Analysis Finds Care Suffers During July Turnover

A new analysis links turnover of medical trainees in July with less efficient medical care and higher patient mortality. (Image: Michael Monu/

Patients may want to avoid hospitalization during July, if possible, when the annual turnover of medical trainees occurs. The reason: the change is associated with an increase in mortality rates and a decrease in the efficiency of care, according to a new analysis of the literature published online by the Annals of Internal Medicine.

The systematic review of 39 studies, most conducted in the United States, bolsters the evidence of a “July effect,” in which the departure of experienced trainees and the arrival of less experienced trainees is associated with poorer care. The reviewers found that higher-quality studies found that the relative risk of mortality increased from 4.3% to 12%, depending on the study, during this turnover in trainees. Many lower-quality studies failed to find such an increased risk, but many may have lacked the statistical power to do so. Additionally, the review detected a reduction in efficiency, such as longer hospital stays, during the turnover.

The authors also wrote that a lack of adequate data meant they were unable to reach such definitive conclusions about whether the July transition was associated with an increase in medical errors or morbidity.

An accompanying editorial by Paul Barach, MD, MPH, of the University Medical Center Utrecht in the Netherlands, and Ingrid Philibert, PhD, MBA, of the Accreditation Council for Graduate Medical Education in Chicago, notes that discussion about the July effect has gone on for 20 years.

“Ensuring safe care in teaching hospitals in July cannot wait any longer,” Barach and Philibert wrote.

They said that the review provides strong enough evidence to warrant corrective interventions and suggest trying identical interventions at multiple locations and studying the results to identify the best ways to mitigate the July effect. Such interventions might include staggering start dates for trainees or easing new trainees into their clinical responsibilities.

Categories: Academic Medical Centers, Evidence-Based Medicine, Patient Safety/Medical Error, Quality of Care