Mitigating the July effect

Why is July a hazardous time for patients and their doctors?

The natural assumption is that the July effect, to the extent it exists in different settings, is due to the inexperience of the new interns. While more experienced doctors may also be starting in new roles, most already have substantial experience of both clinical work in general and of starting in new settings. The new interns are fresh to the responsibilities of clinical work, unaccustomed to the setting, probably anxious and possibly bewildered by the pace and apparent chaos of hospital life.

The risks to patients may however arise more from the challenges the organization poses for new interns. Could it be something as prosaic as how to order a test or obtain the results, and who to call if it doesn’t come back? Or how to work within the team, who is a reliable colleague, who can be approached safely without the risk of judgment or ridicule?

Another hypothesis is that the July effect may be due more to the newness of the second-year residents than of the interns. Many can recall the jarring jump in responsibility of going directly from being an intern on the last day of June to supervising a new crop of interns on the first day of July. In this case we would look to support those supervising the new interns, rather than simply focusing on the interns themselves. We consider this further below.

Finally, it is likely that there are additional contributing causes at higher levels of the hospital system. In particular, various clinical processes may not be sufficiently resilient to withstand the infusion of new team members who are not yet familiar with the culture, coordination, personalities, and workarounds necessary to provide safe and effective care.

Mitigating the July effect

The extent and importance of the July effect probably varies markedly across settings. Regardless of its strength and impact however, there are some valuable pointers that may be useful for young interns. To start, they should know that they are not expected to be perfect, to remember everything, or to get it right the first time. The most basic advice involves the importance of knowing what you don’t know, and being honest about it. If you are not sure – ask. If you do not understand – ask. If you make a mistake – tell others, and reflect on it. They should expect that sooner or later they will get into trouble, and know that in those situations they are expected to ask for help. And if they are worried about what someone else is doing – speak up.

The attitudes and behavior of those supervising interns are probably even more critical. A few will be arrogant or dismissive. This is not only unpleasant but downright dangerous and should be regarded as unprofessional behavior. The great majority of more senior staff will be pleasant and supportive, but this is not enough. They need to give explicit advice about what is expected of their new interns and in particular what is expected when they are not confident or out of their depth. In many organizations the unwritten communication to new doctors remains that calling for help will be seen as a sign of weakness. The advice now should be that ‘I will be angry with you if you do NOT ask for help when you need to,’ explicitly reversing the natural assumption of new staff that they should try to cope at all costs.

Senior staff should advise new trainees that they should not hesitate to ask what may seem like basic questions. Questions can be directed to anyone in the work environment, including ward clerks and other non-licensed personnel. These people can give unexpected help which benefits both trainees and patients. Warn new trainees not to pretend they have enough knowledge and or experience to perform every intervention they might be asked to undertake. It is OK to say “I don’t know” and it is also OK to say “No, I don’t feel comfortable doing that” despite pressure from more experienced practitioners to “Just get on with it.”

Some training programs have lists of specific criteria for which a call to a supervising physician is always required. This takes the guesswork away from trainees and instills written norms for expectations about communication.

If supervision is the more critical issue, then one solution could be for July inpatient teams to be led by third-year residents rather than new second-year residents. Indeed, in the house staff training program where one of us trained, it was the third-year residents that supervised intern teams throughout the year. And the most attentive attending physicians should be deliberately assigned to services with new residents at the beginning of July.

For the initial weeks, supervising residents can be relieved of other responsibilities (attending conferences, clinic, giving talks, etc.) so that they are consistently available to teach and help the new interns get up to speed. For a brief period, orientation and instruction can include basic and practical knowledge that may not feature prominently in textbooks, such as: “This is how to position a patient for the following vascular access procedure.” It can also include quotidian tasks that will soon become routine. For example, supervising ward residents can help interns prepare overnight sign-outs for patients who may require attention during the night that includes what might happen and what to do, and think about, if it does.

Some services already have a robust in-house coverage team with senior physicians. For example, trauma surgery, anesthesiology, critical care medicine, and obstetrics often have a 24/7 attending physician coverage, which may also protect against the July effect. ¹³

Nurse managers are effectively supervisors of new interns and a crucial line of defense at the beginning of the academic year. They should also be on the lookout for problems that interns should not manage on their own. In situations in which a new intern is not responding optimally to a situation, they should encourage them to seek advice.

Going a step further, protocols can be put in place to create a forcing function for graduated responsibility. For example, restrictions can be installed in the electronic health record to prevent ordering by new trainees without the approval of senior physicians. For medications, review of orders by pharmacists could be even more instructive. For procedures, complacency can make the second or third time around more dangerous than the first. To address this, new physicians can be required to perform a designated number of procedures under direct supervision before being permitted to do them independently. Some programs create simulations to test interns’ ability to handle certain patient conditions (e.g. shock, arrhythmia, hypoglycemia, hyperkalemia). Until the interns can show they are competent, they must have a senior physician supervise their management.

Safer care throughout the year

How much should we be making suggestions to young doctors, and how much to the organization? There is always a danger of demanding increased resilience from young staff to compensate for the fragilities and poor organization of the wider system.

The COVID-19 pandemic and Maslow have reminded us of the basics for supporting healthcare workers. ¹⁴ Staff both new and old need proper facilities in which to eat, drink, and rest. New staff need to recognize that they cannot look after their patients properly unless they look after themselves. ¹⁵ They need to care for themselves, too, to foster personal resilience and reserve.

However, they also need to be allowed proper breaks in which they are only interrupted in dire emergencies. Leaders and managers need to arrange for proper resources and sufficient staffing to allow this to happen. More generally, the resources need to be there to support trainees and protect patients: enough senior practitioners to cover and enough staff in general, especially at the beginning of the academic year.

At a higher level, other parts of the health system should do their part to help. These begin with improving education and training of health professionals on patient safety and related topics. In addition, novice practitioners need a new set of attitudes and values to live by, to replace the culture of shame and blame that lingers into the present. Ultimately, creating a “just culture” that ensures fairness to health professionals and patients/families alike would allow the work of safety and quality improvement to proceed apace.

In this pandemic year, the advice provided above may be needed more than ever. It is alarming to hear that the stresses of COVID-19 have at times allowed for safety standards to be overlooked. It may also be that new personnel are not being trained and supervised with the usual degree of rigor.

In this issue of the Journal, Ooi and colleagues describe how the reallocation of surgical staff due to the pandemic delayed communication between hospital and primary care providers in Wales. ¹⁶ Yang and colleagues in the US describe attempts to automate communication of medication changes made at hospital discharge. ¹⁷ Mirafourvand and colleagues found that blame culture was the major barrier to nurse and midwife reporting of medication errors in hospitals in Iran. ¹⁸ Nnebue and colleagues also report on the persistence of punitive responses to medical error in their Nigerian tertiary care hospital, despite improvements in other aspects of safety culture. ¹⁹

There are still many challenges to patient safety. The July Effect only increases these risks. We must not allow ourselves to fall under the spell of the Covid-19 crisis and neglect the implementation of safety standards. Ultimately, it is the responsibility of leadership to be aware of these exceptional risks, and to seek to mitigate them.