The educational leaders at Baylor College of Medicine (BCM) had a better appreciation than did their peers at the medical schools in New Orleans of the challenges that those schools would soon be facing when, on August 29, 2005, the levees around New Orleans broke after Hurricane Katrina. A few years earlier, BCM had experienced a comparable disaster: the Texas Medical Center, home to 11 hospitals and clinics and 14 academic and research institutions, including BCM and the University of Texas Houston School of Medicine, flooded on June 8, 2001, as a result of torrential rains from Tropical Storm Allison.1,2 The recovery time to resume medical school instruction at BCM after Allison was 18 days. The recovery time to resume medical school instruction at Tulane University School of Medicine, which involved a temporary eight-month move to BCM, was 31 days. Although many who were involved in these historic ventures have written about the lessons learned and the need for disaster preparedness, few of the published articles and presentations have emphasized the details involved in the recovery from Hurricane Katrina.3-23 And the devil is in the details. We wrote this article to tell BCM's story with the hope that some of the details discussed here will help other schools plan for a disaster as well as guide them in giving aid to or requesting aid from another institution at such a difficult time.
The Response Begins
Educational leadership at BCM began to realize the plight of medical students in New Orleans on August 30 when two German medical students who were to begin visiting electives at Tulane appeared in the office of the registrar requesting permission to take courses at BCM instead. The registrar, alerted by their request, then contacted the Association of American Medical Colleges (AAMC) for further information about Tulane's status. The BCM president's office was advised of the situation. In response, the president and CEO of BCM, Peter Traber, MD, immediately asked all senior staff to take whatever actions were necessary to sustain Tulane University School of Medicine. That evening, help for Tulane students was offered to its associate dean for admissions and student affairs, Marc Kahn, MD, who had evacuated to Houston. Contact was also made with faculty of Louisiana State University (LSU) Medical School, New Orleans. It was determined that LSU could best be assisted by the other branches of the LSU system in the state of Louisiana.
It quickly became apparent that BCM did not have clinical space for all of Tulane's 310 third- and fourth-year medical students and its 526 house officers. Medical schools across Texas had already offered to help, and soon the schools closest to each other (by Texas standards) joined BCM to form the Alliance of South Texas Health Science Centers to meet the educational needs of Tulane's medical school. They were the University of Texas Houston School of Medicine (UT-Houston), the University of Texas Medical Branch (UTMB) at Galveston, and the Texas A&M Health Science Center College of Medicine in College Station and Temple (A&M). Faculty and leadership of the Alliance schools and Tulane met on September 7 to ascertain needs and offer assistance.
The major needs expressed by the Tulane faculty were (1) to certify as quickly as possible the whereabouts and safety of the students, staff, and faculty and promote communications with everyone involved, (2) to continue to provide high-quality educational experiences for its medical students and residents, and (3) to restart training as soon as possible so that senior students could participate in the Match and begin residencies on time, and so that residents and fellows could finish training in a timely manner. At this meeting, BCM agreed to host Tulane's school of medicine by providing faculty office and classroom space for first- and second-year students. Dr. Traber announced that BCM would not attempt to recruit Tulane faculty, staff, housestaff, or students during this disaster. All of the other Alliance schools concurred. The Alliance schools offered clinical training spaces for all the 310 third- and fourth-year medical students in either required clerkship rotations and/or electives. A total of 605 Tulane medical students transferred with the school when it relocated to BCM: 305 preclinical students and 300 clinical students. The Alliance schools provided a total of 639 clinical rotations (4 to 12 weeks each); BCM, UT-Houston, and A&M also provided a total of 391 clinical electives (two to four weeks each) for Tulane students. Table 1 shows the distribution of rotations and electives in clinical training at the Alliance schools. The graduate medical education (GME) office at BCM acted as a surrogate office for Tulane's GME program, processing their residents through BCM, providing them with pagers, and, when needed, working with the Accreditation Council on Graduate Medical Education (ACGME) on Tulane's behalf. Table 2 shows the size of each BCM housestaff program and the number of Tulane housestaff supported by BCM's GME office who were integrated into programs in the Houston/Galveston area.
Web Site and E-Mail Hosted by Baylor
Tulane's school of medicine needed a quick, inexpensive, and universal way to communicate with its students, residents, fellows, faculty, and staff. A Web site would have been an ideal solution, but the Tulane information technology (IT) infrastructure was not expected to be online for some time. Therefore, a Web site was created and hosted by the Center for Collaborative and Interactive Technologies (CCIT) at BCM to provide a publicly accessible resource for exchanging public and personal information. Web site development began Wednesday, September 7, and the site was launched on Sunday, September 11. BCM faculty and staff worked with Tulane colleagues in developing the Web site content, design, functions, and administrative tools for approval by Tulane educational leadership.24 The Web site development and support was donated to Tulane by CCIT using internal resources.
Once the structure of the public Web site was finished, a private Web site containing content-administration tools was created for Tulane administrators to create and edit the Web site's content. Students, residents, fellows, faculty, and staff were encouraged to submit personal contact information using a self-registration process where only administrators could view the information. After review, registrants' names and brief messages were available for others to see on the Web site. This resource gave the Tulane community the assurance that its people were accounted for and the means to disseminate transition plans as they were developed.
The Web site also allowed those in the Houston area to request housing specific to their individual needs. Faculty, staff, and students at BCM and UT-Houston were extremely generous in offers of housing. An additional Web-based administrative tool was created for Baylor's Office of Public Affairs staff to match housing requests with offers of housing from the Houston community. Within three days after the Web site's launch, approximately 200 housing requests were matched with housing offers.
The Web site used the https transport protocol to assure secure communication of personal information over the Internet. The five major menu divisions were The School, Students, Residents and Fellows, Faculty, and Staff. Some of the resources included information for program directors, admissions, question and answer forums in seven general topic areas, curriculum updates, lists of located people, MD/MPH announcements, emergency faculty practice plan information, the location of facilities provided by BCM, and a telephone number to contact Tulane administrators housed at BCM. The forums were especially valuable to account for particular groups of students and to construct lists of contact information. The Web site also provided links and phone numbers for contacting disaster relief services including shelters, pharmacy services, insurance claim information, and the Federal Emergency Management Agency (FEMA).
Once Tulane students and staff were registered in the BCM administrative system (see the next section) and assigned BCM e-mail accounts, the BCM IT staff set up four e-mail list servers for education and administrative business, based on student year, and four additional unmoderated e-mail list servers for student-to-student communications. An e-mail address was configured for each list server for sending the same e-mail message to every list member.
Administrative and Logistical Support
On September 8, as the first few faculty and students arrived from New Orleans, temporary offices were set up using several small group teaching rooms. The ability to immediately provide larger and more permanent space for faculty offices and a student lounge/study area was possible within a central BCM building. A temporary wall was erected in a cafeteria shell space previously created to replace the BCM cafeteria flooded during Tropical Strom Allison. This wall separated Tulane faculty offices from student space, and electrical, data and telephone outlets were installed in both areas. Rapid construction of this space resulted, as BCM used its own facilities personnel to perform the work. The dean of medical education's office was responsible for requesting the installation of telephones and the purchase and installation of PCs, printers, copy machines, and student lockers. The faculty office consisted of a single large room with a counter around the perimeter. Chairs and file cabinets were provided from BCM's surplus equipment pool. The student area was furnished with a few surplus tables and chairs and was soon transformed into a more livable space by the Tulane students with the addition of a pool table, TV, and refrigerator.
No Tulane infrastructure was available for acquiring supplies, equipment and services, or paying bills, so BCM staff and systems were used. A Tulane account was established in each academic administrative department, and Tulane was permitted to charge goods and services to these accounts. The accounts were consolidated monthly and billed to Tulane University.
BCM security policy requires everyone entering a BCM facility to have an identification badge. Since Tulane faculty and staff would be on campus for an extended time, permanent badges with photographs rather than paper visitor badges were issued. To accomplish this while maintaining a sense of Tulane identity, BCM's office of public affairs developed a new badge prototype with the Tulane emblem and medical school name on one side of the badge and BCM's emblem and name on a vertical edge of the badge. For a permanent badge to be issued, each individual had to be registered in the corporate accounting system. Setting up personal accounts automatically created BCM e-mail accounts, which facilitated communication with faculty, staff and learners. Permanent ID badges for about 125 faculty and staff from Tulane were requested. For administrative and logistical support, Tulane reimbursed BCM for all out of pocket expenses incurred. BCM staff time for providing logistic support was not billed to Tulane.
Psychological Counseling Services
Immediately after introductions at the meeting with the Alliance, psychological counseling services were offered to faculty, students, and staff from Tulane. Psychological counseling services for students and residents were arranged through the department of psychiatry, which provided similar services for Baylor learners. Ultimately, in total, the BCM Student and Housestaff Counseling Service provided 170 individual student visits, 12 individual resident visits, and 12 resident group therapy sessions, with an average of 7.3 residents at each group session. Tulane did reimburse BCM for psychological counseling services provided to these learners.
Office of the Registrar
The registrar's first task was to determine the number of core rotation and elective slots that would be available for Tulane students, by contacting the clinical departments at BCM and the other schools in the Alliance. A matrix of availability was created using a spreadsheet program. Matching students to available slots was complicated by start date and course length differences in the clerkship requirements of Tulane when compared with those of the Alliance schools. (See Core Clerkships below).
The registrar's office began corresponding with BCM students about housing offers; however, the volume of e-mail correspondence offering help quickly exceeded their ability to respond, and the task was turned over to the office of public affairs. The daunting problem of locating suitable housing was solved quickly using the automated matching tool, mentioned above.
The registrar's office accepted the responsibility of establishing contact with all third- and fourth-year students. The office was given full access to the AAMC Tulane Student Registration System to establish an official student census. In addition this system contained approximately five years of graduation data. The AAMC used their Web site to instruct Tulane students and all medical schools of the policy and procedures to be followed for clinical core scheduling and gave authority to the BCM registrar to confirm all core scheduling for the third- and fourth-year student rotations performed at locations not within the Alliance.
The registrar estimated that by contacting 30 students a day by telephone, she could place the students in rotations from September to December in about 10 days; however, she soon realized that everyone had a story to tell and needed to feel connected. She learned who was expecting a baby (that day) and who had only the clothes he was wearing. She later said that she had never felt more loved and more inadequate. Her staff carried on the duties of running the office while she talked and emailed 16 hours a day to students and to most of the medical school registrars across the nation placing students in core and elective rotations and recording their whereabouts on a spreadsheet. The office purchased more than 600 manila folders to begin establishing new academic records for each Tulane student.
In addition to registering the students for clinical rotations, students also required assistance with letters of good standing, course evaluations, course registration documents for those registered in courses away from the main campus, approval for United States Medical Licensing Examination registration, loan documents, certification of graduation, transcripts, and notary services. The office designed forms including a letter of good standing that explained what the office knew to be true and what the office had no way of knowing. They created a generic evaluation form and sent them around the nation in true just in time fashion to get most students started in a minimum eight-week string of medical education sessions. The office provided exam proctoring and grading services as well.
Help from Tulane came and went as the faculty and staff were dealing with every conceivable personal tragedy. The AAMC sent two staff members for three days to help obtain information on the whereabouts of Tulane students who had already secured away-electives before Katrina. As September 26, the proposed starting date for Tulane students, approached, along came another category four hurricane, Rita, this time heading straight for Houston!
A few days earlier, on September 21, the registrar had sent files to the AAMC that, if needed, could help reestablish the educational records of both Tulane and Baylor. Houston did not suffer a direct hit from Rita, but did have to move the opening day of school for Tulane students to October 3, which also happened to be the opening date for Baylor's accreditation site visit from the Liaison Committee for Medical Education (LCME).
Office of Student Affairs
The Office of Student Affairs in conjunction with BCM's IT department created a student e-mail list server for gathering the external e-mail addresses of all Tulane students so that students could contact each other. Eventually, official and unofficial list servers for faculty-students and student-student communication were created.
Classrooms and auditoria under control of the office were reserved for Tulane classes. BCM preclinical classes were held in the morning in two 300-seat auditoria; small group classes met in the afternoon. The small group rooms were reserved for Tulane in the mornings with their large classroom sessions beginning at 2:00 in the afternoon. This arrangement allowed BCM students to eat lunch from 12:00 to 1:00 and Tulane students to eat lunch from 1:00 to 2:00, reducing overcrowding in BCM's small dining facilities.
The office planned and coordinated a half-day orientation on Saturday, October 1 for Tulane students in which 97% of those who were registered participated. The office also coordinated pager rentals for Tulane clinical students in conjunction with BCM telecommunications and requested ID badges for all students. For senior students at each school, the office also facilitated two Match Days on the same date but in different locations on campus, maintaining the Match Day traditions of each school. Whereas all seniors at BCM simultaneously open their envelopes indicating where they have matched, Tulane's tradition had each student in the school open his or hers one at a time to announce to the other members of the class where each had matched for residency.
The Baylor Student Association, with support from the office of student affairs, involved Tulane students in all social events planned for students at BCM in an attempt to be inclusive and to avoid as much as possible an us and them relationship. Tulane also sponsored a Baylor Thank-You Day in the spring providing a crawfish boil-Mardi Gras celebration for many who had helped the school.
Office of Admissions
Although Tulane critically needed to satisfy the educational needs of current students, it became clear that the future was vested in enrolling a new medical school class for the following year. This involved careful coordination of the offices of admission at both schools. In essence, the Tulane Office of Admissions was placed in contiguous space with BCM's Office of Admissions. Two computer systems were purchased for use by the Tulane admission staff. BCM then developed an online process to enable Tulane faculty and deans to screen and review medical school applications. Through productive communication with the American Medical College Application Service (AMCAS), BCM was allowed to access information and application materials for all applicants who applied to both Baylor and Tulane. This procedure required a temporary change in AMCAS policy, which both schools considered vital to the initial data acquisition. BCM and Tulane could then identify applicants who applied to both institutions and offer those individuals interviews at both institutions if schedules could be coordinated.
After the AMCAS database was established for Tulane at BCM, Tulane was able to independently invite and interview applicants at its discretion. BCM's Office of Admissions coordinated the use of a conference room for Tulane's orientation session for applicants and helped orchestrate the needs of applicants invited for interview. It is important to note that BCM personnel remained totally separate from the Tulane applicants while they were on-site. BCM's Office of Admissions did not recruit or in any way influence the applicants to vary from their sole purpose of obtaining a Tulane interview.
The Tulane and BCM admission offices, deans, and staff had excellent rapport and camaraderie throughout the post-Katrina events. BCM was gratified to have helped Tulane through their modified admission process, and Tulane recruited a complete class for the 2006-2007 academic year with grade-point averages and MCATs similar to those of previous years.10 That this occurred was remarkable; we can only speculate on what drew sufficient numbers of high-quality students to Tulane after such a disaster.
Financial Aid
The Office of Financial Aid at BCM had only minimal contact with the Office of Financial Aid at Tulane. The office provided space for the Tulane staff to meet with students, collect forms, answer general financial aid questions, and provide contact information to the students who came by or called. Tulane's financial aid system is managed outside of Tulane, and once the staff was able to access the system, students could be informed of their funding and how soon they could anticipate receiving funds.
On occasion, the office had a surge of students who needed to meet with the Tulane financial aid counselors. The office set up a schedule for the counselors to be on-site twice weekly and had a sign-up sheet for students. The office was generally able to accommodate the flow of students, but as a back-up plan, a conference room was scheduled for any overflow. The professionalism of the Tulane staff contributed to the overall efficiency of the move to BCM.
Many students are stressed financially while attending medical school. Many Tulane students bore the added burden of losing everything they owned in a flood, including computers, cars, clothing, books, furniture, and, in some cases, even the rent they were paying on an apartment in a town where they were not currently living. Many students had also paid for on-campus housing, which was no longer available. There is no on-campus housing at BCM. The result was that some students needed more financial help than the average medical student does.
Many people sent unsolicited gifts of money for the sole purpose of helping Tulane students. By October 24, 2005, BCM's Office of Development had received $176,045, which included a gift of $100,000 from The Michael E. DeBakey Foundation; Dr. DeBakey graduated from Tulane University School of Medicine in 1932. All of the money collected was designated specifically for helping Tulane students with expenses that Tulane could not apply for reimbursement by FEMA. Approximately $35,000 was used for Metro passes for Tulane students, program/curriculum development or enhancement, book funds, resume/placement consults for spouses, and emergency housing funds. In addition, $40,500 was given to Tulane as reimbursement for lost revenue from foreign medical students and $100,000 was used for scholarships (see Epilogue).
Support of the Preclinical Curriculum
Once the Alliance schools identified the resources required to resume UME classes, course leaders under the direction of Kevin Krane, MD, vice dean for academic affairs and Marc Kahn, MD, associate dean for admissions and student affairs, began reassembling the Tulane preclinical curriculum based on the needs of the students and the teaching resources available. This included the teaching of the anatomical sciences in the first year, and the system-based courses on pathology, pharmacology, pathophysiology, and microbiology in the second year. A commitment was made to keep the Tulane students together in their own classes and, when possible, to use Tulane faculty. Teaching materials and instructors from UT-Houston and BCM were used for certain topics when Tulane resources were not available.
The senior associate dean and the assistant dean of medical education relinquished their offices to the educational leadership of Tulane, including both Drs. Krane and Kahn, as well as Ian Taylor, MD, PhD, the associate senior vice president for the health sciences and the dean of the school of medicine. In two weeks, these Tulane educators, with borrowed portable computers in their laps and no clerical help, and with the support of key Tulane course directors, completed the revised Tulane preclinical curriculum.
BCM's Office of Curriculum provided some clerical support, allowed Tulane to charge supplies to an Office of Curriculum account until Tulane's cost center was established, and arranged online access for Tulane students and faculty to streaming video files of past BCM lectures. The office also held a welcome reception at a local restaurant for Tulane deans and faculty to meet BCM deans and faculty involved in curriculum. Drs. Krane and Kahn were invited to participate as liaisons on the BCM Medical School Curriculum Committee. They also attended regular weekly curriculum office deans meetings. The newly purchased Harvey Simulator, managed by the office, was made available to Tulane students and faculty. Faculty in the office developed online surveys to capture stories from faculty, students, and residents from both Tulane and BCM about the Tulane experience at Baylor (see Student, Resident, and Faculty Surveys below).
Anatomy, Histology, and Neuroscience
Because the BCM Anatomy department had accommodated UT-Houston medical and dental school students after Tropical Storm Allison, they felt confident that, with a little schedule revision, the department could accommodate the Tulane students.
Gross anatomy was taught by sharing BCM cadavers. Each cadaver was shared by five BCM and five Tulane students. Each school's students were taught by their own faculty and each group dissected a different part or a different side of the cadaver. The histology (microscopical sciences/cell biology) and neuroscience courses were accommodated in similar fashion. Because of a loss of some of Tulane's faculty in these areas, the BCM faculty contributed lectures where needed.
By careful attention to scheduling there were no significant conflicts in shared facilities. Even though Tulane classes were meeting more frequently than BCM classes, their faculty managed to schedule lecture rooms and labs with remarkable efficiency.
As the BCM faculty worked with the Tulane faculty, they each recognized from the other beneficial teaching innovations and teaching tools. This collaboration led to the production of practice-based-learning-type anatomy teaching cases. In addition, BCM anatomy and neurosciences faculty visited Tulane after their return to New Orleans to see their new facilities and teaching equipment. This interchange continues.
Core Clerkships
Scheduling third- and fourth-year medical students in clinical rotations and electives had its own unique set of challenges, not the least of which was the difference in the length of clerkships at each Alliance school, dates at which they began and ended, prerequisites for particular electives, and students moving, sometimes with their families, to different locations for clerkships and/or elective experiences. When Tulane students joined clerkships or took electives in Alliance schools outside of Houston, each Alliance school tried to offer a minimum of eight weeks of clinical experiences for the Tulane student. Although both schools required seven clinical core clerkships, the lengths of the medicine, psychiatry, surgery, and family medicine clerkships were different. In addition, Tulane required two weeks in the emergency room and in radiology.
When Tulane students evacuated New Orleans, many returned to their family homes, some as far away as Hawaii. About one half of the third- and fourth-year medical students enrolled in electives or clerkships at medical schools near their homes. To assure that Tulane students would be supervised by Tulane faculty, the LCME allowed clinical medical students to take a maximum of one core clerkship or two clinical electives as a visiting student at an accredited medical school outside of the Alliance and they ruled that no more than 50 per cent of Tulane students at one time could be in schools outside of the Alliance. To receive credit, all clerkship evaluations had to be completed on a Tulane evaluation form and reviewed by Tulane faculty. Students with unique circumstances were evaluated on an individual basis by the Tulane administration.
The LCME required constant communication with BCM educational administration to be assured that there would be no decrease in the quality of medical education for BCM students. Dr. Frank Simon, at that time American Medical Association Secretariat for the LCME, was also the secretary of BCM's site visit team, October 2 to 5, 2005. He met privately with school leaders from each school to confirm that the medical education of students at each school was not compromised by having two medical schools on one campus.
Student, Resident, and Faculty Surveys
From late October through the first part of March, the online survey mentioned earlier was available to all BCM and Tulane students, residents, and faculty. Ninety-six people used the survey to comment on the BCM/Tulane experience. One of the BCM faculty said,
I have been privileged to have several Tulane medical students join my rotation. This has been an excellent experience-not only for me, but also for the Baylor students and residents. The educational experience of all involved has been enhanced rather than compromised. I am proud to be a part of this effort.
A BCM student commented,
I had many opportunities to interact with fellow students from Tulane. I had a student live with me for a couple of months. I also had Tulane students on clinical rotations who were bright and eager to learn and certainly added to the teams. At times the system was a bit overwhelmed by the number of new students, but given the circumstances we were always happy to have the Tulane students. I appreciate our administration being receptive to allowing the entire medical school to relocate here, and would do the same again in a heartbeat.
A Tulane student said,
This is a great opportunity to thank Baylor College of Medicine. I feel so welcome. This is a tremendous positive experience. Every where I go they treated me with respect and compassion, and I am surprised of the spirit and willingness to help that Baylor community shows. I am really enjoying this stay.
Most of the issues raised by students related to study space and computer use in the Educational Resource Center (ERC) as exam times approached. In response, the ERC added tables and expanded hours during exam periods. In addition, the Tulane dean asked the Tulane students to use the Texas Medical Center Medical Library, which is directly across the street from BCM, and the newly created Tulane student study/lounge space rather than the limited study space in the ERC. Although it may be hard to believe, these issues, and a few regarding clerkships (reported below), were the only ones raised. The process of integrating Tulane and Baylor students worked remarkably smoothly because everyone was completely supportive and worked together to help the Tulane students and programs. At the risk of being accused of bias, we must state that the unbelievable unselfishness of people from all over Texas, and especially of the individuals at BCM, in making this huge effort succeed cannot be underestimated.
The department of pediatrics also conducted a survey of students who took the core clerkships in academic year 2005-2006 to determine the impact of having both groups of students in the same clerkship. One hundred and thirty-seven students were surveyed-114 from BCM and 23 from Tulane. Of those, 111 students from BCM and 23 students from Tulane (98%) completed the survey. Of those completing the survey, 67, or 50% (48 from BCM, 19 from Tulane) said there was an impact, and 67, or 50% (63 from BCM, 4 from Tulane) said there was no impact on the clerkship. Regarding the question of whether the clerkship experience had been positive or negative, 40 BCM and 17 Tulane students (36% and 74% of the 67 students who responded to the question) reported a positive impact. The positive comments of BCM students focused on Tulane students' resiliency, great outlook, and different perspective, and Tulane students said that the BCM people were welcoming and that they enjoyed interacting with BCM students. Seven BCM students reported the impact on the clerkship as negative, and two Tulane students indicated that the impact had been both positive and negative. The negative comments of BCM students focused on the reduction in the number of patients each student could see, and that the Tulane students had been on more rotations before pediatrics and were potentially showing up the BCM students. Negative comments from Tulane students stated that some BCM students seemed resentful, and they felt at a disadvantage with the different methods of administration.
Medical Licensure and Malpractice Insurance Coverage
The Texas Medical Board devised a streamlined method of processing incoming Tulane resident physicians, most of whom had no documentation of training or medical school attendance. The Tulane resident physician applicant signed an attestation, along with the BCM or another sponsoring institution's program director, stating supervision of the Tulane resident physician would be provided by a fully licensed Texas physician. Tulane faculty were provided temporary Texas licenses with a one-page application that a Baylor faculty who knew the Tulane faculty member signed to vouch for their credentials and standing in academic medicine. The license restricted clinical activity to one of the four Alliance medical centers. It allowed Tulane faculty to conduct clinical teaching rounds in the Texas schools. The turnaround time was 7 to 10 days. Those Tulane faculty and residents working only at the Michael E. DeBakey Veterans' Affairs Medical Center were able to function under their out-of-state federal credentials.
The Tulane legal department obtained malpractice coverage for faculty and residents by modifying the policy so that Tulane residents and faculty were covered in Texas under the Tulane umbrella policy. The Tulane practice plan paid for malpractice insurance.
Tulane Faculty
Many institutions and research groups from across the nation reached out to Tulane's basic science faculty. Some of the researchers were fortunate enough to find homes with collaborators at other medical centers, including some of the Alliance schools.
Although Tulane's clinical faculty had temporary Texas licenses, most were involved only in teaching rounds and overseeing medical students at institutions affiliated with the Alliance schools. Tulane medical faculty helped at the Houston Astrodome, where many people had evacuated from New Orleans, and staffed an outpatient clinic established within the Baylor Clinic for Tulane students, residents, faculty and their dependents. On a limited basis, Tulane faculty also used this space in the Baylor Clinic to see some of their private patients who had evacuated to Houston.
A significant number of Tulane's clinical faculty were able to work in hospital affiliates in Louisiana. Faculty members with Department of Veteran Affairs (VA) appointments were able to transfer to other VA medical centers across the country. VA medical centers are federal facilities and therefore recognize a physician's current license to practice medicine from any state in the union. Drs. Kahn and Taylor both had part time appointments at the VA Medical Center, New Orleans, and transferred their affiliation to the Michael E. DeBakey VA Medical Center in Houston to which many of the patients at the New Orleans VA had been transferred. They both attended morning report there. Many of Tulane's faculty joined in the attending rotation on the wards at the Houston VA.
Although BCM and the other Alliance schools worked hard to sustain the school of medicine at Tulane, Tulane's medical school faculty members were not so fortunate. By December, 70 faculty from the school of medicine had resigned for both personal and professional reasons. Because all three of Tulane's teaching hospitals had closed along with all of New Orleans' public and private school systems, many faculty, predominately in the clinical departments, movedclose to family or to colleagues at other institutions where they entered their children in the local schools. Some moved to other academic institutions or entered private practice outside of New Orleans. In December, Tulane University's renewal plan called for the separation of more than 100 additional tenured and nontenured faculty, although a compensation package was provided to all of these faculty members. Additional faculty also left voluntarily before the next academic year. As a reference, on July 1, 2004, for academic year 2004-2005, the Tulane University School of Medicine employed 534 full-time faculty; for the same date in 2006 and for academic year 2006-2007 the number of full-time faculty employed by the school of medicine was 309.
Graduate Medical Education
BCM's graduate medical education (GME) program had just completed its first full year of transition from one primary private adult hospital affiliation to another. Fortuitously, this transition necessitated considerable interactions between BCM and the ACGME during the preceding year. BCM was also preparing for its own ACGME Institutional Site Visit in January 2006, with a new associate dean for graduate medical education, new director of the office of GME, and new chair and vice chair of the GME committee. Baylor sponsors 1,200-plus residents in 80 ACGME-accredited programs with an additional 75 Texas Medical Board (TMB)-approved programs.
When the magnitude of the situation in New Orleans became apparent, BCM's associate dean for graduate medical education called an emergency meeting with BCM program directors to assess their capacity to absorb additional residents from Tulane, LSU, and Ochsner Hospital should such requests arise. In preparation for the meeting with the BCM program directors, the GME office gathered preliminary data about Tulane, LSU, and Ochsner's GME programs, including program types and resident numbers. Using data from the ACGME Web site, the GME office learned that Tulane's GME program had 496 residents, LSU's GME program had 620 residents, and Ochsner's GME program had 187 residents. Not only did the meeting draw almost every BCM program director, with less than three hours notice, but by this time many of the BCM program directors had already begun networking with their New Orleans colleagues.
After the September 7 meeting of the Alliance schools with Tulane, the Tulane designated institutional officer (DIO) and associate dean for GME, Ron Amedee, MD, and his immediate staff were relocated to space in the BCM GME Office. They were given necessities with which to begin work, such as desk and office space and computers. BCM provided the Tulane DIO with a listing of BCM programs, and he began comparing Tulane's needs to BCM's estimated capacities. The University of Texas Health Science Center at Houston, St. Joseph's Hospital, the University of Texas Medical Branch at Galveston, and The Methodist Hospital all stepped forward to assist in providing training opportunities for Tulane residents that BCM GME could not meet. Some specialties, including obstetrics-gynecology and anesthesiology,25 developed truly integrated residency training experiences for Tulane residents across multiple sponsoring institutions. (A description of the BCM-Tulane obstetrics-gynecology residency training experience was given by Young and colleagues in a paper presented at the 2007 APGO/CREOG Annual Meeting, Salt Lake City, Utah, on March 9, 2007.)
The DIOs at both institutions communicated frequently with Jeanne Heard, MD, executive director of the ACGME Residency Review Committees (RRCs). Dr. Heard and the executive directors of the 26 RRCs and the institutional review committee had developed an internal plan to allow consistency among the RRCs and to expedite RRC approval of requests from either BCM or Tulane. Tulane and BCM GME leadership met with all Tulane and BCM residency program directors to develop program-specific proposals to submit to their respective ACGME RRCs. The ACGME RRCs generally reviewed and responded to these requests quickly. In most instances, the proposed Tulane plans were accepted with minimal change by the ACGME. Each program's proposal to the ACGME had to include information for each and every resident about specific planned curricula, including rotation assignments, anticipated patient volume and case distribution as well as general information about supervision, evaluation, and duty hours.
Although residents could use the BCM-hosted Tulane Web site to find housing, many more residents than students were relocating families and/or pets, so in most instances the Web site housing match mechanism was not a viable alternative. Local real estate companies who provide service to BCM housestaff physicians were enlisted and quickly located blocks of temporary housing. The goal was to provide quick, inexpensive, and furnished housing, but also to keep as many Tulane residents geographically close, again to provide some level of normalcy and community. If these locations were near public transportation, arrangements were made for bus and rail passes. If not, the Texas Medical Center contracted for parking spots directly with Tulane. This was one of the more challenging aspects, as parking is already in short supply in the Texas Medical Center and surrounding areas. Local financial institutions were also contacted to provide emergency loans for the incoming Tulane residents.
Initially, Tulane and BCM considered having the Tulane residents transfer into BCM-sponsored residency programs. However, Tulane ultimately, and wisely it turns out, decided to remain the sponsoring institution for almost all of the Tulane residents as they rotated through BCM-sponsored residency program rotations at BCM affiliated institutions. The Tulane residents, therefore, remained as Tulane employees, with Tulane providing these residents' benefits and pay. However, because the benefits package included medical care that now had to be provided by physicians and hospitals in another state, arrangements were made for a Tulane-run clinic. The Tulane medical insurance for students, residents, and faculty was expanded to include local physicians as well. Tulane residents were issued identification badges that would allow them to work in the various Texas Medical Center facilities as BCM residents. This hiring by BCM also gave each resident a free e-mail account. These residents were encouraged to wear their Tulane coats, and for those who did not have a white coat, the BCM Bookstore made arrangements for deeply discounted prices and quick turn-around times. Pharmaceutical and textbook companies, along with many national specialty organizations, offered supplies to all displaced New Orleans resident physicians.
Although residents rotated through multiple hospitals pre-Katrina, Tulane was a common paymaster, so salaries and benefits were not affected. In many other systems, salaries and benefits for residents are paid by each hospital at which they work. Had this been the case at Tulane, it would have caused major problems in terms of salary and benefits.
BCM did not provide direct funding to Tulane, nor did it charge Tulane for BCM's GME services. Indirect BCM GME costs never charged back to Tulane, however, were probably significant. During the weeks of September 19 through 23 and 26 through 30 as well as October 3 through 7 and 10 through 15, BCM's GME staff provided considerable support to Tulane estimated at 2.4 FTE for staff, 0.2 FTE for the GME office director and 0.15 FTE for the associate dean for GME. Baylor GME and its general counsel also assisted Tulane's efforts to obtain CMS reimbursement for the Tulane residents.
On October 3, 2005, 222 Tulane residents began clinical rotation assignments at BCM-affiliated institutions or at Alliance institutions in the Houston area (Table 2). A few residents did not actually begin until October 10, 2005, because of delays caused by Hurricane Rita. The ACGME had originally requested that all Tulane residency programs' plans be submitted to the RRCs by September 30, 2005. However, because of Hurricane Rita's threat to Houston, the ACGME extended this deadline to October 7, 2005. The ACGME essentially agreed to grant all Tulane and LSU residents credit for September, as long as these residents were able to begin training in BCM-sponsored programs and affiliated hospitals (or at one of the other involved Texas sponsoring institutions) in October. This allowed most Tulane residents to keep their residency training time-line intact and their anticipated dates of graduation as originally scheduled.
Epilogue
A disaster-management plan
As a result of the BCM-Tulane experience, BCM developed a disaster-management plan, which was presented at the AAMC's First Joint Professional Development Conference for Financial Aid and Student Records in January 2007. (See Chart 1 for this document's table of contents.) The Plan contains vital information for faculty, staff, residents, postdoctoral candidates and students in situations that threaten lives, research or property of any medical school. At all times, the priority of the Plan is to safeguard the lives of faculty, staff, residents, postdocs and students. The Plan also seeks to provide for the safety of the institution's research and to protect the facility.
The Plan provides for the mobilization of resources within BCM to respond to emergencies and/or disasters and is applicable to all faculty, staff, residents, postdocs, and students, regardless of their physical location in the campus area. BCM employees who have offices in one of the outlying areas or in leased space should follow the procedures of those buildings regarding emergencies and disasters if available.
The Plan applies to both administrative and academic departments of the college, and is supportive of, and will be coordinated with the plans of BCM-affiliated hospitals, the center, and efforts of the local, state, or federal authorities having jurisdiction. Authorities having jurisdiction may include, but are not limited to, the fire department, including the HAZMAT team, the police department, the FBI, or other outside government agencies. A copy of this plan with references to BCM and the Texas Medical Center removed can be found at (http://www.aamc.org/members/gsa/cosfa/2007pdc/disaster_planning.pdf) and may serve as a reference for other schools as they develop plans for natural or man-made disasters.
What BCM learned
BCM learned a lot from this experience. In response to witnessing the aftermath of Katrina, BCM now requires all resident physicians to maintain an alternate e-mail account with a commercial provider such as Yahoo or Microsoft MSN Hotmail. The e-mail addresses associated with these accounts are contained in a disaster list server maintained by BCM's GME program. Beginning in July 2007, with the implementation of E*Value as a GME management system, resident physicians are asked to provide an emergency telephone contact number outside of the Gulf Coast area. Also, in response to the threat from Hurricane Rita, several BCM residency programs established toll-free phone numbers with recorded information and instructions as a means for quick communication.
It is crucial that an emergency team for centralized LCME and GME administration and for each individual residency program be established before a disaster. Relying on individuals to lead faculty, staff and resident physicians while dealing with potentially devastating personal loss themselves seems beyond what most would consider reasonable. If adequate preparations have been completed ahead of time, a school's leadership team could be evacuated to a predetermined location to provide emergency leadership, coordination and oversight. Beginning in July 2007, BCM's GME program requests each program director to maintain a list of faculty and resident physician volunteers willing to remain in the Texas Medical Center in the event of a disaster. This plan gives individuals who wish to remain in relative safety the opportunity to prepare in advance, and those individuals who need to leave to protect their families can do so without worrying about maintaining clinical care coverage.
While having Tulane as our guests, the institution underwent both an LCME and an ACGME site visit. As a consequence of these visits, both the medical school and the GME programs received continued accreditation for the maximum amount of time: eight years and five years, respectively. Also, both the LCME and the ACGME recognized the efforts put forth by BCM in hosting Tulane.
The students, residents, and faculty from Tulane have made a lasting positive impression on those of us from BCM who worked with them. Their can-do attitude in the face of adversity cannot be overstated. They also added a Mardi Gras flair to Match Day and did small things like sending plaques to the clerical assistants of each of the core clerkships in appreciation for their work. Also on Match Day, the Tulane 2006 graduating class presented a beautiful picture of a grave monument that can be found in a cemetery in New Orleans. (See Image 1.) It pictures an angle with folded wings slumped in grief over a grave marker. In the matting of the picture, each graduate wrote a short note of thanks to the school.
By mid-May 2006, most Tulane residents and medical students had returned to New Orleans. Dr. Traber was asked to speak at the Tulane commencement exercise where he announced two endowed fellowships of $50,000: one for a medical student attending BCM who had graduated from Tulane and one for a student attending Tulane medical school. As part of his address he said,
We believe that these scholarships will serve as an enduring tribute to the administrators, faculty, trainees, and staff of our institutions who were true leaders at a critical time in history. Although your medical degree proudly bears the name Tulane, remember that you will forever be part of the Baylor College of Medicine family. Your presence enriched us, and we were humbled by your gratitude.
There has been much written about lessons learned from Hurricane Katrina, and we offer the following:
* Communication: It is important to have a Web site, not dependent upon the institution's IT infrastructure, where everyone can get information and check in. It is equally important that institutional leaders at all levels be able to communicate effectively with one another. People who think out of the box are a real asset in time of disaster.
* Cooperation: It is necessary to identify a command center for leaders, faculty, and students involved in reconstructing the curriculum, one that has sufficient space for groups of individuals to gather and meet. This space needs to be comfortably located and easy to find. When two schools are on one campus, the ability of all to work together will determine the success of the venture.
* Curriculum: The particulars of reconstructing the curriculum are hard to anticipate and are a function of the number of days lost and the number of faculty available to teach. Clinical faculty are likely to be harder to relocate than basic science faculty. Moving the preclinical curriculum to a new site is a lot easier than moving the clinical curriculum. When moving the clinical curriculum for medical students and residents the adequacy of patient resources and clinical settings is paramount. In 2004 physicians of the TMC managed 5.2 million patient visits, including visits from over 10,000 foreign patients. Because of this patient volume, medical students from schools in the TMC and Tulane were assured of adequate patient contact as they continued medical training.
* Collaboration: The BCM/Tulane activities we have described in this article would not have begun without the complete support of Dr. Traber and BCM's leadership. Nor would it have been successful without the spirit of collaboration between BCM and the medical school leaders from Tulane: Drs. Taylor, Krane, and Kahn. Collaboration is a win/win situation. Because of the collaborative nature of the main players at each school, decisions were made at all levels so that, to the fullest extent possible, both schools could win. People at all levels collaborated with one another. In situations like this, when much is happening very quickly, the value of having many levels of individuals involved with clearly identified roles cannot be overemphasized. They can serve as liaisons to individuals who make decisions more directly or provide resources.
* Contact with accreditation bodies: It is crucial to keep the ACGME and the LCME informed and to get their input to avoid erroneous assumptions about what is and is not going to be permitted during the unusual times caused by natural or man-made disasters (e.g., credit for clerkships taken elsewhere).
* Compassion: People need time and opportunity to tell their stories and to be buoyed up and encouraged. We recommend that victims of disaster be encouraged to talk about what they have been through and offered professional counseling if they want it.
Out of devastation, something wonderful arose: a special bond between BCM and Tulane that will be forever linked to the memory of Hurricane Katrina. As a result, the return of Tulane to New Orleans evokes both joy for their homecoming and a tinge of sadness as our halls are a bit quieter now that a part of us is gone. Faculty and staff at BCM have been asked frequently: How could you take Tulane's medical school in? Our blanket response is; How could we not? In medical education a discussion frequently on the table is how to teach humanism and professionalism; we teach it best by modeling it.
The members of the Writing Committee, all of whom are administrators, faculty, or other staff at Baylor, are Stephen B. Greenberg, MD, chair, Writing Committee, and senior vice president and dean of medical education; Linda B. Andrews, MD, associate dean, Graduate Medical Education; Lori R. Baker, chief publications coordinator, Public Affairs; Claire M. Bassett, vice president, Public Affairs; Cassius B. Bordelon, Jr., PhD, course director, Anatomy; Lisa G. Chebret, registrar; C. Michael Fordis, Jr., MD, director, Center for Collaborative and Interactive Technologies, and senior associate dean and director, Office of Continuing Medical Education; Yvonne Lane, director, Office of Scholarships & Student Financial Planning; Jacqueline E. Levesque, AEd, director, Office of Graduate Medical Education; Lloyd H. Michael, PhD, senior associate dean, Medical Education, Admissions; Amy B. Middleman, MD, MSEd, MPh, clerkship director, Department of Pediatrics; John T. Rapp, MEd, director, Office of Student Affairs; Boyd Richards, PhD, director, Office of Curriculum; John R. Searle, PhD, director of technical operations, Center for Collaborative and Interactive Technologies; Peter G. Traber, MD, president and CEO; Joseph N. Workman, executive director, Office of the Senior Vice President, and dean, Medical Education.
Dedication This report is dedicated to the faculty, staff, residents, and students of Baylor College of Medicine, whose generous spirit and hard work made this unique venture with Tulane University School of Medicine possible.
Acknowledgments
The authors would like to acknowledge the work of Drs. Major Bradshaw and Rebecca Kirkland, Sr. Vice President and Dean of Medical Education and Sr. Associate Dean of Medical Education, respectively, during academic year 2005-2006 for their invaluable help throughout this unexampled experience.
References