Most major cities are home to some of the biggest teaching hospitals in the nation. Baltimore, Maryland, is home to both The Johns Hopkins Hospital with its sister hospital, Bayview Medical Center, and The University of Maryland with its renowned Shock Trauma Unit. So, what happens every July that should make one second-guess, or at least be wary of, an in-patient or out-patient visit to such institutions? New medical residents flood these institutions as new graduates from their associated medical schools and other medical schools for continued clinical training.
As with any other new employment, these new graduates have a learning curve that is reflective of the level of care demanded by the particular service with whom they are working. Some might be in various areas of medicine (e.g. rheumatology, endocrinology, internal medicine, emergency medicine, medical intensive care, etc.), or some may choose to pursue surgery, providing services in general surgery, orthopaedic surgery, or others, working in the operating room as well as managing surgical patients on the floor. Duties include ordering medicines, intravenous fluids and nutrition, respiratory treatments, ordering and interpreting lab tests, and a host of other responsibilities. Fairly recent directives (2003) have essentially eliminated the age-old training regimen of residents working 36 hours straight; however, the demands of today’s healthcare system does not equilibrate the current resident workload with a “walk in the park”.
As reported by “Booster Shots” blog, a recent study conducted at the University of California San Diego (UCSD) and reported in the Journal of General Internal Medicine adds merit to an age-old but previously poorly substantiated phenomenon of increased hospital deaths during the month of July.
David H. Phillips, a social scientist at UCSD, and Gwendolyn E. C. Barker, a graduate student at UCSD, analyzed 62,338,584 U.S. death certificates issued between 1979 and 2006. After focusing their analysis to medication errors, they were able to demonstrate an average 10% increase in medication-related deaths in counties with teaching hospitals during the month of July as compared to other months and counties without teaching hospitals.
Additionally, there were a proportionate higher number of deaths attributed to the counties with a higher number of teaching facilities. Analysis of the data further demonstrated no increase in hospital medication-linked deaths in July in counties with non-teaching hospitals, no increase in non-hospital related deaths in July, and no increase in other causes of inpatient deaths. A similar study of an Australian teaching hospital with anaesthesia trainees over a 5-year period was able to substantiate an increase in errors during the first month of clinical anaesthesia training (February) as compared to other months.
One’s natural instinct is to blame the new residents for their inexperience, and in looking at the various responses to this report from UCSD, that seems to be the case. Is that the reality though? There is a hierarchy amongst the residents, and residency is a multi-year process to build the clinical skills of the new doctors as they rotate through the various medical services. Additionally, all residents must report to a senior attending physician who oversees the care rendered. Different attendings have different styles and different levels of oversight. Factor in vacations of various staff members, from attending physicians to nurses, unit clerks and technicians. Not only do the new residents have to “learn the system” of the facility, they have to form working relationships with a multitude of staff members that can be shifting on a weekly basis. They have to meet and treat a variety of patients, often from all walks of life, with lists of medications up to 2- and 3-pages in length! That’s quite a lot to expect from someone fresh from medical school.
The UCSD study concluded by recommending changes is various areas: re-evaluation of the responsibilities assigned to the new residents, re-assessing the level of supervision of these new residents and increased medication-safety education.
The general public, in the past and even currently to some degree, tend to act in awe of doctors, unequivocably accepting orders without question. Joe Smith, M.D. is Dr. Smith whether he is a first year resident or a 20-year veteran, but obviously the degree of experience and education is vastly different between the two. Perhaps there should be a different designation for residents??? With or without it, the public needs to promote self-advocacy by questioning medical directives, not as a nuisance but for the purpose of understanding their own conditions and needs. If one has to go to a teaching hospital in July, be aware of this fact; identify the treating physicians and the hierarchy; make sure one’s medication list is supplied; and, identify the rationale for any new medications or treatments suggested. Patients should be active participants in their own care and have a basic knowledge and understanding of the condition for which they are being treated.