Medicine in small doses.

Abstract

The January Effect: a spike in hospital-acquired complications when new medical graduates begin in our hospitals Why you should avoid hospitals in January is the advice posed by Stephen Duckett and Greg Moran, from the Grattan Institute (http://theconversation.com/why-you-should-avoid-hospitals-in-january-89857), suggesting that although January is the quietest month in Australia, for hospitals it is a major transition time, with the introduction of new medical graduates. Indeed, it is estimated that over 3000 new graduates commenced their internships in Australian hospitals during the month of January. Indeed, there was a similar influx of new nurses and allied health professionals. They suggest that this causes staff disruption, with a potential impact on patient care, and provide data to indicate a spike in hospital-acquired complications during the month of January, for the 3 years 2013, 2014 and 2015, the so-called January Effect. This is the southern hemisphere version of the July Effect, in the United States (https://en.wikipedia.org/wiki/July_effect). Also referred to as the July Phenomenon, there is a perceived increase in the risk of medical errors and surgical complications occurring in association with the time of year in which United States medical school graduates begin residency. A similar phenomenon has been described in the UK, colloquially referred to as ‘the killing season', but in this context, it is usually the first Wednesday in August, sometimes referred to as ‘Black Wednesday' when the new medical graduates commence. The term ‘the killing season' was coined from a popular television programme Cardiac Arrest in which the character Dr Claire Maitland consoles a junior who has committed a fatal error with the dialogue: ‘You come out of medical school knowing bugger all. No wonder August is the killing season. We all kill a few patients while we are learning' (http://www.imdb.com/title/tt0536437/). But, what about the evidence? A study by Phillips et al. (J. Gen. Intern. Med. 2010; 25: 774–9) conducted at United States hospitals between 1979 and 2006 found that medication errors increased by 10% during the month of July in teaching hospitals, but not in neighbouring hospitals, with no associated increase in surgical errors, suggesting that medication errors are easier for new personnel to make because they are prescribing drugs often for the first time and not necessarily being cross-checked by others. In a meta-analysis, Young et al. (Ann. Int. Med. 2011; 155: 209–15) demonstrated that in the month of July mortality increases and efficiency decreases in hospitals as a consequence of end-of-year changeover. Across the Atlantic, a retrospective study from Imperial College, London, in 2009 (Jen et al. PLoS One 2009; 4: e7103) using hospital emergency admissions data found a significant increase in morbidity on the first Wednesday of August, between 2000 and 2008, showing that the odds of death for patients were 6% higher compared with other Wednesdays in August. There are a number of other studies, but not all show a difference, particularly in obstetric units and intensive care units (https://en.wikipedia.org/wiki/July_effect). Is it fair, however, to blame it solely on new graduates across the healthcare professions? May it also be a time of the year when the senior medical staff take leave, and are covered by less experienced staff. Or may it relate to the fact it is summer and we take a more relaxed approach to our work? Although our focus should be on providing good patient care, we also need to be aware of the anxieties and stressors put on our new medical graduates and focus on nurturing them as they face the challenges of their new role. Whereas the study outcomes are conflicting, there is little doubt that the data provided on hospital-acquired complications (https://www.safetyandquality.gov.au/our-work/indicators/hospital-acquired-complications/) does demonstrate a spike in January and it may well be coincidental that our new medical graduates are commencing their first job as a doctor in our hospitals. So, take care in January!