The July Effect: Is it really more dangerous to go to the emergency room in the summer?

Imagine approaching the counter at a Toronto train station, requesting tickets to Vancouver. The agent tells you, sure, he can do that, but with a few caveats. One, while the staff is terrific, often working double or triple shifts, they sometimes make very grievous mistakes. Two, while the equipment is up to date, some of the cars occasionally break down. Three, one in 13 passengers will experience some kind of critical incident and will be significantly injured. Oh, and one last thing: One out of 100 of you will be dead before you reach Vancouver. Now, how many tickets would you like?

Dr. Robert Robson, emergency physician, healthcare mediator, assistant professor at the University of Manitoba’s Faculty of Medicine, and principal at the Healthcare System Safety and Accountability Advisors (HSSA), loves to tell that story during his mediation sessions. While amusing on the surface, underneath it’s a deadly serious parable. “They don’t have that conversation with you at the train station, do they?” he asks. “Hospitals don’t have that conversation with you, either. But the truth is that one out of 13 adults admitted to a general hospital in Canada will encounter injury or death,” either through a botched surgery, medication mix-up, or equipment malfunction.

Robson refers to the 2004 Baker-Norton study that revealed approximately 185,000 Canadians a year suffer serious injury under hospital care, and between 9,000 and 23,000 die. Add in psychiatric and obstetric patients, nursing homes and chronic care facilities, and the figures climb closer to 35,000 deaths a year. In the ensuing 12 years since that study, Robson suspects those numbers have only increased. They certainly have in other areas. “That study was repeated in 2012 for pediatric adverse events in Canada, and the figure is actually higher. So in 10 years, things did not improve.”

And while there are no hard numbers to support what’s known as The July Effect — when critical incidents spike because newly graduated medical students are entering the hospital to complete their hands-on training — it’s recognized anecdotally as a fact. But Robson refuses to pin any increase in incidents on interns, since these newbies are not exactly flying solo. “They might be overseen by a resident, or other senior staff,” he says, to head off medical errors. “Hopefully, at some point, the staff physician will be involved. In good clinical teaching units, there will be lots of supervision and feedback.”

Also, ideally, the student will be incorporated into the care team and made to feel confident and valued enough to offer input and even alternate diagnostic possibilities. But too often, stifled in a doctor-is-god cultural hierarchy, the student is reluctant to speak up. “So while it may be accurate to say there’s an increase in mortality in the first few weeks of July, just as it’s accurate to say there’s an increase in mortality on weekends, one needs to wonder if that’s not more a reflection of the kind of supervisory structure in teaching hospitals,” says Robson.

“I don’t mean to paint all medical staff with a black brush,” he continues. “There are lots of excellent ones. And there are also many who may be overworked or can’t be bothered to take the time to review the student’s record. Teaching hospitals have to allow people, namely students, interns, junior residents, enough space to potentially make mistakes but have enough supervision to pick up those potential mistakes before they actually harm somebody.”

Kathleen Finlay experienced those mistakes first hand when her mother was on the receiving end of a staggering 4,000 of them. “It is a record in the literature on patient safety,” says Finlay, who, in response, went on to found The Center For Patient Protection. And those mistakes were not committed by medical students or interns.

“I can honestly say, that among all the complaints I receive each day, none has involved errors on the part of interns. The concerns generally focus on the actions of more senior doctors, nurses and hospital administrators.”

And, as far as The July Effect, Finlay says, “The real nightmares for patients and families often happen at night, on weekends and during vacation periods like Christmas.”

Dr. Chaim Bell, physician and scientist at Toronto’s Mt. Sinai Hospital and professor of medicine at the University of Toronto, agrees. “I’ve done a lot of research on the weekend/weekday differences,” he says. “People always worry about The July Effect, but July only happens once a year, the weekend happens every five days.”

As for medical errors made by interns or students, which he says are more accurately referred to as post-graduate year ones, or PGY1, he says, “Only 20 per cent of the care, at least in Ontario, is provided in academic institutions. So 80 per cent of the care is provided in institutions and areas that really have nothing to do with the new intern phenomenon, so to speak.”

Yet, he says, “It’s so well recognized that there might be even more attention to make sure that we build in greater redundancies, support and oversight during that time frame. Where we might double-check in March, we will double- and triple-check in July because we’re more attuned to the possibilities.”

He points to other factors that might contribute to a July effect, namely that many senior staff take vacations during that month, and some residents have become full-fledged physicians and moved on to practice elsewhere. He believes the problem could be mitigated, in academic institutions at least, by allowing fewer vacations by senior staff in July, ensuring more available personnel, and lessening teaching responsibilities.

Robson, the former Chief Patient Safety Officer of the Winnipeg Health Authority, where he remains as a researcher and investigator, says, “All of the large studies have indicated that critical incidents in teaching hospitals occur at the same frequency, or sometimes at a slightly higher frequency, than in community hospitals or even small rural hospitals. So isn’t it surprising that we have apparently the absolute cream of the crop, the most senior professors and physicians who are at least nominally providing the care within those hospitals and yet they’re doing at least as bad as other hospitals. It’s very strange. We need to stand back and ask why that may be the case.”

Certainly staff, resources, equipment and budgets are stretched or cut, making optimal care a challenge. There are also communication breakdowns, especially during hand-offs, when patients are transferred from one department or shift to another. But the way in which teaching hospitals are structured, and the way in which health services are organized, also play a part, says Robson. In addition, he maintains (and the numbers support it), there is “a dramatic under-reporting of critical incidents, and it’s not any different in a teaching hospital than it is in a community or rural hospital. Every province has legislation that says you must report these things and yet in most cases, less than five per cent are reported. They’re not covering up, they’re not bad hospitals or nasty managers or CEOs. But they do have to run their businesses, if I can use that term, in a way that they continue to get funding. Generally speaking, people think, ‘Gee, if I tell everybody that one out of 13 people coming into my hospital is going to be injured unintentionally, that doesn’t look good.’”

But isn’t not injuring or killing somebody better than looking bad? Isn’t reporting, investigating and studying these incidents, remaining open and transparent about them, a good thing? “They think, ‘None of the other hospitals are copping to these problems, so we must be worse than them.’ The fact is, you’re not worse than them. Everybody is like that. But would you rather take your kid to a hospital where nobody looks for problems and fixes them, or to a hospital that says, ‘We’ve discovered these problems and here’s what we’ve done to fix them.’ Let’s be honest about this.”

Finlay could have used a little of that honesty when her mother was deteriorating. “When my mother was hospitalized, I had no idea what a medical error was,” she says. “I just assumed hospitals were like NASA programs, where all kinds of safeguards and redundancies were built in to ensure safety. How wrong I was. In fact, so many errors were inflicted on my mother that, by the end of her six-month hospitalization, we were told her demise was imminent. We brought her home to die. But getting her out of the hospital was what saved her life. And almost six years later, she is living at home and, with my assistance, is enjoying life every day.”

Even Robson says, “When are hospitals going to be required to have a sign over the entry doors that says, ‘Entering here for care is more dangerous than smoking cigarettes’?”

But, he emphasizes, does not believe medical personnel get up in the morning thinking, ‘How many people can I kill today?’ He says most are hard-working, dedicated, caring individuals who do the best they can within the structure, budget and resources in which they work. “I have never met a physician or a nurse or a pharmacist or an x-ray technician who says, ‘I’m going to see who I can bump off today.’ So why is it happening? I think the answer is fairly straightforward – how to fix it is not fairly straightforward – but the answer is that the way in which we provide care is now so complex, and there are so many things interacting that it is virtually inevitable that there will be breakdowns in communication or teamwork. Sometimes it’s as simple as a piece of equipment that’s malfunctioning and nobody knows how to fix it. There are ways of solving it but you have to study them. If you don’t get these things reported and you don’t review them, then you never learn what happened. And if you never learn, it’s just going to repeat itself.”

Finlay believes our lawmakers need to be more aware of what’s happening in the halls of our hospitals, and they need to act. She says research proves that medical errors are the third leading cause of death in the U.S. and Canada, claiming more lives every year than strokes, Alzheimer’s disease, breast cancer, kidney disease and car accidents combined. “The result is a needless infliction of pain and death on patients that, for the most part, is avoidable. It’s a huge added cost on our healthcare budgets and a tremendous cause of emotional trauma for families.”

Dr. Gordon Wallace, managing director of the Safe Medical Care Program at the Canadian Medical Protective Association, says doctors and other medical staff understand the situation and are working to improve it. “We’ve got an issue with the quality and safety of care and I don’t think there’s a hospital in Canada that isn’t trying to address this,” he says. “I’ve been in practice for nearly 40 years. We were always interested in quality, but we’ve very much accelerated that interest in the last decade, developing a lot of tools and approaches to improve quality.”

Most of those tools are detailed on the Association’s website, and would be of interest, he says, to everyone from patients to students to professors and senior medical staff. And while he says he has heard about the July Effect anecdotally, he hasn’t recognized it as a trend. “We as staff physicians are very alert to the fact that residents are one day a medical student and the next day a practicing resident doctor,” he says. “So we’d be much more diligent in our supervision in those times as they’re gaining experience. I think that keeps a lot of residents early on out of trouble.”

Wallace also agrees that it’s important to create and maintain a welcoming culture, where not only new staff are encouraged to have a voice, but the patients themselves should be actively engaged with their health care team. “I think the best physicians encourage patients to speak up.”

Robson also believes the public holds the key to reducing medical errors, either by interns or anyone else, no matter their position. “Patients are the ones who, once they have the proper information, will do something about it. The best quality control agents are patients. Some of the best ideas, the most compassion, have come from people we’ve injured unintentionally or who had a loss.”

He also believes the methods and approach used to head off those injuries or loss need to change. “Most hospitals in Canada are still using techniques called root cause analysis,” he says. “They’re very effective when you’re trying to figure out what went wrong in a car assembly plant, but they’re not effective most of the time to figure out what’s going wrong in a hospital. You need a totally different approach, and there’s resistance to that approach because part of that approach requires honesty and transparency.”

Meantime, he recommends we as potential patients need to be aware of the risks when we walk through those double doors, not just in July, but in every month, every week, every day. We should know our rights, ask questions, be fully involved in our own care, and know how to respond when something goes wrong. And take a loved one with us to ensure we get out alive.

“Injuries and mortalities are occurring and it’s not as simple as ‘those bloody interns’,” he says. “There are many reasons, and we need to have that conversation. Let’s be honest with the patient, apologize and figure out how to fix it. But before we can do that we need to learn about the cases, investigate them in a way that reflects the complexity of the situation in which it occurred. Everybody who’s affected by this needs to be part of searching for the solution.”