Study: Hospital deaths may spike in July

The ‘July effect:’ Does an influx of medical residents lead to an upswing in errors?

by Amanda Cuda
Connecticut Post

July 17, 2010

For years, many in and around the health care industry have been familiar with the so-called “July effect” — the idea that medical errors spike in July, which is when many medical school graduates start their residency programs at teaching hospitals.

But is the July effect a real phenomenon, or an urban legend, much like the idea that emergency rooms fill up during a full moon? A University of California, San Diego study released last month showed some evidence that fatal medication errors spike in July in counties with teaching hospitals. Yet some in the health care industry say the research is inconclusive, and that the July effect is little more than a myth. “The July effect is a largely overrated phenomenon,” said Mark Kulaga, program director for internal medicine residency at Norwalk Hospital. “There are so many systems in place, it really mitigates a lot of the issues you run into with inexperience.”

A wealth of new faces

The UC-San Diego study, conducted by sociology professor David Phillips and his research associate, Gwen Barker, examined 244,388 United States death certificates issued from 1979 to 2006. The researchers focused on fatal medication errors as the recorded primary cause of death, comparing the number of deaths in July with the number of expected events in a given month for a given year. Phillips and Barker found that fatal medication errors spiked in July and in no other month. The increase, about 10 percent above the expected level for such events, was visible only in counties with teaching hospitals. No similar link was observed for other causes of death or for deaths outside hospitals.

Though the information studied included little data about the cause of the medication errors, Barker and Phillips concluded that the spike seemed to stem at least partly from changes associated with new medical residents. According to the nonprofit Kaiser Family Foundation, there are more than 16,000 medical graduates in the U.S. every year. In Fairfield County, there are 26 residency programs at six hospitals — Bridgeport Hospital, St. Vincent’s Medical Center in Bridgeport, Greenwich Hospital, Stamford Hospital, Danbury Hospital and Norwalk Hospital — with a total of about 340 residents now in training. The number of people starting medical residencies in Connecticut this year wasn’t available through the American Medical Association, but 471 residents started their training in Connecticut last year.

Barker said the idea of a link between new residents and a jump in errors has been talked about before but, until now, there’s been little evidence to support it.

“In a way, this isn’t surprising,” she said. “Inexperience causes errors. I think that’s been shown in other occupations, not just in the medical setting.”

To some, the study gives credence to a phenomenon that they’ve observed anecdotally for years. Attorney Michael Koskoff, a senior partner at the Bridgeport-based firm Koskoff, Koskoff & Bieder, has handled a large number of medical malpractice cases and has long seen an uptick in business around this time of year.

“We’ve always noticed that there are certain hot points in the year, and July is the hottest,” Koskoff said. “That’s not news to anybody who works in a health care-related field.”

The findings were also not a shock to Diane Pinakiewicz, president of the National Patient Safety Foundation, a Boston-based nonprofit that works to improve the safety of the health care system.

“Everyone is cognizant of the fact that there are major changes in personnel in July at teaching hospitals,” Pinakiewicz said. “When you’ve got new people, there’s a learning curve.”

Like Barker, she acknowledged that a learning curve exists in all industries, but in medical care, “there’s higher stakes.”

Koskoff agreed, saying medical school graduates “know in their brains what they’re doing,” but might have difficulty translating that knowledge into the real world.

Flaws in the logic

However, many in the health care field point to flaws in the California study and argue that there isn’t a strong tie between new residents and medical errors. The research fails to take several factors into account, said Dr. Alison Hong, the Connecticut Hospital Association’s interim vice president of quality and patient safety. For one thing, she said, the information studied doesn’t specifically say that the errors in question were caused by residents. The mistakes could have any number of factors, including administrative error.

Other health care professionals agreed, and added that much of the data studied was more than a decade old. Thus, it doesn’t account for modern advancements, such as electronic prescriptions, that greatly reduce the risk of error, Kulaga, of Norwalk Hospital, said.

“There is a lot more support today than there was when I trained back in the ’90s,” he said.

Kathleen LaVorgna, president of the Connecticut State Medical Society and a general surgeon at Norwalk Hospital, agreed. “Everything is markedly different now,” she said.

LaVorgna, Kulaga and Hong all said they don’t believe the University of California study conclusively proves there’s a “July effect.” LaVorgna said that there are a lot of fresh faces in hospitals around this time of year, but these new doctors aren’t exactly flying blind. “Patients shouldn’t think that new doctors are making decisions about their care,” she said. “There is always a team of doctors who call the shots for that patient.”

Hong said she’s never believed in a July effect, calling it an “old wives’ tale.”

“I don’t think it’s really a credible thing that doctors worry about,” she said.

However, doctors and the hospital association are concerned about preventing errors at any time of year, Hong said, mainly by making sure the channels of communication are clear.

“Hospitals know that communication is the number one way to prevent errors,” she said. “It’s a way to orient (new people) on `Here’s what to expect when you come into our hospital.’ “

LaVorgna said that communication doesn’t just apply to interactions between residents and their supervisors, but between residents and patients, as well. If a medical resident is contributing to your care, she said, don’t be afraid to ask questions and offer feedback.

On that score, Pinakiewicz agreed. She said, at any time of year, and no matter who in the hospital you’re seeing, patient involvement is key to patient safety.

“There are basic things consumers need to do whether it’s July or January or February,” she said. “Patients should always feel they have the right to ask questions, and patients should ask questions.”