By Kenneth M. Ludmerer
Since the late nineteenth century, medical educators have believed that there is one best way to produce outstanding physicians: put interns, residents, and specialty fellows to work in learning their fields. After appropriate scientific preparation during medical school, house officers (the generic term for interns, residents, and specialty fellows) need to jump into the clinical setting and begin caring for patients themselves. This means delegating to house officers the authority to write orders, make important management decisions, and perform major procedures. It is axiomatic in medicine that an individual is not a mature physician until he has learned to care for patients independently. Thus, the assumption of responsibility is the defining principle of graduate medical education.
To develop independence, house officers receive major responsibilities for the care of their patients. They typically are the first to evaluate the patient on admission, speak with the patients on rounds, make all the decisions, write the orders and progress notes, perform the procedures, and are the first to be called should a problem arise with one of their patients. Such responsibility allows house officers not only to develop independence but also to acquire ownership of their patients — the sense that the patients are theirs, that they are the ones responsible for their patients’ medical outcomes and well-being. Medical educators view the assumption of responsibility as the factor that transforms physicians-in-training into capable practitioners.
Independence and responsibility are not given to house officers cavalierly. Rather, they are earned by residents who show themselves to be mature and capable. Responsibility is typically provided in “graded” fashion — that is, junior house officers have much more circumscribed responsibilities, while more experienced house officers who have accomplished their earlier tasks well are advanced to positions of greater responsibility. The more a resident has progressed, the more independence that resident receives.
The assumption of independence and responsibility comes at different rates for different house officers. Advancement to positions of greater responsibility occurs relatively quickly in cognitive fields like neurology, pediatrics, and internal medicine. There, assistant residents in their second or third year receive decision-making authority even for very sick individuals. Among these fields, house officers in pediatrics are generally monitored more closely because of the fragility of their patients, particularly babies and toddlers. Advancement occurs more slowly in procedural fields, such as general surgery, obstetrics and gynecology, and the surgical subspecialties. In these fields, technical proficiency is so important that residents have to wait many years, sometimes until they are chief residents, to perform certain major operations. The degree of independence afforded house officers also depends on the traditions and culture of individual hospitals. At community hospitals, where private physicians are in charge of their own private patients, house officers often receive too little responsibility. At municipal and county hospitals, where charity patients predominate and teaching staffs are often small, house officers can easily receive too much.
The assumption of responsibility does not mean there is no supervision of house officers. Quite the contrary. House officers are accountable to the chief of service, they have regular contact with attending physicians, and chief residents keep an extremely close eye on the resident service. Moreover, someone more senior is typically present or, if not physically present, immediately available. Thus, interns are closely watched by junior residents, junior residents by senior residents, and senior residents by the chief resident. One generation teaches and supervises the next, even though these generations are separated only by a year or two. Backup and support are available for all residents from attending physicians, consultants, and the chiefs of service. The gravest moral offense a house officer can commit is not to call for help.
From the perspective of patient safety, it may seem that patients should be seen only by experienced physicians and surgeons. However, medical educators have recognized all along that this is not a viable option. Medical education incurs the dual responsibility for ensuring the current safety of patients seen during the training process and the future safety of patients of tomorrow seen by those undergoing training today. Every physician needs to gain clinical experience, and every physician faces a day of reckoning when he practices medicine independently for the first time—that is, without anyone looking over his shoulder or immediately available for help. The only choice medical educators have is to control the circumstances in which this will happen. Should house officers gain experience and develop independence within the structured confines of a teaching hospital, where help can readily be obtained, or must this occur afterward in practice at the potential expense of the first patients who present themselves?
Thus, maximizing safety in graduate medical education is a complex task, for the needs of both present and future patients must be taken into account. The system of graded responsibility provided house officers by the residency system, coupled with careful supervision of house officers’ work, has been developed to maximize professional growth among trainees while at the same time maximizing the safety of patients entrusted to them for care. The system is not perfect, but no one in the United States or anywhere else has yet come up with a better system, and it continues to serve the public well.
Kenneth M. Ludmerer is Professor of Medicine and the Mabel Dorn Reeder Distinguished Professor of the History of Medicine at the Washington University School of Medicine. He is the author of the forthcoming Let Me Heal: The Opportunity to Preserve Excellence in American Medicine (1 October 2014), Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care (1999), and Learning to Heal: The Development of American Medical Education (Basic Books, 1985).
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By Kenneth M. Ludmerer
“Don’t get sick in July.”
So the old adage goes. For generations medical educators have uttered this exhortation, based on a perceived increase in the incidence of medical and surgical errors and complications occurring at this time of year, owing to the influx of new medical graduates (interns) into residency programs at teaching hospitals. This phenomenon is known as the “July effect.”
The existence of a July effect is highly plausible. In late June and early July of each year, all interns and residents (physicians in training beyond the internship) are at their most inexperienced. Interns—newly minted MDs fresh out of medical school—have nascent clinical skills. Most interns also have to learn how a new hospital system operates since most of them enter residency programs at hospitals other than the ones they trained at as medical students. At the same time the previous year’s interns and residents take a step up on the training ladder, assuming new duties and responsibilities. Every trainee is in a position of new and increased responsibilities. The widespread concern that these circumstances lead to mistakes is understandable.
Yet, despite considerable consternation, evidence that there is a July effect is surprisingly hard to come by. Numerous studies of medical and surgical trainees have demonstrated no increase in errors or complications in July compared with other times of the year. Many commentators have declared the July effect a myth, or at least highly exaggerated. A few studies have shown the existence of a July effect, but only a slight one—for instance, on the sickest group of heart patients, where even a slight, seemingly inconsequential mistake can have grave consequences. Even here, however, the magnitude of the effect does not appear large, and the studies are highly flawed. Certainly, there is no reason for individuals to avoid seeking medical care in July should they become ill.
That the July effect is so difficult to demonstrate is a tribute to our country’s system of graduate medical education. Every house officer (the generic term for intern and resident) is supervised in his or her work by someone more experienced, even if only a year or two farther along. Faculty members commonly provide more intense supervision in July than at other times of the year. Recent changes in residency training, such as shortening the work hours of house officers and providing them more help with chores, may also help make residency training safer for patients—in July, and throughout the year.
Uncertainty is intrinsic to medical practice. Medical and surgical care, no matter how skillfully executed, inevitably involves risks. It would not be surprising if a small July effect at teaching hospitals does occur, particularly in certain subgroups of critically ill or vulnerable patients, given that house officers are the least experienced. However, the fact that this effect, if present, is small and difficult to measure provides testimony to the strength of graduate medical education in the United States. Indeed, the quality of care at teaching hospitals has consistently been shown to be better than at hospitals without interns and residents. Patients may be assured that their interests will be served at teaching hospitals—in July, and throughout the year.
Kenneth M. Ludmerer is Professor of Medicine and the Mabel Dorn Reeder Distinguished Professor of the History of Medicine at the Washington University School of Medicine. He is the author of Let Me Heal: The Opportunity to Preserve Excellence in American Medicine, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care, and Learning to Heal: The Development of American Medical Education.
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Image credit: Multiracial medical students wearing lab coats studying in classroom. Photo by goldenKB, iStockphoto.
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Robert M. Veatch is the director and Professor of Medical Ethics at the Kennedy Institute of 
Ethics. His new book, Patient, Heal Thyself: How the New Medicine Puts the Patient in Charge, uses a range of fascinating contemporary and historical examples to reveal how values underlie almost all medical procedures. He makes a strong case that patients must take a more active role in their treatments, so that their values are met. In the excerpt below Veatch uses the example of a broken arm to demonstrate value judgments in treatment.
Phil was a sophomore in his state’s premier university in a city some hundred miles from his home. Playing “severe Frisbee” one fall afternoon, he dove for the dis and landed on his right wrist. He knew instantly that it was broken. His buddies drove him to the school clinic, where the arm was set. In a few weeks he was as good as new - almost.
The arm was left with a slight distortion that concerned the orthopedist but did n ot appear to require surgical correction. The next summer when Phil was skating at a roller rink with his friends, he fell on the arm and rebroke it. This time the orthopedic surgeon said pins would have to be placed to reconstruct the bone. The surgery was uneventful. The surgeon instructed Phil and his parents that he would have to return for the removal of the pins in about a year when the bone was mended.
The following summer the procedure was scheduled for Phil as an outpatient. Everything went fine. His now-screwless arm was placed once again in a cast so the screw holes could mend.
In the conversation with Phil and his parents after the successful events, the surgeon made a statement that was rather remarkable, even though neither he nor Phil as first realized all its implications. He said, “Most surgeons would leave this cast on for about seven weeks, but I found that if you are careful, I can remove it in about four weeks, so schedule an appointment in a month and we’ll get if off.”
Phil and his parents here encounter an amazing array of value judgments made by the surgeon. Pass over all the judgments not to place the pins after the first break and to place them after the second. Forget about the techniques used in setting the arm each time, the type of surgery, the anesthesia, the decision to remove the pins after a year. There is no reason to doubt that each of these decisions easily conformed to the practices of orthopedic surgeons. Of course, they all involved value judgments, but they were judgments that would probably lead to little controversy. Let’s focus on the decision about when the cast should be removed.
First, the surgeon says something very controversial. He announces to his patient what the standard practice is for removing the cast: His colleagues generally removed it after several weeks. He then tells Phil and his parents that he was going to depart from the standard practice - an announcement that surely would have alarmed the surgeon’s lawyer had he heard it. Practitioners of modern medicine might be concerned as well. Modern medicine assumes that there is a correct number of weeks to leave a cast on in these circumstances and that a consensus among orthopedists is good (if not perfect) evidence of how many weeks that is. In the days of modern medicine, Phil would have been left wondering why he should go with his surgeon’s four-week plan rather than the consensus seven. Some might even say that the surgeon has not only made a mistake, but foolishly announced the error to the patient.
The new medicine sees the situation differently. Phil’s surgeon doesn’t actually give Phil a clear reason for this deviation, but we can perhaps deduce it. He says that if Phil is careful, he can have the cast removed three weeks earlier. It appears that the surgeon assumes that wearing a cast is an unpleasant experience, so removing it early is a good thing. Likewise, one might guess that the surgeon believes it is not a terribly onerous task to be careful.
It now becomes clear that there is no objectively correct number of weeks to leave the cast on the arm for this kind of surgery. The more cast-averse one is and the more comfortable one is trying to be careful, the earlier the cast should come off. On the other hand, for those who live an active life, are nervous about having to avoid the risk of injury of the unprotected arm, and are not particularly troubled by the cast, a longer period is surely the right answer…
…Something as utterly trivial and devoid of moral controversy as when to remove a cast turns out to depend on the value trade-offs of the one making the choice. Phil’s surgeon is not making a clear-cut mistake when he deviates from the standard of practice. If the surgeon is really averse to the cast and really uncomfortable with one on his arm, then he is rationally inclined to get it off earlier. For him, four weeks may be just the right time (even though his colleagues have made the value trade-off in a way that leads to the seven-week period). It is not irrational for the surgeon to favor a shortened time for removing the cast, even if he knows his colleagues choose seven weeks and even if he agrees completely with them on all of the relevant facts.
The problem, however, is that it is not the surgeon’s arm that is in the cast. It’s Phil’s. Discovering that the decision about when to remove a cast is a value judgment takes it away from the consensus standard of practice of the surgeon’s colleagues, but, logical, it also takes it away from the surgeon. If a value trade-off must be made between the nuisance of the cast and the nuisance of being careful without it, it should be Phil’s values that get traded off, not those of his surgeon or those of surgeons in general.
If this is right, then we reach a remarkable conclusion: Neither Phil’s surgeon nor the community of competent orthopedic surgeons can know when is the right time to remove Phil’s cast. In fact, we can no longer talk about an such thing as an all-purpose, generic correct time.
![By National Cancer Institute [Public domain], via Wikimedia Commons](http://blog.oup.com/wp-content/uploads/2014/06/Doctor_consults_with_patient_4.jpg)
