THE “JULY EFFECT”
It’s that time of year again. Maybe you’ve already heard of the “July Effect”? Here’s a post making the rounds again today illustrating the depths of sarcasm and irony with which this meme is sometimes considered in healthcare.
Ask a July 1st Medicine Intern http://gomerblog.com/2015/07/medicine-intern/
But this is an idea that goes back for years. The gist of the idea is that it’s dangerous to go to the doctor in July because the new interns start then.
Here are a few pieces presenting that perspective.
Kirchheimer, Sid. Avoid the Hospital in July. Why? New doctors and nurses report to work for the first time. AARP June 2013. http://www.aarp.org/health/doctors-hospitals/info-06-2010/why_you_should_avoid_the_hospital_in_july.html
Headed to the Hospital? Beware the ‘July Effect’ — July means a fresh crop of medical residents. Should that scare you away? http://health.usnews.com/health-news/patient-advice/articles/2014/07/21/headed-to-the-hospital-beware-the-july-effect
This idea has been around for decades, at least since the 1980s.
Dedra Buchwald, MD; Anthony L. Komaroff, MD; E. Francis Cook, ScD; Arnold M. Epstein, MD, MA. Indirect Costs for Medical Education: Is There a July Phenomenon? Arch Intern Med. 1989;149(4):765-768. doi:10.1001/archinte.1989.00390040007001. http://www.ncbi.nlm.nih.gov/pubmed/2495778
Of course, it’s not as simple as the popular press would like to make it sound, and there is far more research presenting the opposing (but less well known) view, or that it is a small effect and one which impacts only certain patients in specific circumstances. Basically, the idea is that The “July effect” is mostly not true, and has been well debunked.
“For the subset of patients with internal medicine diagnoses, the expected “July Phenomenon” was observed, with significant relative declines in diagnostic and pharmaceutical charges in teaching hospitals over the academic year. In contrast, surgery patients showed an increase in length of stay and various charges over the academic year in teaching hospitals. There were no meaningful effects of housestaff experience on mortality, operative complications, or nursing home discharge. These results indicate that housestaff training is significantly related to the use of hospital resources for inpatients, but that the degree and direction of the effects differ by specialty.” (Rich et al, 1993)
“Although this study finds no support for a “July Phenomenon” in terms of quality of clinical care, house officers were found to be more likely to have poor documentation practices earlier in the academic year.” (Shulkin, 1995)
“There was no evidence of an increase in negative outcomes early in the academic year compared with the end of the academic year. We believe that a systematic approach to the diagnosis, resuscitation, and treatment of trauma prevented a July phenomenon.” (Claridge et al, 2001)
“Although small differences in outcome exist with respect to the academic time of the year, the timing of these differences indicates that there is not a “July phenomenon” in obstetrics at our institution.” (Myles, 2003)
“We find that the annual house-staff turnover results in increased resource utilization (i.e., higher risk-adjusted length of hospital stay) for both minor and major teaching hospitals and decreased quality (i.e., higher risk-adjusted mortality rates) for major teaching hospitals. Further, these effects with respect to mortality are not monotonically increasing in a hospital’s reliance on residents for the provision of care. In fact, the most-intensive teaching hospitals manage to avoid significant effects on mortality following this turnover.” (Huckman & Barro, 2005)
“The data suggest a “July effect” on some outcomes related to shunt surgery, but the effect was small. Nonetheless, the potential morbidity of shunt failure, infection, and the cost of treatment indicate that continued vigilance and appropriate supervision of new staff by attending surgeons is warranted.” (Kestle et al, 2006)
“Conclusions: High-risk acute myocardial infarction patients experience similar mortality in teaching- and non-teaching-intensive hospitals in July, but lower mortality in teaching-intensive hospitals in May. Low-risk patients experience no such July effect in teaching-intensive hospitals.” (Jena et al, 2013)
“Particularly in major teaching hospitals, we find evidence of a gradual trend of decreasing performance that begins several months before the actual cohort turnover and may result from a transition of responsibilities at major teaching hospitals in anticipation of the cohort turnover.” (Huckman et al, 2014)
“Data from a single institution study did not show a “July Phenomenon” in the number of operating minutes, overutilized minutes, or the number of ORs working late in July.” (Sanford et al, 2016)
“These data, in combination with the findings of Shah et al,1 suggest that the July phenomenon can largely be debunked in the modern era of surgical education.” (Thiels et al, 2016)
The basic fundamental idea is, unless you are a high-risk patient, it is PERFECTLY SAFE TO SEE THE DOCTOR IN JULY.
TIPS FOR NEW DOCS
Why is it safe? Because the new docs are well trained, and have experience in a variety of situations. This all made me very interested in the annual event on Twitter in which experienced docs share tips with new docs just starting out. The biggest and best hashtag is #TipsForNewDocs, but others included #DearIntern, #DearResident, and #DearPatient.
I’ve collected a bunch of these awesome tips for all those new docs that started today, and you can find them here.
— CIR/SEIU (@cirseiu) July 1, 2016