Is There a "July Effect" in Hospitals? In "Don't Get Sick in July" (Bedside series, Sunday Review, July 15), Theresa Brown writes that one of the secrets you don't learn in nursing school is not to get sick in July. There are two problems. The first is that this is hardly a secret; it is a well-traveled axiom, one I encountered even at my local coffee shop this week. The second is that it may not be true. Despite many efforts, no study has ever definitively documented greater mortality in July after controlling for case mix and severity. Even the extensive meta-analysis Ms. Brown refers to from the Annals of Internal Medicine qualified its conclusions. Care may be more fractured in July, but case mix, an important determinant of mortality, is a huge variable. Compared with winter months, surgical services in July tend to have sicker patients because of more trauma, and medical services have fewer sick patients because of reduced incidence of respiratory problems. Moreover, one month is probably too short an interval to draw overarching conclusions about hospital mortality. You might not want to be in the hospital in July, but until proved otherwise, "more deaths in July" may be an urban myth. The writer is director emeritus of medical intensive care, Cook County Hospital. Theresa Brown highlights a clear and useful way to minimize the "July effect": Never be afraid to ask for help. The temporary feeling of personal embarrassment associated with the phrase "I don't know" is trivial compared with a patient's undue suffering or untimely demise. Asking a senior doctor or nurse for help potentially averts an undesirable outcome and creates a valuable learning opportunity for the first-year resident. When the situation arises again, the new physician will know what to do. When confronted with any dilemma in medical management, the question must always be, What is best for the patient? The writer is a first-year resident in internal medicine at Columbia University Medical Center. Theresa Brown makes an excellent point. When I began my surgical training in the 1970s, I was given some sage advice. My late father practiced medicine and surgery for 40 years. He said to me: "Son, when you are in surgery with an experienced surgical nurse and she hands you an instrument, that is what you need to use next. Pay attention and learn something from the nurses. Having practiced surgery for more than 30 years, I never forgot this piece of advice. I always listened to the nurses" observations and took their advice to heart. A doctor I know cautioned that August, not July, is the worst month to be in a hospital, because by then the residents think that they know everything.