul, and their utter procedural inexperience heaps a giant workload onto my old shoulders.
“Hello, Dr. Reiser, I am your new intern. Do you think I should do a pelvic exam on this young woman with abdominal pain?”
“OK, well, you will have to supervise me; I am not certified to perform them independently.” This elicits chuckles from my colleagues who overhear it. Sheesh, what do they teach in medical school these days?
“Hello, Dr. Reiser, the nurses can’t get an IV in my patient, what should I do?”
“Use an ultrasound to find some deep veins.”
“OK. How do I order that in the computer?”
“No, you do it yourself at the bedside.”
“Oh, I have never done that.”
“Yes, I am getting that,” I reply as the nurses chortle. Where, oh where, are my senior residents? All gone.
“Hello, Dr. Reiser, I have a demented patient from a nursing home who is more confused than normal.”
“Well, what is the differential and workup for that?”
“Um, I don’t know. Is there an app or a smart set in the computer for that?”
Oh, boy. Actually there is an altered mental status button on the electronic medical record but that seems like cheating the thought process, so it remains well-hidden to the uninitiated.
But July is good for me. The interns’ idealism eventually thaws me and their thirst for knowledge inspires me to try to slake it. This is why I became a teaching physician.
But is July good for you? There is a longstanding belief that July is a dangerous month to be a patient in the hospital. An article last year in the Annals of Internal Medicine examined 39 studies of the “July Effect” on mortality from 1989 to 2010 and could come to no firm conclusions, mostly due to the variable quality of the studies. Multiple surgical subspecialties have published studies showing no effect on their surgical mortality in July, though one could argue a lack of impartiality.
The most definitive answer probably comes from a 2010 study in the Journal of General Internal Medicine. The authors looked at all death certificates from 1979-2006, an astonishing 62 million records. They found a 10 percent spike in fatal medication errors in July in counties with teaching hospitals, compared to counties without teaching hospitals.
Much has changed since 2006; we now have clinical pharmacists in the ER monitoring care, pharmacy techs updating patients’ medication lists at every visit and electronic medical records cross-checking every drug ordered. So, yes, there is an app for that. The next study will tell us if it is working.
Meanwhile I am doing what any sane practitioner would do in July if he could. I am going on a long vacation.