#july effect

[teachingrounds]

This week: "the July effect." But first, a public service announcement.

[medschooltutors]

Fake it ‘til you make it! #FridayFunny #TheBestMedicine #JulyEffect 

https://www.medschooltutors.com/blog/get-inspired

[md-admissions]

Is July all that dangerous?

If folks are wondering what these anons are referring to, it’s actually called the July effect. Is it true that it’s dangerous to be hospitalized in July? Dangerous is a strong word, and unsafe is as well.  On the fact check website, Snopes and in numerous papers published in medical journals, it appears that there are certain errors that occur slightly more often than usual in July. The Wiki article I linked actually has a decent summary of these studies. Note that of the numerous studies on this topic listed in the wiki article, ONLY ONE reports increased mortality. However, look at the actual study and you will see that this study doesn’t account for variation in call schedule, program size, surgical or medicine patient, acuity (ICU level or ward) and took heavily from data in the 1990s and early 2000s when hour regulations were not in effect, so take the result with a huge grain of salt.  All the other studies demonstrate no change in mortality/death. Errors that were noted to rise were all reversible and did not result in death. I’m not excusing errors that could have caused morbidity (the term we use for complications or pain/unanticipated harm) but understand that the July effect is primarily focused on people dying in hospitals because new interns, residents, fellows, or attendings don’t know enough. This is clearly not true. 

Now that said, all of us in the healthcare fields dunk, mostly from a well-meaning place. If you’re genuinely shitting on July, seriously, get a grip. We all sucked as newly fledged anythings, not just interns. New fellows. New pharmacists. New nurses. Hell, I wrote a dosing wrong today and my attending caught it. We worry and we groan because we remember our younger selves: scared, confused, overwhelmed, unsure. But the thing with medicine is that the learning is lifelong, the transitions are steep. That said, the onus of responsibility is upon senior staff to guide and grow their fledgings and not to deride them or belittle them. We’ve all been rookies before. Be a teacher, not a bully, to your new learners. 

[teachingrounds]

Despite the furor c.2010 about a possible "July effect" when new interns arrive, it seems that for every article that finds major or minor differences between patient outcomes (length of stay, rate of errors, cost of hospital bill, complications, unexpected death), there is another that finds no difference.

For instance, a 2017 study of Family Medicine admissions found small increases in mortality among patients admitted with myocardial infarction in the first academic quarter of 2011 (July-September) compared with all other quarters in teaching versus nonteaching hospitals, but only increased cost and longer stay for those admitted with heart failure.

However, a larger study using data from 2010 to 2017 found no difference in adverse events in July/August compared to the rest of year once results were adjusted for patient and hospital characteristics; they looked at a range of surgical and non-surgical (MI, PNA, heart failure) diagnoses at major teaching hospitals, minor teaching hospitals, and non-teaching hospitals across. They concluded, "Patients admitted to teaching hospitals in July/August are not at increased risk of adverse events. These findings should reassure patients and medical educators that patients are not excessively endangered by admission to the hospital during these months."

Mims LD, Porter M, Simpson KN, Carek PJ. The "July Effect": A Look at July Medical Admissions in Teaching Hospitals. J Am Board Fam Med. 2017;30(2):189-195. doi:10.3122/jabfm.2017.02.160214

Metersky ML, Eldridge N, Wang Y, et al. Rates of Adverse Events in Hospitalized Patients After Summer-Time Resident Changeover in the United States: Is There a July Effect?. J Patient Saf. 2022;18(3):253-259. doi:10.1097/PTS.0000000000000887

Image credit: Seattle Municipal Archives, Doctors with patient 1999, Flickr

[teachingrounds]

The "July effect" is the idea that medical errors spike in the United States in the month of July because that's when new interns start practicing medicine and the second-year residents start supervising for the first time. The concept comes from a 2010 study published in the Journal of General Internal Medicine by a pair of sociologists interested in studying mortality. Looking at all 62+ million US death certificates from 1797 to 2006, they found that there was a 10% increase in fatal medication errors in teaching hospitals in July and nowhere else at any time. Supposedly there was no spike in other causes of death by medical error (e.g. in surgery, from infection, misdiagnosis, etc.). The authors attributed this to new residents practicing with insufficient oversight by attendings, pharmacists, or nurses. We'll spend the rest of the week looking at the evidence for--or against--a "July effect."

Phillips DP, Barker GE. A July spike in fatal medication errors: a possible effect of new medical residents. J Gen Intern Med. 2010;25(8):774-779. doi:10.1007/s11606-010-1356-3

Image: Parentingupstream, Pixabay (2016)

[escuerzoresucitado]

👀

[oupacademic]

Does the 'July effect' in hospitals actually exist? Kenneth M. Ludmerer argues that you don't need to avoid hospitals in July, despite the annual influx of new interns.

Image: Little boy doctor, © 4774344sean, via iStock Photo.

[newstfionline]

Chicago's Intern 'Boot Camp' Is a Rehearsal for Life or Death Medical Issues

By Dirk Johnson, NY Times, July 14, 2013

CHICAGO--On the first day of "boot camp," Dr. Diane B. Wayne asked the Northwestern Memorial Hospital class of new interns for a show of hands if any were nervous.

Some sat still, wearing poker faces.

"Those of you who did not raise your hand," Dr. Wayne told them, "are not being honest."

Everyone's hand went up.

It is not just the new interns, thrust into settings of real-life health care, who naturally feel some anxiety this time of year. Patients, too, might be a bit skittish. The so-called July Effect, though disputed by some, holds that medical errors spike when beginners arrive at hospitals.

The boot camp, conducted under the watch of Dr. Wayne, the vice chairwoman of medicine at Northwestern University Feinberg School of Medicine, provides the interns with a three-day session in June to prepare them for bedside assignments.

In the view of Dr. Wayne and others, it seems prudent for interns to practice on artificial patients before going to work on those who actually bleed. A study published in the Annals of Internal Medicine in 2011 reported that "mortality increases and efficiency decreases" when a new crew of interns comes aboard.

The 81 interns at Northwestern are graduates of some of the nation's most prestigious medical schools. But they find themselves in an unfamiliar setting. During the first hour of the boot camp, one intern was reported lost in the building.

Northwestern officials say the program is the most rigorous of its kind in the nation, with a requirement that interns pass graded tests in procedures and communication skills before being allowed to move ahead.

In one life-or-death situation, a robotic patient lay motionless on a bed, tubes sticking into the throat, in an intensive care unit filled with flashing lights and ominous beeping.

Dr. Michael Donnan, 26, who hours earlier donned a badge that read, "M.D.," was in charge of the crisis.

"This is tricky," he muttered, sounding apprehensive, as he stared at the respiratory screen, weighing his options.

Seeming a bit tentative, he punched in a series of numbers. His colleagues studied his moves, some of them taking notes.

In a few moments, the beeping ceased. The interns waited for a verdict.

Into the room charged Dr. Matthew Nitzberg, the chief medical resident, who had been watching and assessing from behind the glass.

"You killed it!" he said, eliciting a peal of giggles from the interns. What he meant, he explained, was that it was a virtuoso performance. The patient had been saved.

Dr. Donnan exhaled and managed a smile.

As complicated as the medical procedures can be, Dr. Wayne said, students typically have a harder time with communication skills at the bedside. In a boot camp session titled "Difficult Conversations," residents talk to a dying patient, played by a Chicago actor, Ed Dzialo.

Dr. Suneel Kamath, a graduate of Columbia University College of Physicians and Surgeons, stepped to the bedside of Mr. Dzialo, who said he was "looking forward to the summer" and "going back to work."

The intern needed to explain that a bowel obstruction had made it impossible to do any further chemotherapy or surgery for the man's colon cancer. The patient likely had only weeks to live.

"I hate to be the bearer of bad news," the intern said. Mr. Dzialo, his eyes fixed with fear, listened to the grim prognosis, then turned his head to the side.

"I'm dying," said the actor, lamenting that he was in his 40s and had "wasted my life."

Dr. Kamath tried to reassure the patient otherwise, telling him that he had "worked hard every day" and done his best.

As the patient looked away in dejection, the intern said he wanted to raise end-of-life issues, like who would be designated to make a decision to remove him from life support. The intern conceded that these were "not fun topics."

After the session, the actor asked Dr. Kamath to assess his bedside manner. The intern gave himself good marks, saying he believed he had appropriately "stayed on task."

Mr. Dzialo, who has been trained by palliative experts about such discussions, was a bit more critical. He noted the "not fun" phrase, rather an understatement in the context. He also suggested that the young doctor focus on "exploring my feelings," instead of "telling me" how he had lived his life.

Dr. Kamath acknowledged that having a discussion with a dying patient, albeit an actor playing a role, was quite different from learning from a textbook.

As the boot camp officials see it, this was a lesson that will prove useful in the future, when a scared, dying patient is not pretending.