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Medical morals

Happy Black Wednesday – every doctor’s nightmare

Your doctor will see you now. Steve Bowbrick

Black Wednesday. The July Phenomenon. The Killing Season. Disquieting. Disconcerting. Disturbing. To what event do these evocative terms refer? A stock market crash? A solar eclipse? Genocide? Not even close. They refer to the increases in medical errors, healthcare costs, and mortality rates that allegedly occur when final year medical students throw off their graduation garments, don their stethoscopes, and step on to the wards as fully fledged doctors for the first time.

“Black Wednesday” is the term used in the UK because Foundation Year 1 Doctors traditionally start working on the first Wednesday in August. The less sensational “July Phenomenon” is used by Americans because most interns start their first medical job during July. “The Killing Season” is used internationally, though it seems to have originated in the UK, and, at least in my experience, it is usually uttered sotto voce by despairing, and increasingly desperate, junior doctors during their first few months of paid employment.

The notion that errors, costs, and even death rates spike when junior doctors are unleashed onto an unsuspecting (and, increasingly, suspecting) public for the first time is deeply embedded in the folklore of medicine. So much so that it is almost routine for healthcare professionals to mutter, darkly, words to the following effect: “never get sick in August – you might not live to tell the tale”. But while the idea is now very much a part of the mythology of medicine, actual evidence for the existence of the phenomenon is surprisingly sparse.

Body of proof

A number of studies have suggested that the phenomenon is real. For example, British researchers who analysed data from hundreds of thousands of emergency admissions to English hospitals between 2000 and 2008 found that patients admitted on the first Wednesday of August had 6% higher odds of dying compared with patients admitted on the last Wednesday in July. American researchers, meanwhile, found that the rates of preventable and potentially preventable complications (though not actual mortality rates) increased when new interns started work in Californian hospitals. On the other hand, a number of studies conducted in obstetric units, intensive care units, and in a range of other healthcare settings have failed to demonstrate any correlation between mortality rates (and/or other measures of patient outcomes) and the influx of new junior doctors into medical practice.

Though the evidence may be equivocal it does seem reasonable to argue that the burden of proof should lie on the shoulders of those who claim that error rates are unaffected when junior doctors start working. This is not because junior doctors are inherently incompetent, but because everyone who starts a new job is likely to make elementary errors as they feel their way around their new working environment.

A little learning …

Admittedly, most junior doctors in the UK spend a week on induction courses prior to “Black Wednesday” so that their first “real” day on the job is not, technically, their first day at work. But even though this is true, it seems very unlikely that anyone settles into a new job after just a few days of an induction programme.

She has to practice on the real thing eventually … deadstar 2.1

It may be countered that newly minted doctors will be more hesitant, more cautious, and more willing to ask for help than doctors with a few months of experience under their belts. In response I would agree that doctors with a bit of experience might become too blasé and that Alexander Pope was right to warn us that “a little learning is a dangerous thing”.

Nevertheless, a basic working knowledge of how a hospital is organised alongside a solid team rapport are essential if medical errors are to be avoided and these things take time to develop. As such, any advantage gained by the caution engendered by inexperience is likely to be negated by the inherent disadvantages associated with being the new kid on the proverbial block.

Four ways out of the killing fields

What then should we do about the threat of Black Wednesday? The pessimists might argue that little can be done because new doctors must start work some day and so a “first day/week/month at work” issue is always going to be with us. However, though it is self-evident that some teething problems are inevitable, there are many processes, procedures, and policies that can be put in place to make the transition less painful both for patients and for doctors.

First, the amount of time final year medical students spend working with (and learning from) junior doctors could be further expanded. Medical schools already work hard to ensure this happens and many have introduced junior doctor “shadowing” rotations to help senior students prepare for their new professional roles - but more can always be done.

Second, induction courses could be lengthened by a few weeks and made much more practical than they currently are. The fact that week-long induction courses happen at all is an improvement on the way things were done in the past, but longer and more individually tailored inductions can only help young doctors to get to grips with their new job.

Third, junior doctors could be required to start their foundation jobs in September rather than in July or August. This should help to reduce anxieties and errors because senior doctors are less likely to be holiday in the autumn because school summer holidays are usually over by then.

Fourth, the transition of staff could be staggered through the year to ensure that junior and senior doctors do not change jobs at the same time. Under the current system, somewhat incredibly, senior doctors often move to new jobs in the same month or week (or, even more astonishingly, on the same day) that junior doctors start work for the first time. A better recipe for failed handovers, inadequate communication, disruption of teams, and general mayhem can hardly be envisaged. Staggering the changes through the year would not only reduce the disruption caused when multiple games of musical chairs are played at the same time, but it would also allow incoming doctors to shadow outgoing doctors for longer periods before taking charge themselves.

Doctors are people too

The primary purpose of these changes would be to protect patients. However, although “patient safety” is paramount and must be the first concern of all doctors, it is also vitally important that we protect “physician sanity”.

Becoming a doctor is a very daunting and highly stressful experience. The anxiety created by all that talk of Black Wednesdays, July Phenomena and Killing Seasons is also very intense and can make those last few weeks of freedom before the start of work an appallingly gut-wrenching time.

This really matters not only because anxious, stressed, and overwhelmed juniors do not good doctors make. But also because physicians are human beings too and, as such, they deserve to be protected from any unnecessary psychological distress during those dark days of summer.

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