Wednesday, July 13, 2011

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 2nd than June 25th.


LadySurgeon said...


in july the newbies are so nervous/anxious and eager to do a good job that they check, double check, call their seniors and check again before doing anything. at the end june, there is not only the short staffed issue, but also a general letting down of the guard and perhaps a false sense of security that is (in my opinion) at least as dangerous as having brand new doctors around.

Skeptical Scalpel said...

Thanks for the comment and for agreeing with me. This paper has attracted a lot of media attention which I am trying to counteract by tweeting about this blog explaining the pitfalls of swallowing the abstract uncritically.

dan said...

Seems like april - june would be worst bc the residents are given longer leashes by attendings in the OR, on thr floors and in icu. And by that time all the residents "know everything" about their jobs and become lazy and relaxed.

Skeptical Scalpel said...

That's quite possible. Also, supervision tends to be tighter in July and August. That's why some studies don't show a difference in outcomes in July.

Joe Niemczura, RN, MS said...

Ummm, from the perspective of a nurse as well as somebody who'd had a sick family member at end of June.

from the nurse's viewpoint, there surely is a July effect. In a good teaching hospital, the staff nurses are always warned to pay extra attention to what is written or not, in the order book. in a not-so-good teaching hospital, the staff nurses too, will all be new.

years ago my brother who was dying of AIDS, perforated his intestine in early July. the brand new surgical resident wanted to do surgery (on a man whose T-cells had been zero for twelve weeks). the staff nurses alerted the attending, who called me (I was the POA) and we put the can on that idea, PDQ. My brother's death was "better" due to the alertness of the staff as well as the attending ( who happened to be new, but was on the ball).

everyone needs to start somewhere.

Skeptical Scalpel said...

Joe, sorry to hear of your brother's passing. I agree you did the right thing.

It looks like the system worked in your brother's case. Everyone was paying more attention.

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