It’s one of those secrets you normally don’t learn in nursing school: “Don’t go to the hospital in July.” That’s the month when medical residents, newly graduated from medical school, start learning how to be doctors, and they learn by taking care of patients. And learning means making mistakes. There’s disagreement in the medical literature about whether a so-called July Effect, where medical error rates increase in the summer, actually exists. But a 2010 article in the Journal of General Internal Medicine and a 2011 article in the Annals of Internal Medicine both found evidence of it. In an interview, Dr. John Q. Young, lead author of the latter review, likened the deployment of new residents to having rookies replace seasoned football players during “a high-stakes game, and in the middle of that final drive.” From what I’ve experienced as a clinical nurse, whether or not the July Effect is statistically validated as a cause of fatal hospital errors, it is undeniably real in terms of adequacy and quality of care delivery. Any nurse who has worked in a teaching hospital is likely to have found July an especially difficult month because, returning to Dr. Young’s football metaphor, the first-year residents are calling the plays, but they have little real knowledge of the game. This experience deficit plays out in ways large and small, but I remember an especially fraught situation one July when a new resident simply did not know enough to do his job and a patient quite literally suffered as a result.
The patient was actively dying. He was older and his death was expected. He had kept his cancer at bay for several years, but there were no more curative treatment options left and he had opted to die peacefully in his bed, surrounded by family. He had also wanted to die in the hospital, and his death was coming on quickly enough that the hospital decided to allow it. He was grumpy, charming, funny and impressively clear-eyed about the end of his life. During our brief, two-day acquaintance I developed a strong attachment to him.
Death came closer quickly on that second day and as it neared, his pain increased significantly. Dying from cancer often hurts. He needed oxygen to breathe comfortably, and because he was alert he fully felt the intense pain. I’m a nurse, so legally I cannot decide to increase a patient’s dose of pain medication, but I can call a physician and describe the patient’s distress. That’s part of a nurse’s job, but there is also a chain of command for getting medication orders, and another part of my job is adhering to that hierarchy.
I paged the first-year resident covering the patient. Since it was July he was an M.D. on the books, but he was brand new to actual doctoring. I explained things, but he would not increase the ordered dose. I paged him again. We talked over the phone, and I insisted. Then I pleaded. He would not up the dose.
Looking at the situation from his point of view, I understand his reluctance. I was asking him to prescribe a very large dose of narcotic, a killingly big dose if the patient was unused to opioids. The resident might have learned in medical school about pain during dying, but he had not actually been with a patient going through it. Seeing such pain — the body twisting, the patient crying out helplessly — is categorically different from reading about it.
I also imagine the resident had been taught to prescribe narcotics judiciously, perhaps even sparingly, and the amount of drug I was asking for was neither.
The patient’s wife was kind; his daughter, a nurse, forthright. They and he deserved better than they were getting, so I decided to take a risk. Ignoring the chain of command, I paged the palliative care physician on call. She and I had talked about the patient the 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.
Article by Theresa Brown
Published on July 14, 2012, New York Times Opinion Page Part of a series on healthcare from a nurse’s perspective . Theresa Brown is an oncology nurse and the author of “Critical Care: A New Nurse Faces Death, Life, and Everything in Between.”