A Cemetery at Night


It’s that time of year again – healthcare centers across the country experience a massive cohort turnover as newly graduated medical students become resident physicians, and new responsibilities and autonomy are given to existing trainees. It has long been advised to avoid seeking medical care in July because of the presumed increased risk to patients, so much so this changeover is sometimes called the “July Effect” in the United States and the “August killing season” in the United Kingdom. Indeed, Young’s meta-analysis confirms that mortality is increased and efficiency is decreased around the time of these trainee changeovers, although firm conclusions about causality (including whether more medical errors were made) were not established.

Are trainees in themselves patient safety threats? If so, why?

The first and most obvious hypothesized problem is that inexperienced physicians (and other healthcare team members) make more mistakes. This is not unexpected, and presumably there are systems and supervisory safeguards to prevent knowledge and experience deficits from harming patients.

Are there other factors that contribute to a reduced level of safety?

One possible contributor is communication failure, which I believe is rooted in omission bias and hierarchy. Team members in all disciplines (and at all levels) sometimes fail to “speak up” or ask questions for fear of looking “dumb” or jeopardizing a relationship.

This may be magnified among trainees who are just establishing clinical reputations and professional relationships that will linger with them at least for the duration of their training years.

As well, new teams with unfamiliar members who are just learning to work together lack the mutual trust that fosters uninhibited communication, especially around uncertainty or disagreement. Moreover, medical culture has deeply rooted hierarchical organization that historically discourages challenges or questions to authority figures.

Another possible cause of the July effect is related to teaching itself. Because teaching and supervising require different cognitive processes than direct task performance, and because some of those processes may be new to senior trainees or new attending physicians, the cognitive load on the supervisor is increased. That is, he or she must not only think about the tasks and data at hand, but must also think about the trainees actions and decisions, and must expend mental effort to critique, demonstrate, or direct.

It's the end of summer... you've survived 'The Killing Season'. It's real, but are trainees to blame? #meded Click To Tweet

Because humans can only give attention to a finite number of things at the same time, it makes sense that either some element of teaching will suffer, or some element of patient care will be overlooked, especially in circumstances of time pressure, high stakes decisions, and rapidly evolving clinical conditions. When senior clinicians have trainees of their own to supervise, the potential for performance cross-checking across disciplines (e.g., experienced nurse catching a trainee physician’s misstep) is diminished. Performance cross-checking is a critical element of crisis resource management, and for management of clinical cases even in the absence of a crisis.

By now, many readers are wondering about the supervising physician. Shouldn’t the inexperience of the trainees be irrelevant if they are indeed being properly supervised? Ideally, this would be true. However, attending physicians have the same human cognition limitations as everyone else, and therefore may also have some degradation in their overall performance as they add a higher level of teaching and supervision to their mental load. As well, they may be influenced by automaticity and habits that have developed over the prior months, and not adjust their expectations or attention expenditure and direction sufficiently when one cohort departs and a newer cohort arrives.

“Social shirking” is a factor to be considered as well. This term denotes the phenomenon by which neither party in a “double-check” actually performs their independent verification, assuming the other party has done so. This may be intertwined with hierarchical team dynamics: if a junior trainee assumes that a senior or attending is also checking, they may be more likely to defer. Teamwork is clearly important, but presents a challenge when explicit responsibilities are not clear.

From a systems perspective, cohort turnovers result in a loss of tacit knowledge held by the departing cohort. This is distinct from clinical inexperience, but refers instead to the “usual methods” for getting things done. When workflow is not well understood, the potential for error or inefficiency is increased. Orientation to clinical duty is largely “on the job” as different needs arise. Opportunities to enhance safety may lie in thorough orientation and transparent workflow processes.

Most studies show that by now (September), morbidity and efficiency are back to normal. So take a deep breath – you’ve survived the killing season.


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