‘July Effect’ Revisited: Why Experienced Docs May Not Deliver the Best Care

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“Don’t get sick in July.”

This is a common refrain in teaching hospitals. It’s driven by the academic calendar: July is when the new interns — fresh out of medical school — start work. It’s also when the senior trainees, the residents and fellows, graduate to supervisory, self-managed patient care roles. In other words, it’s when everyone is most inexperienced. The worry is that this inexperience leads to mistakes.

But what is less clear is how a doctor’s experience influences the quality of their care. On its face, it makes sense that the longer a doctor practices, the more expertise she gains — which means better care for you. But, in reality, it’s not that simple.

Say, for instance, your doctor tells you: “In my experience, this antibiotic works great for sinus infections.” Fair enough. It may also be completely true from your doctor’s perspective: when she has prescribed antibiotics in the past for sinus infections, patients got better. But statements like this make us cringe, for two reasons.

First, as it turns out, antibiotics don’t actually work for most sinus infections. In a large study published in the Journal of the American Medical Association earlier this year, people with sinusitis were randomly assigned to take antibiotics or a placebo. People treated with antibiotics did no better than those who got the sugar pill. The reason that bacteria-killing antibiotics don’t help when you have sinusitis is because the infection is almost always caused by a virus.

The second — and perhaps more cringe-worthy — part is the summoning of the phrase “in my experience” as the major reason to prescribe the drug. In the case of sinus infections and antibiotics, doctors’ experiences (and those of patients) support the wrong decision. Here’s why: the natural course of most sinus infections is to resolve on their own over time. People tend to go to the doctor — and get their antibiotics — when they are at their sickest. So they and their doctors falsely attribute their improvement to the antibiotic pills. Here, experience gets in the way of the right medical decision, which is to avoid antibiotics in the first place.

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So let’s get back to the July effect and the inexperienced, error-prone interns. On one hand, some studies suggest that the July effect is a myth: a recent study examining 10 years of data on patients undergoing neurosurgery showed that July was no more dangerous than other months. On the other hand, reports have found that July patients do indeed fare worse: in a study of patients undergoing surgery for spine-related cancer, July patients were more than twice as likely to have a surgical complication and 81% more likely to die, compared with August or June patients.

A recent systematic review of all the research done on the topic concluded that many of the studies showing no July effect had small sample sizes and were not rigorously done, but the bigger and better investigations leaned toward finding that July is truly a more dangerous month in teaching hospitals.

So is medical experience good or bad? Well, in most cases, your doctor’s experience is very helpful, allowing her to pick up on a very subtle symptom early in a disease process, for instance, or to determine the right treatment when your condition falls outside of what is taught in textbooks. And for many medical treatments — especially the highly technical ones — there’s a direct correlation between physician experience (the number of procedures she’s performed) and your outcome (whether the procedure works).

In a variety of situations, though, experience can backfire, and the reason is simple psychology. Doctors are human too, and they fall prey to tricks of the mind — like thinking that an ineffective treatment really works (ahem, antibiotics for sinus infections). In fact, entire fields of research are devoted to understanding why these errors of thought occur. They spring from so-called cognitive biases and false heuristics: mental shortcuts that can mislead even highly educated, well-seasoned practitioners into making the wrong decisions.

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Here are four key cognitive biases that trick even the smartest physicians:

  • Anchoring bias, which causes doctors to lock onto a diagnosis early and disregard new and conflicting information. For example, a patient may be diagnosed with a quickly fatal cancer, but then ends up trying various (ineffective) herbal remedies and lives for 30 more years. Instead of considering whether the initial diagnosis was incorrect, the patient — and maybe even the doctor — may falsely assume that the herbal remedies cured the cancer.
  • Availability bias, when clinicians tend to think that the patient they are treating today has the same condition as the patient they treated last week. Imagine your doctor saw a rare, life-threatening illness last week that presented with a common symptom, such as belly pain. Today, you’re in the doctor’s office for belly pain, and your doctor may be unjustifiably concerned that you too have that rare life-threatening disease just because she’s still thinking about it.
  • Confirmation bias, which causes doctors to believe evidence when it supports their pre-conceived opinion, while ignoring evidence that contradicts it. For example, let’s say your doctor is pretty certain that you have an infection, and orders a test to confirm the suspicion. The test is negative for infection, but she treats you for it anyway because she doesn’t believe the test results; meanwhile, she disregards clues that point to another, correct diagnosis.
  • Commission bias, when doctors err on the side of doing something — like ordering a prostate biopsy — as opposed to watchful waiting because it seems that doing something is better than a doing nothing.

As you can imagine, the effects of these biases can be significant, particularly if it leads to the wrong treatment or a wrong diagnosis. In the case of antibiotics for sinusitis, for instance, the negative impacts of overtreatment include the promotion of drug-resistant superbugs, higher medical spending, and rare but sometimes serious allergic reactions to antibiotics.

So when does experience help and when does it get the way? That’s a tough question because there are clearly many benefits to having a highly experienced doctor, such as technical proficiency and knowing the pitfalls of various treatments. Conversely, there may actually be some intangible benefits to having a less experienced doctor: she may have a more up-to-date education, boundless energy and perhaps less susceptibility to cognitive biases developed by years of thinking and practicing the same way.

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The key here lies in the evidence. The data show that certain procedures have a clear volume-outcome relationship — that is, the more experience a doctor or hospital has, the better their outcomes. These procedures include: open-heart surgery, hernia repairs, obstetrics and trauma care. Note that many of the areas where the volume-outcome relationship exists involve technical expertise. As Malcolm Gladwell so popularly noted in his book Outliers, Andre Agassi got good at tennis through 10,000 hours of practice. The same principle holds with doctors who perform medical procedures.

The flip side involves certain medical situations in which medical evidence trumps experience, such as using routine mammograms to screen for breast cancer in women under 50, prescribing anti-arrhythmia medications for heart rhythm disturbances after heart attack, or adhering to super-tight glucose control in diabetics. In all these cases, as new evidence emerged refuting the benefits of what had once been considered standard care, both doctors and patients were shocked into re-thinking treatment decisions. Here, what seemed to make sense from years of experience turned out to be wrong.

So what can you do as a patient to receive the best care? Well, maybe nothing if you get admitted on an emergent basis to a teaching hospital during July. But one thing you should always do is ask a lot of questions. It may not always be possible to determine that your doctor has fallen victim to an unconscious thinking trap or that she’s practicing outdated medicine. But asking questions does force your doctor to think and justify decisions about your care.

Secondly, become an informed patient: try to learn as much as you can about your medical issues and what trusted sources recommend as the “right” approach. Even 15 years ago, it was rare for a patient to crack open a medical textbook to question a treatment decision. Now, online resources such as MedlinePlus, provide both up-to-date and easy-to-understand explanations of complex medical care. A good summary of evidence-based medicine can also be found at the Agency for Healthcare Research and Quality’s website.

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To be clear, an experienced doctor may provide the best care in the world for you or your loved one. But for some decisions, you’d be better off if she didn’t use that experience as the only reason to choose a medicine or test. Experience may make the mechanics of a medical procedure smoother and more efficient, but it can also make medical decision-making messy, and sometimes plain wrong.

Meisel is an assistant professor of emergency medicine at the Perelman School of Medicine and medical editor of the LDI Health Economist, both at the University of Pennsylvania. Follow him on Twitter at @zacharymeisel.

Pines is the director of the Center for Health Care Quality and an associate professor of emergency medicine at George Washington University. Follow him on Twitter at @DrJessePines.

7 comments
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Kool Dee
Kool Dee

...then there's the "experienced" docs who have not taken a board exam for over 40 years. There is a surgeon practicing in Sacramento who took his board exam once in 1970 and has never been required to re-take the exam (which is now required of all other surgeons every 10 years).  The guy seems to have early Alzheimer's but the hospital allows him to practice. Very high complication rate. Dangerous as can be...

wholefed
wholefed

“Just like a dog who finds a bone, he licks one, he licks the other, he goes in circles until he drops dead”.  – Devo The Standard American Diet has caused our cholesterol to increase as well as our weight, this increase has also caused us to have high blood pressure and increased blood sugar.  The medical industry suggests we take statins to control our cholesterol, but they can cause diabetes by increasing our blood sugars, they also cause us muscle soreness and give us heartburn.  So we take weight loss pills but they increase our blood pressure and give us insomnia.  To offset that we take blood pressure medicine and a sleeping pill but a side effect is depression and impotence.  Fortunately, the erectile dysfunction medicine and antidepressant relieve that issue but the antidepressant causes weight gain and gives us heartburn .  We started taking an antacid but it gives us a headache and makes us moody.  The fish oil should increase our good cholesterol so potentially we can stop taking the statin, but it gives us irregular heart beats.  We would love to have a scotch but our liver’s are toxic and our kidneys are failing.  So rather than commit suicide…

Full Post: Standard American Pill Plan   http://wholefed.org/2012/07/26...

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TheDocisIn33
TheDocisIn33

whats with all the pronouns of doctors being listed as "she." The political correctness is killing me. The majority of doctors are male.

Kool Dee
Kool Dee

That's not true anymore. More than 50% of medical school graduates are female. Furthermore, in many areas Nurse Practitoners and Physician Assistants are making diagnoses instead of doctors, and these are overhwelmingly female.

Fatesrider
Fatesrider

The single-most important thing a doctor can learn, and that experience will teach him, is that you treat the patent, not the disease.  If you do the former, the latter is taken care of.

The focus in medicine today is on specialization, where the doctor is only concerned about one part of you.  This is probably the worst possible method of treating a patient since the GP rarely gets involved once the patient is handed over to the specialist.  The specialist is too narrowly focused on their specialty to consider other aspects that impact a patient's general health.  By parceling out the care based on body parts, parts get overlooked or under regarded, resulting in very poor patient care, health and well being.

Much of the reason there's a push toward specialization is because of greed.  It pays better.  This leaves fewer GP's out there devoting less and less time per patient resulting in a general lack of proper overall patient care.

I've always been an advocate of paying for one's care.  Equally, I've been an advocate of removing the profit motive from ALL health care.  You should be paid for your services, but you should not greatly profit from them.  But until the profit motive is removed from health care while retaining adequate incentives to treat those in need, we're not ever going to have the kind of health care that best serves our needs.

annevincent
annevincent

Experienced physicians who have kept up on their "CME's" (continuing medical education) are probably the best, since they have the benefit of long-term clinical decision-making. The problem with younger physicians is that they have not yet experienced the reality that much of what is currently "in fashion" at any time in medicine, will likely be rejected over time. For instance, the great mammogram debate, with regards to the appropriate age for initiating routine screens for breast cancer. (This controversy will continue to evolve, depending on which study, performed by which specific researcher with specific underlying "agendas", is able to influence the prevailing consensus of opinion at the moment.) As long as pharmaceutical companies, and others with economic interests in the outcomes of medical research, are the parties who are paying for these studies to be performed, the results of these studies will continue to be questionable. Unfortunately, the designs of medical research studies often lend themselves to either deliberate or subconscious influences in conclusions. In addition, studies that are designed to determine "cost effectiveness" from a global public health perspective, are often not relevant to the care provided to an individual patient by a concerned "hands on" physician. 

Dan Bruce
Dan Bruce

You forgot to list age bias.

I care for two 90+ year old parents. My experience is that their long-term doctor is not agressive in  their treatment. Mom had serious anemia several years ago, and it would not have been caught if it had not been for the attention given by a student doctor spending a week of on-the-job training at our local clinic. Mom's doctor (and two others in long-term practice) missed a small fracture in mom's pelvis for more than two months, even after I specifically told them to look for that when I first took her in to the clinic. We have good insurance and supposedly have good doctors with good reputations, but my folks are not getting proper care from their older doctors, imo. It's as if the doctors have given up on them. And before anyone suggests a change, my parents won't consider it.