Is the "July effect" real?

Freshly-minted med school grads start caring for patients each year in July. Does their inexperience lead to a "July effect" that harms hospitalized patients?

Every July, doctors fresh out of medical school don their bright new white coats (or in more recent times, embroidered Patagonia vests), clip their new hospital-issued pager to their hip, and enter the hospital to care for patients for the first time since obtaining their medical degree.

With all these fresh-faced, brand-new doctors taking over important responsibilities each July, it’s only logical to wonder: do patients suffer because of this sudden influx of newbie doctors? Or is the close supervision these new doctors receive from senior residents and attending doctors enough to compensate for their inexperience?

Fresh scrubs, new responsibilities

There are few experiences in a doctor’s career more memorable than their first day in the hospital as an intern (an “intern” is a first-year resident physician who just graduated medical school). Although interns have a senior resident and a supervising attending physician overseeing their work, they’re suddenly given a whole bunch of responsibilities. In the Random Acts of Medicine book, Chris describes the complex feelings of that time, now 10 years ago:

Intern year is often the most strenuous, demanding, busy, and stressful year of training a doctor will endure. We are asked to take everything we learned in medical school and apply it to real patients who need our help…

Taking responsibility for a life, having a sick stranger place their trust in you, is an awesome experience in the literal sense, and it’s what I had been preparing for for many years. It was a thrill and a privilege…

But the thrill was accompanied by no small dose of terror: What if I screwed up?…

There were many things we had responsibility for, since an intern is generally the central physician on a team caring for up to ten or more patients at a time on the hospital ward. We had to respond to pages from nurses when there was a problem, write orders for tests and medications, communicate with the specialists who consulted on our patients, and keep family members up to date. Even with help and backup, it’s still possible to drop the ball, no matter how careful you are.

Is there a “July effect”?

In a 2011 review of 39 different studies looking at various aspects of hospital care in the prior decades, mortality in the hospital was slightly increased in July, but it was not seen across all conditions or necessarily seen consistently. Measures of efficiency, such as the amount of time patients spent in the hospital overall or time spent in the operating room for surgery, were also slightly worse. Although many of the studies researchers examined lacked the scientific rigor to truly establish or estimate the size of an “effect,” it certainly suggested it was possible.

In a 2013 study, Bapu and some colleagues looked at patients with heart attacks in some interesting ways. First, they looked at what happened in July in both teaching hospitals and non-teaching hospitals—where there shouldn’t be a July effect if interns aren’t at the center of care. They also thought that if there was a July effect, it would probably most affect the sickest patients in the hospital, whose care might be most impacted by dropped balls or delays; on the flip side, patients requiring more straightforward heart attack care might not be meaningfully impacted by minor slip ups. The study showed that in teaching hospitals, there was a July effect on mortality rates—but only for the sickest patients. Meanwhile, there was no July effect seen in non-teaching hospitals. The kicker? Mortality rates were lower all year long in teaching hospitals, even in July.

Studies since then using nationwide data have shown mixed results. A study of cardiac arrest patients showed there may be a July effect in the ICU, but not in the emergency department or main hospital wards; another study of ICU patients with septic shock (a potentially fatal condition due to overwhelming infection) found no effect. A study looking at patients getting hip and knee replacement surgery also found no evidence of a July effect. Finally, another study found evidence of increased complications of preventable medical errors for patients hospitalized in July compared to other months.

What’s the bottom line?

There probably is a small July effect, though it doesn’t seem to impact all patients equally across all types of care or across all degrees of illness severity.

If we want to continue to have doctors around, we have to let new doctors start sometime. But we also need to respect that with inexperience comes the potential for mistakes.

Attending physicians like us who supervise interns and residents should—and do—keep a particularly close eye on the care team in July. Doctors don’t have to do this alone—the nurses, pharmacists, therapists, social workers, and others around the hospital are among the many important teachers interns learn from as they begin to practice medicine.

In fact, the observation that July effect studies are “mixed” may be an indicator of when supervision is adequate and when it’s inadequate. For example, if we start with the assumption that all things being equal the relative inexperience of July interns may pose safety risks, the settings where we see no “July effect” may be those where the additional supervision that we know happens in July is actually adequate. And in settings where a “July effect” is found, there may simply not be enough supervision to compensate the inexperience of the new interns. The net effect, in those cases, is harm to patients due to inadequate supervision in July.

All of this being said, it’s also worth noting that our approach to intern and resident education has changed substantially in the years since many of these studies were conducted. Residents work fewer hours than they used to and supervision is more common. Today, we emphasize safety and have increased supervision by experienced physicians in the hospital, particularly when the new interns join the care teams. Reduced work hours and increased support for new doctors from the old ones, patients, and other clinical staff may mitigate the relative lack of experience that comes with being a July intern. It might also just be enough to make the July effect a thing of the past.

What should patients do in July?

Patients shouldn’t fear coming to the hospital in July, and they shouldn’t avoid teaching hospitals. Delaying necessary hospital care almost certainly presents a far greater risk than that newbie intern making morning rounds.

But that doesn’t mean patients have to pretend that the brand new intern knows what they’re doing 100% of the time. Patients and their family members should speak up if they have concerns, think something is off, or want to better understand the rationale behind their doctors’ recommendations. This kind of dialogue can serve to build trust, improve the doctor-patient relationship, and avoid mistakes.

Finally, just because they’re new doesn’t mean interns can’t be phenomenal doctors. Patients should call out good work, too. Encouragement or a compliment from a patient might just be what that stressed, tired, overworked intern needs to hear.