July is almost over. You’re safe to come to the hospital now.

In Editorial, Opinion by Edmund KwokLeave a Comment

The deadly month is almost over. Have you not heard the secret? This warning to the average patient is becoming more and more widespread: “Don’t get sick in July! It is the worst month of the year to be in a hospital.

This supposed pearl of wisdom of course refers to the fact that in Canada, the academic year at teaching hospitals begins on Canada Day – which means freshly minted MD’s are thrusted from their protected medical school classrooms and into the real clinical world. Overnight. Literally. Instead of hearing about coronary disease and such in a lecture, these baby-doctors are suddenly in charge of preventing, diagnosing, and managing your heart attacks, strokes, and traumas. But does it really translate to worse care in (and only in) July?

Numerous articles and studies have in fact delved deeper into this topic. Heck, there is even a Wikipedia page on the subject. This one recent study looked at all death certificates in the U.S. from 1979-2006, and focused on examining whether there was a July Effect on fatal medication errors; in counties that had teaching hospitals, they found a 10% spike in fatal medication errors in July.

Now, not only was this a retrospective study with some methodological issues, the main problem is trying to attribute this finding solely on the July Effect of having new residents. The timing is certainly convenient, and opinion pieces published in major media outlets like this one all help disseminate the legend of the July Effect.

Having been through the residency training experience, and now training those new residents, I can tell you that there is more to this than a once-in-a-year blip. If having new trainees coming onto a service truly equates to spikes in errors, then this in fact will be a monthly phenomenon. You see, residents rotate through different services on a monthly block basis: a brand new resident may spend July in the ER, but then switch to the General Surgery team in August, and then the Neurology team in September, and so on. Each rotation in effect results in having “brand new” trainees taking over patient care in their respective specialties. If the July Effect is real, I bet there is one for each month of the year – we just haven’t looked closely enough into it yet.

It is also unfair to blame the whole month of July. The learning curve in clinical medicine is steep but relatively short; after a few days/weeks on a particular service, the competency of trainees improve drastically. The logistics of how things work are smoothed out, the local workplace culture is understood, and clinical experience is expanded exponentially. I would argue that a trainee’s competence in Emergency Medicine at the end of July is much better than that of a trainee’s competence in General Surgery at the beginning of August.

Finally, the medical staff at teaching hospitals are not completely ignorant of this possible phenomenon. In early July, staff are more likely to spend extra time orientating new learners, to be more available for support, and to review things with increased scrutiny. As a patient, you may in fact get greater direct contact with an experienced staff physician on July 1st, than you may get if you were seen on June 29th.

So, is July the deadliest month of the year? Hardly. Having new trainees in any workplace will almost certainly increase the chances of errors, but the magnitude of that effect is not well understood in clinical medicine – and it is certainly not limited to only one month of the year. Further studies will be needed to fully explore the fluctuating trends of this effect throughout the academic year.

My advice? Don’t hesitate coming to the hospital when you have a heart attack or a stroke – holding out until August 1st is not beneficial to your health.

Edmund Kwok

Edmund Kwok

Emergency Medicine. Quality Improvement. Patient Safety. Change Management. Healthcare Administration.

Frontdoor 2 Healthcare

Frontdoor2Healthcare, founded by Dr. Edmund Kwok in 2012, provides editorial and commentary on issues affecting Canadian healthcare from the emergency department’s “front door” perspective. Frontdoor posts allow for open sharing of the diverse opinions and perspectives of emergency physicians from across the country.

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