The July Phenomenon

While July 1 might just be another hot summer Thursday for most of America, for the world of medicine, it is the traditional day in which every teaching hospital in America initiates interns into the start their residency and all current residents move on to be higher levels.  July 1 signifies a new iteration of hierarchy within medicine and another year gone by. 

Internship, as I had suspected, and have confirmed during orientation, will be a lot of responsibility.   My pager is to be on my person, turned on, at all times so I can be reached in case of an emergency.  Just keeping my pager with batteries and on me is hard enough. There are an incredible amount of sick women to be taken care of and a vast amount of procedures to learn.  Mastering a system, especially a complex, extremely busy, county system, is seemingly impossible even without the massive patient load.

My greatest concern however, is not for my own sanity or vanity (I’m sure I’ll recover), but for the safety and health of the patients.  My friends in medical school frequently joked during graduation week as we had parties and slept late that they hope “nobody gets sick in July”.   We all wonder how we won’t make people sicker when we really don’t know what we’re doing and feel even less knowledgeable and accountable than we did a year ago. 

Fascinatingly, the “July Phenomenon” as it’s so referred to, has actually been studied in depth in a number of specialties, referring to the frequency of medical errors and patient outcomes throughout the calendar year in teaching hospitals.  While some studies show that morbidity and mortality within teaching hospitals is much greater in the beginning of the academic year, some show no difference.  A study recently published from the University of California San Diego reviewed all death certificates in the US for the past 30 years (n=62 million!) and found that deaths from medication errors were much more likely to occur in July than other months [1]. 

Fortunately, there are a few large studies in the labor and delivery suite which found no difference in adverse outcomes between July and other months.  One nationwide study of about 300,000 women between 1998 and 2002 showed no difference between important complications like chorioamnionitis, C-sections, 3^rd or 4^th degree lacerations, or shoulder dystocia  [2].  Another smaller study showed a higher rate of infection during the July months, but other outcomes were similar [3].

How can we, as doctors and as broader society members, reconcile the fact that in some cases we may be putting patients at risk by allowing residents to truly “practice” medicine?  I recently read Atul Gawande’s excellent book “Complications” where he discusses this very quandary.   He suggests that there is no other solution to the problem of training new physicians without human experimentation, under supervision of course, and putting some people at risk.  He concludes, therefore, that training residents ultimately is for the good of everybody. 

The July phenomenon, in a more positive light, I think also refers to the burst of fresh veggies and eggs available as summer comes into full bloom.  I was blessed to be given freshly laid eggs by my new friend and classmate who has four lovely hens.  The beauty of an eggy tart like this is that even though it takes a bit more time than many dinners, it can be eaten for breakfast, lunch or dinner and can really have any fresh veggies, meat and cheese that you choose.  I list below what I used, but substituting almost anything appealing would be just as wonderful.  The whole meal comes together in a snap with a food processor but can just as easily be done the old fashioned way.  It’s the perfect meal to gear up for an insane week (WISH ME LUCK!)

Eggy veggie tart

In 9 inch tart pan or 8 inch pie pan

For crust

1 cup flour

1 stick ice cold butter

¼ cup ice cold water

½ tsp salt

Filling

5 eggs

¼ cup cream

Cut up cooked sausage

1 large shallot or half of onion

½ red pepper

4 oz goat cheese

Whole tomato thinly sliced

Chiffonade basil

To make crust.  Preheat oven to 425.  In food processor pulse flour and butter until butter is pea shaped about 5-6 times.  Add water and pulse a few more times.  Alternatively, you could use a pastry cutter or 2 knives.  Take dough out and bring together with hands.  Do not overmix.  Ideally, refridgerate for 2 hours, but I just rolled it out.  Put in tart pan and cover with foil.  On top of foil use beans, weights or another pan to weigh down.  Bake for 15 minutes.  Take off foil and allow to brown for another 2-3 minutes.  Remove from oven.  Turn oven temp down to 375

For filling, clean out the food processor, pulse eggs and cream with pinch of salt until foamy.  Over medium heat with 1 tbsp olive oil, cook shallot/onion and pepper with salt until shallot starts to brown, about 15-20 minutes.  In pastry shell, add sausage, onion/peppers, then tomatoes.  Add egg mixture, top with cheese and herbs, bake for 15-20 minutes until custard is set.  (sorry the picture is ugly)

1. Phillips, DP.; Barker, GE. “A July Spike in Fatal Medication Errors: A Possible Effect of New Medical Residents.” Journal of General Internal Medicine,, 2010.

2. Ford, AA.; Bateman, BT.; Simpson, LL.; Ratan, RB. “Nationwide data confirms absence of 'July phenomenon' in obstetrics: it's safe to deliver in July.” Journal of perinatology : official journal of the California Perinatal Association, v. 27 issue 2, 2007, p. 73-6.

3. Myles, TD. “Is there an obstetric July phenomenon?.” Obstetrics and Gynecology, v. 102 issue 5 Pt 1, 2003, p. 1080-4.