Category Archives: Education

The “July Effect” and Tips for New Doctors


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

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.

Headed to the Hospital? Beware the ‘July Effect’ — July means a fresh crop of medical residents. Should that scare you away?

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.

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)

… and much more (Pubmed, Wikipedia)

The basic fundamental idea is, unless you are a high-risk patient, it is PERFECTLY SAFE TO SEE THE DOCTOR IN JULY.


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.

Teach Feast: Engaged Learning Through Internships, Badges, e-Portfolios, & Storytelling

Teach Feast 2015: integrative tools for engagement at Michigan

I was invited as a last minute fill-in to be part of a panel at the annual Teach Feast festival of learning technologies at the University of Michigan. It was a great learning experience for me, and I hope also for the participants. I learned more about how engaged learning can be a continuum, incorporating relatively small or subtle changes to traditional instruction or going whole hog and literally uprooting a student from their culture and context and positioning them in a new space for a different type of learning experience. Engagement can originate with either student or teacher (or both); it can be collaborative and/or competitive and/or creative. The one part that seemed foundational to all the strategies was reflection, turning your gaze both inward and outward.

My part was on digital storytelling. I’m a big fan of digital storytelling, in case you didn’t know. I like to test new online storytelling tools, and see how they work to support different kinds of stories. My current fascination with comics is based out of my larger enthusiasm for storytelling. I argue that storytelling is part of every academic discipline. It’s obvious that the humanities dissolve if you remove stories. What is history without story? But when it comes to the sciences, people are more likely to have trouble seeing the story as part of the academic process. Of course, case studies in health care, sure, those are stories. And psychology and psychiatry, they don’t work without stories. Social work, yeah, of course. But physics? And engineering? Maybe if you aren’t in the field you have trouble seeing the story, but if you really think about every research paper, every structured abstract is a frame for a story. Every piece of science has a backstory, a motivation, a reason someone wanted to know THIS. Even mathematics. Even when camouflaged, the stories of science are implied. What changes isn’t the presence of the story, but how we tell them, and the tools we use to carry them.

The advantages of digital storytelling are similar to those of printed stories: portable, inclusive, persistent, and reaching a broader audience. One of the great lessons from education is that communication is never one-size-fits-all. The more ways you present important content, the more people will be able to understand it and engage with it. The greater the variety of media you use to tell a story, the more people will hear it. I’m happy to help people find and tell stories, especially science stories. There are a lot of different types of tools and resources in the slides. If I have time, I’ll spend a little more time on specific ones here some other time. If there is something in particular from the slides that you’d like me to talk about, say so in the comments, and I’ll make it a priority.

Yes? Or No? Or HOW? Catching a Predator at Birth (Maybe)

Originally posted at the Krafty Librarian blog.

Catching a Predator at Birth

I almost called this post: “Create attention for your article; write a layman’s summary,” which was the subject line from the e-mail we are discussing locally in trying to decide if it is a predatory publisher or not. (Short version of what we did for those who don’t have time to read the whole story: Identity, Authority, Credibility, Language, Editing, Timing, Licensing, Accessibility, Openness, Sources, Resources. Basically, defining a chain of trust.) I’ve blogged here before about the idea of layman’s summaries, a.k.a. plain language abstracts. They have a great tagline. It’s a great idea. My first reaction was, “How can we help?” Obviously, I think the idea is awesome, and I’ve thought so for a very long time, many years. I am far from the only person to think so. Just take a quick look at these few selected quotes.

DC Girasek: Would society pay more attention to injuries if the injury control community paid more attention to risk communication science?
“We also need to call attention to the injuries that continue to take lives, despite the fact that solid solutions for them have been published in our scientific journals. We need research on translating study findings into public action. Epidemiology and engineering remain central to the field of injury control. We must look to the social and behavioral sciences, however, if we hope to overcome the political and cognitive barriers that impede our advancement.”

Alan Betts: A Proposal for Communicating Science
“Given that the future of the Earth depends on the public have a clearer understanding of Earth science, it seems to me there is something unethical in our insular behavior as scientists.”

Jason Samenow: Should technical science journals have plain language translation?
“Some scientists might resist the onus of having to write a lay-person friendly version of their articles. However, I agree with Betts, it’s well past time they do so”

Chris Buddle: Science outreach: plain-language summaries for all research papers
“1) Scientists do really interesting things.
2) Scientists have a responsibility to disseminate their results.
3) Scientists do not publish in an accessible format.
This is a really, really big problem.”

Chris Buddle: A guide for writing plain language summaries of research papers
“A plain language summary is different because it focuses more broadly, is without jargon, and aims to provide a clear picture about ‘why’ the research was done in additional to ‘how’ the work was done, and the main findings.”

Lauren M. Kuehne and Julian D. Olden: Opinion: Lay summaries needed to enhance science communication. PNAS 112(12):3585. doi: 10.1073/pnas.1500882112
“But rather than an unrewarding burden, scientists (and journal publishers) should consider widespread adoption of lay summaries—accompanying online publications and made publicly available with traditional abstracts—as a way to increase the visibility, impact, and transparency of scientific research. This is a particularly important undertaking given the changing science media landscape.”

This is seen as SUCH an important idea that multiple grants were provided to create a tool to assist scientists in doing this well!

Center on Knowledge Translation for Disability and Rehabilitation Research (KTDRR): Plain Language Summary Tool (PLST)

You can find more with this Google Search: (science OR research) (attention OR “plain language” OR “clear language” OR layman OR journalist) (summary OR abstract)

Imagine my excitement when a colleague (many thanks to Kate MacDougall-Saylor) alerted me to a new online publication specifically for this purpose! How PERFECT for Health Literacy Month! A faculty member had asked her if it was a legitimate enterprise. So we looked at the email she’d received, and at the web site.

Dear Dr. XYZ,

We are interested to publish the layman’s summary of your research article: ‘ABC ABC ABC.’ on our website.

The new project ‘Atlas of Science‘ started from 1st October 2015. It is made by scientists for scientists and the aim of the project will be publishing layman’s abstracts of research articles to highlight research to a broader audience.
Scientific articles are often difficult to fathom for journalists, due to the scientific jargon.
Although journalists like to assess the news value quickly, that is by no means simple with most research articles. Writing a short, understandable layman’s summary is a good means to reach this goal.

This makes sense, has a good message, and is accurate about the potential impact so far, but the English doesn’t read as having been written or edited by a native speaker of English, and the formatting is inconsistent. It doesn’t look as if a professional editor did a final review before promoting to the world. Warning Sign #1.

The name of the web site (Atlas of Science) is identical to the highly regarded book from MIT Press and authored by Katy Börner of the Indiana University Cyberinfrastructure for Network Science Center. At first, I thought perhaps they were connected, but quickly realized this was a separate group, simply using the same name. Warning Sign #2.

Most of the rest of the message came directly from the “For Authors” page on the web site (Why, What, Use), except for the instructions.

∙ Send your summary to, not later than ##/#/2015.

What do we do with your layman’s summary?
∙ We check the text, and in consultation with you we dot the i’s and cross the t’s.
∙ Your text will be available on the Atlas of Science website, .
We will actively promote this site to the press.

Please, let us know if you are interested and do not hesitate to contact us if you have any question (simply reply to this email).

This was less worrisome, except … the phrase “not later than” (combined with a date of just over a week to respond) seems to be pressuring the faculty member to respond quickly, without thinking it through carefully, and without time to actually create a well-done plain language summary. Warning Sign #3.

Speaking of a well-done plain language summary, do they explain how to do what they say they want? We checked on the web site. Not really. They tell you what they want, but not how to do it, and they don’t point people to any resources to help them understand what a plain language summary is, what this means, or how to do it. They define no standards, set no guidelines, make only the barest and simplest recommendations (such as word count — 600 words with 2 figures), and do not even mention appropriate reading level. Warning Sign #4.

Does the posted content on the site actually appear to match the stated goals of the site? Not remotely. The pieces posted don’t even match the minimal guidelines they stated in their own criteria. I tested a few of the newest posts. The titles alone (“Regulation of mediator’s expression and chemotaxis in mast cells”, “Minute exocrine glands in the compound eyes of water strider”, “Gene therapy not just counseling for your denim obsession”, tell you these are not plain language, but just to be fair and unbiased, I ran them through a Simple Measure of Gobbledygook (SMOG) Tool, which is only one of several tools and resources available for assessing readability.

Regulation of mediator’s expression and chemotaxis in mast cells
The SMOG index: 20.1
Total words: 766
Total number of polysyllabic words: 180
Total number of sentences: 41

Over 150 words more than the defined limit for the abstract (Warning Sign #5), and written for an audience with a reading level matching those with multiple graduate degrees. The SMOG Index, you see, displays the reading level by number of years of education. 12 is a high school diploma, 16 is a college degree, 18 is a masters, and 20 is well into PhD territory. The average reading level for adults in the United States is roughly 8th grade, meaning that a really well done plain language summary would be written to a SMOG level of 8, at most 12. 20 is a long ways from 12.

Minute exocrine glands in the compound eyes of water strider
The SMOG index: 16.2
Total words: 461
Total number of polysyllabic words: 70
Total number of sentences: 35

Gene therapy not just counseling for your denim obsession
The SMOG index: 18.7
Total words: 573
Total number of polysyllabic words: 79
Total number of sentences: 23

Save your pancreas from diabetes! Your beta cell reserve is critical for prevention and treatment of diabetes.”
The SMOG index: 19.6
Total words: 455
Total number of polysyllabic words: 100
Total number of sentences: 25

It’s easy to see that most of the authors take the word count seriously, and that some of them genuinely tried to reduce the reading level and had an idea of where to start with this. None of them came anywhere close to an 8th grade reading level, and none of them were below college graduate reading level. Warning Sign #6. The writing in the abstracts was highly variable, some included grammatical errors, and there was no sign of editorial oversight. Warning Sign #7.

You get the idea of how the checking is being done. I don’t want to walk you through the excruciating details for every piece, but here are a few more criteria, and then ending with a surprise reveal.

“About Us”: Can’t tell who they are, either individuals or institution. Improper grammar & punctuation. No contact information. Contact form has email address hidden. Warning Signs 8, 9, 10.

Content Sources: Most links are to RSS feeds from major science news services, not unique or locally produced content. For the unique content, authorship is unclear (is author of the plain language abstract the same as the author of the original article?), buried deep in the page, no editor mentioned, and no contact information given for the presumed authors. The links for the original articles go back to PUBMED, not to the original publisher, and nont of them give the DOI number for the articles. Warning Signs 11, 12, 13, 14, 15.

Licensing: For a project of this sort to have the impact it is supposed to on journalists and the public, it would need to have a Creative Commons licensing structure, presumably with attribution. Instead it has “copyright, all rights reserved,” but gives no information on how to get permission to use the content. It appears that the intellectual property rights are held by the website, not by the actual authors. This is (in my opinion) terrible. Warning Signs 16, 17, 18.

Accessibility: Problems using the site on my phone. Tested desktop view, and there are a number of fatal errors, missing ALT tags, empty links, duplicated links, etc. Sloppy, sloppy coding. Nobody’s perfect, but MEDLINEplus has zero fatal errors, just for comparison. If this is from a reputable organization, I’d expect better. Warning Signs 19, 20, 21.

Now, the big surprise! While I was digging around online, I found some of the content, almost verbatim, from an authoritative site! Virtually all of the “For Authors” page is from the Technishe Universiteit, Eindhoven (TU/e). Evidently, they have or had a requirement for graduate students to write a plain language summary of their research prior to graduation. Brilliant concept! The submitted content was reviewed, edited, and selected for possible inclusion in their university research magazine, Cursor. They also had a campus website to host the content. The link for this was broken when I checked today, but the Wayback Machine has several examples over the past several years, including just a few months ago.

The big question now is whether this project is taking the Technische Universiteit model and making it bigger for the world, or was the content stolen from TU/e? There is no way to tell by looking. If this is a genuine project from TU/e, there are some changes they could make to improve the project. If the project is not theirs, I would really love to see the National Library of Medicine recreate a project like this, but done properly. They’ve proven they can. And there is a genuine need.

“Most of us will experience a significant diagnostic error in our lifetime”

Today was the webcast for the official release of “Improving Diagnosis in Health Care: Resources to Facilitate Communication Between Patients and Clinicians September 22, 2015.” A distillation of the 8 recommendations includes a focus on improving diagnosis through:

1. Teamwork
2. Education
3. Technology
4. Workflow
5. Culture
6. Reporting
7. Payments
8. Research

There were an incredible number of excellent and insightful statements. I’m hoping later for a full transcript of the remarks! Meanwhile, here is a Storify of reactions to the webcast as it occurred, with what people watching captured as most important.

And the video shown at the end of the webcast.

Improving Diagnosis in Healthcare:

Health Professions Education Day & Taubman Library Grand Opening

I just wanted to say how button-busting proud I am of last week’s Health Professions Education Day and the Grand (re)-Opening of our library. There was an enormous amount of content related to both, so I made them into two separate Storify. The #HPEDay collection includes a rich overview of the innovative and collaborative approach to health education across all seven of the University of Michigan schools and colleges (dentistry, kinesiology, medicine, nursing, pharmacy, public health, and social work), with rich visionary insights into professional ethics and leadership. Profound, and worth a slow deep exploration. The Taubman Health Sciences Library re-opening collection includes many images from tours of the new building which was designed to support these visions. Enjoy!

If you have specific questions, feel free to post them below, and perhaps they can trigger additional blogposts that go into more detail about specifics.

[Updated Sept22 to correct list of participating schools & colleges.]

“Send Silence Packing” at University of Michigan

Send Silence Packing #SendSilencePacking

Yesterday, I was walking towards the Diag at the heart of the University of Michigan’s Ann Arbor campus. I noticed some chalk drawings on the sidewalk, and took pictures. I noticed some carving on a treetrunk and took pictures.

And then I noticed all the backpacks. Everywhere. And all the students standing, bending, crouching to look at the backpacks more closely. I stopped. I bent over. I read the stories. Each backpack represents one person who died of suicide. Most of the backpacks have their story attached to it, with farewells from grieving loved ones. Some are the actual backpack the person used in their own student experience.

I walked around the collection of backpacks slowly. I snapped photos. I finished looking at one section of the backpacks and thought, WOW. Then I started walking again. And then I stopped again. Because it wasn’t just one section. The backpacks were everywhere. I kept looking, and watching, and taking pics, but did not even try to get pictures of ALL of the backpacks.

As I finally straightened up and was about to leave, I heard a woman’s voice behind me, saying "Hurry up. I don’t want to see this. I know, it’s probably a fact of life, but … " It was a woman who is probably my age, certainly past student age, but dressed like a student in tight leggings and a tshirt, with the arms of a light sweater tied around her shoulders. She and her companion sped up, almost sprinting past the display, her dyed-blonde ponytail bouncing in the sunlight of the beautiful day.

Read more from the Michigan Daily:

At The Movies: Tactile Art & Tech for Autism

David Chesney is Back. This Time With Sean Ahlquist (Art & Architecture) and Sile O’Modhrain (Music). The project being highlighted this time is designed to use a flexible stretch “coloring book” to provide a kind of engaging biofeedback to children with autism regarding the amount of pressure they are using. This would have been fantastic to have when my son was small.

David Chesney: “The research that I do here at the University of Michigan is at the intersection of technology and childhood disability.”

Tactile Art | MichEpedia | MconneX

University researchers and students create device designed to aid in Autism therapy

More videos about the project from Dr. Ahlquist.

Social Sensory Surfaces Research Project from Sean Ahlquist on Vimeo.

Social Sensory Surfaces Research Project

Stretch|PLAY from Sean Ahlquist on Vimeo.


Social Sensory Surfaces:

Related work from Dr. Chesney on his work with autism.

Software Engineering Class Hacks Autism

Digital avatars help children with autism – w/video

Hacking Autism and University of Michigan

Video games help autistic students in classrooms

More interesting projects by Dr. Chesney & his students.

Untapped Resonance: David Chesney at TEDxUofM

Engineering with Grace:
Engineering with Grace: Software class aims to help one teen communicate:
Computer Science with Soul:

Provost’s Seminar on Teaching – Presenter David Chesney