It's time to release the R1s!

July phenomenon: fact or fiction?

By Edward Lee

In the medical profession, these blips are known colloquially as "the July phenomenon." Is the phenomenon a reality or a kind of bogeyman story to frighten not only patients but already-uneasy medical trainees?

It's a tantalizing question and one that's been dealt with numerous times in the literature. Most of the research, done in Canada, the US and the UK (where the phenomenon is called, with typical black humour, "the killing season"), shows that there is no noticeable difference in deaths or morbidity in the month of July. A recent study from December 2004 in the Journal of Surgical Research, for instance, from the pediatric surgery department at Toronto's Sick Kids, compared error rates in June and July. They found that in June the rate of adverse events was 5%; that figure rose to only 6.7% in July.

But a newer study, conducted by the Department of O & G at the Royal Alexandra Hospital (RAH) in Edmonton has slightly more disturbing findings. The study, presented at the Clinical Meeting of the SOGC in June, looked at deliveries between 1993 and 2003 — 49,056, of which 9% were in July. The researchers found that though the risk for emergency c-section decreased slightly in July, there was a significant increase in risk for cesarean hysterectomy, which led the authors to conclude that "this may support the theory of a July phenomenon in obstetrics at the RAH."

Despite this gloomier report, overall it seems the worst that happens in most teaching hospitals is a decrease in the quality of documentation. In the main, suggestions of increases in infection rates, operative complications, resuscitative times, length of stay, readmissions, medical errors or costs of care are very rare.

FEARS PERSIST
But for one reason or another, the evidence often seems inconclusive and the rumour persists from year to year. In researching this article, it turned out to be a little difficult to get the opinion of the seasoned physicians who work side by side with the newbies each year. Most of them were on vacation. New residents, on the other hand, were plentiful. Uh oh.

One, Michelle*, admits that the July phenomenon worries her. "I slept quite well as a student on call, but now being a resident, I worry all night wondering if I did the right things for that patient with chest pain," admits the newly minted internal medicine resident. "Now with signing powers, I have to read three articles on the one problem I'm faced with just to confirm that I'm doing the right thing."

Those preparing to enter the resident ring next year are worried too. Visibly spooked fourth year student Jeri admits she's not crazy about relinquishing the security blanket being a mere med student provides. "Sure, you're at the bottom of the totem pole," she says, "but everything you do is checked by someone who's supposed to know more than you. We're quite free to be wrong without adverse consequences."

WE'RE ON IT
Pretty much everyone you ask insists that teaching hospitals are set up to prevent a July phenomenon; in theory there should always be backup, someone higher up on the chain of command who is supposed to know the right answers. Michelle says that's true — in theory. But the reality is sometimes a little different. "There are some doctors who sound happy that you called them, but then there are those who answer the phone with a drowsy 'What?' or who pick up the phone without saying anything at all," she says. "Those are the staff you're more reluctant to call, who sound disappointed in you. You don't want to look dumb, but if I really don't know something, I've never been shy to call a staff. I'm not going to be gambling with a patient's life."

Dr Terry Sosnowski, program director for emergency medicine at the University of Alberta is adamant the safeguards are there, and patients and doctors alike are satisfied with them. "[The July phenomenon] has never been a concern in my practice," he says. "I've been in practice for 32 years and there have only been three or four instances where patients have expressed hesitation towards being treated by residents or students, regardless of the time of year."

For the most part, it seems that Canada's medical education system has bred a sense of being on a team into their graduates, that they're never alone in any situation. Dr Sosnowski agrees and insists that experienced doctors are on hand to help the new R1s. "As emergency physicians, we are often the only staff doctors in the hospital at night and there are times when residents from different departments would come down and ask us to read an ECG or look at some lab work, and we are more than happy to assist. Staff physicians recognize when new trainees come in and we compensate for that," he says. "Just last month, for example, a CCU resident was managing a patient with bigeminal bradycardia and the staff cardiologist didn't hesitate to come in in the middle of the night. This probably would not have happened in June."

SCARE TACTICS?
So is the July phenomenon nothing more than a slightly sinister pedagogical tool, perpetuated to scare students into being more diligent? For those living the season, bleary-eyed from 36 hours of call, the question is a little abstract.

"I don't think a July phenomenon exists," decides Michelle. "I'm still a learner, and the fear of killing someone causes me to be extra-vigilant in my management. I know Canada has excellent medical schools and that the medical association isn't going to grant me a licence if it thinks I am going to start killing people." Which is a timely reminder that medicine — and medical training — is not always an exact science and very often has to come down to a question of faith.

*Student and resident names have been changed.