Preventing the July Effect: A better balance of clinical and training needs

August 31, 2010

For the medical profession to continue to grow and thrive, trainees must be given meaningful opportunities to actively care for patients. New blogger Dr. Arun Krishnaraj discusses how that’s happening now and how it can be made better, for patients as well as doctors.

I walked into Room 9 and there sat “Daniel,” a 22-year-old college student diagnosed with metastatic cholangiocarcinoma. Prior to his cancer diagnosis, Daniel could be found hanging out with his friends on the quad of a prestigious university and throwing his 285-pound frame around the football field blocking opposing defensive linemen. Now, he sits before me a sallow-faced 230-pound man with a protuberant abdomen who participates in brutal chemotherapy sessions instead of two-minute drills. On this day, Daniel is to receive his weekly paracentesis to manage the discomfort caused by his abdominal distention.

Daniel was flanked by his parents. Understandably they have become hypervigilant of their only son and came armed with a series of questions about the procedure as well as my background and experience in performing it. They also requested to be present during the procedure despite hospital policy disallowing this practice. Though I would become facile with ultrasound-guided paracentesis by the end of the week, on my first day in a new hospital I was not familiar with the tray setup, needles used, or the people I would be working with. Daniel’s parents perceived my apprehension as I began to consent Daniel for the procedure and I could sense they did not want me to perform or participate in the procedure. Fortunately, my attending entered the room at the start of the procedure and alleviated their fears.

How do we balance a patient’s wish to be cared for by an experienced physician with the mission of a teaching hospital? Medical errors and their prevention has become a hot topic in health policy circles since the publication of To Err is Human in 2000 (Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press, 2000). This report, published by the Institute of Medicine, found there might be up to 98,000 preventable deaths per year in U.S. hospitals. Additionally, research from the University of California, San Diego suggests that academic teaching hospitals may suffer from the “July effect,” a spike in the number of deaths during the month of July, the traditional start date for new trainees (Phillips DP, Barker GE. A July spike in fatal medication errors: a possible effect of new medical residents. J Gen Intern Med 2010;25[8]:774-779). Given these data, do patients and their families deserve to be able to opt out of care by trainees?

For the medical profession to continue to grow and thrive, trainees must be given meaningful opportunities to actively care for patients. However, greater oversight, the use of validated checklists, and better orientation during the initial months of training seems prudent. The paradigm of “see one, do one, teach one” is a good starting place but could use some updating. We should continue to develop better simulation models to allow trainees to refine their skills before practicing on patients. We should require more hands-on instruction and oversight by attending physicians in the early months of training programs. Our patients deserve no less in July than in December.


I am currently a clinical fellow in the abdominal imaging and intervention division at Massachusetts General Hospital. I am also jointly pursuing a fellowship in Imaging Informatics. Through this blog, I hope to share with you my experiences (both good and bad) in radiology training and how those experiences have been shaped by my background in health policy and passion for advocacy. I hope to lend some perspective on what my generation of radiologists thinks about the current state of the field and would like to open a dialogue with the readers of this blog regarding my opinions.