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Debunking Hospital Lore (Again)

Landing-educationIt seems to come up every July, when the new batch of residents, most fresh out of medical school, begins their hospital rotations. Will the quality of health care decrease during this changeover, as less-experienced doctors move in and start to treat patients?

Results from hundreds of studies over the last 30 years looking to best answer that fall on both sides of the question—keeping the debate alive and the news stories flowing.  But more recently, the data suggest that this so-called “July Phenomenon” is more likely an urban hospital myth than a reality. 

“If anything, there is more oversight in July,” said Rachel Kelz, MD, MSCE, FACS, an associate professor in the department of Endocrine and Oncologic Surgery at the Perelman School of Medicine, who wrote a recent invited commentary on a JAMA Surgery paper looking at the issue in emergency surgery. “The start of the year is an anticipated time of weakness, and the system has been able to accommodate. It’s flexible and designed to safeguard patients from harm while enabling the education of the next generation of surgeons.”

Past studies on surgical outcomes have contradicted one another. A 2006 study showed an increase in surgical morbidity and mortality during the summer months, while a 2011 study, using the same data, found no difference.  Other literature within trauma, cardiac surgery, and obstetrics refutes the “July Phenomenon,” the commentary notes. Another study published in 2013 in the Journal of Neurosurgery: Spine also found no effect on outcomes, this time in spinal surgery patients.

The JAMA Surgery study couldn’t support the phenomenon either. The researchers, from Brigham and Women’s Hospital, found that the influx doesn’t negatively affect morbidity and mortality of emergency general surgery patients.  Looking at outcomes data for more than 1.4 million patients over a four year period, the team found that patients treated in the summer months had a slightly lower risk of death or complications than patients who had operations during all the other months. They did, however, see a spike in the winter. Kelz_rachel_2

This latest study provides additional evidence that the phenomenon may be no more than hospital lore, said Kelz, who co-wrote the editorial with Elizabeth A. Bailey, MD, and Karole Collier, of Penn’s Center for Surgery and Health Economics. But it raises a bigger question about why patients might be doing worse in the winter months.

“A disturbing finding observed in this study…was the increased frequency of survival complications and mortality during the winter months,” the authors wrote. During that time, it’s been well-documented that patients are more likely to have strokes, heart attacks and bloodstream infections, but it’s unclear how this affects the surgical population.

“It seems we should shift our focus from July to January,” Kelz said.

What factors contribute to worse surgical outcomes in the winter? Are holiday schedules compromising attending supervision or leading to a decrease in resident and nursing staff coverage?  Are younger, less experienced surgeons performing more operations compared to earlier in the year?

“As we move forward in our understanding of seasonal differences in surgical outcomes, perhaps these are the new questions that we should be asking,” Bailey said.

Today, at Penn Medicine hospitals, and many across the country, there are built-in protocols to ensure patients receive optimal care.

Attending faculty increase the level of supervision of patient care by working longer hours, rounding with the residents more frequently and for longer periods of time than later in the year, and orientation programs, including simulation training, have been implemented to allow the new trainees to adjust to the new environment and practical aspects of the individual hospitals before they deliver care to patients, Kelz said.

“These systems prompt inexperienced doctors to help train them to recognize patterns of patient stability before the patient becomes critically ill,” Kelz said. “In so doing, it provides a safety net for the patients.”

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