The July Phenomenon Revisited

Abstract

Each July, teaching hospitals experience an influx of new residents and fellows who recently have graduated from medical school or completed residency training programs. During this period, teaching hospitals also assign new positions of responsibility to existing residents and fellows. Medical education is a core mission of teaching hospitals, and, in these hospitals, interns, residents, and fellows play major roles in patient care. This recurrent cycle in which care is delivered by less experienced physicians in the initial month of the academic year has led to the often expressed conventional wisdom of “not to get sick in July.”1 Article see p 2754 In addition to the lore surrounding July admissions to teaching hospitals, previous studies have shown that physician experience is an important determinant of outcomes for a wide range of medical conditions and procedures.2–5 Moreover, literature from economics and other fields has shown that employee turnover can adversely affect organizational productivity.6,7 Given that teaching hospitals face both inexperienced physicians as well as high turnover early in the academic year, it is reasonable to be concerned about the potential for lower quality care around that time. Based on these concerns, a number of studies over the past 25 years have compared patient outcomes in teaching hospitals during July and later months of the academic year. Indeed, a recent systematic review by Young et al6 identified 39 studies that examined care delivered in a wide range of clinical settings, including inpatient medical and surgical wards, intensive care units, operating rooms, and emergency rooms. Of these 39 studies, 27 (69%) evaluated hospital mortality, and of these 27 studies, only 6 (22%) found higher mortality among patients who received care in July or the early months of the academic year associated with housestaff turnover. However, …