Episode 29- “We’re all a little ‘stitious:” Bad words, full moons, and black clouds


Episode Summary:

Days away from Halloween, we discuss a few common ER superstitions. Are they actually legit? Or do you belive the data? Your call.

Show Notes:

Key Points:

“‘We’re all a little ‘stitious’: Bad words, full moons, and black clouds”:
– The “Q” word: in a study from 2019, researchers showed that a microbiology lab was not significantly affected in terms of workload if someone said, “today will be a quiet day”
– However, a different study showed that if the evening hand-off team on an orthopedic service said, “have a quiet night, I’ll see you in the morning,” their on-call night shift colleagues admitted more patients on average (3.1 patients vs 1.7 patients, P= 0.04)
– Full moons and Friday the 13th: multiple retrospective studies around the world, encompassing thousands of patients over spans of years found no differences in injuries, illnesses, suicide attempts, patient visits, admissions, or ambulance runs between full moon nights or Friday the 13th nights compared to “normal” nights
– Black clouds: one study found that self-described “black clouds” admitted 24% more patients on night call shifts, averaging 1 more patient admission than their “white cloud” colleagues (P = 0.013)
ER-Rx Episode 29


Brookfield CR, Phillips PPJ, Shorten RJ. Q fever- the superstition of avoiding the word “quiet” as a coping mechanism: randomized controlled non-inferiority trial. BMJ. 2019; 367: 16446

Lamb JN, Howard AJ, Marciniak J. Does the word ‘quiet’ really make things busier? RCS Bull. 2017; 99: 133-136

Exadaktylos AK, Sclabas G, Siegenthaler A, et al. Friday the 13th and full-moon: the “worst case scenario” or only superstition? Am J Emerg Med. 2001; 19(4): 319-20

Zargar M, Khaji A, Kaviani A, et al. The full moon and admission to emergency rooms. Indian J Med Sci. 2004; 58(5): 191-195

Walling HW. Actual versus perceived workload for house officers: black cloud looming? Ann Intern Med. 2004; 140 (10): 847-848


Hello and welcome to Episode 29 of ER-Rx. So, my last few evening shifts in the ER seemed unusually busy. Was it because someone said the awful “Q” word earlier in the shift? Was it because Halloween is just a few days away? And not only is it Halloween, but this year’s Halloween just happens to fall on a full moon. Or maybe I was working with a “black cloud” resident? This week we dive into these superstitions a little bit.

We’ll start off with every healthcare workers’ favorite superstition. The “Q” word. A word so bad that we can’t even say it out loud, even on a podcast. It’s amazing because this is such a widespread superstition that a good number of people actually took time out of their lives to run randomized, controlled trials on it.

One of the most often-cited studies on the “Q” word was published in BMJ. This was a prospective, randomized, controlled trial that was run in a microbiology department. They had two members of the micro team assigned to either say, and I quote, “today will be a quiet day” (the intervention group) or they were told to not say the “Q” word in any context whatsovever during their shift (the control group) for about 30 days each. The primary outcome was mean overall workload defined as “clinical episodes,” which included telephone calls and the number of significant results during a 24-hour period. Over 61 days, they found that there was no difference at all between workload in the intervention group and the control group. Disappointing, but to be precise, the intervention group did have 145 clinical episodes, and the control group had only 139. Maybe the “Q” word led to 6 more clinical episodes? That’s my takeaway.

Another multicenter, randomized controlled trial had much better results. In this trial, an orthopedic surgeon would flip a coin, and if it was heads they would have to use the “Q” word at evening hand-off. They had to literally say “have a quiet night, I’ll see you in the morning.” If they flipped tails, they would just say “have a good night, I’ll see you in the morning.” The primary outcome was the number of new referrals between 8 PM and 8 AM that resulted in hospital admission. The “Q” word group consisted of 18 nights and the control group consisted of 24 nights. The mean number of night referrals leading to admission was 3.1 in the “Q” word group but only 1.7 in the control group, and that actually was significant (p= 0.04). The authors concluded that the mechanism by which the “Q” word caused an increase in workload is unclear, but they quote, it is “likely that the supernatural forces at work are beyond the grasp of even the most skilled orthopedic researchers” and that we should use words like “calm” and “low volume” instead. They also went on to say that more research should be done on how to reverse the “Q” word’s effects if ever spoken out loud and that we should employ a “Q” word specialist manager. I like these guys.

Next up we have the “full moon” and “Friday the 13th” superstitions, where people believe that full moons and Friday the 13ths lead to busier ERs and even worse patient outcomes. The number 13, Fridays, and full moons are some of the oldest superstitions that humans have, dating back centuries. Friday as the 13th day of the month actually happens about 1-3 times per year. Sometimes, a full moon falls on a Friday. But what about Friday the 13th AND a full moon? This only happened 9 times in the entire 20th century- the last time being in October 2000. The next time this will happen is in August 2049—so what I’m saying is put your PTO request in for that month. This year, Halloween falls on a full moon, and this hasn’t happened since 1944. So basically what I’m saying is we are in for a busy weekend.

But is there any merit to these claims? A study from Switzerland looked at over 14,000 patients in an ER setting to see if a full moon had any effect on patient injuries or illnesses. The data showed no differences in injuries or illnesses between Friday the 13th or full moon nights compared to normal nights. They even looked at a single Friday the 13th that also fell on a full moon and also found no differences in ER workload.

Another study looked at a period of 13 months with 54,000 patients to see if the number of trauma patients was increased during a full moon night in the ER. They also did not find that the full moon caused more injuries and therefore, more trauma patients in the ER, or that it caused more suicide attempts or led to higher severity of traumatic injury.

Yet another trial, this time with over 150,000 patient visits over a 4-year period also found no difference in total patient visits, ambulance runs, or admissions to the hospital on full moon nights. And a full moon occurred 49 times during their study period. So the data says that there is no merit to the claims. If you believe data.

What about “black clouds” and “white clouds.” Providers who admit fewer patients with more straightforward problems are referred to as “white clouds.” On the other hand, providers who get crushed with multiple, complex new admissions are referred to as “black clouds.” “Gray clouds” don’t fall into either group. In one study, they actually looked at 19 self-described “black” and “white” cloud interns over a period of 107 on-call night shifts. They found that the average number of admissions was higher in the “black cloud” group by 24%, and they admitted on average 1 more patient per night, which was significant (p = 0.013). “Gray clouds” admitted a number that was not different between the other two groups. The study didn’t include number of calls from pharmacists or nurses, time spent working-up patients, acuity of illness, or time sleeping, which we all know would be great measures of a busy night shift. But it did agree with a previous study that showed “black cloud” pediatric residents slept less. Is this a self-fulfilling prophecy? Maybe “black clouds” are just less efficient or more anxious? I’m not here to judge; the data speaks for itself.

All in all, you can have your studies and facts but I’m sticking to it: we shouldn’t say the “Q” word, your full-moon Halloween shift is going to be rough, and “black clouds” do exist—I think I may be one of them.

As always, thank you for your time, and Happy Halloween from your favorite “Q” word specialist manager.

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