There was a piece in last Sunday’s New York Times written by an oncology nurse with an injunction to avoid getting sick in July. She wrote about her experience with a fresh resident who would not give her dying patient enough pain medications. She proceeded to remind readers that in July, when the academic year starts, the people taking care of sick patients in the hospital are fresh graduates who know nothing about the art of doctoring.
We’ve all heard this before. And, frankly, it is annoying.
Dr. Karmela K. Chan
In the article she wrote: "Any nurse who has worked in a teaching hospital is likely to have found July an especially difficult month because ... the first-year residents are calling the plays, but they have little real knowledge of the game."
I would like to counter that any new medical trainees who have worked in a teaching hospital are likely to have found July an especially difficult month, because on top of being concerned with patient well-being, they are also being constantly reminded by nurses that they don’t know what they are doing.
The truth is medical school in the United States is structured such that a medical student spends most of his 3rd year and all of his 4th year of medical school in clinical work. So when July comes around, the "brand-new intern" in fact is not "brand new." He has spent the last 2 years of his life in hospitals. He may not have as much experience as nurses that have worked the floors for years, but he is no greenhorn either.
In addition, there are the years of medical education. There has been so much focus on clinical skills – talking with patients, listening, sleuthing around for clues, even prettifying the narrative – that we forget that in order for any of these skills even to be useful, there is a basic knowledge set upon which these clinical skills are built. That knowledge base is what we earn from 2-3 years of didactic work, which is qualitatively different from clinical work, to be sure, but indispensable. The ability to combine clinical skills with sound medical knowledge is part of what makes a good physician good.
New graduates offer a fresh look at habits that have grown petrified. I remember an ICU intern being asked by a family if she could turn the ventilator off but keep tube feeds going. Being young and deferential, the intern asked the nurse about this. The nurse looked at the intern as if she had two heads. "Do they think palliative care can be à la carte?" When I heard the story I was shocked by the strong negative reaction to a request that I thought was reasonable. The patient is dying. Why can’t it be à la carte?
Finally, interns are not unsupervised. Beside the fact that they are not "brand new" and indeed have already had some experience working the floors, they also do not go around without oversight. Interns are accountable to their medical residents, and medical residents are accountable to their attending physicians. Nothing happens without the knowledge of the senior house staff.
Telling the general public that hospitals are not a safe place in July sends a dangerous and irresponsible message. The article is, as with most anecdotes (mine included!), hyperbolic. There is little evidence that medical errors are committed in excess in July, compared with the rest of the year.
We are in training because we want to become doctors, good doctors. Starting a new job is intimidating enough as it is without nurses telling us that we don’t know what we’re doing. What we need, more than being undermined, is guidance. It’s infinitely more productive and makes July a much less harrowing place in time.
Dr. Chan is in practice in Pawtucket, R.I.