Hospital Stays and the July Effect

Dr. Marty Makary's Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care is a searing, insider exposé of the American medical system.

Through gripping real-world stories and sharp analysis, Makary reveals how secrecy, lack of accountability, and a culture of silence in hospitals can lead to dangerous or fatal outcomes for patients like you.

In contrast, he shows how transparency, leadership, and patient advocacy can drive meaningful change. A surgeon at Johns Hopkins at the time of writing the book, Makary offers not only a critique of modern medicine but a vision for a safer, more trustworthy healthcare system.

When you enter a hospital, you expect to exit by the front door, not the back door. This blog post is intended to help you do exactly that, by informing you of the obstacles and culture that can prevent that from happening.

You owe it to yourself and your loved ones to read this today – before you need the information.

The Problem: A Culture of Secrecy

Makary begins by illustrating the vast disconnect between how patients perceive hospitals and how hospitals actually function in real life. Hospitals are assumed to be centers of safety, healing, and excellence.

But as Makary makes clear, the quality of care can vary dramatically from one doctor, unit, or hospital to another – often even within the same institution. You, the public, have no way of knowing this.

He introduces us to doctors who are known internally for dangerous practices but continue to operate unchecked.

One of the most chilling examples is of a surgeon nicknamed "Hodad" by nurses and staff because of his high complication rates. Hodad stood for “Hands of Death and Destruction.”

Despite staff concerns, this surgeon continued operating because he brought in revenue, had a decent bedside manner, and nobody wanted to "rock the boat" or risk losing their job.

Hodad’s popularity was in sharp contrast to the reputation of another surgeon on the staff, nicknamed the Raptor.

Despite his awful behavior and gruff bedside manner, the Raptor operated with surgical precision and insistence on perfection, which earned him a reputation within the hospital walls as the best surgeon on the staff.

Makary notes that in all the hospitals at which he trained, quality was highly variable, and teamwork was horrendously lousy.

The Transparency Solution

Rather than simply exposing flaws, Makary advocates for transparency as a core remedy.

He argues that making performance metrics public—including surgical complication rates, infection statistics, and patient outcomes—would allow patients to make informed decisions and pressure hospitals to improve.

As it stands right now, hospitals have little or no incentive to make their safety scores public. Indeed, data suppression means that only the hospital administrators know how abysmal their hospital safety score is.

Makary points to industries like pilots in aviation, where safety outcomes are publicly scrutinized, a model he says healthcare should emulate. When surgeons and hospitals know their outcomes will be visible, they tend to adopt safer practices.

One of the more hopeful stories comes from a hospital where performance metrics were made visible to the entire surgical staff.

One surgeon, initially angry about being ranked poorly, eventually improved his practices and rose in the rankings—not because of punitive action, but because transparency motivated him to change.

Good Actors: Speaking Up Saves Lives

Makary also highlights cases where clinicians made a difference simply by refusing to remain silent. In one example, a nurse caught a potentially fatal medication error about to be administered. Despite pushback, she stood resolute and prevented a tragedy.

Another inspiring story involves a surgical resident who risked professional retaliation by reporting repeated safety violations by an attending physician. Though it took courage, his reports ultimately led to reforms that improved patient safety across the department.

These stories show that while systemic problems are widespread, individual integrity and advocacy can still make a tremendous difference.

Silent Harm: Why Bad Doctors Persist

Makary is especially concerned with how hard it is to remove dangerous physicians.

Hospital politics, fear of lawsuits, and internal loyalty often protect doctors who should no longer be practicing.

He notes that a small percentage of physicians are responsible for a large percentage of malpractice claims, yet they are rarely sanctioned unless the misconduct becomes extreme or public.

He calls out the inefficacy of state medical boards and internal peer review processes, which too often prioritize institutional reputation over patient safety in hospitals. "If the public only knew," he writes, "they would never set foot in certain hospitals."

The Patient's Role: Ask the Right Questions

Makary encourages patients to be more proactive in managing their own care. He offers several practical recommendations:

• Ask who will be performing the procedure—the attending physician or a trainee?
• What are the hospital’s complication rates, especially for this procedure?
• What is the hospital’s surgical volume for that procedure?
• Always bring a trusted advocate for your care and communication.
• Don’t be afraid to seek a second opinion or change providers.

He even suggests asking medical professionals you trust where they would go for care. Patient satisfaction ratings can only tell you so much... where health care workers go for their care tells you everything! They know what no one else knows.

Makary later became a health policy researcher. One of the key questions they asked staff to answer in surveys in this role was,

“Would you feel comfortable receiving medical care in the unit where you work?”

In more than half the hospitals surveyed, 50% of the healthcare workers said no. At other hospitals, 99% said yes.

The percentage that say they’d go to their own hospital for their personal care is more telling than any ranking.

It stands to reason... those who work in operating rooms know more about surgical errors such as operating on the wrong body part, or on the wrong patient, or leaving surgical tools inside someone, than any hospital administrator ever will.

Another problem lies in the fact that once a doctor receives his or her license to practice, there’s virtually no oversight on how they use that license.

Data transparency would allow patients to make more informed decisions about where they should spend their healthcare dollars. Unfortunately, the business of medicine works against patients making those informed decisions.

However, hospital administrators move amazingly fast when their public image needs repair. That’s like a Code Blue for hospital administration.

Medical Errors After Surgery

A landmark research study published in the New England Journal of Medicine quantified what doctors and nurses already knew – that surgical death rates are directly related to a surgeon’s experience with that particular operation.

And the rarer the condition, the more experience matters.

High-volume doctors performed much better than low-volume doctors. One study showed that low-volume heart surgeons had a mortality rate 4x higher than the state average.

ProPublica, an advocate for patient safety, has extensively studied the problem of medical errors and complications after surgery.

They note that even in highly ranked hospitals like Johns Hopkins, some surgeons are outliers with complication records that are much worse than average.

One surgeon had complication rates for prostate removals that were double the national rate and 3x that of other surgeons at Hopkins. And Hopkins was just one of many top-ranked hospitals that had surgeons with problematic track records.

“The idea that it’s all systems and there are no individual performance differences is absurd,” said Dr. Robert Wachter, chief of medical service at the University of California, San Francisco Medical Center and a nationally known expert on patient safety.

“A good system has a mechanism to identify poor performers and either make them better or get rid of them.”

To those who shrug their shoulders and say that complications are just part of doing medicine, it should be noted that there are renowned surgeons who do hundreds of surgeries within their specialties with ZERO complications.

As ProPublica points out, if complications are like lightning bolts, they keep hitting the same surgeons while missing others.

The American College of Surgeons has stated that surgeons are responsible for all aspects of patient care and can reasonably be held responsible for complications.

Some surgeons have started working together in pairs, sacrificing volume and getting paid little or no extra for having two surgeons work on the same patient. But they act as a backup for each other, and it’s proving effective in reducing complications and improving outcomes.

Patient Outcomes to Ask About

Makary warns patients not to become too laser-focused on just one statistic or one piece of data, because there are often shadow statistics that shed much light, and an improvement in one might skew other key metrics.

Here are some of the most important to ask about:

1. Bouncebacks. What percentage of patients with that condition are readmitted to the hospital within 30 days? Readmission rates are measured by hospitals. You should also ask about the average length of stay for each medical condition category.

2. Complication Rates. Any adverse event that occurs during or after a medical treatment or procedure. You should be able to go online and enter the medical condition or proposed surgery and find the hospital-wide complication rate for that procedure.

This is true for each of the 7 major complication types: respiratory, cardiovascular, bleeding, wounds and infections, GI, kidney, and neurologic.

This data could be sorted by algorithms that adjust complication rates for condition complexity, and it should be accessible to patients.

3. Never Events. These are things that should never happen in a hospital. “Never events” are by definition avoidable, including:

• Leaving sponges/instruments inside a patient,

• Operating on the wrong side or the wrong patient,

• Performing the wrong operation,

• Death during elective surgery in a healthy patient.

• These things should never occur. Yet nearly every hospital has at least a couple of these “never events” every year.

4. Safety culture scores. About 1500 hospitals administer this survey to their staff. The number of hospital workers who say “yes” to these 3 questions should be made public. It could be the most revealing metric in healthcare.

a) Would you have your surgery at the hospital in which you work?

b) Do you feel comfortable speaking up when you have a safety concern?

c) Does the teamwork here promote doing what’s right for the patient?

5. Hospital volumes. How many patients with a particular type of medical condition do they treat and how many of each type of surgery do they perform annually? Again, more volume is better, indicating greater expertise.

This particular metric involves no delicate issues or individual doctor reputations, so why not make it public?

Beware the July Effect 

A timely point in the context of patient safety is Makary’s discussion of how transitions—between providers, between shifts, or even between academic years, such as in July—can expose cracks in the system.

These are moments when your care is most vulnerable to medical errors.

One notable example has been dubbed the "July Effect," when errors spike as new medical residents flood teaching hospitals, often while senior doctors are on vacation and oversight is reduced.

Understanding these patterns can help patients choose the safest time for surgery, especially for elective surgeries, avoiding periods when the system is under the most strain.

How to Protect Yourself from the July Effect

Each July, thousands of these newly minted doctors step into hospital hallways for the first time as interns and residents. While their training is rigorous and intentions are good, the reality is stark:

July marks a transition period in teaching hospitals when inexperience, miscommunication, and shaky coordination can significantly increase the risk of medical errors — a phenomenon widely known as the “July Effect.”

This isn’t just a theory. Studies have found that medication errors and surgical complications increase during July, especially in large academic medical centers. Some studies have shown a 5% to 12% increase in fatal medication errors in July.

A 2011 meta-analysis published in Annals of Internal Medicine found evidence of increased hazards in July, highlighting teaching hospital risks such as:

• Medical errors
• Mortality
• Hospital complications

“Mortality increases and efficiency decreases in hospitals at the time of year when new medical residents start working.” — Ann Intern Med. 2011;155(5):309–315

The July effect is most pronounced in large, academic medical centers with active residency programs.

Combine that with a patient’s limited ability to evaluate a doctor’s track record or hospital safety ratings, and it’s no wonder many feel powerless when facing surgery or hospitalization.

4 Hospital Safety Tips to Protect Yourself from the July Effect

1. If possible, avoid elective surgeries during July. If you must have surgery, choose your hospital carefully. Choose a smaller regional hospital instead of a large academic one, as non-teaching hospitals don’t experience this same July effect.

2. Ask who will be performing the procedure and what supervision residents will have. Confirm who the attending physician is who will oversee your care and find out how hands-on they are.

3. Choose hospitals with strong oversight, such as those with Magnet status for nursing care and Leapfrog “A” safety ratings.

4. Bring a patient advocate to be your “eyes” and “ears” when you’re not at your best. Make sure they’re in the room, especially during all shift change times.

Questions to Ask Before ANY Surgery at ANY Time

About the Procedure Itself

1. What is the goal of this procedure, and what will it accomplish?

2. What are your surgical complication rates, and how does it compare to national averages?

3. Are there non-surgical or less invasive alternatives?

4. What happens if I don’t get the procedure done right now?

5. What are the potential risks, complications, or side effects — both short-term and

long-term?

6. What is the success rate for this procedure at this hospital/with your team?

7. What does recovery typically look like (pain, limitations, follow-up)?

8. How soon can I resume normal activities, including work, driving, and exercise?

About the Surgeon or Specialist

These aren’t rude questions. They’re essential. Good providers welcome them.

1. How many of these procedures have you performed personally in the past year?

2. What is your complication and infection rate and how does it compare to the

national average?

3. What protocols are in place to reduce surgical errors and prevent infections?

4. Are you board-certified in this specialty?

5. Will you be the one performing the entire procedure, or will someone else be

assisting or leading? Whom?

About the Hospital or Facility

1. What is this hospital’s rate of infections, readmissions, or complications for this

procedure?

2. Is this hospital a high-volume center for this type of surgery or condition? How

many of these procedures did this hospital do in the past year?

3. What kind of support services are available during recovery (e.g., physical therapy,

nutrition, wound care)?

4. Is this hospital accredited for surgical safety and patient outcomes?

About Patient Safety and Coordination

How you prevent surgical site infections and medication errors...

1. Will I have a dedicated care coordinator or case manager during my stay?

2. If something goes wrong, who will communicate with me and my family — and how

soon?

3. How are transitions of care (handoffs) managed between teams or shifts?

4. What steps should I take before surgery to prepare and reduce risks (labs, fasting,

meds)?

5. What do you do to prevent falls while I’m in the hospital?

About Cost and Insurance 

1. What is the estimated total cost of the procedure (including facility, anesthesia, 

lab, etc.)?

2. Is this covered by my insurance, and are there any out-of-pocket surprises I

should  expect? (Confirm this directly with the insurance company also.)

3. Will I receive multiple bills (hospital, surgeon, anesthesia, etc.) or just one?

Bonus Questions for Peace of Mind

1. Can I talk to other patients who’ve had this procedure here?

2. Do you provide written instructions and a clear recovery plan before I leave?

3. What’s the process if I have questions or concerns after I go home?

4. If I’m unsure, can I take time to think about it or get a second opinion?

Opt for Minimally Invasive Procedures When Possible

Makary tells the story of a man named Ronald who reported to the hospital one night. Had he known that there were vastly different ways of practicing medicine, his story might have ended much differently.

Ronald got an open surgery and endured a month-long recovery filled with excruciating pain, complications, inactivity, and lost time at work. 

His surgeon’s complication rate was around 20% -- whereas the other doctors at that hospital had rates close to zero. Had Ronald been offered a minimally invasive option, he would’ve been spared a lot of grief. 

Makary recommends always asking the following questions about any procedure or treatment option:

• Are there other ways of treating this?

• What percent of these operations are done open vs. the minimally invasive way in the US?

• What percent of these operations do you do open vs. the minimally invasive way?

• What are the complication rates for each?

• How many days will I be in the hospital if I pursue one option vs. the other?

• Can I get a second opinion while I’m here in the hospital?

Many surgeons don’t offer the minimally invasive or cutting-edge option simply because they don’t know how to do them. 

This is more common among older, experienced surgeons who have done routine surgery for years, even while new methods have been developed.

To make sure you’re not getting a “Fred Flintstone” treatment, run a senior doctor’s “open surgery” recommendation by a younger doctor to validate. You might learn about newer, less risky options.

All surgery has risks. Your goal should be to minimize your risks as much as possible. According to Makery, the proven benefits of minimally invasive surgery include:

• Reduced pain

• Fewer infections

• Shorter hospitalizations

• Lowered risk of needing subsequent surgeries

• Earlier return to work after surgery

• Less medication use during recovery 

• Cost savings, and maybe more!

Choice of procedure matters. And may depend on your choice of doctor, as only some surgeons perform minimally invasive surgeries.

Google can be your friend here. It can lay out your options so you’re not going into a doctor’s appointment blind and believing there’s only one option for your condition. Knowledge is power!

Concerns While In the Hospital

1. Bring a Patient Advocate

One key strategy for how to avoid medical errors is having a trusted friend or family member act as your advocate. 

They can ask questions, track medications, and notice problems you might miss—especially during shift changes, which are frequent in July but common year-round. An advocate can help ensure your care doesn’t fall through the cracks.

2. Double-Check Medications and Plans

Makary emphasizes that many hospital errors stem from assumptions – especially surrounding medications and transitions of care.

You or your patient advocate should always ask what each medication is for... Also, clarify what will happen during shift changes or transfers. Make sure your discharge plan makes sense and that you understand everything in it.

Red Flags to Watch for...

Be alert to these breakdowns in care that can lead to errors. Ask for a patient advocate or charge nurse if you’re concerned:

• Contradictory information from different providers

• Staff who seem rushed or dismissive

• Delays in answering questions.

How to Research Hospitals and Doctors Further

Hospitals, surgeons, and the medical system don’t make it easy or simple to discover the information you want about patient safety and physician complication rates.

However, you can try to cobble together information from various sources. And when you consider the stakes – and how your choice of hospital (or surgeon) could be a life-or-death decision – it’s worth a bit of effort.

Hospitals vary a great deal on infection rates, surgical errors, and patient injuries... not to mention ER wait times, patient satisfaction, and other newer metrics.

Even within the same individual hospital, some surgeons have complication rates that are 4 or 10 times higher than other surgeons at the same hospital. It makes you want to ask, “What gives?”

That said, here are some useful tools for choosing the right hospital. Your goal is to find a safer (preferably, the safest) hospital that will work for you.

Use the Leapfrog Hospital Safety Grade search tool to locate the safest hospital in your area, preferably one with an “A” grade.

The Leapfrog Group is a non-profit advocacy group for patients who desire more safety and transparency in their medical care. 

They compile the Leapfrog Hospital Safety Grades twice a year and offer hospital safety grades based on various performance metrics. 

In some cases, one unit or hospital may have a high score for one metric and be lacking for others. 

Hospitals are not required to divulge their safety information, even to Leapfrog. Therefore, Leapfrog does not have information on every hospital. 

Don’t turn down treatment in an emergency, but for ongoing care or elective surgeries, choose the safest hospital you can find.

Hospital websites may publish their quality metrics. They are allowed to market their Leapfrog “A” score if they earn one.

Bear in mind that they won’t likely publish their inferior metric scores... only the scores that serve them well. Which means they’ll probably cherry pick the results. Try to find out all the metrics – not just the ones they put on their website.

Assume that you’ll probably see partial information on the website. Like an “ocean view” hotel room that only gives you a squinting glimpse of the ocean, this partial information only gives you a tiny glimpse of the real picture. 

Try to complete it with scores from Leapfrog, health professionals you know, and Medicare.gov, a website that lets you compare providers in your area.

Conclusion: A Call to Courage and Clarity

Unaccountable is ultimately a guide and consumer warning for all of us. It argues that while healthcare is filled with dedicated professionals, the system they work in often fails to prioritize safety and transparency.

This is not just a book for insiders, but for anyone who will ever be a patient—which is to say, all of us.

With Makary’s insights, you can start asking smarter questions as a patient. Hospitals can also be pushed to share real data, helping to break the dangerous silence that surrounds American medicine.

Your voice is one of your strongest tools for staying safe. Your vigilance, your questions, and your voice matter. Be willing to ask the hard questions. Bring a second set of eyes and ears.

Don’t hesitate to speak up. In health care, silence can be deadly. Advocacy can save lives – potentially yours or someone you love dearly.

Frequently Asked Questions

1. What is the most dangerous month to be a patient in a hospital?

According to Unaccountable by Dr. Marty Makary and various studies, July is the most dangerous month to be in a hospital due to the July Effect—a rise in errors as new medical residents start and oversight decreases.

2. What are the top problems in hospitals that jeopardize patient safety?

Key threats to patient safety include poor communication, especially during handoffs, a toxic culture that discourages speaking up, overtreatment, lack of transparency, long work hours leading to sleepiness, and failure to hold unsafe doctors accountable.

3. What are the most important questions to ask your surgeon prior to surgery?

“Would you have this surgery yourself or recommend it to a loved one?” “What are the alternatives?"  “How many of these procedures have you preformed?” “What are the risks and expected outcomes?”

These questions help ensure informed decisions and safer care.

4. Which type of surgery has fewer complications – open surgery or minimally invasive surgery?

Minimally invasive surgery generally has fewer complications, shorter recovery times, and less pain compared to open surgery—when performed by experienced surgeons. However, outcomes depend on the surgeon’s skill and the patient’s specific condition.

5. What are the important tasks a patient advocate should have in the hospital with you?

A patient advocate should ask questions, track medications, monitor treatments, and speak up about concerns. They help prevent errors, especially during shift changes or transitions in care, by ensuring nothing falls through the cracks.