Published 13 October 2009, doi:10.1136/bmj.b3949
Cite this as: BMJ 2009;339:b3949

Editorials

Reducing variation in adverse events during the academic year

Trainees need practice and mentorship, and graduated clinical responsibilities

Every summer—July or August in the northern hemisphere, February in the southern hemisphere—academic health centres brace themselves for the arrival of new trainees who are as unfamiliar with their roles and responsibilities as they are with their new environments. For patients, and staff, this "July phenomenon" (the trend for the efficiency and safety of inpatient care to drop sharply at the start of the academic year and then gradually increase over the subsequent months) raises community concerns about teaching hospitals and the processes in which we train doctors.

In the linked retrospective cohort study (doi:10.1136/bmj.b3974), Haller and colleagues found a significantly increased rate of undesirable adverse events among trainees at the beginning of the academic year regardless of their clinical experience.¹ This effect decreased progressively after the first month and disappeared completely after the fourth month of the year. Previous studies of the potential adverse effects of new trainees on measures of quality including cost and efficiency have been inconclusive. Two reported adverse effects,^{2 3} but most have concluded that the quality of care remains uniform throughout the academic year, albeit with financial charges increasing during July. For example, one study found that in a sample of 320 216 Medicare recipients having surgery between 2003 and 2006, operative mortality did not change at the start of the academic year.⁴ A more recent study that looked at 300 000 patients in the NHS found no difference in August when examining the raw figures, but a small increase in mortality in non-surgical patients.⁵

The most compelling of Haller and colleagues’ findings was that the number of undesirable events was greater among trainees at the beginning of the academic year regardless of their level of clinical experience. These studies suggest that the current clinical microsystems—the patient caregiving units—cannot absorb the effects of new personnel at the beginning of a new academic year.⁶ Could it be that all new members of the microsystem—whether trainees or more experienced doctors and nurses—put patients at greater risk of harm during the first few months of the academic year?

We can no longer ignore the elephants in the room. Problems with the system that affect trainees and patient care, such as the July phenomenon; handovers of clinical care; and the association between excessive working hours, sleep deprivation, and increased medical errors highlight the need to develop robust and resilient systems to mitigate the chaotic healthcare settings in which trainees must perform and survive.⁷

The organisation and delivery of health care is complex, with little standardisation and great variation across disciplines and healthcare organisations. A single optimum approach to "breaking in" new trainees is not possible. As Haller and colleagues suggest, new trainees are unfamiliar with the working environment, supervision is insufficient, and communication suffers.¹ So what are the next steps?

The safe maturation of trainees should be seen as a complex adaptive process, in which an appreciation of the link between explicit processes, results, and the learning curve that drives the results is needed.⁸

The culture of the microsystem underpins all processes and improvements in patient care. Junior or new workers may be reluctant to ask questions and challenge dogma and authority. To develop a culture of safety, trainees must feel safe and able to speak out.

Human factors need to be considered when training new staff.⁹ For example, fatigue is the main cause of mistakes, harm to patients and providers, and depression and burn out. Slow uptake of responsibilities in the first week of service, and avoiding overnight responsibilities during that period seems prudent. Variation in care at the start of the academic year can be reduced by staggering the start dates of trainees over the year.

Haller and colleagues remind us that patients with complex needs (for example, emergency cases) should be fully supervised when trainees are new.¹ Supervisors should have explicit tools to evaluate trainees for safety and allow them to have graduated clinical responsibilities.¹⁰ Staffing patterns of attending doctors need to be carefully planned at the start of the academic year to compensate for inexperienced trainees.

Reducing variation in patient care at the start of the academic year requires developing resilient systems in which individuals, teams, and their organisation can adapt and compensate for the disruptions of incoming inexperienced trainees.¹¹ These systems could include rapid response teams to help trainees identify deteriorating patients, checklists, and electronic reminder systems.

Providing regular meaningful feedback and dedicated reflection time using deliberate practice,¹² simulation, and team training (such as TeamSTEPPS),¹³ while coupling experienced providers with inexperienced ones in a buddy system, will greatly enhance individual performance and patient safety.

More research and patient follow-up are needed to understand how best to protect patients and providers from the July phenomenon. In future, trainees should be immersed in a new clinical environment that facilitates practice and mentorship, but with increased patient awareness, closer supervision, and graduated clinical responsibilities.

Cite this as: BMJ 2009;339:b3949

¹ Department of Anaesthesia, Utrecht Medical Centre, Utrecht, Netherlands, ² Centre for Clinical Governance Research, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia

Research, doi:10.1136/bmj.b3974

---

Competing interests: None declared.

Provenance and peer review: Commissioned, not externally peer reviewed.

References

1. Haller G, Myles P, Taffé P, Pernegger TV, Wu CL. Rate of undesirable events at beginning of academic year: retrospective cohort study. BMJ 2009;339:b3974.[Abstract/Free Full Text]
2. Englesbe M, Pelletier S, Magee J, Gauger P, Schifftner T, Henderson W, et al. Seasonal variation in surgical outcomes as measured by the American College of Surgeons-national surgical quality improvement program (ACS-NSQIP). Ann Surg 2007;246:456-65.[CrossRef][Web of Science][Medline]
3. Shuhaiber J, Goldsmith K, Nashef S. Impact of cardiothoracic resident turnover on mortality after cardiac surgery: a dynamic human factor. Ann Thorac Surg 2008;86:123-31.[Abstract/Free Full Text]
4. Englesbe M, Zaohur F, Baser O, Birkmeyer J. Mortality in Medicare patients undergoing surgery in July in teaching hospitals. Ann Surg 2009;249:871-6.[CrossRef][Web of Science][Medline]
5. Jen MH, Bottle A, Majeed A, Bell D, Aylin P. Early in-hospital mortality following trainee doctors’ first day at work. PLoS one 2009;4:e7103. doi:10.1371/journal.pone.0007103.[CrossRef][Medline]
6. Mohr J, Batalden P, Barach P. Integrating patient safety into the clinical microsystem. Qual Safe Health Care 2004;13(suppl 2):ii34-8.[Abstract/Free Full Text]
7. Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. Washington, DC: National Academies Press, 2009.
8. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001.
9. Mohr J, Barach P. The role of microsystems. In: Carayon P, ed. Handbook of human factors and ergonomics in health care and patient safety. Mahwah, NJ: Lawrence Erlbaum Associates, 2006:95-107.
10. Ten Cate O. Trust, competence and the supervisor’s role in postgraduate training. BMJ 2006;333:748-51.[Free Full Text]
11. Weick K. The collapse of sensemaking in organizations: the Mann Gulch disaster. Admin Sci Quart 1993;38:628-52.[CrossRef]
12. Ericsson A, Krampe R, Tesch-Romer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev 1993;100:363-406.[CrossRef][Web of Science]
13. King HB, Battles J, Baker DP, Alonso A, Salas E, Webster J, et al. TeamSTEPPS, strategies and tools to enhance performance and patient safety. 2006. www.ahrq.gov/downloads/pub/advances2/vol3/Advances-King_1.pdf.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    StumbleUpon    Technorati    Twitter    What's this?

Relevant Articles

Effective, safe, and a good patient experience

Fiona Godlee
BMJ 2009 339: b4346. [Extract] [Full Text]

Rate of undesirable events at beginning of academic year: retrospective cohort study

Guy Haller, Paul S Myles, Patrick Taffé, Thomas V Perneger, and Christopher L Wu
BMJ 2009 339: b3974. [Abstract] [Full Text] [PDF]

Trust, competence, and the supervisor's role in postgraduate training

Olle ten Cate
BMJ 2006 333: 748-751. [Full Text] [PDF]

Blogs

Podcasts

Online poll

Find out more on doc2doc>