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July is the month that medical students, fresh from medical school, start learning how to be doctors. That gives rise to the “July Effect,” where medical error rates increase as these new doctors learn on the job.
In this article in the New York Times, Theresa Brown, a nurse, looks at whether the July Effect exists, and how nurses can deal with it if so.
She notes that the medical literature is inconclusive regarding the July Effect, but cites two articles that found evidence of it. The author of one off the articles compared the deployment of new resident so to having rookie football players replace veterans “during a high-stakes game, and in the middle of that final drive.”
Brown’s own conclusion is that the July Effect “is undeniably real in terms of adequacy and quality of care delivery.”
She goes on to describe an experience she had as an oncology nurse, where a patient was dying of cancer and was in unbearable pain. She paged the first-year resident, brand-new to actual doctoring, and explained why the patient needed a much higher dose of pain medication. The doctor refused to up the dose. After trying repeatedly to convince him, as her patient writhed in pain, Brown paged the palliative care physician on call, who she had talked to about the patient day before.
I described the patient’s sudden lurch toward death, the sharp increase in pain and the resident’s reluctance to medicate the patient enough to give him relief. “Ah,” she said, “I was worried about that,” meaning that the patient might begin actively dying sooner than the medical team had expected. She ordered a morphine pump. I got the drug, loaded and programmed the machine. The patient died fairly soon after. He was conscious to the very end, and I can say he did not meet his death in agonizing pain.
A FEW hours later I ended up in the elevator with the new resident. He and I both started talking at once. Looking stricken, he apologized to me for having been busy, overwhelmed with several new patients. Knowing it is never easy to have someone’s footprint on your head, I apologized for having called in an attending physician. “I don’t usually jump the line,” I started to explain, when he interrupted me. “You did the right thing for the patient,” he said.
Such an exchange is rare. A nurse who goes over a doctor’s head because she finds his care decisions inappropriate risks a charge of insubordination. A resident who doesn’t deliver good care risks the derision of the nurse caring for that patient. Nurses aren’t typically consulted about care decisions, and this expectation of silence may lead them to lash out at doctors they see as inadequate.
The July Effect brings into sharp relief a reality of hospital care: care is becoming more specialized, and nurses, who sometimes have years of experience, often know more than the greenest physicians. We know about medicating dying patients for pain, but we know a lot of other things, too: appropriate dosages for all kinds of drugs, when transfusions and electrolyte replacements are needed, which lab tests to order and how to order them, whether consulting another specialist is a good idea, whether a patient needs to go to intensive care because his vital signs are worryingly unstable.
The problem can be limited by better supervision from senior residents, fellows and attending physicians, as well as by nurses. We need to acknowledge this fact, because admitting that new residents need help, and that nurses can and do help them, is the beginning of owning up to our shared responsibilities in providing care. For the good of our patients, nurses and doctors need to collaborate.