Conlay, Lydia A. MD, PhD; Searle, Nancy S. EdD; Gitlin, Melvin C. MD
The city of Houston knows disasters. In 2002, Tropical Storm Allison caused torrential rains and flooding, forcing the closure of many institutions in the Texas Medical Center (TMC). Twenty years prior, Hurricane Alicia caused significant damage, breaking windows and uprooting trees when it swept through the city. In 2005, the possibility of disaster confronted Houstonians again in the months just preceding Hurricane Katrina, with terrorist threats to the city as it hosted some 70,000 visitors for the Super Bowl. Because of this history, Houstonians pride themselves in being prepared and having a plan for any type of disaster, whether natural or man-made. But no one in Houston, at Baylor College of Medicine (Baylor), or in its department of anesthesiology was prepared to precipitously host an additional medical school or residency program after a disaster. Such a move had never happened before.
In September 2005, in the aftermath of Hurricane Katrina, the Tulane University School of Medicine relocated its medical school to the Baylor campus in Houston, Tex. (For a description of that remarkable process, see the article by Searle in this issue of Academic Medicine.) The fate of Tulane's graduate medical education (GME) programs was more varied. Only two programs—anesthesiology and obstetrics–gynecology—were fully integrated into the TMC.1 The rest of them dispersed: some moved to Houston, others across the country. In this article, we summarize the events that surrounded the relocation of the Tulane residency program in anesthesiology, including the constraints under which everyone involved operated, the actions that were helpful and those that were not, and the lessons learned and those that are still being learned. In retrospect, many of our lessons seem obvious. But they were not obvious at the time. We hope this article will be useful to others forming contingency plans, should they find themselves in a similar situation.
Why the TMC?
The TMC is the largest conglomeration of medical facilities in the world. It houses over 6,500 acute-care hospital beds and two medical schools, the University of Texas at Houston (UT Houston) and Baylor, each with its own training program in anesthesiology.2 Residents from these programs have the opportunity to rotate at a number of different hospitals, including the St. Luke's Episcopal Medical Center, which includes the Texas Heart Institute, the Memorial Hermann Hospital, the Ben Taub General Hospital, the Michael E. DeBakey Veterans Affairs (VA) Medical Center, the Texas Children's Hospital, the M.D. Anderson Cancer Center, and the Lyndon Baines Johnson Hospital just north of town.
At the time of Hurricane Katrina, many if not most of the anesthetics in the TMC were performed by anesthesiologists working alone (as in the case of Texas Children's Hospital and the Texas Heart Institute), or by the anesthesia care team, which consists of anesthesiologists supervising certified registered nurse anesthetists (as in The Methodist Hospital or St. Luke's Episcopal Hospital). With an annual surgical case volume in excess of 118,000,2 the TMC could support additional residency training positions with relatively minor reallocation of resources. The TMC had also received many new patients after the evacuation of New Orleans, further increasing both the surgical and anesthetic case volumes.3 This was especially true at the Michael E. DeBakey VA Medical Center, which accepted patients from the New Orleans VA Hospital after its closure. Serendipitously, the department of anesthesiology at Baylor had recently reduced its class size in an attempt to standardize its curriculum and improve the quality of residents' education. So, for these reasons, at the time of Hurricane Katrina, the anesthesiology training programs in Houston possessed, or could easily make available, additional capacity for clinical training in anesthesiology.
Before Hurricane Katrina had existed, the Tulane program had established affiliation agreements with the Texas Heart Institute for rotations in cardiovascular anesthesia and with M.D. Anderson for rotations in thoracic noncardiac anesthesia and neuroanesthesia. The familiarity of Tulane residents with TMC institutions from having rotated at those institutions would ultimately play a significant role in their decisions to move to Houston.
A Consortium, An Offer, A Plan
On September 1, 2005, barely 72 hours after the levees broke in New Orleans, Baylor's associate dean for GME initiated an assessment by asking the school's chairs whether there was additional capacity to accommodate Tulane residents. Although Baylor's anesthesiology program had some additional capacity, it was not consistent throughout the training continuum. By working collaboratively with other local programs, it seemed possible that more Tulane residents might be accommodated. A conference call was convened with departmental leaders at UT–Houston, University of Texas Medical Branch at Galveston (UTMB), M.D. Anderson, and Baylor. Remarkably, each department seemed to have additional capacity in a different segment of the training continuum. A consortium of programs was envisioned, because UTMB, UT Houston, and the VA could accommodate residents in their first year of anesthesia training, and Baylor (which included Texas Heart and Texas Children's) and M.D. Anderson could accommodate more rotations at a senior level (see Table 1). In combination, the consortium could accommodate 30 additional residents. The Tulane program consisted of 30.
A consensus was rapidly reached to extend an offer to relocate all of the Tulane residents contingent on approval by each of the institutions. Funding was a concern and was noted to potentially complicate the situation. Guiding principles were agreed on, including eventually returning the program intact to Tulane, and preferring that residents remain as Tulane residents and not be absorbed into the individual consortium programs. The department chairs agreed to act as program stewards, as “guardians, not conquerors.” It was also agreed that there would be no “poaching” of the Tulane residents or faculty. Each consortium department would manage its respective Tulane residents according to its existing institutional and departmental administrative policies.
Approval in principle was garnered from the Accreditation Council for Graduate Medical Education (ACGME), the committee on credentials for the American Board of Anesthesiology, and from each participating institution by September 2. Thus, a consortium of anesthesia training programs was formed and its principles agreed on and approved in principle some five days before the initial meeting of the respective institutional deans. Final approval would take somewhat longer and was largely contingent on the availability of funding for the training positions.
Questions That Needed Answers
As the consortium's leaders began to consider the logistics associated with potentially moving residents from Louisiana, the paucity of available information became starkly apparent. It was common knowledge that Tulane's program was the only anesthesia residency located in a New Orleans institution that had closed. Although the Louisiana State University trained some anesthesia residents on rotation, it did not have a formal residency per se. And while the Ochsner Foundation had an anesthesia residency, it remained in operation after the storm. The size of the Tulane program and the name of its program director were listed on the Web site of the ACGME4; almost everything else was unknown. Questions included:
▪ Where were the department chair and program director, and how could they be contacted?
▪ How many residents would likely come to Houston, and how could they be contacted?
▪ What would be their personal needs? Had they been paid? Would they have transportation?
▪ What would be their levels of training? Which rotations would be required?
▪ Were they in good standing with their program?
▪ What psychological and/or medical issues should be anticipated, and, if so, how would they be optimally managed?
The answers to many of these questions ultimately depended on happenstance and networking within the specialty. For example, at the Texas Society of Anesthesiologists' annual meeting held from September 8 to 11, 2005, one of the practitioners mentioned that the Tulane chair had evacuated to north Texas, enabling that contact to be made. Similarly, the chair of an anesthesia program in New York City received an unexpected visit from the Tulane program director and arranged for contact between him and the Baylor chair. The program director had permanently relocated to New York with his family during the week after the storm. He was offered a temporary faculty position at Baylor with the understanding that he would manage the Tulane residents, but he declined for personal reasons.
Uncertainty Impeded Planning
Issues relating to GME infrastructure were handled collaboratively by the GME offices of Baylor and Tulane. The residents remained employees of Tulane, were paid by Tulane, and retained Tulane's medical liability insurance. Before Hurricane Katrina, TMC institutions had already exceeded their “cap” on funding for GME training positions with the exception of The Methodist Hospital (which did not train residents in anesthesiology). Therefore, the institutions that accepted additional residents were unable to receive any additional funding for their positions, although they likely benefited from the residents' additional service. Payroll and information systems were established at Baylor, and badges were issued with joint Tulane and Baylor logos.
Credentialing was a concern after Hurricane Katrina. For instance, some volunteers who arrived at Houston's Astrodome Katrina Clinic had credentials that could not be verified. The Texas Medical Board agreed to issue temporary residency training permits within 48 hours of application that would be valid for up to 45 days, during which time standard permits would be processed. The temporary training permits required the signature of a physician licensed in Texas, but the consortium's physicians did not know most of the Tulane residents. It was decided to put the residents in a room together and let them “vouch” for themselves. Before that became necessary, the Tulane chair was located and assumed that responsibility.
A Resident Found Us, Then They Found Each Other
After the hurricane, the potential for communication was lost for most of the Tulane community. Forced evacuations, nonoperational information systems, and inoperative cell phones created a tremendous challenge. Six days after the levees broke in New Orleans, Dr. Wolf Kremer, a midlevel Tulane resident, reported to the Texas Heart Institute. Because of the preexisting affiliation between Tulane and the Texas Heart Institute, Dr. Kremer had completed a rotation in cardiovascular anesthesiology at Texas Heart. With his home hospital no longer in operation, he asked whether his residency training could be continued at the institution with which he had become familiar. Dr. Kremer and his wife were living temporarily with another Tulane resident on rotation at the Texas Heart Institute. He had been recently paid, but he had no car and only the clothes he was wearing. Dr. Kremer had had no contact with the Tulane chair, the program director, or any other Tulane official since his evacuation from New Orleans. He knew nothing of the possible program relocation to Houston, but he was acquainted with Tulane's associate dean for GME, having served as a resident representative on Tulane's GME committee. Dr. Kremer was given a faculty office, a telephone, a computer with e-mail and Internet access, and was put in contact with his relocated associate dean. For a period of time, he worked directly with the dean as the department's representative and coordinator in Houston.
Other residents were scattered from Sweden to Argentina, but they quickly connected via the Internet. One of the Tulane anesthesia faculty members set up a chat room where the residents could communicate and where news regarding the program could be posted. Residents were asked to contact Baylor regarding whether they planned to come to Houston, and to provide information regarding their level of training, upcoming rotations, and any personal needs, including types of lodging and numbers of family members and pets. Many hours were spent by departmental personnel and Dr. Kremer networking with the residents; some just needed to talk.
Housing was a special challenge, because most of the residents had families and/or pets. Apartments were becoming scarce in Houston because many businesses were quickly relocating to Houston as well. These businesses rented large blocks of apartments, often 30 to 40 at the time, for their employees. A real estate broker familiar with TMC ultimately placed over 100 Tulane residents in rental units, many with access to public transportation. In addition to faculty, private practice anesthesiologists in the Houston area also offered shelter to the residents.
A Specialty Supports Its Trainees
As stories of the personal tragedies in New Orleans unfolded in the media, many in the anesthesiology community wanted to help their colleagues in need. One of the most generous and expeditious efforts came from The Anesthesia Foundation, an organization with the mission of providing low-interest loans to anesthesia residents. The foundation's board quickly realized that the residents would need money for apartment deposits, replacements of personal items, and other needs. Within a week, the foundation changed its bylaws to allow grants-in-aid of $2,500 for every resident displaced by Hurricane Katrina. Residents had only to apply, promise that they would continue their training in anesthesiology, and obtain the signature of their program director or chair to be eligible. The checks arrived at the Baylor departmental office within a week of application (most of the residents did not have a mailing address), and additional loans were made available if needed. The Anesthesia Foundation quickly exhausted its reserves, but its funds were ultimately restored by generous donations from anesthesiologists around the country and from the American Society of Anesthesiologists.
Many suggestions and other offers of support were forthcoming as news of the consortium plan spread. The Society for Academic Anesthesia Chairs developed a list of every vacant residency position within the United States, which was sent to the ACGME. Anesthesia departments from the Harvard-affiliated hospitals (Brigham and Women's, the Massachusetts General Hospital, the Beth Israel Deaconess Medical Center, and Boston Children's) jointly offered to provide any amount of any type of training that might be needed. Like the programs in the TMC, they had extra capacity, although their programs were technically filled. Harvard faculty also offered to house the residents in faculty members' homes until other arrangements could be made. In the only instance where residents could not be accommodated within the consortium (pediatric cardiac anesthesia at the Texas Children's Hospital), Boston Children's agreed to help. Responding to offers and suggestions required almost as much time as communicating with the residents.
Key Aids to Recovery: An Angel, a Grief Counselor, and a Reunion
Although the Tulane chair and the Baylor chair had not met before the evacuation, they quickly became acquainted via telephone and e-mail. In one conversation, the Tulane chair related that the department's residency coordinator had lost her home and had relocated to Houston. The next day the coordinator called and offered to help with the Tulane residents. This was extraordinarily welcome, because she knew the residents, could provide additional administrative support, and would have access to Tulane's information systems once they were restored. The residency coordinator was given an office, a computer, and Internet access in Baylor's department of anesthesiology, where she worked from late September until shortly before the program returned to New Orleans. Support for her salary was maintained throughout the program's relocation and subsequent reconstitution.
In anticipation of the residents' arrival in Houston, the Tulane chair consulted two Baylor psychiatrists who specialized in crisis management regarding the best practice for interacting with the residents. Together, they developed a plan for the initial meeting. Salient components of the plan included:
▪ Acknowledging the change and being comfortable and matter of fact about it;
▪ Telling the residents that the chair and the consortium were there to support them and describing the support mechanisms that were available;
▪ And, most important, telling the truth and resisting the temptation to “spin” a more positive interpretation of the situation than actually existed.
The residents were asked to report to Houston on Friday, September 30, 2005. Before that meeting, neither the number of residents who would attend nor their level of training and rotational requirements were known. The Tulane chair, the residency coordinator (to the residents' delight), the educational leadership from the consortium of anesthesia programs, and the grief counselor attended.
That day, 23 of the 30 Tulane residents arrived at Baylor. It was the first time they had seen each other since the storm. There were hugs and tears, joy at being together, an unmistakable sense of community, and an outpouring of gratitude for the opportunity provided by the consortium. Any questions regarding the strategy of relocating the program versus dispersing the residents were laid to rest in that meeting. The residents were oriented to the TMC and the consortium, special requests were collected, and the next month's schedule for the four institutions was completed and circulated that same evening.
The Nuts and Bolts of Putting It All Together
The departmental administrations began the task of reconstituting the residency program without basic information. The Tulane chair knew that all the residents were in good standing with the program and that no remedial training was required. During the evacuation, one of the Tulane residents had hastily grabbed a copy of the yearly rotation schedule from his refrigerator as he left New Orleans. Under the assumption that the schedule reflected the rotations that each resident needed to met his or her requirements, that schedule formed the basis for the rotational assignments. Although Tulane's information systems became operative by the end of September, much of the information regarding the residency program was not available until Tulane's residency coordinator could retrieve her office computer from New Orleans some two months later.
Evaluation forms were created by replacing the Baylor logo with the Tulane logo on preexisting forms. Once the residency coordinator had her computer, a portfolio was constructed for each resident. It included a listing of the types and numbers of cases that each resident was required to complete, and a column tracking the individual's progress on a monthly basis. Another checklist tracked each resident's required rotations for his or her level of training, noting which had been completed and which were outstanding. Each resident's portfolio was updated monthly and used in conjunction with the pre-Katrina rotation schedule to determine the monthly assignments. All residents completed the required rotations, types, and number of cases before returning to New Orleans in July 2006, with one exception for personal reasons.
Perhaps the human response to the crisis should have been no surprise at all. To quote the Tulane chair: “It is unrealistic to anticipate that anyone who has been through what we went through will behave in a normal manner and as though nothing happened.” Yet, we were surprised by the effects of this crisis on human behavior. The majority of residents were a joy to work with and remarkably resilient. Many marveled at how they had resumed training and relocated seemingly “without missing a beat.” However some atypical and less-than-professional behavior occurred at each of the sponsoring institutions. For example, one resident was barred from one of the institutions (ironically, the institution from which he graduated), two failed to report to the institution to which they were assigned, and another declined to take a call on a date he had personally chosen. Although we expected some emotional trauma associated with uprooting these residents, we were unprepared for the behaviors exhibited by a few. In any other situation, some of these behaviors could possibly have resulted in disciplinary action. But because of their ordeal, allowances were made. There was also surprisingly atypical behavior from some of the ex-Tulane faculty. Soon, a pattern began to emerge of behaviors that were inconsistent with those exhibited before the storm. This change led to the perhaps obvious conclusion that such trauma can significantly affect behavior in some individuals.
Only several weeks after Hurricane Katrina, another challenge presented itself in the form of Hurricane Rita moving on a path toward Houston. This was yet another potentially traumatic event for the relocated residents. Fortunately, most had not yet arrived in Houston. But many of those who had arrived were living without transportation near the TMC in an area prone to flooding. They faced the prospect of being marooned during and after the storm. Plans were made for these residents and their families to stay at the Baylor chair's home during the storm.
Another challenge was that Tulane residents would not be allowed to return to New Orleans in stages. Funding mechanisms for GME from the Center for Medicare and Medicaid Services required that the program remain intact—whether in Houston or New Orleans. Tulane's surgical case volumes, particularly for the specific types and numbers of cases required to support an anesthesiology program, had not reliably returned by the spring after the storm. Moreover, the clinical demands on existing faculty could not assure a cohesive educational program with lectures, journal clubs, scholarly activity, and so forth. So although the remaining residents were most anxious to go home, they had to wait until July 1, 2006, the date that was set for their return to New Orleans.
As time wore on, so did the effects of the relocation on residents' morale, despite repeated visits to Houston by the Tulane chair and other faculty. During the spring of 2006, six months after the storm, it was apparent that the residents were ready for the next phase of their lives and, especially, to return to New Orleans. Waiting was not easy, and it was understandable that they could not comprehend the complexities of reconstituting an accreditable program in an institution that had closed. The time frame for this reaction was surprising, because at that point, their lives in south Texas had seemed to stabilize or at least become routine. Perhaps for some, the impact of the trauma had not resolved. Recent evidence has shown that grief processes peak at approximately six months after a traumatic event.5
Outcomes and Reflections
Of the 30 original Tulane residents, 23, or 77%, initially relocated to Houston. Many elected to transfer to other programs. Of those who relocated, 17, or 74%, either graduated or returned to New Orleans the following July to complete their training. All but one of the senior residents who remained in the program passed their written board examination. (He elected to defer the examination for personal reasons.)
As of this writing in April 2007, the Tulane anesthesiology residency numbers 16 residents, including those in the categorical internship year, and filled in the 2007 Match for anesthesiology. The program was recently reviewed by the ACGME, and it retained its status of full accreditation.
The transfer of many of the residents to other programs has made evaluating educational outcomes challenging. Departments typically receive reports of their residents' individual performance on yearly examinations. Such information is used to evaluate a individual resident, and also to evaluate the program. Both the American Board of Anesthesiology and the Anesthesiology In-Service Training Examination report scores to the institution where a resident is currently in training. Because many of the residents transferred from Tulane, there is no central repository for those residents' individual data that would allow comparisons of performance before and after the storm, or between those who transferred and those who did not. The Tulane chair has requested information from the American Board of Anesthesiology and from the Anesthesia In-Service Training Council for residents in the program before Hurricane Katrina. Because this information is confidential and because many of the residents have been dispersed across the country, it would otherwise be lost to follow-up.
The consortium was successful at providing an administrative and academic framework, providing logistical support for the relocated program, identifying reserve clinical capacity, placing recruits in locations where they could complete the required numbers and types of cases, and integrating the program into preexisting didactic curricula. However, the geographic dispersion did somewhat hinder the coordination of decision making and the maintenance of confidentiality, which might have been better preserved with a single, on-site person in authority. It also probably made us easy marks for manipulation (“Can I do X? Dr. Y at another institution said I could”). And, although many of the leaders worked individually with the Tulane residents, a coordinated program of individual attention and career counseling was not undertaken.
Many of the logistics of relocating a residency program are more likely (and appropriately) handled at an institutional rather than a specialty level. This includes such things as payroll, licensing, malpractice, and the ultimate decision as to when and where to relocate. Group needs are considerable in times of crisis and must take precedence over individual needs. It is probably not reasonable to expect that an institution can expeditiously accommodate requests for individual transfers except during extreme hardship. During a disaster, an individual's inconvenience is unlikely to represent an extreme hardship.
Proximity and community are important to residents. Proximity allowed the Tulane residents to travel to New Orleans to retrieve salvageable personal items such as cars, and to observe what had happened or was happening to their previous homes. Being together, they could draw support from each other. It is important to anticipate the time needed to ameliorate the effects of trauma and grief and to seek professional assistance in crisis management early and for as long as needed.
Despite a desire to remain with residents during their time of need, a relocated department chair is unlikely to be able to do so. He or she may, by necessity, need to remain at the site of the disaster to render medical care for those who stayed behind, salvage practice opportunities, and thus preserve the department and provide a basis for the program's return. After Hurricane Katrina, this was certainly the case for the Tulane chair and for other departmental leaders within the city. It may well be desirable to appoint a “guardian” program director at the relocated site. Such an individual would ideally have both the time and authority to deal with issues as they arise, and should report to and work in partnership with the relocated department's chair or program director.
In a disaster, everyone experiences similar concerns and needs. Residents and businesses are likely to compete for resources such as housing and transportation. Medical personnel in the “receiving” city will be confronted with additional patient-care responsibilities from individuals who have relocated, whereas those who have relocated will be challenged with finding care.
Whether providing emergency care or relocating an educational program, simply managing the generous outpourings of suggestions and offers to help requires significant time and effort. This was noted at the Houston Astrodome's Katrina Clinic,3 at St. Vincent's Hospital after 9/11,6 and while relocating the Tulane residency program. It might be helpful to have the assessment and planning associated with volunteer efforts coordinated off-site, to free those “on the ground” to channel their resources towards managing and executing the many other tasks at hand.
And last, but certainly not least, it is important to have a departmental disaster plan, including a routinely updated list of contact numbers for key individuals, and methods of communication that are not dependent on a single modality or provider (phone, e-mail, pager, Web). An interactive Web site listing key personnel and operated by a national provider with associated e-mails outside an institution's network can be set up for less than $10 per month. Any Internet access would be sufficient to allow relocated individuals to send and receive updated information. And, when all else fails, professional networks also provide a means of communication.
We realize, more than ever before, that there is more to a residency program than an academic framework. We are honored to have been a part of the relocation endeavor just described, and we will no doubt remember it for a lifetime. It is also our fervent hope that should our own residency program(s) ever meet a similar fate, others will welcome our residents as their own.
The authors wish to acknowledge Dr. James Arens, professor and chairman of the department of anesthesiology at the University of Texas at Houston, Dr. David Brown, chair of operative anesthesia at the M.D. Anderson Cancer Center, and Drs. Don Prough and Lynn Knox at the University of Texas Medical Branch at Galveston for their leadership, wisdom, and many efforts on behalf of the residents in anesthesiology from Tulane University. The authors also acknowledge Dr. John Searle for his most able assistance in editing the manuscript of this article.