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Don’t Get Sick in July?

One of my colleagues just forwarded me a NY Times article by Jerome Groopman.  The article begins with the issue of inexperienced interns – how newly minted MDs begin clinical care for patients in July of each year, and how these rookies can make harmful mistakes.

He goes on to explain that doctors aren’t trained to think well about the diagnostic process (the thesis of his recent book) and that we’d all benefit from studying cognitive psychology.

Dr. Groopman makes some interesting points in this article, but I was most struck by his flippancy regarding the dangers of getting treatment in July.  He simply says, “Today, most hospitals closely watch over interns.”

I personally think the issue is more sinister than that – there are many ways that an intern can make mistakes, without ordering a single test or procedure, and under the full scrutiny of red tape regulations and documentation practices.

When an intern fails to recognize a life threatening condition and chooses to do nothing, or to let the patient wait for an extended period of time before alerting his or her team to the issue, serious harm can befall that patient.  And that harm is not caused by inexperienced procedural technique, or ordering the wrong medicine – it’s caused by doing nothing.  This “doing nothing” is the most insidious of intern errors – and it is not remedied by any form of hospital quality improvement initiatives.  It is the risk that a hospital takes by having inexperienced physicians in the position of first responders.  Interns gather large amounts of information about patients and then create a summary report for their supervisors.  The supervisors (more senior residents) don’t have time to fact check every single case, and must rely on the intern’s priority hierarchy for delivering care.

But many hours pass between the time an intern examines a patient and when a supervising physician checks back in with that patient.  And within that period of time, many conditions can deteriorate substantially, resulting in the loss of precious intervention time.

Dr. Groopman describes an experience from his own life in which a surgical intern (in July) correctly diagnosed his son with an intussusception (twisted bowel) but then incorrectly determined that the baby could wait to go to the O.R.  Of course, untreated intussusceptions are nearly always fatal, and each minute that passes without intervention can increase the risk of death.

And so, in my opinion, it is in fact more dangerous to be admitted to a teaching hospital in July, but not necessarily for the reasons that people assume (procedures performed by inexperienced physicians or drug errors – though those mistakes can be made as well). Rather, it is because interns don’t have the clinical experience to know how to prioritize their to-do lists or when to notify a superior about a patient’s health issue.  Timing is critically important in quality care delivery – and that variable is not controlled by our current intern oversight system.

Now that I’ve completely terrified you – I will offer you a word of advice: designate a patient advocate for your loved one (or yourself) if you have to be in the hospital as an inpatient (especially in July).  If you can, find someone who is knowledgeable about medicine – and who knows how to navigate the hospital system.  A nurse, social worker, or physician are great choices.  That person will help you ensure that concerns are prioritized appropriately when your intern doesn’t yet fully appreciate the dangers behind certain signs symptoms.  If you have no advocate, then befriend staff members who are particularly caring and experienced.  Be very nice to them – but don’t be afraid to insist on being examined by the intern’s supervisor if you really are concerned.  Unfair as it may seem, sometimes the most vocal patients get the best care.This post originally appeared on Dr. Val’s blog at

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5 Responses to “Don’t Get Sick in July?”

  1. Dr. Scherger says:

    Great message Val, but I have a different observation about interns and July (there is very little scientific data on this).  In July, the interns are very nervous.  They tend to check everything out with their upper level residents and attendings.  They are very nervous about making mistakes.  This may slow the process of health care, but such double checking would make care safer.  It is when the interns get too confident, after a few months, that they get dangerous.  I think we need a study!


    The message for people is that teaching hospitals are good, they tend to deliver higher quality of care, especially with unusual health problems, but have someone there and ask about everything!

  2. ValJonesMD says:

    I searched the literature on this and it seems that currently there is no evidence to support the July effect in ICUs in teaching hospitals:  So I guess I stand corrected (unless the July effect is more obvious in less acute settings where patients are not monitored as frequently by the senior physicians).  Though I will maintain my assertion that “doing nothing” is a kind of intern error that has not been well explored by quality improvement strategies.  And I also maintain that having an advocate with you in the hospital can improve the care you get.

  3. Anonymous says:

    This is so very true unfortunately. With 22 years Hospital experience, July in the hospital can be very interesting.also fortunately nursing staff realize that the “new” doctors are also scared of messing up and  act as patient advocate to ensure patients get the best care.; checking and re-checking orders, questioning them if necessary. Nurses want their patients safe and also want to develop the best physicians possible.

  4. Anonymous says:

    Hello VAL;

                     Groopman himself went to 3 top Hand specialists with very busy practice–it was the 4th hand surgeon–youngone who listened carefully–was not doctor on ROLLERBLADE as Groopman called the third surgeon in his book–he reasoned using his brain and not textbook and found a “torn ligament”–Guess Groopman did not believe that–so he went to the fifth surgeon who had NEWER MRI than MGH/Harvard–that machine showed “Torn Ligament”.

               Second point: July has the heart attacks at half those in January–big study in 1500 hospitals for 250,000 heart attacks.

              Third point:Young Interns are not in a hurry–they work long hours,but LISTEN WELL–It is the older doctors who lose “LISTENING ” power because they have reached the judgement in ONE MINUTE.

              Please read his book about his own hand ailment.

  5. Anonymous says:

    70% of doctors are bookish–by the book doctors–Research teaches you to THINK and imagine.

               Crohn’s disease misdiagnosed by ER as Stomach ache.,2_5_AU22_DUNCAN_S1.article


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