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The July Effect

Improving Patient Safety

Are You Using Simulation to Reduce the Learning Curve For Your New Interns?

As July approaches, medical students brace themselves to begin their intern residency programs. In 2016, nearly 19,000 students graduated from medical school, and nearly all were matched with positions across the 4,800+ residency programs within the U.S.1 This marks a continued annual growth in new resident positions in America.

For some patient safety advocates, this raises a repeated concern about the so called "July Effect", a potential increase in medical error during July as new interns assume their new roles as practitioners and as leaders.

Medical errors can be defined as:

  • Lapses in judgment, skill or coordination of care
  • Mistaken diagnoses
  • System failures that lead to patient deaths
  • The failure to rescue dying patients
  • Preventable complications of care2

While some studies argue that the "July Effect" marks an increased risk to the care of patients, others indicate no effect at all. Conflicting data aside, introducing new team members to an established hospital workforce during any month can put everyone involved on a new learning curve, especially the new intern. This may end up affecting daily operations, morale, and some say patient safety.

With the change of guard [each July] come new questions, new relationships, and a generation of our country’s brightest minds quickly understanding that they are real doctors

Dr. John Henning Schumann, President and former Residency Program Director at University of Oklahoma School of Community Medicine 3

For interns, this transition means making a leap from the breadth of the information needed to graduate from medical school to practicing a narrow set of skills just to perform daily tasks. Dr. Matt McCarthy, author of The Real Doctor Will See You Shortly: A Physician's First Year, reflects that if he had been asked to "recite pages from a journal article on kidney chemistry or coagulation cascades, I could've put on quite a show...But I hadn't learned much of the practical business of keeping people alive – skills like drawing blood or putting in a urinary catheter".4 One solution to avoid the "July Effect" is to use simulation to minimize the learning curve for greater control and efficiency.

What Some Residency Programs are Doing with Simulation

Using simulation in residency programs is not a new concept. Residency programs in emergency medicine have often led the way in using simulation to train new interns. By 2008, greater than 90% of the then 179 accredited emergency medicine programs in the U.S. reported the use of some form of simulation to train their residents, with 85% specifically using manikin-simulators.5

The last decade has placed numerous stressors on the traditional "see one, do one model of medical education," with a subsequent influence on resident training. Practicing safe medicine continues to depend on the acquisition of medical knowledge, proper judgment, and practical skill. With stricter clinical governance and a greater focus on patient safety, acquiring these skills before independent practice is challenging for residents.6

A study conducted by Magee-Women’s Hospital of University of Pittsburgh Medical Center concluded that simulated patient exercises can be utilized in multiple arenas to teach OB/GYN residents communication skills, while simultaneously addressing their clinical knowledge deficits.7 In another study conducted by Johns Hopkins University, simulation training was used to improve critical patient hand-off by pediatric interns.8

How Hospitals Are Placing Patient Safety at the Core


patient deaths 9 from preventable medical errors in U.S. hospitals

1 million

injuries per year from preventable errors in U.S. hospitals


"It boils down to people dying from the care that they receive rather than the disease for which they are seeking care," says Martin Makary, Professor of Surgery at the Johns Hopkins University School of Medicine.10. And, yet, new interns often find themselves in situations where their role is crucial in this equation.

To address this, many facilities, including Massachusetts General Hospital and Yale-New Haven Hospital, have implemented longer and more robust training for interns. Despite questioning the legitimacy of a “July Effect”, doctors and administrators working in these hospitals support sensible precautions which include interns completing simulations, task training, and online learning.11

Similarly, the University of Miami-Jackson Memorial Hospital Center for Patient Safety now uses a blended learning approach that involves lecture, web-based learning, and small group simulation.

The center developed an innovative curriculum that is taught the first week of the intern year and specifically addresses:
  1. Calling for help
  2. Teamwork and communication
  3. Hand hygiene compliance
  4. Preventing medication and other system errors12

If these or any other patient safety issues are your concern, even basic simulations can address them and turn practice into permanence.

So, Why Not Make Simulation Part of the Tour?

At this point you might be asking:

  • What does it take to address all of this?
  • How do I leverage simulation in a world where I can't afford to take interns away from their scheduled rounds?
  • How do I avoid a long-protracted training effort that could further isolate interns from the very environment they need to become accustomed to?

If these are your concerns, perhaps you may wish to consider using in situ (i.e. on site) simulation in the very environment in which your new interns will practice starting on day one.

Residents typically have no prior experience yet are expected to diagnose and treat patients in these unfamiliar settings.13 This can be important especially if a new intern finds him or herself at the center of treating a patient emergency.

"New residents are unfamiliar with their new working environment, equipment, hospital layout, and culture, which can cause anxiety," according to Dr. Chopra and Dr. Kondapalli of Iowa State University. A cardiac arrest, for example, is no time to be discovering functionality of your defibrillators, layout of your crash carts, or how to activate a code. It's equally no time to be discovering your protocol, processes, and procedures.

As a solution, in situ simulation can effectively introduce interns to their new work environments. In situ simulation is simulation conducted at the point of care in the intern's own care setting involving the same staff, protocol, processes and equipment that the new intern and surrounding team will use every day. And, since new interns will be dependent on working with teams, in situ simulation allows everyone to review and reinforce their skills, all the while identifying hazards and deficiencies in their systems and environment.14

Download the free infographic, "The July Effect," for a quick-reference guide of current statistics.

Download Infographic

Simulate for Leadership, Followership, and Mutual Support

Interns will work with a mix of individuals including nurses, senior residents, physicians, paramedics, and personnel which they may not get the chance to know on a personal level. Understanding how to manage team dynamics despite who is on the team becomes an important asset. Great teams know this and that's where they focus – not just on refining individual skills but on instilling the skills necessary to excel within teams.15

The To Err is Human report recommends that simulation training be used to prevent errors in a clinical setting. According to the report, " care organizations and teaching institutions should participate in the development and use of simulation for training novice practitioners, problem solving, and crisis management, especially when new and potentially hazardous procedures and equipment are introduced".

This is especially true if you find yourself struggling to teach Crew Resource Management Principles or TeamSTEPPS®. In this arena, simulation offers teams benefits that outpace didactic learning.

Some benefits include:
  • A focus on quality of the experience – not quantity
  • The chance to debrief and truly understand the strengths and weaknesses in a team's behavior
  • Instillation of good leadership and followership skills
  • Enhancement of communications skills and maintaining situational awareness as the team coordinates efforts

Transition To Practice is Real Enough. The Patient Doesn't Have To Be

In their paper, "Emergency Medicine Simulation: A Resident's Perspective", Drs. Meguerdichian, Heiner, and Younggren describe a new resident stepping into an emergency department (ED), immediately confronted by the commotion of a team trying to save a patient who has begun to code. The new resident quickly determines that the patient needs to be intubated. The airway proves to be difficult, and with every step the new intern takes, first using a Macintosh blade, then a video laryngoscope, the patient deteriorates one step ahead. Alarms blaring, and sweat building up on his brow, the new intern prepares to perform a cricothyroidotomy. With that decision, the alarms halt, and the new intern is commended for his efforts. The case was a simulation, part of what all three doctors encourage as part of an onboarding process for new residents.16

This type of situation, a low frequency, high acuity event, can be especially problematic for a new intern given the infrequency of true hands-on practice.17

70% of sentinel events reported to the Joint Commission have been found traceable to communication failure as the primary root cause.18 Additionally, 80% of patient harm is traceable to a breakdown in teamwork and communication during patient hand-offs.19 Simulation can help.

Three leading indicators of good patient-centered performance are:
1. Staff Confidence
2. Competence
3. Compliance

Yet, interns can reportedly feel paralyzed in the first year of their residency program as they adjust to the change in their environment and an awareness of how much there is to learn. "I spent much of [my first year] in a state of crisis and doubt," says Dr. Sandeep Jahuar, author of the memoir Intern.20

Incorporating simulation in your program will not only benefit the new interns but will give attending physicians a chance to gauge resident confidence, competency and compliance with hospital regulations, their new environment, and their new teams – all while protecting the patient.

Download the free infographic, “The July Effect,” for a quick-reference guide of current statistics


  1. Press Release: Results of 2016 NRMP Main Residency Match Largest on Record as Match Continues to Grow. (2016, March 18). Retrieved June 15, 2017, from
  2. Collins, S. (2016). BMJ analysis calls medical errors third leading cause of death, shines new light on ongoing problem. Pharmacy Today, 22(7), 36-37. doi:10.1016/j.ptdy.2016.06.022
  3. Schumann, J.H. (2012, July 28). A year inside a medical residency: Part 1. Retrieved from archive/2012/07/a-year-inside-a-medical-residency-part-1/260457/
  4. McCarthy, M. (2016). The real doctor will see you shortly: a physician’s first year. New York: Broadway Books.
  5. Okuda, Y., Bond, W., Bonfante, G., Mclaughlin, S., Spillane, L., Wang, E., . . . Gordon, J. A. (2008). National Growth in Simulation Training within Emergency Medicine Residency Programs, 2003-2008. Academic Emergency Medicine, 15(11), 1113-1116. doi:10.1111/j.1553-2712.2008.00195.x
  6. Meguerdichian, D. A., Heiner, J. D., & Younggren, B. N. (2012). Emergency Medicine Simulation: A Residents Perspective. Annals of Emergency Medicine, 60(1), 121-126. doi:10.1016/j.annemergmed.2011.08.011
  7. The NCSBN National Simulation Study: A Longitudinal, Randomized, Controlled Study Replacing Clinical Hours with Simulation in Prelicensure Nursing Education. (2014). Journal of Nursing Regulation, 5(2). doi:10.1016/s2155-8256(15)30062-4
  8. Young, O., & Parviainen, K. (2014). Training obstetrics and gynecology residents to be effective communicators in the era of the 80-hour workweek: a pilot study. BMC Research Notes, 7(1), 455. doi:10.1186/1756-0500-7-455
  9. Mccrory, M. C., Aboumatar, H., Custer, J. W., Yang, C. P., & Hunt, E. A. (2012). “ABC-SBAR” Training Improves Simulated Critical Patient Hand-Off by Pediatric Interns. Pediatric Emergency Care, 28(6), 538-543. doi:10.1097/pec.0b013e3182587f6e
  10. Sternberg, S. (2016, May 3). Medical errors are third leading cause of death in the U.S. Retrieved from news/articles/2016-05-03/medical-errors-are-third-leading-cause-of-death-in-the-us
  11. Eunjung Cha, A. (2016, May 3). Researchers: Medical errors now third leading cause of death in United States. Retrieved from
  12. Shekhter, I., Nevo, I., Fitzpatrick, M., Everett-Thomas, R., Sanko, J. S., & Birnbach, D. J. (2009). Creating a Common Patient Safety Denominator: The Interns Course. Journal of Graduate Medical Education, 1(2), 269-272. doi:10.4300/jgme-d-09-00028.1
  13. Chopra, S., & Kondapalli, M. (2015). Applying lean principles to mitigate the “July Effect”: Addressing challenges associated with cohort turnover in teaching hospitals. Journal of Technology, Management and Applied Engineering, 31(4). Retrieved from http://lib.
  14. Patterson, M.D., Blike, G.T., & Nadkarni, V.M. (2008). In situ simulation: Challenges and results. Advances in Patient Safety: New Directions and Alternative Approaches, 3. Rockville, MD: Broadview.
  15. Wachter, B. (2011, February 15). Teamwork helps doctors with patient safety. Retrieved from blog/2011/02/teamwork-helps-doctors-patient-safety.html The “July Effect” 7
  16. Meguerdichian, D. A., Heiner, J. D., & Younggren, B. N. (2012). (See reference #5)
  17. ibid
  19. Joint Commission on Accreditation of Healthcare Organizations (Vol 32, Issue 8) (2012). Joint Commission center for transforming healthcare releases targeted solutions tool for hand-off communications. Retrieved from http://www.jointcommission. org/assets/1/6/TST_HOC_Persp_08_12.pdf
  20. Hester, J.L. (2015, October 1). The misery of a doctor’s first days. Retrieved from archive/2015/10/the-misery-of-a-doctors-first-days/408004

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