The 'July effect' challenge

Each summer, teaching hospitals undergo a transformation as a team of experienced residents leave and are replaced by trainees fresh out of medical school. Some view this as a time of peril for patients—commonly referred to as “the July effect.” This year brings the possibility that the danger could be amplified as the agency overseeing residency programs rolls out a new evaluation system July 1.

In the United Kingdom, the resident turnover is referred to as the “August killing season.” But experts are predicting that the Accreditation Council for Graduate Medical Education's Next Accreditation System, or NAS, could lead to a safer healthcare system because of its focus on measuring outcomes rather than evaluating processes.

Specifically, the ACGME will require institutions to evaluate residents at different points or milestones in their training for competency in patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal skills and communication. In July, NAS will be rolled out for residency programs in seven specialties. It will be rolled out for the 19 other specialty programs ACGME oversees in July 2014.

Program administrators are not anticipating a more hazard-filled July because of NAS, just a heavier workload. But it is work that they say will help raise the level of safety and quality of the care.

“Staff will be required to be more hands on than ever before,” said Dr. Chad Vokoun, associate program director for internal medicine at the University of Nebraska Medical Center College of Medicine in Omaha.

Dr. Susan Vanderberg-Dent, associate dean of the graduate medical program at Rush University Medical Center in Chicago, agreed. “From an institutional perspective, it's going to be a lot of work,” she said. “But, ultimately, it will have a salutary effect.”

In fact, Vanderberg-Dent's colleague, Dr. David Ansell, called the accreditation changes “one of the greatest things to happen in medical training.” Demonstrating residents' competency in practice-based learning and improvement requires integrating residents' training into an institution's efforts to improve quality and patient safety, said Ansell, chief medical officer at the medical center and associate dean for clinical affairs at Rush Medical College.

Experts have mixed views of whether the July effect is a real phenomenon. Two years ago, the Annals of Internal Medicine published a review of 39 previous studies that concluded mortality increases and quality decreases because of resident changeover. But the authors also said literature does not explain how this happens or define the degree of risk. This year, the Journal of Neurosurgery: Spine published a report declaring that “the influx of new residents and fellows in July has a negligible effect” on national spine surgery rates for mortality, infection and other complications.

Residency administrators recognize the obvious risk in the transition.

Ansell said that Rush's own data tracking doesn't indicate a rise in negative trends associated with new residents. “I'm not saying we don't have medication errors occur—we do and every place does—but we don't see a spike,” he said, adding that Rush tracks near misses and rates for complications, length of stay, medication errors and mortality.

Dr. Brian Owens, general medical education director at Virginia Mason Medical Center in Seattle, said the institution has developed an intensive program that prepares and integrates first-year residents, also known as interns, into the staff without overwhelming them.

In summer-long boot camps for anesthesiology, radiology and surgery, residents rehearse interdisciplinary team-based responses to medical events, both frequent and rare. Virginia Mason also has more attending hospitalists on hand to assist in July and limits vacation for attending anesthesiologists so more are available to supervise. Rounds are done in teams and interns present their patients with faculty and senior residents—any errors an intern may make in developing a treatment plan are corrected immediately. “Essentially, we stress oversight,” Owens said.

At Nebraska Medical Center, Vokoun said giving interns “people to lean on” and establishing a “there-are-no-silly-questions policy” helps new doctors through their first month of training. “It's not based on the July effect,” Vokoun said. “We want to set residents up for success.”

Perhaps the most damning study suggesting the July effect is a danger was published in May 2010 by the Journal of General Internal Medicine. Researchers studied death certificates from 1979 to 2006 and found a 10% spike in July for in-hospital fatal medication errors in U.S. counties with teaching hospitals—and no such spike in counties without teaching hospitals.

Lead author David Phillips, a professor of sociology at the University of California San Diego, said the fatalities linked to medication errors did not diminish after the Institute of Medicine's To Err is Human report on patient safety was released in 1999. “We showed in our paper that the effect wasn't getting smaller over time,” he said. “This is important for other people to study because nobody wants to be injured by someone whose job it is to help them.”

Follow Andis Robeznieks on Twitter: @MHARobeznieks