The ‘July ef­fect’ chal­lenge

ACGME ef­fort aims to im­prove doc trainees’ skills

Modern Healthcare - - THE WEEK IN HEALTHCARE - Andis Robeznieks

Each sum­mer, teach­ing hos­pi­tals un­dergo a trans­for­ma­tion as a team of ex­pe­ri­enced res­i­dents leave and are re­placed by trainees fresh out of med­i­cal school. Some view this as a time of peril for pa­tients—com­monly re­ferred to as “the July ef­fect.” This year brings the pos­si­bil­ity that the dan­ger could be am­pli­fied as the agency over­see­ing res­i­dency pro­grams rolls out a new eval­u­a­tion sys­tem July 1.

In the United King­dom, the res­i­dent turnover is re­ferred to as the “Au­gust killing sea­son.” But ex­perts are pre­dict­ing that the Ac­cred­i­ta­tion Coun­cil for Grad­u­ate Med­i­cal Ed­u­ca­tion’s Next Ac­cred­i­ta­tion Sys­tem, or NAS, could lead to a safer health­care sys­tem be­cause of its fo­cus on mea­sur­ing out­comes rather than eval­u­at­ing pro­cesses.

Specif­i­cally, the ACGME will re­quire in­sti­tu­tions to eval­u­ate res­i­dents at dif­fer­ent points or mile­stones in their train­ing for com­pe­tency in pa­tient care, med­i­cal knowl­edge, prac­tice­based learn­ing and im­prove­ment, sys­tems­based prac­tice, pro­fes­sion­al­ism, and in­ter­per­sonal skills and com­mu­ni­ca­tion. In July, NAS will be rolled out for res­i­dency pro­grams in seven spe­cial­ties. It will be rolled out for the 19 other spe­cialty pro­grams ACGME over­sees in July 2014.

Pro­gram ad­min­is­tra­tors are not an­tic­i­pat­ing a more haz­ard-filled July be­cause of NAS, just a heav­ier work­load. But it is work that they say will help raise the level of safety and qual­ity of the care.

“Staff will be re­quired to be more hands on than ever be­fore,” said Dr. Chad Vok­oun, as­so­ciate pro­gram di­rec­tor for in­ter­nal medicine at the Univer­sity of Ne­braska Med­i­cal Cen­ter Col­lege of Medicine in Omaha.

Dr. Su­san Van­der­berg-Dent, as­so­ciate dean of the grad­u­ate med­i­cal pro­gram at Rush Univer­sity Med­i­cal Cen­ter in Chicago, agreed. “From an in­sti­tu­tional per­spec­tive, it’s go­ing to be a lot of work,” she said. “But, ul­ti­mately, it will have a salu­tary ef­fect.”

In fact, Van­der­berg-Dent’s col­league, Dr. David Ansell, called the ac­cred­i­ta­tion changes “one of the great­est things to hap­pen in med­i­cal train­ing.” Demon­strat­ing res­i­dents’ com­pe­tency in prac­tice-based learn­ing and im­prove­ment re­quires in­te­grat­ing res­i­dents’ train­ing into an in­sti­tu­tion’s ef­forts to im­prove qual­ity and pa­tient safety, said Ansell, chief med­i­cal of­fi­cer at the med­i­cal cen­ter and as­so­ciate dean for clin­i­cal af­fairs at Rush Med­i­cal Col­lege.

Ex­perts have mixed views of whether the July ef­fect is a real phe­nom­e­non. Two years ago, the An­nals of In­ter­nal Medicine pub­lished a re­view of 39 pre­vi­ous stud­ies that con­cluded mor­tal­ity in­creases and qual­ity de­creases be­cause of res­i­dent changeover. But the au­thors also said lit­er­a­ture does not ex­plain how this hap­pens or define the de­gree of risk. This year, the Jour­nal of Neu­ro­surgery: Spine pub­lished a re­port declar­ing that “the in­flux of new res­i­dents and fel­lows in July has a neg­li­gi­ble ef­fect” on national spine surgery rates for mor­tal­ity, in­fec­tion and other com­pli­ca­tions.

Res­i­dency ad­min­is­tra­tors rec­og­nize the ob­vi­ous risk in the tran­si­tion.

Ansell said that Rush’s own data track­ing doesn’t in­di­cate a rise in neg­a­tive trends as­so­ci­ated with new res­i­dents. “I’m not say­ing we don’t have med­i­ca­tion er­rors oc­cur—we do and ev­ery place does—but we don’t see a spike,” he said, adding that Rush tracks near misses and rates for com­pli­ca­tions, length of stay, med­i­ca­tion er­rors and mor­tal­ity.

Dr. Brian Owens, gen­eral med­i­cal ed­u­ca­tion di­rec­tor at Vir­ginia Ma­son Med­i­cal Cen­ter in Seat­tle, said the in­sti­tu­tion has de­vel­oped an in­ten­sive pro­gram that pre­pares and in­te­grates first-year res­i­dents, also known as in­terns, into the staff with­out over­whelm­ing them.

In sum­mer-long boot camps for anes­the­si­ol­ogy, ra­di­ol­ogy and surgery, res­i­dents re­hearse in­ter­dis­ci­pli­nary team-based re­sponses to med­i­cal events, both fre­quent and rare. Vir­ginia Ma­son also has more at­tend­ing hos­pi­tal­ists on hand to as­sist in July and lim­its va­ca­tion for at­tend­ing anes­the­si­ol­o­gists so more are avail­able to su­per­vise. Rounds are done in teams and in­terns present their pa­tients with fac­ulty and se­nior res­i­dents—any er­rors an in­tern may make in de­vel­op­ing a treat­ment plan are cor­rected im­me­di­ately. “Es­sen­tially, we stress over­sight,” Owens said.

At Ne­braska Med­i­cal Cen­ter, Vok­oun said giv­ing in­terns “peo­ple to lean on” and es­tab­lish­ing a “there-are-no-silly-ques­tions pol­icy” helps new doc­tors through their first month of train­ing. “It’s not based on the July ef­fect,” Vok­oun said. “We want to set res­i­dents up for suc­cess.”

Per­haps the most damn­ing study sug­gest­ing the July ef­fect is a dan­ger was pub­lished in May 2010 by the Jour­nal of Gen­eral In­ter­nal Medicine. Re­searchers stud­ied death cer­tifi­cates from 1979 to 2006 and found a 10% spike in July for in-hos­pi­tal fa­tal med­i­ca­tion er­rors in U.S. coun­ties with teach­ing hos­pi­tals—and no such spike in coun­ties with­out teach­ing hos­pi­tals.

Lead author David Phillips, a pro­fes­sor of so­ci­ol­ogy at the Univer­sity of Cal­i­for­nia San Diego, said the fa­tal­i­ties linked to med­i­ca­tion er­rors did not di­min­ish af­ter the In­sti­tute of Medicine’s To Err is Hu­man re­port on pa­tient safety was re­leased in 1999. “We showed in our pa­per that the ef­fect wasn’t get­ting smaller over time,” he said. “This is im­por­tant for other peo­ple to study be­cause no­body wants to be in­jured by some­one whose job it is to help them.”

Vir­ginia Ma­son hos­pi­tal­ist Dr. Thomas Gunby, left, leads rounds in a team that in­cludes two first-year res­i­dents and one sec­ond-year res­i­dent.

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