The July Effect

So it’s the end of July, and my first month as a doctor came and went.

Those of us in medicine and even those who are not have probably heard of the “July Effect.”It refers to the phenomenon in which there is a discernible spike in all sorts of bad things at teaching hospitals during the month of July because that is when all the new and inexperienced residents start working. Bad things like higher rates of mortality, more post-surgical complications, increased rates of infection, longer median lengths of stay, etc. You name it, and it’s probably been pinned on some poor intern somewhere. And the lesson for patients? Avoid coming to the hospital in July if you can.

So…is it real?

Interestingly enough, you can find many studies that can either prove or disprove the idea. More often than not, studies will suggest that the difference in any of these adverse outcomes is negligible across all months including July. However, some have occasionally reported slight differences. For example, a 2010 study in Journal of General Internal Medicine suggested that medication errors went up 10% in July in teaching hospitals, but not in neighboring hospitals. A 2013 study in Circulation suggested that cardiac patients had a lower risk of death at teaching hospitals than at non-teaching hospitals, but that risk rose to equivalent levels in July. Plenty of studies with lots of nuances here and there.

So now that I’ve survived that infamous first month, here’s what it felt like from the perspective of the new doctor in his first month with such new and immense responsibility. Yeah, I was scared at times. I felt overwhelmed sometimes. After all, I learned so much medicine over the past four years, and I could still recall a fair amount in enough basic detail to do my job. But I was never confident of any decision or action I made. Every time I ordered a medication, I still looked it up again to make sure it was correct and appropriate. Unlike as a med student, this time, when I placed an order, it just went through without requiring anyone else’s co-signature because I’m a doctor now, and that was a new and scary feeling.

Of course, along with all the fear and anxiety, there were also great first moments. That first time you put on a long white coat. That first time you sign a prescription for your patient with your signature. That first time that you introduce yourself to a patient almost on reflex as a medical student, but then catch yourself, and correctly introduce yourself as a doctor (although I still tell them to call me by my first name). That first time that someone calls you doctor, and they’re not confused or being facetious.

In terms of preparing interns for that transition, I think we’re doing a couple of things well in emergency medicine residencies. First, we actually have a lighter clinical schedule in my residency program during July and spend more of our time on mandatory trainings and didactics. During orientation month, we work “intern shifts” in the emergency department, which are shorter 8 hour shifts in which we are on as additional staffing. The purpose of these shifts is to give the new interns a chance to learn how the hospital runs, get used to the electronic medical systems, and develop some time management skills and efficiency without the pressures of “moving the meat.” Often, the biggest challenge of intern year isn’t necessarily the medicine, but actually learning the ins and outs of your hospital and the minute details, such as how to call consults, place orders, or complete documentation. It’s a good opportunity to develop good practices before we really need to start seeing lots of patients each shift. In other words, don’t worry about that never-ending and constantly growing mountain of patients who need your help in the waiting room…for now. Take it slow, and learn to do things right and well.

Secondly, in the ED, you’re never really alone in residency. You have your attending, your fellow residents, and experienced nurses and staff to rely on for help when you need it. We all work together side by side in the emergency department. Any time I had a question about how to manage a patient or place an order, I always had someone I could tap for advice. Not so for other specialties like internal medicine when the only time you may see your attending is during rounds in the morning and your residents every so often throughout the day.

Sometimes I wonder, if the July Effect was really a concern, why don’t we try to do something about it? After all, I have friends in medicine who started on night float their first night and carried a dozen patients and friends in surgical fields who were already violating work hour rules their first week. I believe they did have a rougher time than I did, and I’m not sure I know enough about their situation to comment on the impact on patient care. In emergency medicine though, most EM residencies include a longer orientation program that combines lighter clinical time and preparatory didactics, so I think we’re doing a better job of orienting our interns. Perhaps it’s especially important in EM to do so because of the unpredictability and potentially higher acuity of the medical cases that an intern may work with. In any case, I’m glad we do it.

So, back to the original question, is the July Effect real? The literature says probably not, but maybe. Personally, I’m not convinced. Yes, interns are inexperienced. But you learn by caring for patients. A little fear also makes you strive harder to be better. That’s how medical education works. There’s no way around it. This moment had to come eventually. And I don’t think patients are harmed by it. I think we recognize the important responsibility that we have trained so long for and that we now carry, and we take good care of our patients, even when we are scared, unconfident, and overwhelmed.

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Starring Emergency Medicine

I recently watched “Code Black” at the IFC Center in NYC. It’s a great documentary by an EM physician about emergency medicine and the challenges that we face in practicing medicine today. It focuses on LA County Hospital and the infamous C-Booth, which is the trauma bay where supposedly “more people have died and more people have been saved than in any other square footage in the United States.” It was especially enjoyable to watch this film at this early point in my training because I connected so strongly to the humanity and frustration of the young resident physicians who chose to train at a county hospital similar to my own. It was an accurate and sometimes disheartening depiction of emergency medicine, especially as it delved into the challenges of modern day regulations and paperwork as we work to provide excellent emergency care and also ultimately serve as a safety net for so many who have nowhere else to go.

A few months ago, I had also watched another documentary by EM physicians entitled “24/7/365: The Evolution of Emergency Medicine,” which is a more academic take on the history of our specialty. It’s actually really interesting and features many of the fathers of emergency medicine. As an EM doc, it’s great to watch the interviews with the “mavericks” who dared to forge a new field in medicine when everyone thought they were crazy.

With both of these films, emergency medicine as a field is starting to claim some control over how the future of EM will be portrayed not only in film but in society. EM is a relatively young specialty, and its perception as a specialty has always been shaped in part by its portrayals in media and film. The depiction of emergency medicine in the media has come a long way. I’m too young to have watched M.A.S.H. or Emergency!, which were both TV shows that were instrumental in EM’s development. I’m more of the ER, Scrubs, House, and unfortunately Grey’s Anatomy generation. ER in particular wins the award for not only introducing America to emergency medicine but also maintaining a fairly accurate portrayal of the pluses and minuses of the field.

Of course, there’s a new crop of medical dramas that premiere every season, and not surprisingly many of them will feature emergency departments because apparently the ED and the OR are the only interesting places in hospitals. Increasingly, many of these new shows often trade in realistic medical scenarios for ridiculous but dramatic life-saving interventions and of course sexy love triangles, the most egregious new offender being NBC’s The Night Shift. I understand it’s going to get big ratings, but it’s just painful to watch the wild inaccuracies as a medical provider.

Besides just misrepresenting our work in popular culture though, these inaccuracies do have an impact on patient care and perceptions. For example, surveys and studies have looked at what percentage of resuscitations depicted in media were successful. Some of these TV shows have shown success in as high as 75% of resuscitations depicted. Consequently, patients and the public believe the chances of successfully resuscitating someone are much higher than they actually are. In reality, the percent of cardiac arrest patients who are successfully resuscitated after CPR and survive to hospital discharge is less than 10%. If we keep this up, we’re just setting everyone up for disappointment.

Emergency medicine is a very cool specialty obviously. People’s interest in it will only grow, and there will be countless more TV dramas and films based out of the emergency department. That’s great for us, but we owe it to medicine, our patients, and ourselves to make sure that these depictions of our field in media maintain a respectable and responsible degree of accuracy. We can’t just let Hollywood run the show.

 

Finally, just for fun. Here’s my quick rundown of some popular TV shows ranked from more realistic to not.

NY Med and Boston Med – These were TV documentaries based on real doctors and patients, so I feel obligated to rate them as most realistic. However, it absolutely sensationalized and over-dramatized medicine and made you think there were no other doctors in the entire hospital besides surgeons and emergency medicine physicians. And of course, anything that features Dr. Oz these days is questionable.

Scrubs – My personal favorite. The most accurate depiction of residency and hospital medicine out there. As long as we completely just ignore that whole ninth season.

ER – Sometimes a little dramatic, but overall a faithful and honest depiction of our field. Maybe what happens in one episode actually happens over a whole week, but otherwise totally spot on. We’re pretty much all as good-looking as George Clooney and Noah Wyle, if not more.

House MD – I wish diagnostic medicine, House’s department on the show, was a real specialty because I would totally do that. You get to solve the most interesting cases and do everything from operating on your patient to interpreting all your own scans. No other specialties needed. Also, we all wish we could just do whatever we want like House and not get fired.

Grey’s Anatomy – I wish it was true, but not so at all. Nothing happens in the call rooms except unsatisfying sleep. Also, I’ve never seen surgeons hang out in the emergency department so much or respond to traumas as they come in. In fact, why are surgeons the only doctors in the entire hospital? Why are the chiefs of departments so young and good-looking? Why a million other things?

The Night Shift – This latest newcomer is probably pushing the field of emergency medicine backwards and actually doing a huge disservice to medicine in general. There’s so much wrong in every episode. Go check out EP Monthly and their live tweets for the best recaps on all that is wrong with this show. For doctors, that’s actually better entertainment than the show itself…

The Scions of Medicine?

I recently read some statistics that shocked me, but not really. In the US, 60 percent of medical students come from families with incomes in the top 20 percent of the nation. Meanwhile, only 3 percent come from families with incomes in the lowest 20 percent. Not much socioeconomic diversity in the house of medicine.

Now, I realized early on that I didn’t have a lot of company in this respect, but I didn’t think it was as lonely as a mere 3%. As a first generation college graduate, let alone doctor now, I know all too well that feeling that I had stumbled into an exclusive club to which I didn’t perfectly fit in. More often than not, it seemed like many of my classmates had parents who were physicians or at least some better sense of what a life in medicine was like. Looking back on my journey into medicine, I remember firsthand the challenges facing aspiring doctors from lower SES backgrounds.

If nothing else, my personal journey illustrates the importance of early recruitment and sustained mentorship in the field of medicine. It’s just more challenging for those without any prior exposure to higher academics to realize that a career in medicine is a possibility. To this day, I can’t say exactly what it was that first made me think that it was feasible for me. My father delivered takeout, and my mother was a seamstress in a factory. In my family, a high school diploma already made me a pioneer in education. I was very fortunate though. I got accepted into medical school at the age of 17 through a joint BA-MD program. While most would consider the greatest benefit of this set-up to be a guaranteed seat in medical school during undergraduate, I actually considered the greatest benefit to be the mentorship and guidance that I was connected to through the program. Even with a guaranteed seat in medical school, I would never have successfully made it to medical school without that added support, direction, and community.

Of course, the other large obstacle, perhaps the greatest impediment of all, is the exorbitant cost of medical education today. The AMA reports the average debt of medical students in 2013 to be around $170,000, and that amount can easily be as high as $250,000 or more, especially if you attended a private university for both your undergraduate and medical degrees, as I did. In my case, I consider myself very fortunate once again because I received a near-full ride scholarship from my generous alma mater for my undergraduate education. As for medical school, it was a combination of scholarships and loans that was pretty typical for many medical students. As a result, I still owe some people a lot of money, but perhaps not nearly as much as I could have for someone in my position. It’s hard to say how these things may have affected my choices in retrospect. If I didn’t get that scholarship in college, would I have dared to take on more debt by going to medical school? If I was in more debt, would I have felt more compelled to go for a more lucrative specialty?

The ramifications of a lack of socioeconomic diversity in medicine are great and significant to patient care. Looking back, it seems obvious how we can start to remedy the problem. We need more outreach to those from lower SES backgrounds early on and more learning opportunities for those interested. We need to provide sustained mentorship to those already on the medical track. And, most importantly, we need major reforms to the funding and costs of medical education today. It will take more than just 3% of us to improve this. As a profession, we must recognize increased diversity in our field as an important goal to strive towards.

The Next Chapter

They say the jump from medical student to intern, which is the infamous and grueling first year of residency, is the steepest. Of course, I heard that same thing about the jump from MS2 preclinical year to MS3 clinical year and from resident to attending and from young attending to seasoned attending. So who knows? By this point in my medical career, if nothing else, I am very comfortable with being uncomfortable. Or at least very used to it. Willingness to deal with uncertainty is must-have in emergency medicine after all.

What I do know is that MS4 year was awesome. This last year of medical school was truly wonderful and revitalizing. You can have dinner with your family and friends again; you can read a book just for fun; you can actually sleep the number of hours that you recommend to patients, and then some.

Now, with my very newly minted MD, I’m finally making the big jump from medical student to doctor. It took four years to reach the top of the medical student totem pole, and I enjoyed those good times while they lasted. Now, the reward for reaching the top is to start back at the bottom of the “real doctor” totem pole. It’s okay because, by this point, I’ve also grown very accustomed to perpetually being at the bottom of a totem pole.

So why would I choose to start a blog now? At the end of the most carefree period of my life/career and the beginning of what many have told me is the most challenging phase of my medical training? Well, that’s easy. For my sanity and my patients.

Once upon a time, I was a normal human being. I loved to read and write. I had interests and normal reactions to things.

Let me illustrate further what I mean with a simple example. Diarrhea. When people hear about diarrhea, they are generally grossed out, as normal people are, so I’m told. Now, after the brainwashing that is medical training, I’m intrigued about your diarrhea and have a million questions for you regarding it. I want to know the color, odor, consistency, presence of blood…something has happened to me.

I wish I had documented that change in myself more. I wish I wrote more in medical school. So that’s why I’m going to do a better job of it in residency. I want to be able to trace that gradual evolution and at least still recognize the individual in the white coat that I see in the mirror. Physicians are storytellers at heart; patients tell us stories; we present stories to one another. We collect and tell stories all day long. I think the best doctors are the still the ones who remind themselves and remember why they chose to don the white coat in first place.

Medicine is the best job in the world. The training and day to day work can be a little rough on your soul, creativity, and humanity. I have to do what I can to try to preserve and save them.