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A doctor’s view

‘July effect’ may be the opposite of what you think

Anthony Russo for the Boston Globe

Recently, as I was about to leave the hospital for the day, I got a page that the wife of a patient who had just been discharged was calling. I was concerned — the patient had been in the hospital with a severe infection — so I called her back right away. She was equal-measures angry and mortified. Her husband had a fever, and she was afraid he needed to come back to the hospital.

As I tried to understand what was going on, she quickly interrupted, saying she wanted to speak to my attending doctor.

“I know it’s July, I know what’s going on,” she said.

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She, of course, was referring to the infamous “July effect.”

July represents the yearly introduction of medical students into residency programs, and the influx of new hands and minds into the hospital is thought to result in poor-quality care, hence the fear. Even though I reassured her that I was a senior resident weeks away from completing training, she told me she wouldn’t be comforted unless she spoke to someone superior.

The idea of the “July effect” has now made its way into popular culture. All month, I read story after story warning patients and caregivers to avoid the hospital during July.

Doctors too worry about July. When I got my schedule for this year, just knowing that I was going to be supervising day-zero interns made me shake beneath my scrubs. Yet this July, like every July before it, I reached month’s end with a sense of elation. Far from getting worse care, I feel that in many ways, patients may in fact receive some of the best care during this maligned month.

When medical students get their degrees and start working as interns in July, they make a big transition from being students to practitioners. Over the course of their internships, they gain a lot of medical know-how, yet what they truly master is the hospital machinery. They become better at using the computer system, they learn where all the restrooms are, they learn who to call to get stuff done. While they learn a whole lot more about clinical medicine, trainees also lose something equally important yet much less easily quantifiable.

Fresh interns are fascinated by medicine and are interested in their patients in a way that hardened practitioners are not. Just a few weeks ago, I had a patient who had recently been enveloped in the throes of Huntington’s disease — a hereditary disease that results in early dementia and death.

Almost like clockwork, as soon as he turned 56, much like other family members who had since passed away, he became severely delirious. He became paranoid to the extent that he stopped eating, thinking his food was poisoned. One of my interns, who was just days into her training, found a solution to his refusal to eat. The intern started to have lunch with the patient. She would divide his meal and have half herself and leave the rest for him. Perhaps this was not the most efficient thing to do, but there was something truly special about that interaction that couldn’t be tabulated.

At the heart of fear over the July effect lies the assumption that more experience leads to better care and fewer errors. However, one article published in the Annals of Internal Medicine in 2005 showed that quality of care in fact dropped in relation to the length of a practitioner’s experience. Medical errors, while frequently due to a lack of knowledge, occur mostly because of system-based issues — such as a computer system without adequate safety checks — as well as provider burnout.

If anything, I find myself being much more vigilant in July when I am supervising new interns than I am at other times of the year. Newer interns are also more likely to run their decisions by their supervising resident or attending doctor than interns who feel more confident about their ability.

The fact is, the July effect has only been demonstrated in a few studies, with a majority of studies showing no significant rise in mortality in July. Those who warn patients about the July effect perhaps don’t understand just how many people are involved in carrying out a simple task in the hospital. A single antibiotic order is vetted by a resident, approved by an infectious disease specialist, released by a pharmacist, and administered by a nurse. This diffusion of responsibility offsets any effect that a new intern might have in the grander scheme of things.

Further diluting any possible July effect, residency classes actually now start working in mid-to-late June instead of July 1 and programs such as mine go the extra mile to ensure new interns are as oriented as possible.

Residency training should be redesigned to train more efficient physicians who retain the curiosity and humanity so particular to medical students and fresh interns. At the end of a busy call night just a few days ago, I was trying to wrap up my day but I couldn’t find one of my interns. Was she still working on a note, or completing an admission order set, or being interrogated by a nurse for an error she had made? I walked down the empty hallway to find her leaning over the bedside of one of her patients. It was 11 p.m., and I was worried about trying to get the team home. But she seemed to be in no rush, as she held the patient’s hand and talked with her as the night ticked away.

Dr. Haider Javed Warraich is a resident at the Beth Israel Deaconess Medical Center.
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