Rethinking The 'July Effect'

“Never get sick in July.”

Everyone who works in the medical world has heard that line, and while there’s lots of upheaval in teaching hospitals this time of year, something else happens too: those of us who’ve been in the business for a long time are called out of the trance of routine and reminded of why we went into medicine in the first place.

A few weeks ago I began a turn on the inpatient service and, on that first day, our “morning” rounds lasted through lunch.

“It’s July,” serves as shorthand for: Check all the orders, again. Check all the labs, again. Check the discharge prescriptions, again.

“I’m sorry,” my resident apologized.

“No apology necessary,” I reassured him. “It’s going to take time.”

Our service was busy with lots of complicated patients, but that wasn’t the issue. For a change, the long rounds were because of the clinicians, not the patients. Although it was still June, the arrival of two new third year medical students meant that “July” — academic medicine’s equivalent of the New Year — had arrived.

Every July, personnel changes abound: third year medical students migrate from lecture halls and laboratories to the hospital; freshly minted medical school graduates debut as new interns; “old” interns bump up to supervisory positions; and doctors who’ve completed a general residency move on to specialty training.

Studies have looked at how significant the impact is on the care: Are there more mistakes? Are the mistakes more deadly? Whatever the data show, for all of us who work in the field — nurses, doctors, respiratory therapists, pharmacists — “It’s July,” serves as shorthand for: Check all the orders, again. Check all the labs, again. Check the discharge prescriptions, again.

The new third year students, setting foot in the hospital for the first time as clinicians, were quiet and awkward while we rounded. Where, exactly, to begin? Which books to carry in the pockets of their new white coats? How to use the stethoscope? How to raise the head of the bed? How to ask for help from a nurse? Why do we care so much about some leads on an ECG but disregard others? Why are we so worried about the platelet count or a small temperature spike late in the day? There’s so much to learn.

And yet, there’s this other remarkable thing: Without even realizing it, they call me out of my routine. Through them, I recall the challenge and responsibility of medicine. Their self-conscious hesitation in touching patients, reminds me that an exam can be an invasive act. Where, on any other busy day, the team might slip into habit, quickly dispensing with someone as a “frequent flyer” or a routine admission — rule out MI, alcohol withdrawal, sickle cell crisis — we stop, we slow down. Third years help all of us remember that the patient is a person, not a discharge-planning project.

A few days after those first long rounds, I took the students to listen to a patient with an unusual heart exam. The patient had been whisked off to a test by the time we arrived, but by happy circumstance, her roommate was a woman who’d been my patient for many years.

And yet, there’s this other remarkable thing: Without even realizing it, they call me out of my routine. Through them, I recall the challenge and responsibility of medicine.

“Oh Dr. Crowley!” she called. “I’m so happy to see you!” We hugged and I introduced the students to her. We chatted for a few minutes about why she’d come in to the hospital and how things had been going for her. And then I asked if she would mind if the students listened to her heart.

“Oh no, I don’t mind! I am always happy to help!” And help she did, allowing them to listen and listen… and listen. The room was quiet, the lights were off. Late afternoon sun seeped in through the window. Both students held themselves very still as they bent over, eyes closed, stethoscopes resting on her chest.

“Just listen for the first heart sound,” I told them. “And then, when you’re sure you hear that clearly, listen for the second one.”

We moved slowly through the exam, with stretches of silence between my instructions. I worried about imposing on my former patient, a woman in her 80s, but she smiled up at me and I realized she didn’t mind in the least.

Finally the students finished, withdrawing their stethoscopes, stepping back from the bed, nodding shyly at my patient. Before we left, she hugged them both and wished them well. She, with her warmth and generosity, and they, with their gratitude, brought back to me how human and good medicine can be.

As we left the quiet of her room and emerged into the bright lights of the hallway, into the rush of dinner tray trolleys and lumbering tribes of consultants, one of the students said, “That was amazing.”

And I had to smile, because it was.

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