The Rookie Goes to Bat: Is there a “July Effect” on Stroke Treatment at Teaching Hospitals?

Historically, July 1st is the infamous date when, each year, newly graduated doctors (formerly medical students a few hours ago on June 30) start their internship and junior residents advance into senior roles. Along with the excitement and nervousness of students morphing into resident doctors emerges the “July Effect (JE),” a concept that patient outcomes are worse during this transition. The mantra of “Don’t get sick in July” emanates from this annual rite of passage—as seasoned, graduating residents are suddenly replaced by relatively inexperienced newbies. Inside most academic teaching hospitals and university medical centers, neurology residents are among the first-line responders to a “stroke alert” emergency. They must identify the precise time the patient was last known normal; interpret physical examination findings, such as limb weakness, numbness, aphasia, and the like; address abnormal vital signs, such as markedly high blood pressure; correct abnormal laboratory test results, such as hyperglycemia and coagulopathy; and recognize images on various brain scans, which can be a hyperdense clot in an artery or subtle blurring of the graywhite matter. In order to appropriately diagnose, time, and treat a stroke, it is critical to know how various stroke syndromes present and their usual etiologies, how to manage the hospital’s triage logistics and personnel, and how to order intravenous (IV) thrombolytic and intra-arterial (IA) clot extraction therapies. Predictably, brand new neurology residents may lack these skills, and therefore, it seems unlikely that patients with hyperacute stroke have optimal outcomes, door-to-needle times (DTNTs), and IV or IA treatment rates in July. Moreover, clinical presentation of stroke varies significantly from one patient to another and can flux from 1 time point to another in the same patient. Incoming residents have not had much (if any) exposure to dynamic, hyperacute stroke outside of textbooks. Residents’ decisions for diagnosis and treatment in this intense setting, where “time lost is brain lost,” is limited by a paucity of real-world experience. Hence, we read with interest the article “Door-to-needle time in acute stroke treatment and the ‘July Effect’” by Dr Hawkes and colleagues from Argentina in this month’s Neurohospitalist. In a span of over 13 years, they retrospectively studied 101 acute ischemic stroke cases, divided into 3-month intervals, to assess differences between DTNT, thrombolytic-related intracranial hemorrhage, and 3-month outcomes using modified Rankin Scale and National Institute of Health Stroke Scale. They found no detrimental JE with their neurology residents; however, the sample size was small, as only 27 and 31 patients were studied in the June to August and March to May time frames, respectively, over 13 years. This equates to about 2 to 3 patients per year, per time block, and only about 1 thrombolysis per month. These sparse numbers, from only 1 center, lack generalizability and cannot confirm the presence or absence of a JE, especially vis-à-vis DTNT. Moreover, any difference in thrombolytic rates is unclear between the June to August and the March to May groups, as only about 5% of those who presented with an ischemic stroke eventually received thrombolytic there. Possibly, in Argentina versus the United States, there are differences in thrombolytic inclusion/ exclusion criteria, which importantly, were updated around the time of this project. It seems likely the more complex revisions may impact JE also. To better evaluate JE, the methods section should describe, more specifically, the role of junior residents, senior residents, attendings, and radiologists. It is unclear what the junior residents do in this study—are they making decisions themselves or is there intensive oversight because of a self-fulfilling