The July Phenomenon: Are Residents of Other Specialties Your Problem?

July 31, 2014

As a specialty, Ob/Gyn seems immune to the so-called “July Phenomenon. But are your patients safe from the errors that eager first-years of other specialties may make?

Don’t get sick/deliver in July! You’ve all heard it. The good thing for ob/gyn departments is that they seem to be immune to the “July Phenomenon”-when residency programs begin and greenhorns make enough errors to increase hospital morbidity and mortality rates. Luckily for Ob/Gyns, there is no good evidence showing these increases, presumably because Ob/Gyn residents receive a significant amount of oversight. No one wants any medicolegal situations to arise, and experienced Ob/Gyn nurses don’t want new doctors to “mess up” their patients.

So the great news for women is that July is as good a time as any to deliver or have a gyn-related hospital procedure. Some may even argue that this is the safest time because of the extra oversight. But even with this extra vigilance among the Ob/Gyn department staff, your patients may not be safe from the errors of new, eager, and inexperienced residents of other specialties?

Consider this scenario:

It’s mid-July, and a 32-year-old woman who is 38 weeks pregnant has been admitted after going into labor spontaneously at home. It’s about 1:00AM, a full moon, and L&D is slammed. The patient knows she wants an epidural but has been very specific and vocal about wanting the procedure performed by someone experienced-she knows she’s delivering at a teaching hospital, but for the epidural, she doesn’t want anyone to “practice” on her.

Around 3:30AM, she is briefly seen by the on-call doc from her 6-physician Ob/Gyn practice; he apologizes for not checking on her sooner, explaining he just finished an emergency surgery, is about to perform another emergency surgery, and that his replacement, who is known to the patient, will be in shortly after change of shift at 7:00AM to check on her. He reassures the patient that she’s in good hands with the nurses and that he’s requested her epidural.

The anesthesiologist, however, is really backed up due to several emergency C-sections and doesn’t make it down. Then change of shift happens. Luckily for the patient, the anesthesiologist showed up around 7:30AM. The patient greets him and reiterates that she only wants an experienced anesthesiologist to place the epidural. He said he understands, excuses himself to step out of the room, consults someone in the hallway near the door, and comes back in and begins to prep for the epidural. By this time, the patient has been experiencing piggy-back contractions for hours, is miserable and desperate for pain relief, and is relieved that her epidural is imminent.

It took 3 sticks and 45 minutes to place the epidural; to the patient, it felt like forever. She was helped to lie back down on her back; her bed was slightly elevated. A minute or so later, she becomes hypotensive; the baby’s heart rate drops as well. The patient loses consciousness, ephedrine is administered, and just as the patient is coming to, the anesthesiologist shows up.

The patient is groggy but understands that the anesthesiologist-the real one-has just come in the room and seems angry. Apparently, a newbie nurse anesthetist, supervised by a very green first-year resident, was the one who placed her epidural, and he had no authorization by the anesthesiologist to do so. The patient’s room is full of clinicians and feels chaotic, and the nurses seem tense. The patient is confused and looking for reassurance that her baby is okay but keeps being told to keep her oxygen mask on.

Before the patient is fully coherent, the anesthesiologist asks her to sign a consent form, which the anesthetist forgot to do. Still groggy and confused, the patient signs the form. Without speaking to the patient, the anesthesiologist grabbed the signed consent form and left the room. But here’s the thing: if she would have known that a newbie nurse anesthetist was going to place the epidural, she wouldn’t have given consent and would have waited for the attending anesthesiologist.

Later, after the patient better understood what had happened, she felt completely deceived by the anesthetist and the resident anesthesiologist, disappointed in the way the anesthesiologist handled himself, and duped by the nurses as well. She remembers that the anesthetist never said he was a doctor; rather, he said, "I'm here to make you more comfortable. Are you ready for your epidural?" Essentially, the patient felt that all of the clinicians present during her “epidural debacle” had undermined her trust. Even her own doctor, before change of shift, had assured her that she was in good hands. Meanwhile, the patient kept wondering, where was her doctor during all of this?

Around 9:15AM, her “new” Ob/Gyn (who the patient knew well, liked, and trusted) arrived to check on her-apparently she had been delayed by yet another C-section. Feeling upset and overwhelmed, the patient commented, “Guess you have to have a C-section to get noticed around here.”

All's Well That Ends Well?

Of note, the epidural had been extremely effective during L&D, but after a typical vaginal delivery, the patient experienced occasional “shooting nerve pain” that began just below the site of the epidural and down and around her left hip-nothing debilitating, just uncomfortable. The patient attributed this to the multiple attempts to place the catheter for the epidural, with the second attempt feeling as if the anesthetist had literally touched a nerve. The nerve pain resolved without treatment about 18 months after delivery.

In L&D, patients tend to be grateful to the docs who offer pain control, but they generally perceive their Ob/Gyn to be their care leader, the person they’ve entrusted to oversee and manage every facet of their care. Scenarios such as the one described can chip away at the trust and confidence that patients have in their care providers-all of them, even the ones not in the room and ones they’ve yet to meet. But is that fair?

Is it unrealistic for a patient to expect their Ob/Gyn to be in charge of every aspect of their care, including oversight of “green” non-OB specialists who have a clinical interaction with the patient?

We welcome your responses in the Comment section below.