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Thursday, July 12th 2007

It\'s Probably All Right To Get Sick Right Now

The Intern Will Be In To See You

DB revisited the “July phenomena” recently. That is wherein you, by medical legend, get poorer care during the month of July at teaching facilities when all the new interns and residents start. Dr. Bob says that,

[T]here is no July phenomenon. Is There a July Phenomenon? We should oppose any mention of this urban myth.

I have a few thoughts about why we do not have a July phenomenon. Those who supervise in July (and I have done July wards for at least the last 10 years) are acutely aware that the new interns need careful supervision. The supervising attendings and residents are hand chosen for this task.

And, indeed, putting aside the potential for bias and thus error in any self evaluation, the literature supports him. Not just the study he linked to but others. See here and here and here. The only evidence for a July phenomena is anecdotal. Case studies and stories and such.

What I think some fail to realize is what goes into making the plan of action for the care of every patient. Everything is talked out; every decision is ultimately in the hands of the attending. It isn’t like new interns are running around ordering procedures without talking to anyone.

Being on your first rotation, as I am, provides a unique perspective. On one hand, you don\’t have something on hand to compare the workings of the wards in July to. Are errors and inefficiencies I\’m seeing systemic? Will they improve as the interns and residents mature into their positions? On the other hand, your view isn’t tainted by years through the looking glass. You settle in as a resident, and in the second and third year or as staff you may lose perspective.

I\’ve admitted my ignorance, this being my first rotation, but I will say I’m probably better informed than most MS3s in the same position. With two parents who have been academic physicians for most of my life I’m not completely blind on the maturation process of interns, residents, and even medical students. And how all that effects patient care.

With all that said, if at all avoidable I would still not want to be in the hospital in July versus September. The efficiency is just not what it will be. There is evidence interns make more mistakes earlier in the academic year (at least in other countries). There is some evidence they’re poorer documenters. And they’re just less efficient. The measurable effect that has on adverse outcomes appears nill but what the effect on what I’ll deem “quality” of stay is less documented and I for one think it’s a real thing.

A young intern forgets to document consent and it\’s four o\’clock by the time the resident notices…whoops, you don’t get that procedure until tomorrow.A young intern doesn’t ask the right questions when he just pops in to check on you after lunch. Blah, blah, blah.

I’ve got some really talented and smart interns, but I know they\’ll be even better later in the year. My attending and/or my resident can\’t stay on top of all 12 patients with the same detail my interns can of their six. Sure, the attending is immensely more skilled at knowing what to look at and picking out what is relevant and thus needs less time to keep up with each patient but It ain\’t the same though.

By choice, I’d wait for July to come and go before I went out and got myself sick enough for an admission. No matter what the mortality figures say.