Yalda Afshar, MD, PhD
Dr. Afshar is a third-year resident in the Department of Obstetrics and Gynecology at Cedars-Sinai Medical Center in Los Angeles, CA.
Come July 1st, thousands of newly minted interns with freshly pressed long white coats, but experience-green, flood the floors of teaching hospitals around the country. For most of the country July 1st means another glorious summer day of basking in the bliss of summertime sun. For the labor and delivery floor this is NOT the case.
The lure of the July phenomenon—the day that the most inexperienced physicians hit the floor—looms over the nursing stations, operating rooms and cafeteria for weeks before D-day. The senior residents have created biased assumptions, the L&D nursing staff have sharpened their sassiness, and the OR techs are ready to make the medical students feel godly in comparison to the intern. New prey is in town. By the fall of the year, all above-mentioned parties will have transformed into a chummy family and this dark transition period will be suppressed deep in the brain where dark secrets live. Everybody comes out stronger; but nobody talks about the transformation because it’s really a supernatural phenomenon and nobody can point to what it was, or who said what, but everyone’s changed and everyone’s stronger because of it. “You’re welcome, newbies,” say the above-mentioned parties.
Despite several studies that have attempted to look at data that point to differential outcomes associated with the July phenomenon, no study has shown a striking difference (or any) in morbidity, mortality or efficiency, though some allude to it. The only weak piece of possible correlation that exists is a 2011 systematic review that assessed 39 studies.1 It concluded that efficiency decreases with year-end change-overs, but alluded to heterogeneity in the existing literature that does not permit firm conclusions. One of the largest studies compared hospital deaths and lengths of stay from July to September to the rates for other months in teaching and nonteaching hospitals, looking at 48,000 patients admitted to the ICU in 28 hospitals from 1991 to 1997.2 There was no significant difference in mortality rates or lengths of stay.
The case in obstetrics is even clearer. The July phenomenon is not seen.3. A retrospective review of data from the Nationwide Inpatient Sample, for the years 1998 to 2002 looked at the 26,175 singleton live birth admissions in July compared to 266,158 such admissions in August to June. There were no statistically significant differences in the rates of cesarean delivery, urethral/bladder injury, third- or fourth-degree lacerations, wound complications, postpartum hemorrhage, transfusion, shoulder dystocia, brachial plexus injury, birth asphyxia, chorioamnionitis, or anesthesia-related complications.
So patients, senior residents, and attendings, fear not. The July phenomenon is most likely a myth. I’d argue that the reason the phenomenon is not seen is directly related to the counter-coup phenomenon of July: more hand-holding and more vigilance from above. What the new residents lack in medical experience is more than made up for in supervision from their seniors and attending physicians.
Interns, as for you, please do not be the “n-value” that adds to the body of evidence that provides validity to the July phenomenon in the year to come. Congratulations on starting the most exciting journey in medicine. You’re a physician. But please, don’t let it get to your head.
Here are a few rules and pieces of advice for the start of intern year:
- Be kind. No matter how stressed or busy you may be, you have the privilege of sharing your time in the hospital with somebody who is relying on you, YOUR patient. Be a patient advocate. When you enter the hospital, remind yourself of your med school and residency essay and your intention to help. Smile. Talk to your patients. Listen to them. Be courteous to the support staff: They have seen endless interns come and go before you. Know your patients. An attending once advised me to consider a page as a “zen bell” (even at 3 am). Look at it as a tool for positive mindfulness. Answer your phone/page without attitude.
- Be a team member. Listen to your upper levels. They don’t want you to look bad, because that makes them look bad. While you’re at it, answer your pages on time. Do not forget about the medical students. Remember how difficult it was to be a med student—guide them like you wish you were guided. Touch base with the RNs taking care of the patient. Never leave clinic or the hospital until the whole team is done. Work well with your classmates. You didn’t pick your work family (and guess what, they didn’t pick you), but they are your family so be flexible when somebody asks for a shift switch and do not become obsessed with who worked more than who. Everybody works their asses off.
- Listen to feedback. Do not be argumentative. Residency is a time of endless feedback. Lots of the feedback is helpful while other will make you want to cry. Hell, sometimes you will (do it in private). Some feedback is direct; some is packaged into a nice sandwich. Inevitably you will get negative feedback (we all do), and it can be really hard to turn criticism into something constructive. One negative comment can stick in your mind more than ten positive ones. But criticism happens. Just try to take something positive out of it. There is always something positive there (even if it's that you got bad feedback from an awful attending, and you learned that you never want to give feedback like that!)
- When you're tired, push yourself harder. Do I really need to go back and check on that patient with the wound infection after I already went 4 hours ago? Yes. The answer is always yes. Always do more rather than less (unless it's harmful). You will sleep better at night, and over time, efficiency and knowledge will make this "extra work" seem not-so-extra. You'll just be a good doctor, and it will seem natural to you. On that note, wear good shoes.
- Don't be afraid to say "I don’t know.” You are an intern; you are not expected to know all the answers. However, do follow all "I don’t knows" with "I’ll find out." So, keep reading, and try to make your reading relevant to what you are doing. Read your surgery H&Ps ahead of time, and if you're doing a case for an adnexal mass, for example, read about adnexal masses. Be proactive. This comes with time also, but you are very bright and your ideas are (usually) good ones, so share them and don't hesitate to come up with plans. You are not a robot, even though at times you may feel like one.
1. Young JQ, et al. "July effect": impact of the academic year-end changeover on patient outcomes: a systematic review. Ann Intern Med. 2011;155(5):309-315.
2. Barry WA, Rosenthal GE. Is there a July phenomenon? The effect of July admission on intensive care mortality and length of stay in teaching hospitals. J Gen Intern Med. 2003;18(8):639-45.
3. Ford AA, et al. Nationwide data confirms absence of 'July phenomenon' in obstetrics: it's safe to deliver in July. J Perinatol. 2007;27(2):73-6.