July in the hospital – If it’s broke…
This article originally appeared in The Daily Progress on September 23, 2012.
If you were laid up in a teaching hospital in July, you probably encountered a whole bunch of short-coated interns frantically paddling in the deep end. Just weeks after taking the Hippocratic Oath, medical school grads are expected to figure out the rules of their new residency programs, unfamiliar computer systems and where to park — while making life or death decisions, with little or no oversight.
So dodgy is the summer switch-up that grown-up doctors are known to warn loved ones away from academic centers during the dog days between Midsummer’s Eve and September. With nary a wink or a nod the message is: If you don’t have to have that operation done right after school gets out — don’t.
Replacing employees en masse is called “cohort turnover” — a fancy name for “how stupid is this idea?” What it means is that you have lots of new people running around who don’t know the ropes. In our teaching hospitals, it means that the multitudes of shiny new faces ready to assume responsibility for patients might not actually be ready. And unfortunately, the experienced doctors who do know the ropes are off celebrating the Fourth of July and summer vacation with the rest of us.
The danger is not just anecdotal. In a 2011 Annals of Internal Medicine article, Dr. John Q. Young and his colleagues reviewed two decades worth of studies evaluating July patient care. They saw negative findings that ranged from unnecessarily extended hospitalizations to an actual spike in deaths.
When my daughter, a transplant patient, was hospitalized for excruciating inflammation around her heart this past summer, I learned first-hand about the dicey staff changeover euphemistically known as the July Effect. (In England, the switch up is actually called the Killing Season.) At one of the best hospitals in the country I saw a slew of problems that, from this lay vantage point, came from a calcified hospital culture that casually accepts bleary-eyed exhaustion, knowledge deficits and communication snafus as just an annual rite of passage.
But it doesn’t have to be this way. We don’t issue all 16-year-olds their drivers’ licenses simultaneously, letting them loose on the highway in a frantic convoy. Instead we have graduated licenses. When public safety is involved, caution makes sense. New drivers need to be eased, so to speak, into the driver’s seat.
And so do the some 17,000 recent medical school graduates.
Competency should never be assumed. Training in everything from the new employers’ computer system, to correctly ordering medications, to knowing when to call for help, needs to be given. And the intern’s mastery should be proven before free reign is permitted.
The ones who were assigned to my daughter made a range of rookie mistakes. Their ineptitude ran the gamut. From not returning nurses’ pages to prescribing clashing meds to neglecting to order a critical test, the young physicians needed better supervision.
When a rogue intern unilaterally and prematurely decided to hasten my daughter’s discharge by exchanging IV morphine with oral pain killers, he caused the heart pain to come screaming back, slowing recovery, extending the admission.
I lost it. Think Shirley MacLaine in “Terms of Endearment.” On speed.
After I was through “talking” with the intern, he looked so bad I almost felt guilty. Because maybe it was the system’s fault. Maybe the poor guy’s judgment had been impaired from being overtired.
While airline pilots are limited to nine hours of flight time for passenger safety, hospital interns work 16-hour shifts* and 80-hour weeks. And that’s nothing compared to the second- and third-year residents who are supervising them. They’re on call for 24-hours at a pop.
Fortunately, some hospitals offer post-call taxi fare so the same exhausted people who are making medical decisions for your loved ones won’t get behind the wheel half an hour later.
If it’s broke — it needs to be fixed. And not just with a Band-Aid. Our medical system can and must do better. For the patients and for the accomplished men and women in the short white coats. They shouldn’t have to begin their careers being set up to commit avoidable errors.
*In the few years since this article was first published in the Daily Progress, the number of hours that interns work when on call has actually increased to 24.