Does the "July Effect" Exist?

The “July Effect” is said to be an increase in patient morbidity and mortality due to the annual influx of new medical trainees and the promotion of existing residents to new levels of responsibility in teaching hospitals. On July 11, an extensive review of the literature on this topic was published in Annals of Internal Medicine. The authors conclude that the “July Effect” probably does exist at least concerning increased mortality and decreased efficiency. The study was unable to state whether the rate of complications is higher in July.

This is another example of why the entire paper must be read. The abstract simply does not give the reader enough information. The abstract has a four sentence [54 word] description of the limitations of the study while nearly the entire discussion section of the paper [over 1100 words] highlights the myriad problems with existing studies on the subject.

Some of the issues with the studies reviewed are methodologic limitations, study heterogeneity, ascertainment and detection biases, statistical questions, failure to adjust for risk, failure to account for variation by season, lack of description of levels of supervision, publication bias [negative studies may not have been accepted for publication]  and many more.

The authors concluded that more and better research is needed for both inpatient and ambulatory care.

The “July Effect” may exist, but even the New York Times agrees that this paper certainly does not prove anything.

Let me give you something else to consider. Having been a surgical residency program director for 24 years, I’ll tell you a secret. The real problem is the “End of June Effect.” What happens at the end of June is the graduating chief residents leave early [from June 15 onward] to start their fellowships [or in rare cases, their real jobs] and the preliminary residents leave to go to their next training programs. Most surgery programs are extremely shorthanded during the last two weeks of June. The new residents have not arrived yet [or are going through as many as two weeks of mind-numbing orientation] and the residents who remain are moving up in responsibility. For me, I’d rather get sick on July 2^nd than June 25^th.