Is there a July phenomenon?

Mental Malpractice

ONE kind of new year comes for all of us in January — the one we celebrate with Champagne. But another, more stressful new year begins for doctors in July, when the new interns arrive in our emergency rooms, clinics and wards. Hospital personnel have always joked, “Don’t get sick in July,” since for decades the trainees were loosely supervised.

Today, most hospitals closely watch over interns. But at the start of this new medical year, a significant deficiency remains in the system: the way in which doctors are trained to think.

Now I am a huge fan of Dr. Jerome Groopman, and I like this op-ed, but I must disagree with two of his points. First, there is no July phenomenon. Is There a July Phenomenon? We should oppose any mention of this urban myth.

I have a few thoughts about why we do not have a July phenomenon. Those who supervise in July (and I have done July wards for at least the last 10 years) are acutely aware that the new interns need careful supervision. The supervising attendings and residents are hand chosen for this task.

Additionally, new interns fear making mistakes. They often ask too many questions, but too many questions trumps too few.

Enough about July, Dr. Groopman also makes this statement –

I have started teaching these concepts of cognitive psychology in continuing medical education courses, and recently used my misdiagnosis of the torn aorta to illustrate the common thinking trap. My wife, Pam, has introduced fourth-year medical students at our hospital to the cognitive detours doctors commonly take. But such instruction needs to be widespread. In classes and on hospital rounds, medical schools and hospitals should teach doctors why some diagnoses succeed and why some fail. And as part of the assessment of clinical competency for obtaining a license, doctors should be expected to demonstrate their fluency in the application of cognitive science, as they are required to do in other sciences.

Once we are schooled in the way we think, we will also be better able to answer questions from patients and their families about how we arrive at our diagnoses. And that may make everyone more confident about visiting a clinic or a hospital in July.

As I wrote recently, we really should focus on one major error – premature closure – Do not marry the diagnosis!

I consider myself a devotee of Tversky and Kahneman and their explorations into cognitive science. However, I believe Dr. Groopman’s solution of studying the basic science would do more harm than good. Rather, we who teach clinical medicine must always provide role models for inquisitiveness. We should avoid premature closure. We should present cases which make these points clearly.

We need not know the names for all the mistakes we make. Rather we need a few basic principles to avoid premature closure. We need to study clinical examples of such errors. We need to teach clinical problem solving.