According to an article published early online in Annals of Internal Medicine, year-end changeovers in medical trainees are associated with increased mortality and decreased efficiency at teaching hospitals during the month of July.
Researchers reviewed 39 published studies to determine the effect of trainee changeover on patient outcomes. While the research results are mixed, the authors found evidence of increased patient mortality and lower efficiency (longer hospital stays and surgical times and higher hospital charges) in July.
Dubbed "The July Effect," the phenomenon occurs in teaching hospitals when experienced trainees (residents) graduate and new interns begin their training. As a result, the average experience of the teaching hospital's workforce abruptly declines, established teams are disrupted, and many of the remaining trainees are promoted to assume new roles in the care delivery process.
"At year-end, teaching hospitals experience a massive exodus of highly experienced physician trainees who are also familiar with the working environment of the hospital," said John Q. Young, MD, MPP, Associate Program Director, Residency Training Program, Department of Psychiatry at UCSF School of Medicine, and co-author of the study. "The 'July Effect' occurs when these experienced physicians are replaced by new trainees who have little clinical experience, may be inadequately supervised in their new roles, and do not yet have a working knowledge of the hospital system. It's a perfect storm."
Some training programs make efforts to safeguard patients against the July Effect. Some hospitals have their "best" attendings on service throughout the month, while others alter rounding practices to provide additional oversight for new physicians. These changes may mitigate the effects of the changeover.
According to the editorialists, these findings are fertile ground for developing approaches to reducing potential harms of the July Effect. First, emphasizing graded responsibility, or increased autonomy based on level of competency, may help ensure that individual residents are entrusted with a level of responsibility appropriate for their skill level. Second, developing changeover systems that account for human factors and emphasize avoiding cognitive overload and fatigue may also have benefit. Finally, taking practical measures to reduce system disruption, such as staggering start schedules for trainees, could be helpful.
- John Q. Young, Sumant R. Ranji, Robert M. Wachter, Connie M. Lee, Brian Niehaus, Andrew D. Auerbach. 'July Effect': Impact of the Academic Year-End Changeover on Patient Outcomes. A Systematic Review. Annals of Internal Medicine, 2011; [link]
- Paul Barach, Ingrid Philibert. The July Effect: Fertile Ground for Systems Improvement. Annals of Internal Medicine, 2011; [link]
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