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Experienced physicians share a joke about this changing of the guard: “Don’t get sick in July.”
Today I will discuss a few concerns about when to seek treatment. Some of these are results of studies, and the debates continue as to whether they are truth or myths. I bring this up now because currently, it is late June, and the more famous one is about July, in fact, it is called “The July Effect”.
The initial study seemed to spawn a cascade of other studies, all were about effects upon healthcare delivery: error, infections, adverse effects, and death rates.
I would review studies that made sense, and then I’d read one that did not support the first one. Then I was part of a healthcare encounter for a loved one that debunked much of what I’d read and adopted. I have a real and personal story for you.
Lastly, I will cover what all of us can do to remain safe in a hospital encounter any month, any day, and any time.
So, fact or fiction? Truth or Myth? Urban legend? Let’s take a look.
In the past years, there has been an ongoing discussion as to whether or not to have surgery or even to be in the hospital in July. Here’s why.
There exists a phenomenon called “The July Effect”. The July Effect refers to a time when teaching hospitals experience a sharp increase in medication errors – which just happens to coincide with the July arrival of new residents, medical students who graduated in June and are to begin their first year of residency training or internship. This group of eager new interns enters the hospitals to learn, care for patients and make medical decisions. The idea has been floated and studied that July brings about an increase in medical errors resulting in harm to the patient.
An often-cited study in the 2011 Journal of General Internal Medicine reported a 10% spike in teaching hospital deaths during the month of July due to medical errors. Calling it “The July Effect”, that spike was attributed to the influx of new interns and residents who enter their hospital training in – you guessed it – July.
The rationale there was that even though medical students receive a rigorous academic education, they lack the experience required to make sound medical decisions, especially involving medication. Therefore, it was thought that they may not recognize certain symptoms that indicate a drug reaction, an infection, or another type of complication. They may also not have had time to master the protocols of documentation and other important hospital procedures.
Furthermore, doctors in training are often sleep-deprived, which can increase the risk of medical mistakes.
Plausible, I suppose, but whether you believe or adopt this thinking in your healthcare decision-making can be up to you.
Before we pin this effect on the entry of new residents alone and what has led to multiple studies on cause and effect, let us look at some other factors that may be contributing. More studies. There have been plenty.
Let me say that I am glad there are studies. Thanks for minding the store! We need eyes on healthcare from many directions. Scrutiny brings about improvements and safety.
Yes, new residents enter the scene in July. But what about the summer vacation season, when the more experienced staff are requesting time off (in July)?
Might that also leave many patients at risk for patient safety errors? If that is true, might the holiday seasons in December and 3-day weekends like Memorial Day and Labor Day weekends also present challenges to patient safety?
I would be remiss (and you might become bored) if I did not mention other factors explored that are similar to this line of thinking. Oh, there are more. What other factors should we consider relative to seeking treatment that are similar to this July Effect?
What about June?
June could be the problem some professionals cite because there is a general assumption that the aforementioned residents are competent in their 11th month at their level, and the work is less stringently overseen. The residents are tired, sometimes burnt out, or their eyes are thought to be on the next steps in their careers.
Then there is the Birthday effect. There was a study whose findings suggest or demonstrate how “surgeons might be distracted by life events.” But what does that mean? Were the surgeons less focused? Were they rushing the surgery to get home sooner to start celebrating? Did the excitement of their birthday somehow affect their physical performance of the surgery? All of these potential explanations (and, perhaps, others you might suggest) are speculative since the study did not focus on exactly what or why the results were observed.
I am not trying to spread any misinformation here, I am looking at these studies to see if they will hold water. (You know, something can pass muster and still not hold water).
Again, I wish to express my gratitude that someone is studying this stuff. Thank you for your work. I also want to encourage everyone, as consumers of our healthcare information, to look deeper into the research, how it was performed, what it has rendered, and for whom it may apply.
Extensive research has been conducted on The July Effect in years past. These studies have yielded a range of results, from substantial increases in patient deaths and other serious outcomes to surgeries in minor mistakes that did not result in significant harm. Which is right? Does it matter? It can.
Even a small mistake can be dangerous for high-risk patients.
Even a small mistake can be dangerous for high-risk patients, such as the elderly and those with compromised immune systems or underlying medical conditions. High-risk patients are certainly a “for whom it may apply” population. For example, one study rendered that in July, of the high-risk patients who came to the teaching hospitals with heart attacks, the risk of death went from 20 percent to 25 percent.
You can bet I am studying the studies: who performed them, when, and how. Margins for error. Were they studying errors, preventable harm, deaths, and adverse outcomes – and what is meant by those definitions? The devil is in the details, after all.
I spent some time reading studies published in BMJ (a health informatics outfit), Harvard Medical School, Stanford University Hospitals, University of Southern California, the RAND Corporation, and even The Annals of Thoracic Surgery. What I noticed was that most of the studies and the articles surrounding the July Effect seemed to taper off after 2017.
For every article I read, one would lend credence to the idea of The July Effect, and another would discredit the idea. My hunch is that the one in 2011 that reported the spike gave it a name and likely spawned more research. The articles commenting on and citing that study and others extended into 2017, 2018. Then not so much.
Has subsequent research debunked this July phenomenon, and has it become a lingering and rather interesting urban legend?
Don’t get me wrong, I am glad research occurs and that it is being reported. But methinks we consumers may be comparing apples and oranges here, only to glom onto something sensational that says we have a July problem. We in America do love a sensational headline, do we not?
Side Effects (pun intended)
All of this stuff makes sense, could certainly be. I feel a little like the tv pitch guy, Billy Mays, when I say to you, “But wait! There’s more!”.
As long as we are looking at July (or even June), holidays, and vacation, there is another factor that could come into play with this kind of thinking: Time of Day. Researchers found that patients whose procedure began between 9 p.m. and 7 a.m. were 50 percent more likely to develop complications compared to patients with a surgical start time after 7 a.m. or before 9.
A five-year study by the World Federation of Societies of Anesthesiologists (2016) found that patients who have surgery during the night are twice as likely to die as patients operated on during regular working hours. A possible explanation for their findings is the “After-hours effect,” also known as the “Weekend effect”: When a task is done outside the “normal” timeframe (i.e., after-hours or on the weekend), the outcomes for that task are statistically worse.
One study begets another, and you and I can be the ones to lump all the data together or make gross generalizations. I know that I have.
I adopted the Time-of-Day theory because it seemed plausible and logical to me. Then I had an encounter that debunked it for me, front and center. Once and for all.
From what I’d heard and read, it may make good sense to me to go for early surgeries, for the ‘Power Hours’, as some call them. I agreed that when scheduling surgery, time of day could very well matter. I always request or recommend the second or third slot of the morning, the theory being that any kinks in the team’s coordination or machinery would have been worked out, and the medical team is still fresh.
Then it became time for unexpected surgery for a loved one of mine. A medical appointment deemed her matter to be much worse than was thought, and surgery was offered three days later. Good that she would not have time to become too anxious about it, but what I heard this provider offer was (an opening that he just happened to have this Friday) at 3:30 PM. I provided counsel to my loved one, aware and citing the factors that could be a part of her decision. My loved one opted to proceed.
On the day of the surgery (and as fate would have it), our city was feeling the effects of a hurricane. Let’s just say there were power outages and delays affecting everything in our city that day. When my loved one and I arrived the required two hours early for the 3:30 PM surgery, the storm was in full swing. At the check-in desk, I noted that hers was the sole remaining wristband and paperwork laid out. She was told there had been delays and an expectation set for a 5:30 PM surgery start rather than 3:30. As we sat there waiting, I ruminated over the July Effect, the Time-of-Day Effect, and wondered if there might be a “Friday-last-day-of-a-surgery-week Effect” and a “Hurricane Effect”.
As for how the encounter ended for my loved one, it went well! She had a terrific pre-op visit with the surgeon (asking the surgeon if he needed a break first, please take one, she said). She was taken into surgery not at 5:30 PM but at 7:30 PM. I returned to the lobby to wait, and I was informed that this lobby was being closed. The staff went home. I was relocated to sit alone in the small lobby whose front doors had malfunctioned in the hurricane and were stuck open in the hurricane! I was cold and damp and zipped up in my windbreaker and hoodie. I received the comforting text updates that surgery was underway, then completed. Further texts informed me that my loved one had been moved to recovery and that I would soon be able to meet her in a room.
Watching the hospital staff come and go, I recognized the surgeon preparing to exit the hospital, his day completed. Somehow, he recognized me (in my rain suit with hoodie) and came over to debrief me. He was still fresh and communicative. The procedure had gone well, he expected no problems. He asked if I had questions and gave me his cell number. That conversation debunked all the “Effects” for me then and there.
As much as I’d been operating under the July Effect, the Time-of-Day stuff, and manufacturing The Hurricane Effect in my mind, my loved one, and I had done our part. We had arrived prepared and had remained vigilant – which is what we all can do: continue with knowledge and proceed with watchful eyes.
Let’s shift into the solution (because you readers know I like to live in the solution).
Prevention – and avoiding preventable errors – never goes out of style for a Patient Advocate! Let’s talk about…
Common sense and recommendations surrounding surgery and hospital stays.
Here are some things that we all can do to ensure our healthcare encounters go well in any month and any time of day.
Communicate – The key is communication. Discuss with your provider any concerns you may have about surgeries or hospital stays.
Speak Up – As such, or during such, if you have concerns about the July Effect, or vacations, or Time of Day, then talk about that and then make your own best decision when you have the most information.
Move – If you are now wary of July variables (whether truth or urban legend) then move your procedure or appointment.
Act – Act upon what is important to you – If having the Power Hour seems important to you for surgery – ask for the second or third slot of the morning.
Know What To Do if questions arise. (Think post-visit or post-discharge). Take this question with you to every encounter: “Who do I contact if I have questions? Ask that question at every appointment. Make sure that you know what to do, who to contact, and how. I cannot emphasize this enough.
Let us all and always remember the Tried-and-True actions we can always take.
- Have with you a current list of your medications (or take them with you to appointments, scoop them up on your way to an ER, even).
- If your provider has a medical portal for you, get to know and use it. You may find faster response and answers to your questions by using this tool.
- Hire a Patient Advocate to guide you in your care. We educate, and we are looking up and down the line for you. We support.
- Have someone, whether Advocate, a family member, or a loved one, with you always. They can ask questions the patient has not thought of, and–because they know their loved one/patient–they understand what he or she’d be anxious or unclear about. By acting as extra eyes and ears for you, these key people can keep track of your treatment and may prevent errors that would otherwise go unnoticed.
- Begin to journal the course of events. Have your Advocate or loved one who is with you take that over when you are unable. You will hear me always sing-song my recommendation: “Chrono because you never know…”, meaning you might need to refer to it later. If not, great! If you do need to know when the time and day meds were changed or when that BP shot up, or what time the doctor rounded to give you test results, then you will have it: for the patient, or family and friends, for a care issue or simply as a lookback.
And here is a terrific, effective, and free resource for hospital stays: Before going into the hospital, and even while you are there, harness the power of The Care Partner Project, the work of Patient Advocate Karen Curtiss, and her robust website that offers Hospital Care Checklists. The website is thecarepartnerproject.org. We can all learn a lot about staying safe and avoiding preventable errors.
We make our best decisions when we have the most information.
It is my belief that our best protection is from being aware (not paranoid or misled). We make our best decisions when we have the most information! Think about the factors that might impact your planning and procedures. Know infection prevention. Ensure clarity of information (like with meds) by communicating with your providers. Have someone with you at appointments and when at the hospital. Understand discharge and your action steps for follow-up.
My Rx for you, as a professional Patient Advocate (I’m not a doctor), would be to approach all this with common sense and pragmatism. Maybe get a little methodical about it. It has been my experience that forethought and planning are good, and I will bet there are studies on that!
Contact me if you need some help in thinking through your particular situation and protecting yourself or a loved one while in the hospital.
Summer’s here, it is nearly July. I hope that all is (and that you will remain) well.
Nancy Ruffner is a Patient Advocate who consults online to join and guide you through our wacky healthcare system. For and with, Nancy helps her clients gain the most information so as to make the best decisions. Offering Complimentary Consultation toward engagement, schedule yours here or call 919.628.4428.