New Medical Residents and Patient Mortality – Does the ‘Nurse Effect’ Lessen the ‘July Effect’?

By Shawn Kennedy, AJN editor-in-chief—Last week, a post on the New York Times Well blog discussed whether mortality rates in hospitals are worse during July when new interns and residents begin their clinical training. It described findings from three studies, with the final conclusion, “Though the debate continues, most studies have not found a spike in hospital mortality rates in July.”

It was common thinking in hospitals when I worked clinically—“Never be sick enough to have to go to a hospital the first two weeks of July, and NEVER, EVER need surgery during that time”—and I’d venture that many people still believe it, despite what studies may report. (And, as I write, I see that ABC News is reporting on a new review of 39 studies, published in the Annals of Internal Medicine, that does support the existence of the July Effect. Click the image below for the ABC article and videos.)

I remember working in the ED when the new residents on call would come to see patients, their “whites” impeccably spotless and starched, with new blank index cards in their pockets, looking eager and anxious to finally be getting to the real work of their profession. By mid-August, they all seemed a bit haggard, the whites rumpled and the pockets torn a bit, bulging with notes-filled index cards clipped together, tourniquets and empty blood tubes, the Merck Manual and usually a big stain from a leaky Bic pen.

There seemed to be two kinds of new residents: first, there were those who recognized that they were new to this world and that experienced nurses had a lot of knowledge about hands-on care, clinical technology, and how to get things done in a hospital bureaucracy—these were the men and women who truly wanted to learn and do right by their patients.

And then there were the “others”—those who felt (or at least acted) the opposite. For these, it was all about the title and prestige and insisting they be addressed as “Dr. ____.”  These residents scared us—these were the ones who often got into trouble because they wouldn’t ask for help. I recall on more than one occasion waking up a sleepy second-year resident and telling him we really, really needed him to come to the ED.

The Times article notes this caveat about most research on the topic: “Some researchers say looking at surgical residents and outcomes for severely ill patients obscures the effect, since surgical residents are often part of a team and patients with the most serious conditions receive more attention.” I agree, as most of those patients will be under the careful scrutiny of nurses in the early postoperative period or in an ICU.

I don’t think one can realistically evaluate the “July effect” without considering the “nurse effect.”

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Senior editor/social media strategy, American Journal of Nursing, and editor of AJN Off the Charts.


  1. […] New Medical Residents and Patient Mortality – Does the ‘Nurse Effect’ Lessen the &#821… Another good one by AJN‘s Shawn Kennedy. Here’s an excerpt: I remember working in the […]

  2. fancyscrubs July 13, 2011 at 9:22 am

    “The review was limited to English-language reports. No study focused on the effect of changeovers in ambulatory care settings. The definition of changeover, resident role in patient care, and supervision structure varied considerably among studies. Most studies did not control for time trends or level of supervision or use methods appropriate for hierarchical data. ”
    This led us to think what about supervision by supervisors? Are they on vacation during July more than other months?

  3. Bruce July 12, 2011 at 4:32 pm

    Another example of the divide between physicians, especially of certain specialties, and frontline nurses. Terribly sad, disappointing and damn wrong…for everybody, but particularly so for people dependent on the collegiality of all health care providers—nurses, physicians, social workers, respiratory therapists, physical therapists, etc.

    Bruce Stern, RN (for 26 years)
    Staff Nurse on Tele and Med-Surg units for 22 years

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