July 1st is the medical new year.  Medical interns begin their journeys into the real world of clinical medicine, journeys that started during medical school but become much more real when they sign their own orders in a chart.  Every year around this time medical bloggers (among others of course) discuss the "July Phenomenon".  Today's post is not about the "July Phenomenon", something that may exist in some contexts but is likely dwarfed by other problems in medical education.

Rather than re-hash the debate on whether July in the most dangerous month to be in a hospital (it probably isn't), I'd like to give a little advice to newly minted doctors.  The rest of you are welcome to read it too.  This applies mainly to internal medicine, but I'm sure much of it crosses over into other specialties.

1. Embrace your fear.  You have good reason to be scared.   You are directly responsible for the lives of others.  These others are very sick, or they wouldn't be in a hospital.  But remember that you aren't alone.  Your colleagues can and will help you, and you can help them.  Support each other.  And remember that your senior resident and attending physician are there to help you, whether they act like it or not.  Never be afraid to ask for help, but when you call, have your information in hand; anticipate questions.  If you don't know what to do about a cardiac dysrhythmia, make sure you have an EKG and have ordered some labs before you call the cardiac fellow.  It will save you time and embarrassment, and will get the patient help more quickly.
2. Listen to the nurses and ancillary staff.  They spend much more time with the patient than you do, they've seen many years of interns come and go.  They can help you, but if they sense you don't respect them or that you aren't caring for their patients well, they will hurt you.  They will do whatever they can to help their patients, and they will not care if they make you miserable in the process.  They will often know more than you do.  If you don't trust what they tell you, verify it.  You do posses a different sort of knowledge, one that you can combine with theirs to help your patients.
3. Read up on your cases.  You may not have a lot of time for formal reading and studying.  Read up on the diseases your own patient has, and soon you will have an impressive breadth and depth of knowledge.  Listen on rounds, especially when your colleagues are presenting their patients and you'll get more bang for your buck.  Teach the medical students if you have them and you'll learn even more.
4. Sleep when you can.  Sleepiness harms both you and the patient.  I cannot emphasize enough the value of sleep.  Go to bed early, nap if you can.  If you're too tired to drive home, don't.
5. Don't abuse substances other than caffeine.  Even caffeine isn't that good, but if you are susceptible to substance abuse, the stress of internship can be dangerous.  Be honest with yourself, and if you develop a problem, seek help from your program.  You'd be surprised how much help you can get.
6. Eat well and exercise.  Even if it's only taking the stairs (three down, two up), exercise will help you.  You'll need it.  Try to avoid all the crappy free food at conferences.  Go for the healthy choices at the cafeteria.
7. Wash your hands.  If a patient asks you if you did, don't be offended.  Thank them for the reminder and do it again.  If you can, wash them in front of the patient so they can see that you care enough to do it.  Remember that certain pathogens, such as C. difficle, sporulate and will not be killed by topical alcohol solutions but must be physically scrubbed off.
8. Learn to live with uncertainty.  In the hospital you get used to having information at your fingertips.  You can order stat labs, get X-rays and other studies quickly.  You can't do that in the clinic.  Not every patient will present classically.  It is more common for an common disease to present uncommonly than an uncommon disease to present commonly.  Dig?
9. Trust no one.  Patients will come up from the ER "pre-packaged", work up done, diagnosis made.  Don't believe it.  Verify it for yourself.  Start from the beginning, because leaning on others' workups simply perpetuates errors.
10. Corollary: examine every patient yourself, and do it right.  The exam can be focused, but do it.  If your resident or student says that the skin is intact, turn the patient over and search for bed sores.  Listen to the lungs.  Check the mouth for thrush.  Be confident in your skills, skills which will improve every day as you use them.
11. Senior residents, remember the interns are the interns, not you.  Let them do their work.  Let them answer their own questions.  While they are pre-rounding, do your own pre-rounding, checking labs, checking in on patients.  This way, when you pimp the intern on Mr. Smith's potassium and she doesn't know it, your team will realize that not only are you on top of things, but you're watching them,  both to help and to make sure they stay on task.
12. Wikipedia is not a valid medical reference. I'm sorry I have to even say this.
13. Ars longa vita brevis.  Enjoy the art.  Medicine is interesting.  It's fun.  And there are no bad patients.  It's just as important to learn how to manage a drug-seeking sociopath as it is to treat an acute MI.  There is always something to learn, even if that "something" is that you don't want to be a gerontologist.

OK, folks.  Go for it.

First, this piece is not a how-to guide for getting into medical school; the title is a shameless ploy.  But I use this ploy for good, and not for evil.  Through conversations with a number of non-medical colleagues, I've been forced to think a bit more about premedical and medical education.  A letter from a reader (which is presented in a highly altered version below) made me decide to more thoroughly and publicly examine the educational arc that turns undergrads into doctors.

Dear Pal:

I am an academic scientist at a university where I often teach and advise premedical students. I can't tell you how many kids come in to my office for advising sessions saying they want to go to medical school and then get upset that Yes, they really have to take Organic, Calc AND Biochemistry. Then it turns out that they got a D in one semester of intro Bio and Physics and are holding down a solid 2.3 GPA. WTF? I'm not going to tell them the can't go to med school (there may be places they can get in, for all I know), but last I checked it was kinda tough to get into med school.

Should I bother with the reality check? I kinda feel like that isn't my job.

Let's step back and examine the mechanics of becoming a doctor.  Becoming a doctor is a hard, long, expensive road.  Most practicing physicians have had four years of undergrad, four years of medical school, and at least three years of residency (and significantly more training for subspecialists).  In the U.S. the average medical school debt burden is about 156,000 USD.   That is somewhat above the average yearly salary for a primary care physician.  Paying back these loans has a non-trivial effect on quality of life and on specialty choice.  Given the hard work, the time, and the debt, no one should go into medicine unless they really believe they will enjoy it.

That's not something that's easy for an eighteen year old to figure out, but spending time with doctors and with patients is a good start.  Before I applied to medical school, I spent some time at a pediatric urology clinic at a major university hospital.   That experience help solidify my interest in medicine, but I've met others for whom these experiences have pushed them in the other direction.  But evaluating your own desire to enter a lifelong profession is always going to be an educated guess.  When you're 19 years old, it's impossible to know what the future may bring, but you should at least do some soul searching and gain some experiences that would help lead you to a good decision.

Once an undergrad has arrived at a (hopefully well thought out) decision to pursue medicine, they have some serious work ahead of them.  As my correspondent discovered, there are some adolescents who do not quite get the idea that prerequisites are required.  Medical schools usually publish their admission requirements online, so no one can plead ignorance.  Whether or not you agree with the standard premed coursework, it still has to be done, and done well.  The statistics on medical school admissions are clear: if you have lousy grades or lousy MCAT scores, your chances of getting into medical school are minimal.

Something noted by a number of my colleagues is that some medical students seem to approach pre-medical education as a checklist: get good grade in organic chemistry; volunteer in lab; help sick people at homeless shelter.  There's nothing inherently wrong with this, as long as the student realizes that there is a reason for these activities beyond gaining admission to medical school.  But they must also be cognizant of the future responsibilities they are taking on.

Just as I have little sympathy for a premed student who doesn't want to complete the required coursework, I have little sympathy for the common TA complaint that, "those pre-med gunners only care about the grade and don't really care about redox reactions."  It would be terrific if all pre-meds loved all science,  but sometimes it is enough understand the material enough to do well.  That is a minimum, and as an undergraduate advisor, I do think it is your responsibility to tell a student early on that, like it or not, medical school admission comes with a rigorous set of required course work, and that this course work must be done well to have any reasonable hope of being admitted to medical school.

No one likes to hear that they aren't progressing well toward a desired goal, but if you want to pursue medicine for the right reasons, and cannot succeed in the required coursework, there are other vocations that are both interesting and altruistic.  There are also resources available at most universities to help students who aren't succeeding.  I would rather help someone alter their dreams while they are young.  While an undergrad advisor shouldn't tell a student they can't be a doctor, they can show them the stats and tell them they are unlikely to get into med school.   If the student is still committed, then they need to make every effort to improve their grades to become competitive.

Over a quarter century ago, a young woman was admitted to a New York hospital with fever and agitation. She never walked out. Libby Zion died while under the care of he primary care doctor and two medical residents. The exact cause of death was never identified, but the case led to a forced examination of medical residents' work hours. This was driven largely by Zion's father who felt that his daughter had been killed by inexperienced, poorly supervised, and overworked resident physicians.

"You don't need kindergarten," he wrote in a New York Times op-ed piece, "to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call -- forget about life-and-death."

It was largely thanks to Zion's tireless work that in 1989 a bill was passed in New York State limiting resident work hours and requiring senior physicians to be physically present in the hospital. But though you might not need kindergarten to recognize this problem, you do need data. That came later.

Medical residents have traditionally worked long hours, especially in their first ("intern") year. In fact, they used to "reside" in the hospital, and were universally young, male, and single. Now, graduating medical students are about 48% female, compared to just over 26% in 1982 (although age hasn't changed much, which sort of surprised me).   The Libby Zion law limited resident work hours to 80 hours per week and 24 hour shifts.  During my internship in Chicago, we would typically work about 32 hours in a row on call and post-call, and call took place every fourth night,  which has long been typical for internal medicine residencies.  

In 2003, the Accreditation Council on Graduate Medical Education (ACGME) instituted the first national work hour limitations for residents. These limitations looked very similar to those imposed by NY state. These work hour limitations required significant changes to how hospitals and residencies were run.  Hospitals can only support a certain number of residents, and they count on these residents and the care they provide.  Hospitals have had to reduce the number of patients cared for by residents, and has led to an increase in so-called mid-level providers (physician assistants and nurse practitioners).  And residencies had to find ways to accomplish the same or similar amount of work with the same personnel but with significant time constraints.  

Many of these changes involved a more toward "shift work" and night float systems, where residents worked shifts of limited hours throughout a 24 hour day, handing off patients to the next shift.  This creates its own problems for both patients and residents.  There are concerns that shift work may lead to a disruption in continuity of care, since patients are being "handed off" potentially several times a day.  Also, residents are not supposed to be performing functions that are primarily "service" rather than educational.  During the day, residents can break away from clinical duties for educational conferences, but a 11pm-7am shift is all service.

These, and the urgent questions about the safety of both patients and residents were addressed in a comprehensive report released in 2009 by the Institute of Medicine, part of the National Academies.   While it makes sense that long sleep-free work hours might be dangerous to both patients and residents, knowing the data allows us to make proper, evidence-based decisions about these potential problems.

Resident Safety

As medical educators, we have a duty to our residents to ensure not only their education, but their well-being, at least as it relates to work. It is conceivable that long, sleepless work hours may have adverse health effects.  The 2009 IOM report summarizes some of the evidence for fatigue-related injury.  Much of this evidence is readily available through PubMed.  Needle stick injuries, for example, are a relatively common problem and there is evidence that these are related to fatigue.  There is also good evidence that medical residents have an elevated risk for falling asleep at traffic lights and being involved in motor vehicle accidents.  And these data are not new.

Patient Safety

Data on patient safety isn't new either.  A name that pops up again and again in this research is Charles A. Czeisler. He published a study in the New England Journal of Medicine in 2004 showing fairly convincingly that first-year residents in the ICU are at risk of committing significantly more medical errors when working extended shift vs. less onerous ones.  That's just one good study of many.

Individual errors are inevitable, but as a phenomenon, errors can be reduced significantly, often through simple systems fixes.  One of these fixes is the implementation of reasonable resident work hours.

Denialism?

Responses in the literature and in doctors' lounges have been tangential and almost intentionally obtuse. A colleague of mine at another institution has opined that the medical profession is in a state of "institutional denialism" about the effect of long hours on safety and performance.  I don't think that is unfair.  The evidence on this has existed for years, yet we've made only cosmetic adjustments to our training programs.  Even the latest ACGME rules (which take effect in July 2011) fail to address the most significant implications of the problem.  The work hour limitations they mandate will very likely help, but there is a larger systemic problem.  Medical training is lengthy and expensive.  If we're going to cut back on hours, we need to re-evaluate whether the new hours are sufficient to meet educational needs.  If not, we are going to have to find a way to fund longer training programs and to fund the debt-ridden trainees who will spend extra years not paying their educational debt.    Quick fixes, even smart ones, aren't going to do the trick.  

The Libby Zion case that eventually led to the new work rules was over a quarter century ago.  How long will it take us to create real, comprehensive solutions?

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When it comes to medical blogging, no one has been as consistently good, fresh, and snarky as Orac. Respectful Insolence sets the standard for all other medical blogs, and though Orac may not be a media star like some other med bloggers, his writing has had a significant impact on some important medical issues such as vaccination. The fact that he is often the target of vicious attacks by anti-vaccination activists and other quacks and wackos shows just how good a job he is doing.
Though he has been criticized for being a bit loquacious, his thoroughness is one of the traits that makes him so effective. So I was very happy to see his post on the so-called "July Effect", the idea that hospitals are more dangerous in July when the new interns start. I love July, as difficult as it sometimes is. I always call the new interns "Doctor" and it always makes them do a double-take. Orac's takes a very detailed look at a new study of the July Effect, and the data still aren't clear as to whether and how July may be more dangerous to patients.
Another question regarding resident training and safety is resident duty hours. The data are not at all clear as to the effect of these hours on residents and patients, but despite a paucity of data there are reasons to believe that some parts of medical training may not be great for young doctors or their patients. In their continuing effort to address these concerns, the Accreditation Council on Graduate Medical Education (ACGME) today released a new set of standards for medical resident supervision and duty hours.
Before I explain these changes, which residencies will be expected to adopt, let me explain the traditional schedule. It's no secret that residents work some crazy hours, although over the last ten years there have been some efforts to control this. Residents have been known to have fatigue-related auto accidents, and as stated above there may be patient safety issues related to fatigue. Different specialties have different schedules, with internal medicine (my specialty) being neither the worst nor the best (surgery and OB/GYN tend to be the worst). Classically, internal medicine interns take call "q4", meaning that every fourth night they stay in the hospital. This means that on Monday, for example, they may come in at 0530 to pre-round, stay all night, finish all their work by Tuesday evening and go home to roll out of bed early again the next morning. It's usually pretty easy to identify the "post-call" residents: they are wearing scrubs, unshaven (if relevant), rumple-haired, and they look tired.
The ACGME has decided to focus on first year residents (interns) in their new standards, as these are the residents who have the least experience, and the data indicate they may---maybe---be at higher risk for committing preventable errors.
The new standards set a limit of 80 hours of work per week. They also limit interns to no more than 16 hours of work at a stretch, with at least 8 hours between shifts. This is going to have a significant impact on the design of medical residencies. One of the advantages to the more torturous schedule was continuity-of-care. When I admitted a patient on Monday afternoon, I would be with them during the critical first day of their admission, seeing the patient through the whole initial work up. The new standard will essentially mandate a shift-work model, in which an intern will admit the patient, then hand her off to another intern to go get the mandated rest break. The ACGME recognizes the potential problems of "hand-offs" and allows some time "off the clock" for them.
One of the shifts likely to be implemented is "night float", where a few residents will take admissions and keep an eye on the house. Many programs already have night floats, but the new system will make them nearly unavoidable. When I was a resident, we generally did 14 nights in a row (if I recall correctly) from 11 pm to 7 am. The new standards will limit these shifts to six in a row.
Residency spots are limited in number. Institutions can only afford so many residents per year, and with further work limits, hospitals that depend on these doctors are going to have to rely increasingly on other clinicians to care for patients. Physicians assistants and nurse practitioners are already being used extensively to care for patients in hospitals, and this role will probably increase as a direct result of these changes.
As valuable as my "in the old days" training was, these changes are probably positive in the long run. It's not good to over-fatigue our young doctors, who may be risking their lives driving home after 30 hours at work, and if it has a positive effect on patient care, great.^* But we still must remind our young doctors that when they get out into the real world, there is no ACGME, no limit on work hours.
______________________________
^*DrugMonkey pointed out the implication of this statement. Upon self-examination, a few things underly this. First, I have a responsibility to both my patients and my trainees. The evidence of benefit to patients of these changes is not strong, but I do anticipate benefits to trainees. I am also biased by my own post-call traffic accident.

A young relative of mine recently asked me my thoughts about medicine as a career.   It's a relatively common question in my mail bag, and a tough one to answer, especially when asked by strangers.  Career choices are very personal, so I don't like to give advice as much as let people know what they can expect from a career in medicine.  Here's one of the latest letters to show up in my inbox (edited by me for anonymity, etc.).

Dear Pal,

I'm a third year medical student at the end of my clerkships now, and I've found that I pretty well like everything.  I did my pediatrics rotation early and absolutely loved it, but I also really liked women's health and it turns out that adult medicine is also pretty good.  I used to think that I want to be a super expert on one system or group of diseases, but I also like the relationships you can have with people in a primary care setting, and I find the epidemiology of preventive medicine interesting.

With this conundrum brewing as I near the point of applying to a residency, I've started to think about family medicine.  Could you please tell me your opinion on family medicine as a career? Do you think family practitioners provide high quality care? Or do you think that people should generally go to pediatricians, internists, and OB/gyns?  I realize that this is very highly doctor dependent.

Brutal honesty is appreciated.  Thanks, and have a good weekend.

Medical training is so prolonged, and practice so specialized, that medical students often have to choose a specialty before they've had the change to really explore potential careers.  This particular student is a third-year, meaning that he is done with his basic science coursework and is rotating through various clinical specialties.  As is not uncommon, this student has found that developing longitudinal relationships with patients can be both rewarding and interesting.  From the perspective of more than ten years out of medical school, it sounds like he is interested in primary care of one sort or another.

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The medical education calendar begins and ends on the first of July each year, and in the hospital, that means a brand spanking new crop of young doctors. While this may sound a bit scary, the facts are a bit subtle (and not terrifying). Some of the questions regarding the so-called July Phenomenon are:

• Are hospitals more dangerous in July?
• Is care more expensive in July?
• Are hospital stays longer in July?

The data show that there does not appear to be an increase in poor outcomes in July vs. other months, but in some fields hospital stays may be longer and care may be more expensive due to increased utilization of tests.
Most of the data that support a July phenomenon in hospitals aren't all that strong, indicating that it's unlikely hospital care is significantly different in July vs. other months.
July is fun though. New doctors are excited to learn and to work, and soak it up like sponges, except in crisp white coats.
References
Rich, Eugene C.; Hillson, Steven D.; Dowd, Bryan; Morris, Nora. Specialty Differences in the 'July Phenomenon' for Twin Cities Teaching Hospitals. Medical Care. 31(1):73-83, January 1993.
Barry, W., & Rosenthal, G. (2003). Is There a July Phenomenon?. The Effect of July Admission on Intensive Care Mortality and LOS in Teaching Hospitals Journal of General Internal Medicine, 18 (8), 639-645 DOI: 10.1046/j.1525-1497.2003.20605.x
Myles, Thomas D. Is There an Obstetric July Phenomenon? Obstetrics & Gynecology . 102(5, Part 1):1080-1084, November 2003.
Ford, A., Bateman, B., Simpson, L., & Ratan, R. (2007). Nationwide data confirms absence of 'July phenomenon' in obstetrics: it's safe to deliver in July Journal of Perinatology, 27 (2), 73-76 DOI: 10.1038/sj.jp.7211635