The July phenomenon

Short White Coat is a blog about learning to be a doctor. Posts appear here as part of White Coat Notes. Joshua U. Klein, MD, is a fourth-year obstetrics and gynecology resident at Brigham and Women's and Massachusetts General hospitals.

Conventional wisdom dictates that hospitals should be avoided every July, the first month of the medical academic year. Like Cinderella in reverse, alarm clocks around the country erupt before dawn on or around July 1st (typically the last week of June), and yesterday’s inexperienced, naïve pumpkin -- medical student -- is magically transformed into Jane/John Doe, MD, the intern who will diagnose your heart attack or stroke and save your life in the emergency room.

The thing that most people don’t recognize is that this miraculous transition in responsibility extends far beyond the medical student who now calls himself or herself doctor. The entire hierarchy of the medical team finds themselves awkwardly filling new, unfamiliar, and seemingly oversized shoes.

Second-year medical students, who have essentially never worked in a hospital environment before, become third-year students, often workhorses of the medical team, taking patient histories, reviewing lab results and imaging studies, and performing other basic but crucial tasks. Interns, only one year removed from their own clumsy initiation into doctor-hood, are now residents, responsible for supervising the incoming crop of interns. More senior residents take on new roles as chief resident or clinical fellow, and are expected to feel comfortable performing challenging procedures and shouldering enormous supervisory responsibility for the medical team. And the attending, from whom the entire team seeks calm, experienced guidance, may have been a resident herself just a few days prior.

Sound scary? Numerous studies have been published in the medical literature examining just how scary this transition might be. Perhaps surprisingly, these studies, performed in such varied settings as intensive care, trauma, labor and delivery, and (of all things) pediatric neurosurgery, have demonstrated with some consistency that there are no significant differences in how well patients ultimately make out, whether they get sick in July or any other time of the year. But despite the scientific evidence, many in the medical community have a hard time accepting that the so-called "July phenomenon" is nothing more than urban legend (a recent Newsweek article discusses this in detail).

This past weekend, I was on call as the chief resident on Labor and Delivery for the first time. While there is always an obstetrics attending in the hospital supervising all management decisions, deliveries, and c-sections, the "chief" is expected to run the show, only to be corrected/criticized when making a significant error. It’s also the chief’s job to teach the new interns to perform c-sections (yes, by doing them).

I must admit that at the start of the night I was probably more nervous than the new intern who was on call with me. Luckily, however, it turned out to be a relatively slow night. Nonetheless, I did take the intern through her first c-section ever. Once again, I think I was probably sweating a lot more than the intern until we got the baby out safely and the bleeding under control.

So what do I think of the July phenomenon? There is no question that everyone is more experienced, comfortable, and confident later in the year than they are in July. But I think this lack of experience is more than compensated for with careful, even aggressive supervision. Take my on-call: the c-section I did with the intern was routine, but I haven’t worked that hard during a cesarean in years. Knowing that the intern across the table from me did not yet know how to stay out of trouble, I couldn’t relax and take any chances with less than complete attention and concentration. I think the attending standing at the table felt the same exact way.

Perhaps it is no coincidence, then, that almost all the studies showing the absence of a July phenomenon were performed in high-acuity, high supervision settings (I don’t know much about pediatric neurosurgery, but I think it’s a safe bet that the oversight when doing brain surgery on kids is going to be pretty thorough).

So are hospitals less safe in July? I don’t think so. But they certainly can be much more stressful!