Not Getting Sick in July

1 07 2013

Today is July 1st.  While everyone has heard the old adage about not getting sick in July because of new interns, the truth is that new interns nationwide have started already. Yet, you don’t hear much about the “late June effect?”  So is the July effect overblown or true?  Well, there have been many studies – so many so there was a recent systematic review co-authored by one of my own co-interns a long time ago.    While I am sure it was hard to synthesize the studies of often sub-par quality, the review does state “studies with higher-quality designs and larger sample sizes more often showed increased mortality and decreased efficiency at time of changeover.”  The study I recall best examined over 25 years worth of death records and found a pattern.  In the 240,000 deaths due to medication errors, mortality rates did increase in July, especially in counties with teaching hospitals.  I’m not sure death certificates are accurate as a way of diagnosing cause of death but that’s another story.

While it’s not possible for patients to time their illness, the question becomes what can be done to ensure July is as safe as possible? While there is scant literature on this topic, over the last several years, I have had the privilege of attending in July.  While I ended up attending in June this year before the interns switched, I was reminded of several ways in which July is different and can be made safer.

  • July requires more intense supervision.  Residency is a time of graduated supervision.  In June, a few weeks before third year residents graduate, it would be tragic or perhaps a sign of a problem if an attending had to oversee every little decision in the moment.  It would also annoy the senior residents to no end.  The senior residents have matured to the point that they are the team leaders and you are often the advisor and hearing about their decision-making and rationale and providing advice and guidance where needed.  That is certainly not the case in July.  In July, attendings often are hovering (even if they don’t admit it) or “epic-stalking” checking on every lab and medication.  Moreover, greater attending supervision is more commonplace since 2011 due to a huge push by accreditation agencies and in part due to shorter resident duty hours.   The truth is that interns are rarely acting alone and are often working in tandem with a more advanced resident and attending.  While a recent ICU study questions the utility of overnight attending supervision, a systematic review from our group found that enhancing supervision was associated with improved patient outcomes and resident education in a variety of settings.  Faculty can be more formally prepared for their bigger responsibility in July as it will not only require more time, but also more intensity of supervision. While this would include traditional in-person supervision, attendings can be taught to provide formal oversight of care through technology tools, such as the EHR, mobile computing, and yes, even Google Glass.
  • The residents are more eager to learn in July.  July is a time when interns and residents want to learn.  They are eager for feedback.  It is much harder to teach interns and residents in June since they have gotten good at their role…and picked up a lot of medical knowledge on the way.  Because of their umpteenth case of a certain disease, they may not find any additional learning in the case.  Of course, there are always more things to teach, but it is just a little harder than in July when your new interns are ready to soak up knowledge like a sponge.  You can also have a big impact on practice patterns before they form and cement best practices.  While some faculty shy away from signing up for July, many I know prefer to do July because of this reason!
  • Everyone is new in their role in July. July is a time of transition for all residents, such as senior residents, chief residents, not to mention new attendings.  Moreover, other health professional training programs are turning over too such as pharmacy residents.  One potential solution that has been mentioned is to stagger the start date of various specialties/professions so that not everyone is new in July.  While this is probably not as feasible as it sounds (and it doesn’t sound feasible), it is an interesting idea worth entertaining.
  • Anticipate the inefficiency. Because of the turnover in all staff, everything is a little less efficient.  While a little less efficiency may not seem like much, for a resident team, less efficient means likely higher census because of delayed discharges.  These higher patient workloads make caring for existing patients hard, and admitting new patients even harder, and of course all of this is under the pressure of the time clock.  Although not commonplace, I have heard of some programs lower workloads early in the year, anticipating this inefficiency.  Another way is to restructure teams so that there is more ‘redundancy’ on the team to help care for the patients.  Either mechanism seems like something to consider especially for teams that are struggling to get all the work done in time.
  • The patients seem to get sickest when the senior resident is off.  In the back of my head, I know this is probably some type of heuristic in which I am overweighting what the days are like when my senior resident is off….  Regardless, for some reason, it does seem like a good practice to anticipate patient illness on those days. And of course, extra supervision and assistance to the intern when the senior resident is a terrific idea.

While these observations may refer to July, just when the residents get accustomed to their role and rotation, its time to switch.  For this reason, it could be that August (and even September) is not that different from July…so while we focus a lot on July, it may be better to prepare for the Summer of Supervision.

Vineet Arora MD

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3 responses

2 07 2013
Brandon Scott

Hi Dr. Arora!,

We are students at Temple University and the Johns Hopkins School of Medicine who have a deep interest in medical education, which is what attracted us to your blog. We appreciate your thoughts because there are so many ways med ed can be improved upon. As a former med student and a Dean at a University we thought you might agree.

One of the ways we’re working to do so is through a medical education app called Osmosis that close to 5,000 medical students across the nation have signed up for (http://invite.osmosis.org). Our goal is not only to provide medical students a free or low-cost alternative to the really expensive question banks they currently rely on, but also to deliver these questions via a novel mobile app that pushes out questions for review.

It would be great to speak with you about this and other areas of medical education. Please let us know if you’re interested in having a brainstorm session. We’d also be happy to give you early access to the app to check it out.

Thanks!
Brandon Scott
Temple University

Shiv Gaglani
MSII, Johns Hopkins School of Medicine
shiv@osmosis.org

11 07 2013
Dr Pullen

It’s been a long time since day 1 of my second year in my FP residency, but I still rememember arriving at Ft. Hood labor and delivery, one day removed from my internship. I arrived at the appointed hour, 6 AM. I walked into L&D, and the resident there enthusiastically greeted me, just before he stated that he was worried about catching his 8 AM flight back home. (this was an training location in the Army far from the residency teaching programs where FP and OB residents could go to get high volume OB experience), He literally raced out the door, as Mrs. Gilbert, a crusty older L&D nurse escorted me to the doctor’s dressing room and suggested I quickly change into scrubs. I followed orders, and by 8 AM when the attendings arrived had already attended 6 vaginal births, three by outlet forceps which Mrs. Gilbert explained were necessary as the delivery rooms needed to be “turned over” and we could not wait for long second stages of labor. I had done one outlet forceps delivery as an intern. Anyway all turned out well, but I agree it would have been much better to have been a woman in labor on other than July 1 all those years ago.

1 08 2013
davefromcamp (@davefromcamp)

I wrote for ‘Tylenol’ as my first order. I’ve come a long way but I think my thoughts were it’s OTC should be straight forward. Obviously a lot to learn, medical school teaches you everything but day-to-day stuff I’m glad I had supervisors. Here is a funny satire article. http://gomerblog.com/2013/07/report-the-worst-time-of-year-to-be-sick/

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