Cora-Bramble, Denice MD, MBA; Joseph, Jill MD, PhD; Jain, Swati MD; Huang, Zhihuan Jennifer MB, PhD, MPH; Gaughan-Chaplain, Maura MA; Batshaw, Mark MD
Historically, selected academic health centers, health systems, and, to a lesser degree, medical schools and residency programs have merged, consolidated, or formed strategic alliances. The factors driving such mergers are varied and include such reasons as the desire to augment dwindling market share, improve reimbursement, provide new corporate acquisitions, address financial pressures, meet accreditation demands, and others.1–3 Although the relative success and failure of health systems mergers have been examined in the medical and health care management literature,4 there are few published reports of residency program mergers. Moreover, there is only one report of the circumstances surrounding a merger between a medical program at a historically black college and university (HBCU) and that of a predominantly white institution.5
The purpose of this case study is to describe a merger between two dissimilar pediatric residency programs at Howard University Hospital (HUH) and Children's National Medical Center (CNMC), one affiliated with a HBCU and the other with a leading children's hospital that had relatively few underrepresented minority physicians or residents. In presenting this case study, we also refer to selected and illustrative data collected from residents after the merger.
A Medline query of merger and residency articles published in English during the last 40 years revealed only a few examples of residency mergers. These mergers involved departments of surgery,6 family practice,7 obstetrics–gynecology,8 dermatology,9 and psychiatry.10 Published evaluations of these mergers were even less common. The motivations for the merger were varied and included a health system merger,6 a hospital acquisition,7 a change in hospital ownership,9 and an attempt to “complement each other's strengths and help compensate for each other's weaknesses.”10 Of the programs that evaluated the outcome of the merger from the residents' perspectives, both positive and negative outcomes were cited. In one study,6 the expanded surgery clinical and faculty pool created by the merger was viewed somewhat favorably, but the loss of a small, familiar clinical team was viewed negatively. The authors concluded that “a merger process certainly is disruptive to well-established working relationships, roles, expectations and the usually understood but perhaps rarely articulated relational ‘glue' that governs the day-to-day conduct of a residency program.”6 Similarly, Smith et al7 note that the merger of their “two programs was a painful process with many challenges.”
Institutional cultural differences were frequently cited as one of the most difficult aspects of a merger. This challenge may be significantly compounded by ethnic or racial differences between the individuals in the merging institutions or programs. Chatman et al5 briefly mention this challenge in describing the formation of a strategic alliance between Meharry Medical College and Vanderbilt University Medical Center. The authors state that “inherent differences in shared values, beliefs, and experiences at each institution are particularly obvious because Meharry is predominantly African American and Vanderbilt University Medical Center is predominantly white.”5
Premerger Environment: Residency Programs, Faculty, and Residents
Before the merger between CNMC and HUH, the two pediatric residency programs differed in size, residents' race/ethnicity, and presence of international medical graduates (IMGs). The premerger residency program at HUH contained one track of 30 residents, whereas a much larger 72-resident program at CNMC contained two tracks: categorical and primary care. The categorical track was predominantly hospital based, and the primary care track included substantive, longitudinal, office-based, ambulatory educational experiences. Neither track focused specifically on community health issues or health policy. Compared with CNMC, the HUH residents were predominantly graduates of foreign medical colleges or racial/ethnic minorities. Specifically, the HUH residents at the time of the merger were 33% African, 30% Indian, 20% African American, 7% Caribbean, 7% Latino, and 3% white. Seventy-seven percent of the HUH residents at the time of the merger were IMGs. In contrast, the CNMC program comprised 88% white residents, 8% African American residents, 3% Latino residents, and 1% other. At the time of the merger, there were no IMGs in the CNMC residency program. The majority of residents in both programs were female (67% at HUH and 70% at CNMC).
There were also significant differences between the hospitals involved in the residency program merger in terms of size, pediatric population served, and patient acuity. CNMC is a tertiary care, 240-bed, independent children's hospital with a 38-bed pediatric intensive care unit (PICU) and a 40-bed, level 3 neonatal intensive care unit (NICU). Additionally, highly specialized services such as extracorporeal membrane oxygenation, dialysis, solid-organ transplantation, and surgical repair of congenital heart disease are frequently provided at CNMC. In contrast, HUH is a 482-bed hospital with 38 assigned pediatric beds. The full-time faculty at CNMC exceeds 350, of which over 200 are pediatricians. Of the 200 faculty at HUH, only 16 are engaged in full-time pediatric clinical practice. Howard University Hospital is affiliated with a prominent HBCU, Howard University, and CNMC is affiliated with George Washington University (GW).
The main proximate motivations for the merger were the Accreditation Council for Graduate Medical Education (ACGME) citations of the HUH program in 2002 that proposed withdrawal of the residency program accreditation. A pivotal event that had adversely impacted the program at HUH was the closure of their main affiliated hospital, the District of Columbia General Hospital (DCGH) in 2001. The sudden and unexpected closure of DCGH, a high-volume public hospital that had been closely integrated with the HUH pediatric residency program, resulted in fewer pediatric patients being available for residency education purposes. After the closure of DCGH, Howard residents were scheduled for additional clinical rotations at other hospitals, yet the accreditation challenges persisted because of the absence of longitudinal exposure to several subspecialty patient populations. The HUH citations were specifically related to low patient volume, absence of interinstitutional agreements, and lack of longitudinal subspecialty training in gastroenterology, pulmonology, and nephrology. It is important to note that there were no citations related to the qualifications of HUH faculty, resident-board pass rate, or size of the pediatric department's research portfolio.
Although the ACGME citations were the critical catalyst for the merger, growing CNMC-HUH collaborations created an environment that was conducive to the magnitude of change generated by the merger. This had not always been the case. Before 1998, there were few interactions between the two institutions, and those that had occurred had often been contentious. At HUH, there was a feeling that CNMC lacked respect for its unique history and strengths. This attitude began to change in 1998 when the new chair of pediatrics at CNMC developed a strong and trusting relationship with the pediatric chair at HUH. This led to a number of joint initiatives in clinical work, research, and teaching that benefited both institutions. By 2002, they shared several collaborative National Institutes of Health grants, subspecialists at CNMC cared for patients at HUH, and students from Howard University College of Medicine participated in inpatient rotations at CNMC. In 2002, CNMC conducted a national search and recruited an HUH medical school and pediatric residency program graduate to lead a clinical center of excellence, the first minority to assume this role.
From CNMC's perspective, the institutional motivation to merge was fourfold: (1) to increase the size of the residency program without additional cost, (2) to increase the racial and ethnic diversity of residents, (3) to provide needed support to the historic HUH pediatric residency program, and (4) to establish a community health track
The merger timeline from planning to implementation phase was compressed to only eight months (November 2002 to July 2003) because of ACGME accreditation deadlines imposed on the HUH residency program (see List 1). Preliminary discussions started in October 2002. In late 2002, a series of leadership planning meetings were conducted by a six-member team that included the pediatric department chairs, residency program directors, and other leaders from both institutions. Additionally, other institutions that had undergone mergers were consulted. In January 2003, a Memorandum of Understanding was drafted and signed by the Chief Executive Officer and Pediatrics Department Chair at CNMC and by the Chief Medical Officer and Pediatrics Department Chair at HUH.
The plan outlined in the letter included:
* Combining the HUH and CNMC pediatric residency programs.
* Creating a new community health residency track that would comply with ACGME regulations.
* Establishing six positions for each of the three years of the community health track.
* Assigning HUH financial responsibility for the community health track residents' salary and expenses as well as 20% of the CNMC residency program's administrative costs.
* Seeking adjunct academic appointments at the George Washington University School of Medicine and Health Sciences for selected members of the HUH faculty who were involved in directing the community health track.
In addition to Howard University and George Washington University faculty appointments that were already in place, appointments were sought for additional faculty members at both institutions.
Subsequently, CNMC forwarded a letter to the ACGME requesting permission to absorb the HUH residency program by creating a new track within CNMC's pediatric residency program—the community health track—and to increase the resident allotment for all tracks from 72 to 90 (not including chief residents).
The number of residents to be recruited for the community health track represents a decrease from the former HUH residency program (from 13 per year to 6 per year). However, any former HUH residents still in the process of completing residency were allowed to move to the community health track, so 22 continuing second- and third-year Howard residents accepted positions in the new track as part of the merger process. After the initial transition year, future candidates for the merged residency program would receive information on all tracks and would apply to one or more through the National Resident Match Program.
The Howard/CNMC community health track
The main objective for the new community health track is to accentuate the focus of the former HUH pediatric residency program by providing academic learning experiences and clinical care for underserved and minority populations. Specifically, the curriculum focuses on the care of underserved populations, health care disparities, cultural competence, health policy, special populations, child health advocacy, and community-based health care services. From a clinical perspective, the community health track provides residents with core rotations at CNMC that are complemented by inpatient and ambulatory rotations at HUH. Approximately 15 months are spent at HUH and, as per ACGME requirements, 18 months are spent at CNMC. Additionally, these residents are offered clinical, policy, continuity, and/or elective educational experiences that dovetail with the track's curriculum. For example, community health residents could opt to participate in a health policy elective or a school-based rotation. It should be emphasized that, as a result of the merger, the clinical rotation schedule for all residents was impacted and included, at minimum, two clinical rotations at HUH (adolescent medicine and developmental/behavioral pediatrics) for the categorical and primary care tracks. List 2 describes CNMC's three pediatric residency tracks.
In response to these organizational, educational, and clinical changes, the ACGME's Residency Review Committee for Pediatrics issued an official approval of the request in April 2003. A HUH-CNMC Change Management Committee was formed, which included faculty members, the residency program director and associate director, chief residents, and nurses from both CNMC and HUH. This committee held its inaugural meeting in March 2003 and met monthly or bimonthly until June 2004.
The merger posed challenges to both institutions on three main fronts: clinical, operational, and interpersonal. In the clinical sphere, CNMC and HUH residents had been exposed to vastly different patient populations in terms of diagnostic spectrum, volume, and acuity. Specifically, the CNMC residents were involved in the care of a larger volume of patients who were usually sicker and had a wider range of diagnoses than typically seen by the HUH residents. It should be noted, however, that many HUH residents brought significant clinical experience from both foreign and U.S. training sites. The work pace and demands associated with the treatment of a large volume of critically ill neonates, children, and adolescents was particularly challenging for HUH residents who had been exposed only to a small NICU, with limited exposure to a PICU, before the merger.
On the operational front, macro- and micro-level challenges abounded, such as HUH residents' unfamiliarity with the organization of the CNMC hospital, patient units, charts, order entry, and laboratory retrieval systems. Moreover, the relatively short planning and implementation phase leading up to the merger resulted in limited interactive discussions between the CNMC leadership and the front-line clinicians and residents.
Perhaps the most complex and difficult challenge involved the interpersonal sphere. HUH residents struggled with an absence of CNMC peer relationships and support systems, unfamiliarity with personalities and expectations of faculty, absence of relationships with nursing staff, and uncertainty in terms of encountering bias, racism, and elitism from CNMC peers, faculty, and staff. Although each sphere presented a unique set of challenges, the confluence was most acutely felt by HUH second and third year residents. These residents were tasked with supervising junior residents who may have had more clinical, interpersonal, and operational experience at CNMC. The unequal playing field, which at times evolved along racial lines, created a daunting environment to lead and manage.
Several important interventions were implemented to bridge the experiential and racial differences between the HUH and CNMC residents and to maximize the success of the merger. These interventions targeted three specific areas: resident development, organizational change, and curricular innovation. Cultural competence was the cross-cutting theme of each intervention, extending the concept beyond the physician–patient dyad to include resident–faculty, resident–resident, and faculty–faculty behaviors, knowledge, and attitudes. Interventions for residents included multidisciplinary retreats, designation of nurse advocates, resident–resident shadowing sessions, and a hospital orientation program. The resident retreats provided traditional team-building exercises as well as conflict-management and cross-cultural communication training sessions.
Involvement and structure of HUH-CNMC leadership
The process of managing change at the institutional level was led by the 21-member Change Management Committee. This committee was instrumental in implementing the merger and in addressing problems that emerged, such as interpersonal conflicts and cultural differences among residents.
The administrative leadership of the CNMC residency program—a director and an associate director—remained essentially unchanged throughout the merger. The CNMC leadership worked collaboratively with the leadership at HUH to develop the community health track. Community health track decisions were largely made by the pediatric department chair at HUH in consultation with the GME committee at HUH and the CNMC residency director. An additional associate program director at HUH (the first chief resident of the new community health track) was added to the leadership team in July 2004.
Two years after the merger, the leadership structure was further modified. The designated institutional officer (DIO) at CNMC, who had also served as the residency director, relinquished that position to oversee all of CNMC educational programs. The new residency director was chosen from the associate directors. A graduate of the former HUH residency program became the director of the overall CNMC residency program in July 2006. The CNMC residency program leaders report to the CNMC DIO, who, in turn, reports to the chief academic officer/chairman of pediatrics at CNMC/GW. The associate program director of the community health track reports to the CNMC residency director and to the chairman of pediatrics at HUH.
Evaluating Residents' Attitudes Toward the Merger
In the context of this case study, we present survey information obtained from residents at both HUH and CNMC. Notwithstanding the pace of the merger and the time constraints imposed by protocol development, IRB clearances, and staff hiring, the Change Management Committee was committed to obtaining information from the residents who had experienced these events. To do so, we developed a brief, self-administered, anonymous questionnaire using both Likert scales and open-ended questions similar to those that we had developed in the past to survey other groups regarding potentially sensitive issues.11 Given the residents' busy schedules, the questionnaire was designed to be completed in five to seven minutes. Questions focused on the perceived effect of the merger on residency training, patient care, the individual institutions, and child health in Washington, DC. Other questions focused on the perceived adequacy of learning resources for the merger, receptiveness of leadership to feedback, and the residents' overall experience.
After obtaining IRB approval, the survey was distributed to every resident who was available onsite by research staff hired specifically for this purpose. Residents on rotations outside the institution, on extended sick leave or vacation, or with highly idiosyncratic schedules were not available to be given the survey. The data were collected between February and March 2005, approximately two years after the merger.
Surveys were distributed to the 18 community health residents and interns, of whom 15 (83%) participated, and 50 (73%) of the available 68 CNMC/categorical and primary care residents and interns participated, for an overall response rate of 75%. Simple proportions were calculated without any attempts to draw statistical conclusions based on the absence of specific hypotheses and based on the nature of the investigation.
One striking feature of the data obtained was the sharp contrast between the opinions of the HUH and CNMC residents with respect to many of the issues presented. Based on feedback from the 40 residents in 2005 who had experienced the merger either as a former HUH resident or a CNMC resident (of the 65 survey participants, 15 were interns at the time of survey and did not experience the merger), only 13% (4/32) of CNMC residents felt that the merger had positive effects on CNMC as an institution, whereas 63% (5/8) of HUH residents believed it had positive effects. Even more dramatically, whereas 63% (5/8) of HUH residents believed that the merger had a positive effect on the residents and training programs, fewer than 10% (3/32) of CNMC residents held this view. Similarly, whereas 75% (6/8) of HUH residents were positive about the adequacy of learning resources and perceived receptiveness of leadership to feedback, only 19% (6/32) of CNMC residents felt they had been prepared and that leadership had listened to them. Perhaps most distressingly, only 1 of the 32 CNMC residents perceived that the merger had any positive effects on patient care, whereas five of the eight former HUH residents endorsed this opinion. These data, though only descriptive, reinforce the impression that residents from the two programs were sharply distinct and that the effects of prior experiences and expectations had affected their evaluations of the merger.
Despite these sobering results, there were also data suggesting that the merger's disparate effects were disappearing over time as new resident groups came into the system and the merged program was their daily reality. There was a marked effect of class year on opinions regarding the merger success. When asked to evaluate the overall success of the merger experience, the responses of third-year residents from HUH and CNMC were markedly different, with negative responses from the CNMC residents and quite positive responses from HUH residents. By contrast, the second-year residents who had been interns during the merger experience held both more moderate and more similar views. Finally, the new interns, who did not experience the merge because they started their training at CNMC after the merger had been completed, seemed to be relatively neutral about the merger experience and, therefore, remarkably similar.
Lessons Learned from the Merger
The merger of two pediatric residency programs at HUH and CNMC presented unexpected opportunities as well as challenges for CNMC and HUH residents, faculty, and leaders. The increase in both numbers and diversity of CNMC's resident pool and the granting of accreditation for the newly developed community health track were positive outcomes; the magnitude of the institutional change process and the disruption to residents' routines and schedules were significant challenges. The lessons learned from this merger have implications for other residency programs and academic health centers that are striving to diversify their workforce, recruit and retain minority physicians, and/or respond to cross-cultural conflict. Even though institutions may not face change processes of the magnitude involved in this merger, they are likely to be challenged by unanticipated dynamics involving differences of race, ethnicity, and culture.
Differences in residents' perceptions of the success of the merger could be attributed in part to challenges faced by and assumptions of the IMGs who had been residents in the former HUH residency program. Although IMGs are more likely to practice in medically underserved areas than U.S. graduates,12,13 they face challenges gaining admission to the more prestigious residency programs. The residency program merger could be viewed by some IMGs as an unexpected opportunity to bridge the disparity in access to selective residency training programs and to avert the career insecurity and relocation that would result from the loss of accreditation. Any interpersonal, clinical, or organizational challenges faced by HUH residents as a result of the merger could be viewed as minor inconveniences in comparison with the career and personal obstacles that would result from the loss of residency program accreditation.
Conversely, applicants to residency programs may use the percentage of IMGs as an informal benchmark of quality of the training program.14 When faced with the influx of IMGs into the combined residency program, the CNMC residents' perception of the success of the merger may have been influenced by their underlying attitudes and assumptions regarding IMGs. After the merger, a smaller numbers of foreign-trained medical students were accepted into the community health track. This might help explain why the merger was viewed by first- and second-year residents in progressively more neutral terms.
Even though these results are not generalizable to other residency programs, they offer a rare view of pediatric residents' perception of a merger between two vastly different programs. From an objective perspective, the merger is accomplishing what it set out to do. From both curricular and recruitment perspectives, the community health track is thriving. Whereas only one of six positions filled from the match at the time of the merger, all six positions filled in 2005 and 2006. One third of the incoming residents in the community health track in 2005 had dual MD-MPH degrees. Based on the results of the match, the other two tracks at CNMC have remained highly competitive (i.e., no significant change in the match number to fill all slots) since the merger, and the three tracks are currently indistinguishable in terms of the clinical quality of residents. These findings suggest that the caliber of applicants to all CNMC residency tracks has not suffered as a result of the merger. (Outcomes data such as community track residents' board pass rates were not available at the time this paper was written.)
In addition, the uniqueness of the HUH focus on community health has been retained. Because HUH and CNMC were combined into one pediatrics residency program, the percentage of underrepresented minorities in residency at CNMC more than doubled from a premerger level of 11% to 26% in 2006. And, as the questionnaire suggests, the current first-year residents consider the merger a nonevent. They simply feel part of this combined program.
We have learned a number of lessons from our experience. Although we spent considerable energy on being responsive to the HUH residents and their needs, we did far less to prepare the CNMC residents for the merger. Frequent communication between the leadership team and CNMC residents would have provided an important forum to listen and respond to specific issues raised. Although a zero-tolerance policy for bias was understandably adopted and enforced by the merger leadership, it left some CNMC residents feeling that they could not voice legitimate patient-care concerns without having to justify the race-blind nature of their concerns when HUH residents were involved. On the interpersonal sphere, traditional events such as happy hours and other social gatherings, although helpful under most circumstances, were not useful for many HUH residents because many had young families and/or different cultural norms. Finding common ground socially could have decreased some of the difficulties faced in the work environment. Another important lesson learned from the Change Management Committee's perspective was the critical role of a “safe learning space” to initiate, discuss, examine, and resolve difficult issues involving race, culture, bias, racism, classism, and others in an atmosphere of respect, openness, fairness, tolerance, and inquisitiveness.
Although this paper focuses on the residents' responses, it should be noted that a similar questionnaire provided to faculty at both institutions mirrored the responses by the residents regarding lack of communication. Most notably, the faculty at CNMC felt they had not been consulted about this important change. They were quite negative in their assessment of the merger. Given sufficient lead time, more input should have been sought from all stakeholders. It is plausible, however, that this input could have led to resistance that ultimately might have doomed the merger, as has occurred in some recent medical school mergers.4
Faculty members' negative perceptions of the merger, although significant, have not had any deleterious effects on faculty retention at CNMC. Turnover rate at CNMC has not changed appreciably, and three years later there is general agreement by CNMC faculty and residents that the merger was a good thing to do. Interestingly, HUH faculty turnover has spiked, which may be attributed in part to the increase in workload that resulted from a smaller, postmerger HUH-based resident pool.
In summary, the merger of the pediatric residency programs at Howard University Hospital and Children's National Medical Center provided an unexpected and challenging opportunity to develop a community health residency track, to help address accreditation challenges at HUH, and to expand and diversify the CNMC residency program. While meeting these goals, the merger served as an impetus to embed cultural competency guiding principles and expectations into theorganizational fabric.
This project was completed as part of Dr. Batshaw's participation in the Association of American Medical Colleges (AAMC) Council of Dean's Fellowship Program, and he would like to acknowledge the support of Joseph Keyes at the AAMC. The authors would also like to acknowledge the contributions of Dr. Renee Jenkins, Chair of Pediatrics at Howard University Hospital, and Dr. Sohail Rana for their valuable contributions to the merger.