The July Phenomenon

Hippocrates implored physicians to "First do no harm," and yet in the process of learning how to practice medicine, I wonder how much harm I've already done.

Medical education is one of only a few instances in health care (the others being medical research and control of communicable diseases) when the interests of the individual are sometimes superseded by the interests of society. However, unlike with medical research where the risks and benefits are plainly laid out for patients, medical education leaves no room for full disclosure. The "See one, Do one, Teach one" mentality is common amongst physicians but I wonder how many patients know that such a system (however unofficial) exists.

The first issue is whether or not there is risk associated with having relative novices "practice" medicine on patients. New housestaff start their training in July and the bump in complications during July is euphemistically referred to as the July Phenomenon. Hypothetically, new trainees are more closely supervised to ensure that there is no harm to the patient. However, in my personal experience, this oversight is oftentimes shoddy and inadequate. A recent study examined how comfortable medicine trainees were with their own competence in performing various procedures. The results showed widespread discomfort with performing most of these procedures. More simply, ask yourself how good you were when you first did something that required even an iota of physical skill -- hitting a baseball, catching a Frisbee, painting a picture -- and then think about how your ability improved as you gained experience. Common sense tells us that the more experience we gain, the better we do.

If there is even a slight chance that patients are at higher risk by having new trainees perform procedures on them, shouldn't they have the right to know? However, most physicians argue that patients that come to a teaching hospital are aware that they will have trainees work on them. Unfortunately, this is far from the truth. Up to 60% of patients presenting to teaching hospitals were unaware that they could have procedures done on them by physicians that had never done the procedure before. Clearly, there is chance of increased risk with novices performing invasive procedures and this risk is not clearly explained to patients. Just as we do with experimental drugs and new procedures, I believe INFORMED consent has to be obtained whenever patients are exposed to physicians in training.

Wouldn't this proposal hurt our great medical education system? Who would want to be the guinea pig? I would like to believe that full disclosure would not hurt medical education. Just as we continue to lead the world in the development of new drugs and innovative procedures (that were all once tested on volunteers), I believe we will continue to have a great medical education system. How can I know this for sure? Consider the following two facts:
1) The same study which showed that up to 60% of patients were unaware that they would have trainees practice on them also found that about half of those very same patients would still undergo the procedure even if it was the first time the physician was performing the procedure.
2) Teaching hospitals as a whole usually have lower mortality and morbidity rates compared to non-teaching hospitals. This is usually attributable to the fact that these hospitals have higher patient volumes. In contrast to the individual rookie physician who might not be great at performing any given procedure, the combined expertise of a large teaching hospital provides a great safety net that results in very good patient outcomes. Also, as physicians in training start doing procedures they become competent very quickly. The key is to make sure that they don't hurt anyone in the time it takes them to become competent.

Going through medical school and currently being a resident makes me a pretty informed consumer on where to get my health care. As a patient, I have never had any qualms about going to teaching hospitals. However, I make this choice after knowing all the facts. I just wish my patients knew all the facts.