Study Dispels “July Effect” for In-Hospital Training for Heart Surgery

The perception that more medical errors occur in July for heart surgery (referred to as the “July Effect”) compared to other months due to an arrival of new influx of medical school graduates starting their in-hospital training is wrong, say researchers at Boston-based Brigham and Women’s Hospital and Harvard University in a research study, “\”Debunking the July Effect in Cardiac Surgery: A National Analysis of Over 470,000 Procedures,\” published in The Annuals of Thoraoic Surgery, published by Elsevier. .


\”While the perception of the \’July effect\’ persists culturally among health care providers, we hope that this study reinforces the fact that hospital systems have in place processes that help provide the highest level of care and ensure patient safety,\” said Sameer A. Hirji, MD, of Brigham and Women\’s Hospital in Boston, MA, USA, in a July 31 statement released to dispel the mistaken belief.

Taking a Look at the Data

The researchers examined data gleaned from the Nationwide Inpatient Sample, which is part of a database family developed by the Agency for Healthcare Research and Quality and provides information on more than 35 million hospital admissions.

The study analyzed more than 470,000 standard cardiac procedures such as coronary artery bypass grafting (CABG); aortic valve replacement; mitral valve repair or replacement; and thoracic aortic aneurysm (TAA) replacement that were performed between 2012 and 2014 on adult patients. For each procedure, overall trends were compared by academic year quartiles: Q1 (July to September with the least experienced residents) vs. Q4 (April to June with the most experienced residents). The researchers say they observed no differences in mortality, in-hospital complications, costs, or length of stay between patients who were treated in Q1 compared to those in Q4.

\”Cardiac surgery patients are managed in a multidisciplinary fashion; therefore, the well-being of patients is not solely dependent on one individual, but rather on the entire caregiving team and so may be more resistant to changes in hospital staff,\” said Rohan M. Shah, MD, MPH. \”What this means for patients is that they should not be fearful or concerned about having surgery in July when new residents are starting,\” he says.

The study findings showed that while hospital teaching status did not influence risk-adjusted mortality rates for CABG and TAA replacement surgeries, teaching hospitals did perform better than non-teaching hospitals with lower mortality in Q1 versus Q4 for the aortic and mitral procedures. This is an important finding with implications for overall resident training and education in the operating room, says Dr. Shah.

Training Future Surgeons

Most cardiac surgery teams recognize that July is a \”vulnerable\” period when \”direct and strict\” supervision of residents is expected, according to Dr. Hirji. As the year progresses, though, resident autonomy increases, he says.

\”The balance between attending supervision and resident autonomy constantly shifts during teaching,\” adds Dr. Hirji. \”This is a fine balance and, as indicated by this study, our specialty is doing a great job,\” he says.

In spite of that, Dr. Shah believes that the effectiveness of traditional training programs versus newer training paradigms, such as the increasingly popular Fast-Track Pathway (4-plus-3 model) and the Integrated Pathway (I-6 program), should be evaluated.

Under the Traditional Pathway, residents complete five years of general surgery training, consisting of clinical rotations through the various surgical disciplines, followed by two to three years of cardiothoracic surgery residency. This results in a surgeon who is trained broadly in general and cardiothoracic surgery, say the researchers.

The 4-plus-3 model includes four years of general surgery training, followed by three years of cardiothoracic residency. The resident is introduced to cardiothoracic surgery earlier in the training pathway, resulting in more time to master skills.

The researchers note that the I-6 program is the newest training model and offers even earlier exposure to cardiothoracic surgery. Residents apply directly to an integrated cardiothoracic surgery residency program for 6 years of comprehensive and total immersion in the diagnosis and management of cardiovascular and thoracic diseases through multidisciplinary training and exposure to related fields such as cardiology, radiology, oncology, and endovascular surgery.

\”This study highlights the pivotal role of appropriate resident teaching that doesn\’t compromise patient outcomes,\” said corresponding author Tsuyoshi Kaneko, MD, noting that \”Patient safety will always be the first priority.\”


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