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By Kenneth M. Ludmerer

“Don’t get sick in July.”

So the old adage goes. For generations medical educators have uttered this exhortation, based on a perceived increase in the incidence of medical and surgical errors and complications occurring at this time of year, owing to the influx of new medical graduates (interns) into residency programs at teaching hospitals. This phenomenon is known as the “July effect.”

The existence of a July effect is highly plausible. In late June and early July of each year, all interns and residents (physicians in training beyond the internship) are at their most inexperienced. Interns—newly minted MDs fresh out of medical school—have nascent clinical skills. Most interns also have to learn how a new hospital system operates since most of them enter residency programs at hospitals other than the ones they trained at as medical students. At the same time the previous year’s interns and residents take a step up on the training ladder, assuming new duties and responsibilities. Every trainee is in a position of new and increased responsibilities. The widespread concern that these circumstances lead to mistakes is understandable.

Yet, despite considerable consternation, evidence that there is a July effect is surprisingly hard to come by. Numerous studies of medical and surgical trainees have demonstrated no increase in errors or complications in July compared with other times of the year. Many commentators have declared the July effect a myth, or at least highly exaggerated. A few studies have shown the existence of a July effect, but only a slight one—for instance, on the sickest group of heart patients, where even a slight, seemingly inconsequential mistake can have grave consequences. Even here, however, the magnitude of the effect does not appear large, and the studies are highly flawed. Certainly, there is no reason for individuals to avoid seeking medical care in July should they become ill.

That the July effect is so difficult to demonstrate is a tribute to our country’s system of graduate medical education. Every house officer (the generic term for intern and resident) is supervised in his or her work by someone more experienced, even if only a year or two farther along. Faculty members commonly provide more intense supervision in July than at other times of the year. Recent changes in residency training, such as shortening the work hours of house officers and providing them more help with chores, may also help make residency training safer for patients—in July, and throughout the year.

Uncertainty is intrinsic to medical practice. Medical and surgical care, no matter how skillfully executed, inevitably involves risks. It would not be surprising if a small July effect at teaching hospitals does occur, particularly in certain subgroups of critically ill or vulnerable patients, given that house officers are the least experienced. However, the fact that this effect, if present, is small and difficult to measure provides testimony to the strength of graduate medical education in the United States. Indeed, the quality of care at teaching hospitals has consistently been shown to be better than at hospitals without interns and residents. Patients may be assured that their interests will be served at teaching hospitals—in July, and throughout the year.

Kenneth M. Ludmerer is Professor of Medicine and the Mabel Dorn Reeder Distinguished Professor of the History of Medicine at the Washington University School of Medicine. He is the author of Let Me Heal: The Opportunity to Preserve Excellence in American Medicine, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care, and Learning to Heal: The Development of American Medical Education.

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Image credit: Multiracial medical students wearing lab coats studying in classroom. Photo by goldenKB, iStockphoto.

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Ethics, the foundation of a working society, are especially important in a patient/surgeon relationship. In The Ethics of Surgical Practice: Cases, Dilemmas, and Resolutions authors James W. Jones, M.D., Ph.D., M.H.A, Laurence B. McCullough, Ph.D, and Bruce W. Richman, M.A., provide a collection of clinical case studies representing a wide range of the ethical issues surgeons confront today. In the excerpt below the authors ask, how to balance the privacy rights of a famous patient with the public’s right to know?

Fama volat (The rumour has wings)
Virgil (70–19 bc), Aeneid

The governor of your state has had a three-vessel coronary bypass graft at your center. Three weeks later he is returned unconscious to the hospital after suffering a right hemiparetic stroke while catching up on paperwork in his office. An emergency arteriogram reveals embolus to the left internal carotid artery at the bifurcation. As you leave the operating room following an emergency carotid endarterectomy with embolectomy, you are met by the hospital’s public information officer and the governor’s top political aide. They inform you that the press corps is assembled in the auditorium and expects you to provide them with a detailed description of the governor’s condition and prognosis.

You should respond by:
(A) Acknowledging the press’s right to know about a public official and providing an immediate and complete report on the governor’s presenting symptoms, the operation performed, his current condition, and his prognosis.
(B) Requesting advice from the political aide about how the governor would like the situation presented.
(C) Insisting that a report to the press await authorization from the governor or his next-of-kin.
(D) Refusing to meet the press.
(E) Relying upon the public information officer to direct you in implementing the hospital’s disclosure policy on treatment of public figures.

Many of us have been involved in or observed the frenzy of activity generated by hospitalization of a celebrity or prominent public official, particularly when emergency treatment for a life-threatening condition is involved. The convergence of news media places extraordinary demands upon the hospital, and the institution’s staff and management naturally want to be favorably represented by these highly influential opinion-makers. Representatives of the press will often assert the public’s right to know important information about highranking government officials or entertainment figures who experience medical crises, cite the press freedoms guaranteed by our Constitution, and insist upon your full cooperation in describing the patient’s condition and medical care. Nevertheless, neither the public nor the press have a statutory entitlement that outweighs a patient’s right to confidentiality in seeking or receiving medical care, and patients do not relinquish that right when they become public figures. The American College of Surgeons’ Statement on Principles requires that “the surgeon should maintain the confidentiality of information from and about the patient, except as such information must be communicated for the patient’s proper care or as is required by law.” The United States Constitution’s guarantee of a free press imposes an obligation upon government to refrain from interfering with the gathering and dissemination of information; it does not require individuals or nongovernmental institutions, such as physicians or hospitals, to satisfy the demands of journalists. The “public’s right to know” is an artificial concept promoted by the press, not a constitutional or moral right. Option (A) is inconsistent with your ethical obligation to insure confidentiality in the doctor-patient relationship.

Option (B), accepting guidance from the governor’s aide about the manner and degree of information to be disclosed about the governor’s condition, is unacceptable because the aide has no authority as next-of-kin or legal surrogate to speak for the governor in personal matters. Although the political adviser may speak with great authority and in the expectation that you and other members of the hospital staff will respond obediently to his directives, his opinions and desire to control the flow of information are irrelevant to your professional relationship with your patient.

Option (D), refusing to meet with the assembled press, is certain to project an unnecessary attitude of arrogance and hostility that will poorly serve the fine hospital in which you practice, and which values the community’s good will. Your refusal will also insure that some other member of the hospital staff, one who does not share your special fiduciary relationship with the patient, will be sent to the press room and probably discuss the governor’s condition and your case management in a manner neither you nor your patient is likely to approve of. You may visit the press room and advise the assembled journalists that until your awake and alert patient, his next-of-kin, or legally designated surrogate authorizes you to release medical information, you are prevented by rules of confidentiality from doing so. You may apologize for any inconvenience to the group, ask that they respect the patient’s right to privacy in his medical care, and assure them that appropriate information will be made available at such time as the patient’s permission is received.

Option (E), permitting the hospital’s public relations officer to interpret the hospital’s disclosure policy and direct your actions, surrenders your fiduciary role. Maintaining confidentiality in the physician-patient relationship is your responsibility, and it should not be ceded to a nonprofessional whose primary goals may not entirely reflect your ethical values. Even assuming no unethical or misguided motives in the public relation’s officer’s recommendations, you the attending physician should not permit yourself to be governed by support staff who do not share your responsibilities.

Option (C), declining to disclose sensitive medical information about your well-known patient until he or an appropriate surrogate authorizes such disclosures, insures that the physician-patient privilege is protected. Although your patient is an important political figure upon whom the public depends for the complete and efficient operation of state government, the physician’s relationship with him is identical to that of a patient who does not reside in the public arena. Famous patients are entitled to all the consideration the medical profession affords private citizens, including personal respect and confidentiality. Even when, and if, the patient, spouse, or legal surrogate authorizes public release of medical information, the patient maintains the authority to control how and how much material will be made publicly available. The patient, not the physician, not the hospital, and not the press, is the owner of his medical information, and only he and his designated surrogates should decide upon the form and content of its disclosure.

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Stuart Vyse is Professor of Psychology at Connecticut College, in New London. In his new book, Going Broke: Why Americans Can’t Hold On To Their Money, he offers a unique psychological perspective on the financial behavior of the many Americans today who find they cannot make ends meet, illuminating the causes of our wildly self-destructive spending habits. In the excerpt below Vyse looks at the psychology of credit limits. Check out the tips he provided us with this morning or his podcast.

The Magic of Credit Limits

It is a wonderful feeling. You apply for your first MasterCard, hoping to be accepted. Finally it arrives in the mail, and you feel like a million bucks. It is shiny and new, and it comes with a letter that tells you your credit limit. In most cases, this happy event occurs when you are quite young: just after graduation from high school or somewhere in your twenties. As a result, the credit limit often seems like an amazingly large figure. (more…)

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