The "July syndrome:" who's minding the interns?

June 29, 2004 -- In today's "Their Coats Are White, but Their Hands Are Green," a New York Times "Cases" piece, Richard A. Friedman, M.D., discusses the popular notion that July is a perilous time to visit U.S. hospitals because of the influx of recent medical school graduates (interns) with little clinical experience. He admits that such fears are rational, but argues that there is little scientific basis to believe care actually suffers, and concludes that this is so because of "vigilant supervision" by attending physicians like himself. Dr. Friedman, in whose piece the word "nurse" does not appear, evidently does not realize that a great deal of the "vigilance" protecting patients from interns is supplied by nurses.

Dr. Friedman describes the "horror stories" that he has heard about the "so-called July syndrome." But he notes that there is a little scientific evidence to support the idea that hospital patients suffer significant adverse results, citing studies that found little difference in mortality rates or lengths of stay during the summer months. He acknowledges that one field in which there may be some effect is psychiatry, where the changeover can be "destabilizing" for patients who have grown "attached" to their therapists. However, he suspects that the purported phenomenon is "mostly a myth" because he, like many of his attending colleagues, "will be watching [his] new residents like a hawk this summer."

We're glad Dr. Friedman has wrapped this issue up so easily, but we feel compelled to note that most experienced nurses could regale him with some intern "horror stories" that had a happy ending not because of luck or because an attending happened to stop by, but because highly trained nurses were there 24 hours a day to protect their patients and teach the interns how to practice more safely. Educating new physicians is in every teaching hospital nurse's informal job description, though it is not in writing and is rarely discussed. But if nurses did not play this role, patients would be in real trouble (and physicians would have malpractice issues that would probably shock them). And despite the research Dr. Friedman cites, some nurses might be able to share stories whose endings were not so happy. Though attendings have of course been through residencies themselves, it may be that many of them are not aware of all the potentially serious problems that this changeover presents, problems that nurses regularly handle with no physician involvement. We also detect a note of complacency, and wish that some pragmatic person would explore options for new physician staffing that would not depend on the ability of busy senior nurses and physicians to find additional time and energy to protect patients from the sudden influx of new residents. Perhaps there are vital medical reasons why every intern must start on July 1, and the start dates cannot be staggered, but one might expect a discussion of the "July syndrome" to at least discuss potential structural changes that could address the issue.

Perhaps such a discussion will occur only when nurses are frequent contributors of health care pieces to publications like the New York Times.

See Richard Friedman's article "Their Coats Are White, but Their Hands Are Green," in the June 29, 2004 edition of the New York Times.

Send your letters to the Editor at letters@nytimes.com and please blind carbon copy the Center at letters@truthaboutnursing.org and please post your letters and thoughts on our discussion board.

Please snail mail your letters to Dr. Friedman at :

Richard A. Friedman, MD, Health writer
The New York Times
229 West 43rd Street
New York, New York 10036

Thank you.