Back The July Effect: Fact or Fallacy

The July Effect: Fact or Fallacy?

By Megan Murdock Krischke, contributor

It happens every July, at every teaching hospital across the country. All the doctors-in-training “level-up,” so to speak.

New interns arrive and those who were interns on June 30 become second-year residents who may suddenly be asked to help supervise the new arrivals. This leveling up goes all the way up to the most experienced residents, who are completing their residencies at the end of June and becoming independent doctors, often in new locations.


While “leveling-up” might sound like a good thing, it puts a significant amount of stress on a hospital’s system, as there is a significant drop in the amount of experience at each level. Everyone is in a new role and team dynamics are disrupted.

Most workplaces experience constant low-level employee turnover, but turning the calendar to July in a teaching hospital means whole cohorts of doctors-in-training change out simultaneously. This has led to the theory of the “July Effect”: the belief that there is higher patient mortality, more medical errors and lower efficiency in teaching hospitals during the months of July and August.

The July Effect: A review of the research

John Q. Young, MD, MPP, PhD, was the lead researcher on a systematic review of 39 studies done on the July Effect between 1990 and 2010; the research team’s findings were published in the Annals of Internal Medicine in 2011. Young currently serves as the director of residency training for psychiatry at the Zucker School of Medicine in Hempstead, New York.

“When we looked at the studies and rated them on quality—characteristics such as methodological rigor in controlling for patient acuity and other things that can affect patient outcomes —there was a clear marker for a higher mortality rate following the turnover. In fact, this same marker is seen in the UK and Australia following their cohort turnovers,” explained Young.

The loss of knowledge and experience that happens in the turnover of medical residents isn’t just clinical.

“Medicine is complex and it is a team sport and requires a lot of collaboration; if people are in new roles it is going to affect the overall functioning of the team,” he stated. “There is a drop in knowledge of how to navigate the hospital’s system—such how to input data into the EMR, how to initiate labs, and who to talk to if you want to get something done, and so on.”

How teaching hospitals have responded

Since the report from Young’s research team came out, a lot has been done to mitigate the July Effect. Hospitals are paying more attention to how they are structuring supervision during the first couple months of the transition. Many are looking at ways to increase both the quality and the quantity of the supervision by bringing in their best teachers and supervisors.

“Another set of changes has been to create a more gradual on-ramp to a full patient load—say starting with six or seven patients and working your way up to 10 patients,” Young remarked. “There is also a recognition that onboarding has to go beyond having talking heads explain HR policies and benefits.”

“We need to be making sure interns and residents are ready to actually work with patients,” he continued. “This is done through work in the simulation lab—trainees can respond to actual scenarios, but in a controlled environment and then have the time to debrief and learn from the experience. The lab allows for more rigorous training and the opportunity to train as a team.”

The general move toward creating safety cultures and empowering the whole healthcare team to speak up if they think there is a problem also works to mitigate the July Effect. 

Should patients be concerned?

“Sometimes I get asked, ‘Should I just not go to the teaching hospital or delay care because of the July Effect?’” Young mentioned. “My view on that is that studies show that the quality of care people receive in teaching hospitals is generally better, so even if there is a decrease, you can still expect to receive great care. I would advise people, however, to be more vigilant and if they have concerns to request to talk to the attending or supervising physician.”

“Of course there can always be arguments that certain hospitals or specialties or procedures aren’t affected by the July Effect,” he continued. “Yet, the question isn’t whether or not it is real, but how do we manage it?”

“It very well may be better than it was a decade ago when we did our report,” he said. “It would be great to find that the cohort transition is no longer increasing mortality or that it has improved by 50 percent. Given the amount of attention this topic has received, it would be very discouraging if it hadn’t improved.”

Young suggests that the next area of study on the July Effect could focus on which of the best practices for cohort transitions are the most effective.

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