In the aftermath of a mass disaster such as Hurricane Katrina, one thing becomes clear-everyone has a story. For some, it is one of extraordinary inconvenience: the unanticipated displacement from home, work, all belongings, and perhaps family for weeks or months. For many, it is a story of complete devastation: loss of job, loss of pets, loss of home and all personal belongings, perhaps even the loss of loved ones. For most affected by Hurricane Katrina, there were stories of 12- to 24-hour drives in search of refuge from the storm. For many, there were stories of harrowing evacuations through floodwaters or stories of heroic goodwill trying to save others. In August 2005, just before Katrina struck, the Louisiana State University (LSU) School of Medicine in New Orleans comprised 693 students, 622 residents, 572 full-time faculty, and more than 1,200 other employees. So, in September 2005, in the aftermath of the storm, the LSU School of Medicine had more than 3,000 stories ranging from displacement to devastation. No one was spared Katrina's effects.
In addition to these individual stories, the school of medicine itself has many stories that are equally remarkable. Like every other institution of higher education in New Orleans, the LSU School of Medicine was threatened with closure because of the damage sustained during and after Katrina. However, the school of medicine survived with support from its parent institution and the state of Louisiana. It succeeded because the staff, students, residents, faculty, and administration were committed to the institution and its missions. Despite also dealing with many personal tragedies, the people involved made the school's story one of triumph. In this article we describe how the educational missions of the school were restored in the aftermath of this monumental disaster. We hope it will be of interest to other medical schools as they develop response plans for potential disasters that disrupt or devastate their communities.
The Storm and the Damage
When Hurricane Katrina entered the Gulf of Mexico on August 25, 2005, the LSU Health Sciences Center in New Orleans (LSUHSC-NO) began to implement critical emergency procedures. Core information technology (IT) staff backed up critical data and records and then evacuated to Shreveport, Louisiana, with the tapes to support all administrative operations remotely. Payroll personnel worked to complete the upcoming payrolls ahead of schedule and also evacuated to Shreveport. Meanwhile, a voluntary evacuation for citizens of New Orleans was implemented on Saturday, August 27, and LSUHSC-NO officially suspended all operations other than those essential for clinical care in Charity Hospital and University Hospital, the two primary sites for clinical training for the school of medicine. On Sunday, August 28, New Orleans Mayor C. Ray Nagin ordered the first mandatory evacuation in the history of the city. Over one million people evacuated from the metropolitan area. It is estimated that 150,000 citizens remained behind, most of whom were poor, disabled, or otherwise unable to evacuate.1
Hurricane Katrina made landfall in southeast Louisiana at 6:10 am on Monday, August 29. The 32-mile-wide eye of the storm passed just east of New Orleans, but the area of impact extended from Louisiana to the Florida Panhandle. Sustained winds of 120 mph damaged homes and buildings in New Orleans and its surrounding parishes. A storm surge of up to 32 feet devastated the coasts of southeastern Louisiana, Mississippi, and Alabama. The storm surges into Lake Borgne and Lake Pontchartrain ultimately breached the levees of three major canals and flooded 80% of the City of New Orleans.1
Total damage estimates exceed $34 billion ($22 billion in Louisiana alone), making Hurricane Katrina the most costly disaster in U.S. history. The storm was directly responsible for over 1,500 casualties in Louisiana and left more than 500,000 people homeless. Thirty-one Louisiana parishes and 52 counties in Mississippi were declared eligible for federal disaster aid.2 More than 2.5 million households requested assistance from the Federal Emergency Management Agency (FEMA). Over 5 million people were left without power.1 It took four months to restore electrical power to most of New Orleans, but the most heavily damaged parts of the city did not receive power until spring 2006.
LSUHSC-NO comprises the schools of medicine, dentistry, nursing, allied health, graduate studies, and public health, and most of these schools are located in downtown New Orleans. In the early morning hours of August 30, remaining staff in campus buildings reported that water in the streets had risen dramatically and was entering the first floor or basement of every building. All buildings sustained extensive flood damage. Emergency generators were inundated and the buildings lost power. Critical electrical, mechanical, plumbing, elevator, and air conditioning systems were damaged. The cost of clean-up, environmental remediation, facilities repairs, and replacement of lost contents on the LSUHSC-NO campus alone was approximately $130 million. In addition, revenue losses from business interruption, still being evaluated, were substantial and may equal those of damages to the physical facility.
The downtown campus of LSUHSC-NO is bounded by its two primary sites for clinical training, Charity Hospital and University Hospital. Together, these hospitals comprise the Medical Center of Louisiana at New Orleans (MCLNO), the flagship institution of a statewide system of public hospitals and clinics. Both hospitals were severely damaged by the flood. Over six feet of water stood in the streets outside University Hospital, and water was waist deep outside Charity. The water did not subside for weeks. University Hospital reopened in November 2006, 15 months after the storm. However, Charity Hospital will not reopen in the building it has occupied since 1939, and it is still uncertain whether the institution will have a future in any location.
The Immediate Aftermath
In the days immediately after the storm, LSUHSC-NO leaders gathered on the main LSU campus in Baton Rouge (85 miles northwest of New Orleans). As soon as the levee breaches were confirmed on August 30, we began to reestablish core administrative functions of LSUHSC-NO in Baton Rouge. For the first two weeks, we operated out of two rooms equipped with several phone lines and computers. Communication with dispersed faculty, staff, students, and residents was essential, so the IT staff were mobilized and immediately established an emergency Web site with daily messages from the chancellor, vice chancellors, and deans beginning on August 31.
Our initial priority was to ensure the safe evacuation of all patients, residents, faculty, and staff remaining in the hospitals and academic buildings. When Katrina struck on August 29, there were 220 patients at Charity Hospital and another 167 at University Hospital. There were approximately 600 employees at each institution, including housestaff and attending physicians. As time passed, additional patients were brought to each hospital and citizens sought refuge at the hospitals, so the exact number of people who required evacuation from our hospital facilities is unknown. Although both hospitals lost power on August 29, the first patients were not evacuated until late on August 31, and the last patients and staff were evacuated on September 2. Despite the sweltering heat and absence of electricity for five days, there were only five deaths at Charity Hospital and three deaths at University Hospital. This remarkable statistic is a testament to the dedication and heroism of the clinical faculty and residents from LSU and Tulane medical schools who were working at the hospitals and of the nurses and staff of both hospitals.
In the days immediately after the evacuation, we began working to restore the school's educational missions and to reconstruct the clinical enterprise. For example, registries were established so employees could log in and list their location and contact information. Students and residents created their own Web sites and bulletin boards for communication. Computer and IT personnel worked 24 hours a day to install servers, network equipment, and back-up systems for a complete data center in Baton Rouge. It took weeks to restore all core administrative systems and to gather complete contact information for displaced members of the LSUHSC-NO community.
Restoring the Undergraduate Medical Education Program
Once we set up administrative operations and established contact with LSUHSC-NO faculty, staff, students, and residents, we moved on to the challenge of restoring the undergraduate medical education (UME) program. The critical issues involved in reestablishing the UME program differed for the preclinical and clinical years of school. Our preclinical curriculum is grounded in lectures, labs, and small-group seminars. This core curriculum is combined with computer-based clinical problem-solving cases and clinical skills training in a simulation laboratory. As such, the necessary task of finding adequate teaching space in our new temporary home presented a significant challenge. Locating the core teaching faculty and developing revised course schedules was also critical to restoring preclinical education. However, the single greatest challenge to restoring the clinical education program was developing adequate training sites. As clinical education for students is closely linked to resident training, this challenge was ultimately resolved in conjunction with the residency program directors. Overall, rapid identification of teaching and training sites and early announcement of target start dates were crucial to successfully reestablishing our UME programs. We recognized that faculty and students would require time to relocate to Baton Rouge, so these decisions were made quickly. Less than one week after the storm, we announced that preclinical courses would resume on September 26, 2005. Ten days after the storm, we announced that clinical rotations would resume no later than September 19.
Preclinical curriculum
Preclinical courses resumed on September 26 as announced at LSU's Pennington Biomedical Research Center (PBRC), which is situated on 237 acres, four miles from the main LSU campus in Baton Rouge. We were fortunate to have the support and cooperation of the PBRC leadership and staff. We made arrangements to use their conference center (with 13,000 square feet of meeting space) for our first- and second-year medical school courses. An auditorium that comfortably seated 180 students served as the main lecture hall. We used five smaller meeting rooms for small-group seminars, labs, and demonstrations. The conference center provided wireless Internet access. We also occupied common areas; one lounge was converted into a temporary cafeteria (prepared foods were brought in and heated on-site during breakfast and lunch hours for faculty and students). Another common area was outfitted with simple tables and chairs, and it served as a good place for students to congregate, hold meetings, and study.
When planning the resumption of preclinical classes, our first priority was to ensure that students were adequately prepared for United States Medical Licensing Examination (USMLE) Step 1. We worked closely with course directors to restore the entire preclinical curriculum, keeping in mind that many of their faculty members had suffered great personal loss and also needed time to solve problems related to their homes and families. It became apparent that many displaced faculty members would have to travel long distances from the various places to which they had evacuated to teach in Baton Rouge, so we designed schedules to consolidate their lectures. In some cases, courses that normally had classes four or five times per week were rescheduled to have more intensive classes two or three days per week. Flexibility on the part of the administration helped maintain faculty morale. The largest morale boost, however, occurred on the Monday morning that classes resumed in Baton Rouge, four weeks to the day after Katrina struck. The room was packed-99% of our preclinical students were still with us, and the emotion was palpable as the dean addressed the students and faculty.
Despite losing four weeks of classroom time, we were able to maintain most of the course hours from our pre-Katrina basic science curriculum, excepting laboratory-intensive courses such as gross anatomy and physiology. Because we were unable to provide cadavers for each student, a modified cadaver lab was established at the LSU School of Veterinary Medicine. Anatomy faculty dissected five cadavers and used an overhead camera to demonstrate lessons during tutorial sessions for groups of 30 to 40 students. Additionally, because we were unable to perform our live-dog physiology labs, we provided a scaled-back version of the lab experience in the physiology course. Before Katrina, Cell Biology 100 and General Pathology 200 course directors had converted their labs to digital format. Thanks to these digitally formatted labs, students who had brought along their laptop computers when they evacuated were able to continue their lab experiences with no adverse effects. In some courses, online tutorial exercises were developed to enhance units that had to be compressed after the four-week break in the curriculum.
Overall, the number of contact hours in the first year was reduced from 739 to 653, with most of the reduced hours occurring in Gross Anatomy 100 and The Science and Practice of Medicine (SPM) 100. In the second-year curriculum, contact hours were reduced from 709 to 656, with the majority of the reduced hours occurring in the General Pathology 200, SPM 200, and Introduction to Clinical Medicine (ICM) 200 courses.
SPM 100 and 200 are interdisciplinary courses that introduce the fundamentals of clinical medicine. Clinical faculty agreed to continue working with our preclinical students despite, in some cases, considerable travel time. Because basic interviewing skills and medical ethics were taught in small-group seminars with clinical faculty, and we were able to restore these classes relatively quickly, some of the seminars were redesigned to include discussion about patient care during a mass disaster. This allowed students the opportunity to discuss their post-Katrina experiences with colleagues in a classroom setting. The use of computer-based cases to develop clinical problem-solving skills is another important element of the SPM courses. Because they are computer based, students were able to continue working on these cases with little change.
SPM students also learned physical examination and basic procedural skills in a specially designed lab. The clinical skills lab was located in our four-year-old student learning center on the first floor of the clinic facility in New Orleans, and it sustained substantial damage from floodwater. Although we were able to salvage a small amount of equipment in early October 2005, most of the simulators and mannequins in the lab were destroyed. However, replacing the simulation equipment became a priority for the school and for the Medical Alumni Association. Thanks to the resources provided by the Medical Alumni Association, we purchased new mannequins and simulators within a few months. Given that SPM 100 and 200 are yearlong courses, we opted to move fall semester labs to the spring, and students were able to receive the full complement of skills lab training in the spring semester.
Direct patient contact in the hospitals and clinics was limited during the preclinical curriculum (it occurred only in SPM 100 and 200 and ICM 200). As a consequence of the storm, these experiences were also deferred until the spring, when they were implemented on a limited basis in Baton Rouge hospitals (emergency department visits for first-year students and scheduled history and physical practice for second-year students). The decrease in overall contact hours mentioned above was caused partially by reductions in these scheduled early clinical experiences. However, we believe that this had little impact on the overall preclinical education program.
In retrospect, there were unanticipated benefits to our adapted classroom facilities and modified schedule. Because most faculty members did not have office space in Baton Rouge, they often worked in the PBRC conference center in close proximity to the students. Therefore, the faculty was more immediately accessible to the students than ever before. It was not uncommon to see impromptu Socratic tutoring sessions in the cafeteria. Additionally, lecture attendance was higher than before the storm, which is perhaps attributable to students' heightened appreciation after realizing their educational program had been threatened, or possibly to fewer distractions in Baton Rouge as compared with New Orleans. Either way, faculty felt that these hidden and unexpected benefits easily compensated for the four weeks of classroom time we lost after Katrina. In the 2005-2006 final analysis, student performance on standardized examinations was similar to or better than it was in prior years. For example, many courses use National Board of Medical Examiners subject examinations, and the results of these were consistent with previous years. Also, the results of student performance on the USMLE Step 1 for the Class of 2008 were better than those of previous years' classes.
Clinical curriculum
The storm struck while third-year students were two thirds of the way through their first clinical clerkships. Because our students are almost exclusively Louisiana residents, many of them evacuated to Baton Rouge and Lafayette to stay with friends and relatives. In the days after the storm, without prompting, many of these students reported to Earl K. Long Hospital (EKL) in Baton Rouge and University Medical Center (UMC) in Lafayette to resume their clinical training. Both hospitals are part of the statewide public hospital system operated by the LSU Health Care Services Division (LSU HCSD), and both were used as training sites for LSU School of Medicine, New Orleans, students and residents before Katrina. Additionally, the patient census nearly doubled at these hospitals and at Leonard J. Chabert Medical Center (LJC) in Houma (also part of the statewide public hospital system) in the initial weeks after the Katrina. In retrospect, we witnessed a natural migration of the patient population, residents, and students from Charity Hospital and University Hospital into these hospitals in the cities surrounding New Orleans (Figure 1). Clinical faculty also reported to these public hospitals, and additional patient-care services were established to accommodate the increased patient census.
Clerkship directors and program coordinators immediately began to establish or expand rotations at EKL, UMC, LJC, and other sites under the direction of their department heads, the associate dean for academic affairs, and the associate dean for clinical affairs. Ten days after Katrina, the clerkship directors had already sketched out plans for their respective clerkships to continue at these alternative sites. However, clerkship directors had yet to determine details regarding the precise starting and ending dates of the relocated rotations and policies regarding LSUHSC-NO faculty and student volunteer work and students completing rotations at other schools that were more conveniently located to their temporary post-Katrina residences. In the days and weeks immediately after the storm, many students volunteered at temporary field hospitals in Baton Rouge and Lafayette, in some cases under the supervision of our faculty and residents who were also volunteering. We briefly considered giving academic credit for such volunteer work, but ultimately we decided against it.
Our clinical curriculum consists of four clerkship blocks, each lasting 12 weeks. To make up for the break in training, we reduced blocks one and two to 11 weeks each, to complete the semester on time before the winter holidays. Once this was decided, students were contacted and reassigned to rotations at hospitals in Baton Rouge, Lafayette, and Houma to finish their first clerkship. Many students had already resumed training by reporting to area LSU HCSD hospitals, but all third- and fourth-year students were expected to resume training on September 19, three weeks after the storm.
Some students sought out rotations at other medical schools. Guidance from the Liaison Committee on Medical Education (LCME) was extremely helpful in dealing with these situations. We were permitted an exception to the LCME policy that all of our required clinical clerkships be done under the direct supervision of our faculty. Students were able to do clerkships at schools that were LCME accredited; clerkship directors had to approve requests for these rotations and ensure that the educational objectives were similar to our own.
By the end of the 2005 calendar year, it became apparent that we could accommodate all of our third-year clerkship students in LSU School of Medicine programs in Baton Rouge, Lafayette, and Houma, so we increased the restrictions on requests for core clerkships at other schools. Third-year students were only permitted a single clerkship at another school. Out of 166 third-year students, four transferred to other schools and 23 completed a required clerkship at another school during the fall 2005 semester (15 did so at LSU School of Medicine in Shreveport).
For the most part, each of the clinical departments was able to recreate an experience that closely matched their pre-Katrina clerkships in terms of time spent on general inpatient, outpatient, and subspecialty rotations. Because the patient population from Charity and University Hospitals in New Orleans had migrated, the mix of patients and diseases remained fairly consistent with our pre-Katrina training. Students remained under the supervision of LSU faculty and residents, who had migrated to the same clinical training sites. Faculty and residents based at EKL, UMC, and LJC before the storm supervised more students than they had previously, and, in some cases, faculty and residents from New Orleans continued to supervise students on expanded services in these public hospitals or in newly developed training sites at private hospitals.
Although we were able to preserve the structures and schedules of most of the clerkships, one notable change occurred in the structure of the third-year surgery clerkship. Before Katrina, all students were required to take eight weeks of surgical subspecialties and four weeks of general surgery within the 12-week surgery rotation. After Katrina, some of the surgical subspecialties were no longer required because we no longer had a clinical volume adequate to train every medical student in these subspecialties. The surgery clerkship remained 12-weeks in length, but it was modified to six weeks of general surgery and two three-week rotations in surgical subspecialties, such as otolaryngology, urology, orthopedics, pediatric surgery, or vascular surgery. Despite the reduction in subspecialty training time, we found that devoting more time to general surgery was a positive change that was consistent with our overall goal to provide a firm foundation in primary care.
Because our clinical students were widely dispersed after the storm, some logistical challenges emerged, particularly with respect to didactic teaching in the third year. Clerkships developed various strategies to cope with these challenges. For example, some of the clerkships condensed lectures into a weekly half-day block in a central location. This solution required students to travel, but having lectures just once a week reduced overall travel. Some instructors gave lectures using telemedicine conference delivery (e.g., satellite broadcasts) to reach students at outlying sites. Some reduced their lecture schedules at selected sites and provided learners at those sites with copies of the complete lecture series on CD ROM. Still, in other cases, faculty traveled to various cities to deliver lectures and participate in conferences. We continue to face such logistical challenges today. Because our clinical students are likely to remain more dispersed than they were before Katrina, we recognize the need for some distance learning and for employing mechanisms to ensure educational equivalence across our learning sites.
Before Katrina, third- and fourth-year students participated in learning sessions using high-fidelity human-patient simulation in the LSUHSC-NO Student Learning Center. Third-year students typically spent eight morning or afternoon sessions in the Human Simulation Lab where each student had the opportunity to manage acutely ill patients in a realistic intensive care unit, operating room, or emergency department setting. These bedside teaching sessions were an effective educational experience for all third-year students. However, flooding in the student learning center damaged the human-patient simulators and the anesthesia workstation beyond repair. The human-simulation center was a total loss, and replacing the ruined items was a priority for the Medical Alumni Association and in our negotiations with FEMA. At this time, thanks to the resources provided by the Medical Alumni Association, the simulators have been replaced, and these learning sessions have resumed in a temporary lab on the LSUHSC-NO campus.
During the fall 2005 and spring 2006 semesters, we surveyed third-year students to obtain their input regarding the adequacy of the current patient load for learning and whether they were they were receiving adequate teaching and supervision from residents and faculty. The survey results indicated that the patient volume, case variety, faculty and resident teaching, and the overall learning environments met our goals. However, we were not surprised that the results also revealed concern among third-year students that the quality of their education was adversely affected by the impact of Hurricane Katrina. Under normal circumstances, when students begin their third-year clerkships, many feel isolated from their classmates and uncertain about educational goals and expectations. They are less directed than in the preclinical years. These feelings were amplified by the uncertainty after the storm. For example, students revealed anxiety about being dispersed from the campus and their classmates because of the storm. Some raised concern about no longer being able to learn at New Orleans-based hospitals (Charity and University). Still others raised concern about the future of New Orleans and how circumstances would affect patient care and the students' plans for residency programs.
Other results from the same survey suggested that although students' concerns increased after Katrina, their education was not adversely affected. Furthermore, these students' preliminary results from USMLE Step 2 Clinical Knowledge and Clinical Skills examinations are as good as or better than those in previous years, indicating that their clinical training experiences were probably comparable with those of prior classes.
Restoring the clinical curriculum in the fourth year posed fewer challenges because many fourth-year students typically spend considerable time on elective rotations at other schools. However, clerkship directors permitted fourth-year students to take required clinical rotations (acting internship, neurology or neurosurgery, internal medicine, and an ambulatory rotation) at other LCME-accredited institutions, provided that they met the educational objectives of the LSU rotation. This policy remained in effect for the duration of the 2005-2006 academic year, and approximately 20% of the required fourth-year rotations were completed at other institutions. Overall, the impact of Katrina on the fourth-year curriculum was minimal. For example, 92% percent of our fourth-year students initially matched into first-year residency positions without resorting to the scramble, a slightly (but not significantly) lower percentage than in previous years. Also, graduation ceremonies occurred as originally scheduled in May 2005, but they were held in Baton Rouge rather than New Orleans.
Restoring the Graduate Medical Education Programs
Before Hurricane Katrina, LSU School of Medicine in New Orleans sponsored 78 graduate medical education (GME) programs: 20 accredited residencies, seven other residencies (e.g., preliminary and combined programs), 31 accredited fellowships, and 20 other fellowships for which there is no accreditation. Across 18 clinical sites, 622 residents and fellows were receiving training. Most trainees (87%) were located in the metropolitan New Orleans area, and the majority of them were at MCLNO (Charity and University Hospitals). The closure of MCLNO and almost every other hospital in the city of New Orleans forced most GME programs to move temporarily. Relocating 78 programs and 622 residents was described as a true logistical nightmare for the GME office. It was particularly challenging to identify adequate training sites and ensure continued funding of residency positions.
As previously described, much of the population that formed the patient base for Charity Hospital migrated to cities surrounding New Orleans, and patients began to use EKL in Baton Rouge, UMC in Lafayette, and LJC in Houma for their care. After the storm, these three hospitals had a collective census increase of over 210 beds. This increase almost equaled the 270 MCLNO beds for which LSU clinical training programs were responsible before the storm. Moreover, many residents evacuated to family or friends in south Louisiana, relatively near EKL, UMC, and LJC, where support and housing were available to them. For these reasons, we chose to reconstitute our residency programs at those sites and transition back to New Orleans as hospitals reopened.
Program directors and department heads, who were on the front lines of the GME rebuilding process, were best suited to identify the specific hospitals and clinics that met their training needs. In the weeks after the storm, replacement resident rotations were established at a combination of public and community hospitals in Baton Rouge, Lafayette, and Houma. Program directors initiated the cooperative agreements between LSUHSC-NO and the new training sites and reported directly to the LSUHSC-NO designated institutional officer (DIO) as temporary training sites were established. Several steps were essential to the successful restoration of our GME program. A master spreadsheet was created to track resident assignments. Once training sites were identified, the GME office assisted all programs in establishing funding mechanisms for these temporary placements. Finally, the DIO met weekly with program directors to ensure that resident placements were adequate and accreditation standards were being met at the new training sites.
The program structure for GME that emerged in the weeks after the storm differed from our pre-Katrina program in several aspects. First, while many programs were forced to add new sites for training, all New Orleans sites were forced to close, rendering the overall number of sites for training relatively stable in the end. By spring 2006, clinical training was being conducted in 19 hospitals, one site more than before Katrina. Second, the percentage of programs using multiple training sites changed minimally; before Katrina, 34% of programs used a single site and 79% used four sites or fewer, and these numbers were 37% and 63%, respectively, after the storm. Third, the distribution of trainees in public and community settings changed significantly. Before Katrina, 63% of our residency positions were assigned to public hospitals, but this fell to 36% by spring 2006 because of the public hospital system's reduced capacity for training after the closing of MCLNO. Fourth, the scope of GME is smaller as a result of our post-Katrina recovery. Several training programs (especially fellowships for which there is no accreditation) have closed because of loss of faculty and resources for training.
The public hospitals elsewhere in Lousiana (e.g., EKL, UMC, and LJC) could absorb many but not all LSUHSC-NO residency positions. Consequently, we established training sites at several private hospitals in Baton Rouge and Lafayette as faculty clinicians attempted to rebuild their practices in those cities. This process was often facilitated by the goodwill of alumni physicians working in those hospitals. Additionally, residents began returning to private teaching hospitals in New Orleans within a few months of the storm. Some of these community hospitals were used as training sites before Katrina, but others initiated residency training for the first time. The health care landscape in New Orleans changed with the loss and closure of so many facilities, and some returning clinical faculty members were forced to reestablish their practices and training programs at different sites. Resident numbers within New Orleans continued upward as the population returned and the patient census increased in the open hospital facilities.
However, the net result of restoring GME and returning to New Orleans is that much of the LSU GME experience has shifted in an unprecedented way to private sites. We anticipate that the public/private distribution will shift again with the reopening of an interim LSU Hospital to temporarily replace Charity and University Hospitals. Nonetheless, the delayed opening of that hospital actually solidified new relationships we forged with private training sites, in some cases rectifying challenges and deficiencies in clinical education that were present even before the storm. Hence, maintaining these new relationships will be important to our continued recovery and future growth.
The post-Katrina recovery of GME has resulted in a smaller number of LSUHSC-NO residency programs. Fifteen of the prestorm 78 programs were closed or withdrawn for various reasons and some programs voluntarily reduced the number of positions offered in the 2006 residency match. Additionally, approximately 130 of our 622 graduate trainees permanently transferred to other programs. In some instances, this was because their programs had closed. In many instances, however, residents transferred because they lacked a local family support network to help them through the crisis.
Residents permanently transferring to other programs created some confusion among our own programs as well as within the programs to which our residents transferred. Our GME office provided crucial leadership, through the DIO, to help resolve the ensuing problems. Policy guidelines and procedures to clarify the process and consequences of transfer were widely publicized and posted on the GME Web site. A resident requesting transfer was required to send an e-mail request to his/her program director at LSU, the director of the program to which the resident wished to transfer, and the LSU DIO. The LSU program director's reply would contain information about the transferring resident's level of training and specific information about funding for that residency position. Many residents and program directors elsewhere were initially under the impression that GME funding would automatically accompany a transferring resident. The DIO would inform all parties that the permanent transfer was approved and again remind the transfer institution that GME funding for the transferring resident was its responsibility.
Transferring funds for resident positions and executing affiliation contracts in new sites were particularly challenging aspects of establishing new training sites. In some cases, resident placements were intended to be temporary, and Medicare issued emergency waivers to facilitate training in temporary alternate sites; however, some hospitals mistakenly interpreted these temporary transfers as permanent. At other hospitals, personnel were unfamiliar with the details of Medicare funding for residency training, the expectations for resident experiences, and the requirements of resident supervision. Shifting existing residents from MCLNO into new (temporary or permanent) training sites created many complex financial and legal issues. The DIO, the GME office, and the associate dean for finance spent many long hours addressing the financial and legal issues involved in the shift and communicating with hospital personnel so that program directors could devote more time to day-to-day operations of their educational programs. In retrospect, we would have benefited from the services of a consultant with expertise in the transfer of Medicare GME funds.
The periods of transition required oversight from and frequent communication with the Accreditation Council for Graduate Medical Education (ACGME). Every graduate training program underwent a focused ACGME visit in late November 2005 to assess the effects of relocation to Baton Rouge and other sites. The associate dean for academic affairs oversaw these visits. At the same time, the assistant dean for undergraduate medical education prepared for a limited survey visit from the LCME in early December 2005. Then, after most operations returned to New Orleans, half of the GME training programs underwent formal reviews in July and August 2006. These reviews were done against the backdrop of preparations for an LCME site visit in late August 2006.
At the time of this writing, our GME programs have largely returned to New Orleans. Even without MCLNO, 78% of our resident trainees are located in the metropolitan area. Thus, 16 months after the storm, we expect the same percentage of residents in New Orleans facilities as there was before Katrina. Looking ahead, the GME office plans to continue and expand our previous mission of supporting clinical education with advanced training and assessment in a simulated setting. We plan to continue our previous mission of providing care to the medically underserved in MCLNO and other public hospitals around the state. Overall, however, we have established some new training sites that clearly enhance and diversify the clinical experiences of our residents.
Student Affairs and Support Services
The reconstruction of our educational programs could not have succeeded without the support of many other offices in the health sciences center. As communication with students was reestablished in the days after Katrina, it became clear that students would require assistance with housing, enhanced access to financial aid, and expanded access to counseling, to deal with the crisis and remain in school. Other support services were also needed, such as student health, library access and study space, career counseling, and assistance with residency applications for seniors. However, from the outset, it was evident that housing presented the greatest challenge.
More than 250,000 people evacuated to Baton Rouge after the storm, essentially doubling its pre-Katrina population of 227,818 overnight.3 Approximately 50% of Baton Rouge households housed one or more evacuees after the storm,4 and many students found accommodations with family or friends in the area. However, it was nearly impossible for many students, residents, faculty, and staff to find places to live. LSUHSC-NO provided assistance in various ways and posted housing needs on its emergency Web site, but these displaced members of the LSUHSC-NO community needed immediate assistance. With support from FEMA, arrangements were made to dock a Baltic ferry (the FinnJet) that could serve as living quarters at the Port of Baton Rouge, thus addressing the bulk of our unmet housing needs. FEMA-supplied trailers local host families provided other housing assistance. Students also developed their own networks for assisting one another with housing and provided information on their independent Web site.
The FinnJet arrived in early October with 600 cabins available for either single or double occupancy. Living accommodations on board the ship were free for students and residents and modest in cost for faculty and staff. Breakfast and dinner were provided free of charge on the ship to residents and students, and the cost of these meals was included in the service fee for faculty and staff. Free wireless Internet access was also provided on the ship and laundry services were available. There was free parking adjacent to the port and a shuttle bus ran between the parking area and the ship throughout the day. The FinnJet remained in Baton Rouge until early June 2006; more than 800 faculty, staff, residents, and students lived on board during that time. The close quarters and nontraditional accommodations made the ship an imperfect living arrangement for some, but the proximity of faculty and students created greater opportunities for academic and personal counseling and fostered an espirit de corps among the entire LSUHSC-NO community.
We anticipated an increased need for personal counseling and mental health services, given the losses that many suffered and the uncertainty that everyone experienced. These services were available through the Campus/Employee Assistance Program (CAP), a free service provided by LSUHSC-NO to assist employees, faculty, staff, residents, and students in resolving personal or work-related problems. The program established a discreet office on the PBRC campus and a counselor was on call 24 hours a day for crisis management. Staff from CAP and the department of psychiatry met with the first- and second-year classes soon after school resumed to discuss the wide-ranging psychological effects of a mass disaster and to emphasize the availability of faculty for counseling. Recognizing the increased risk for posttraumatic stress in certain groups, the CAP staff prioritized and offered services to students and residents who required evacuation from New Orleans after the storm, especially staff and residents who had remained in University and Charity Hospitals to care for patients.
With 693 students who had just survived a mass disaster, the office of student affairs was busy solving problems. To further complicate matters, the associate dean for student affairs retired on short notice due to unexpected health problems. The acting associate dean for student affairs underwent a true trial by fire. Two student affairs offices were established on the EKL and PBRC campuses in Baton Rouge. Most of the administrative staff was on the EKL campus along with the acting associate dean and assistant dean for student affairs. Their proximity to the majority of our clinical students was particularly helpful in matters pertaining to career counseling, fourth-year scheduling, and assistance with residency applications. The acting associate dean also spent several hours per day at the PBRC campus for preclinical students. Additionally, both the acting associate dean and the assistant dean made frequent trips to Lafayette to meet with the third- and fourth-year students on rotations there. All members of the student affairs office were readily accessible by phone or e-mail.
Students also required study space, library access, and a bookstore. Study space and Internet access were available in the Pennington Conference Center and students had access to all libraries on the main LSU campus in Baton Rouge. Our campus library had restored its extensive catalogue of electronic resources for student use through a Web site. The LSUHSC-NO bookstore established service and limited hours on the PBRC campus, although space limitations precluded opening a fully stocked store. Students were able to request a textbook from the director of the bookstore via e-mail, and the text could be picked up within a few days of the request. Many publishers offered our students a considerable discount for replacing textbooks, and we urged all of our students to claim any destroyed textbooks with FEMA for compensation.
Other student support offices were also reestablished on the PBRC campus. The office of student financial aid provided financial counseling, application processing, and check disbursements for displaced students. The temporary offices of the bursar and registrar were established in the same location. The office of minority affairs reopened in office space shared with admissions, adjacent to the PBRC campus. Student health services relocated to the LSU multispecialty clinic; it was staffed by physicians in the section of comprehensive medicine, as it had been before the storm. The clinic hours were more limited, but students could make consultations and appointments by phone or e-mail. Emergency care was provided as needed, independent of normal student clinic appointment times.
Admissions
The admissions process for the class of medical students entering LSU in academic year 2006-2007 was well underway when Katrina struck. Records from previously submitted applications remained in New Orleans and could not be recovered in a timely fashion. Furthermore, correspondence from applicants was compromised by the breakdown in electronic communications and conventional mail systems. Therefore, after consultation with the Association of American Medical Colleges, we decided to cancel the early decision program and begin the admissions process anew. The program director of the American Medical College Application Service (AMCAS) generously agreed to supply our admissions office with new copies LSU School of Medicine applications previously submitted to AMCAS as the admissions office restored operations in Baton Rouge.
The admissions office maintained contact with applicants through our Web site and the AMCAS listserv and extended the application deadline. These measures helped minimize the negative impact caused by restarting the admissions process. Applicants were reassured by the speed with which we resumed all levels of medical education as evidence of our commitment to our educational mission. Ultimately, the number, quality, mean Medical College Admission Test scores, and demographics of the applicant pool did not differ significantly from that of previous years. Applicants began interviewing in early November 2005 and interviewing continued until April 2006 for students to begin in fall 2006. Slightly fewer candidates were interviewed than in previous years, but the size of the class entering in 2006 was maintained at 180 students. In summary, the quality of our first class of students to enter LSU School of Medicine after Katrina was similar to previous years and remains high.
Faculty Affairs
Before the storm, LSU School of Medicine had significantly expanded both basic and clinical faculty components in New Orleans. There were 572 full-time faculty members employed on the New Orleans campus alone; of these 451 were clinical faculty and 121 were basic sciences faculty. The closure of teaching hospitals and disruption of outpatient services caused by Katrina resulted in revenue losses (including those which supported resident and fellow salaries and benefits) that threatened the financial viability of the school. Some New Orleans-based faculty members resigned and others retired or took voluntary leave without pay as a result of the disruption to their lives and work. Although these spontaneous faculty reductions meant that we had to cover fewer salaries and benefits, budget projections still forecast a serious revenue shortfall. Consequently, in November 2005, the LSU Board of Supervisors adopted a force majeure exigency plan outlining a rationale and methodology for further involuntary reductions in faculty and staff. The board of supervisors made the difficult decisions to place certain faculty members in involuntary furlough status in the context of this plan and with the principles established in our mission-based budgeting (MBB) process, which had been implemented at the start of the academic year 2005-2006.
During the MBB process we identified the core teaching faculty positions that were required for UME and GME, and maintaining the core teachers was considered critical to the school's survival after Katrina. Therefore, some full-time New Orleans core clinical faculty members were temporarily relocated to new teaching sites to accommodate the increased needs for UME and GME teaching and to care for the increased patient volume at those sites. Nonetheless, work and funding were not available for all faculty members. Using the MBB principles in the decision making process, the board of supervisors determined involuntary faculty furloughs, which dominantly affected the New Orleans-based clinical faculty. Faculty who were not considered essential to the educational programs and who no longer had a source of funding from clinical activity or research were most vulnerable to furlough. At the conclusion of the process in December 2005, the New Orleans-based faculty comprised 481 full-time faculty members-387 in clinical departments and 94 basic science departments. The reduction represented a mix of resignations, retirements, and voluntary and involuntary furloughs. Some of the involuntary faculty furloughs affected our ability to maintain specialty and subspecialty training programs, as previously described, so we had to modify some clerkship curricula accordingly. The associate dean for faculty affairs and human resource management undertook an individualized approach to faculty counseling, attempting to work through situations such as impending retirements planned before the storm, health coverage for faculty members close to retirement eligibility, and medical leave for faculty members recently diagnosed with serious illnesses.
Clinical and teaching operations at the LSU training facilities in Baton Rouge and Lafayette were expanded after the storm, and the effects of the furlough process on these campuses were relatively small. In fact, some limited expansion of faculty in several programs began at these sites and continues.
Lastly, the school is now rebuilding programs and clinical coverage in New Orleans as hospitals and outpatient facilities reopen. Involuntarily furloughed faculty members are reactivating as activities and availability of faculty members permits. We are also hiring new faculty members in areas of clinician shortage and to restore investigational programs.
Ongoing Challenges: Returning to New Orleans
From the beginning, LSUHSC-NO leadership was determined to return to New Orleans as soon as possible after Katrina. However, returning to a campus that had been badly damaged and a city that had dramatically changed presented many challenges. Returning home required restoring and rebuilding our campus and facilities, anticipating the capacities and needs of the city (e.g., housing, hospitals, and health care), and staging another transition of educational programs and support services for students, residents, faculty, and staff, this time from Baton Rouge back to New Orleans.
The most obvious challenge for buildings and facilities was the process of demucking: the environmental remediation and repair of critical systems in every major building on the LSUHSC-NO campus. This was an extraordinary task. Today, crews continue to work on repairing critical systems in some of the most heavily damaged and oldest buildings. Daily progress updates are posted on the campus Web site, informing the entire LSUHSC-NO community of the complexity of the assessment and repairs that continue.
We originally hoped to return to the New Orleans campus in January 2006, but it became apparent that most buildings would not be ready for occupancy. Likewise, we learned that many faculty and employees would not have housing available at that time. Therefore we planned to reoccupy the buildings sequentially, giving first priority to research labs and the faculty and staff support they needed. Research faculty and graduate students resumed work in some campus buildings in January 2006, and the remainder of the campus was repopulated over the ensuing months. Dormitories opened in May and June 2006. The LSUHSC-NO administration and most schools had returned to New Orleans by June 2006. The school of dentistry, whose buildings sustained the most severe damage, plans to return in July 2007.
As the medical school planned to resume classes and rotations for the 2006-2007 academic year, it became clear that the logistics of student housing would continue to be challenging. First-year students and incoming students understood that all classes would be in New Orleans so they arranged housing in the dormitories or elsewhere in the metropolitan area. However, housing was more complicated for those about to begin their clinical clerkships. The date for reopening University Hospital was still in question and the transition back to New Orleans was occurring at different rates in different departments. Consequently, a significant number of students were likely to remain on rotations in Baton Rouge and Lafayette. However, at the time of planning, it was difficult to predict the exact percentage of students that would be assigned to each site throughout the year.
Some student rotations were able to begin in New Orleans by January 2006, and a number of third- and fourth-year students were able to return to their homes in the city. Consequently, we prioritized clerkship assignments based on where students had accommodations and paid particular attention to providing equivalent educational experiences for all students. Cooperation between the students and clerkship directors and coordinators was essential for this transition. We knew that coordinating student clerkship placements with their housing availability would continue to be a challenge throughout the 2006-2007 academic year. For example, many students had signed long-term leases to get apartments in Baton Rouge and some decided to relocate there permanently. Students were informed about the how clerkship placements would likely be distributed throughout the year. They were also given the opportunity to select the order in which they did their rotations to accommodate their current and future housing needs. The process has not been perfect. Some students have had rotations in cities where they do not have housing, but we have provided these students with apartments when possible. Some students have arranged apartment swaps and others have decided to live with friends and family for portions of their third year while they complete certain rotations.
By July 2007, we expect that all of our third-year students will have housing and receive the majority of their clinical training in New Orleans. The numbers of students rotating in Baton Rouge and Lafayette is likely to remain greater than it was before Katrina, but we should be able to provide appropriate housing when students are assigned to rotations in those cities.
Although the challenges of renovating buildings, finding housing, and maintaining educational programs have been manageable, far greater ones remain. The health care infrastructure in New Orleans has changed and the future of Charity Hospital is still being debated by the state legislature and the Louisiana Recovery Authority. Since Governor Huey P. Long founded the LSU School of Medicine in 1931, its identity in New Orleans has been closely tied to Charity Hospital, the primary site of medical training for Louisiana citizens and medical care for Louisiana's poor.
Originally founded in 1736, Charity Hospital (along with Bellevue Hospital Center in New York) is the oldest continually operating hospital in the United States.5 The current structure was built in 1939 and it has suffered from inadequate funding and neglect in recent decades. When Katrina struck, the hospital was already in severe disrepair. Damage from the flood raised questions about the value of renovating the 67-year-old building and raised even more serious questions about the future of Charity Hospital itself. Charity Hospital is the flagship institution of a statewide network of public hospitals and clinics that provide care for Louisiana's large underinsured population, but the costs and merits of this system have been debated in the state legislature for years. The need for a new hospital in the aftermath of the flood has renewed this debate with vigor. Some of the current questions about the system's value stem from uncertainty about the size and demographics of the post-Katrina population that will emerge in New Orleans, as it was estimated that only 39% of the pre-Katrina population had returned to the city by October 2006.6 However, these questions are philosophically and politically rooted in national issues about health care financing for uninsured or underinsured patients.
For LSU School of Medicine, the stakes in this debate are high. Questions about the future of Charity Hospital, our flagship training site, force us to examine our institutional identity and core values. While we await a decision about Charity's future, we have developed new and stronger relationships with private hospitals, resulting in more diverse clinical training experiences for our students and residents. We will build on these relationships as the school moves forward. However, the fate of Charity Hospital and its consequences for our institutional identity may be the final story about Katrina's effects on the school, and it has yet to unfold.
Lessons Learned
Much can be learned from our story-foremost is the importance of organizational preparedness. In all likelihood, institutions will need to count on their own plans and resources in the face of a disaster like Hurricane Katrina. Responders may be overwhelmed by a mass disaster and federal agencies may be slow to respond and encumbered by red tape. A medical school should have a detailed preparedness plan that includes the following:
1. Ensure that there is adequate food, water, security, medicine, and sanitation for those who remain to care for patients and the physical facilities.
2. Establish predetermined transfer hospitals and a defined evacuation plan for all patients.
3. Plan for the evacuation of remaining staff and their families.
4. Prearrange hospital affiliations (and mechanisms for temporary GME funding) for clinical training. Prearrange facilities for preclinical classes and laboratories. Traditional school or conference facilities are not necessary (i.e., the LSU School of Nursing held morning lectures in a movie theater).
5. Ensure that emergency communication systems can be established quickly. Ensure that information is backed up for all core administrative functions. Each administrative unit and department should have its own disaster plans, including communication systems and data back-ups.
Even the best plans will not be effective without good leadership. During a crisis, leadership may arise from various levels in an organization. Implementing even the most detailed preparedness plan is likely to require creative thinking, decisiveness, and good communication. Leaders should keep the organization focused on the immediate and intermediate goals through frequent communication with administrators, faculty, staff, residents, and students. Among all of the problems faced by an institution after a mass disaster, housing is likely to require some priority. Be prepared to develop creative solutions in conjunction with government agencies.
Many employees and faculty may need psychiatric help and emotional support in the aftermath of a disaster. Many members of the institution may need financial support as well. Develop plans for the provision of emergency funding and counseling for those in need.
All members of the institution need to maintain perspective and professionalism. With thousands of individual stories, there will seem to be an infinite number of problems. Some problems will slip away unresolved, but administrators need to clearly establish and maintain their priorities, from housing, to aid, to curriculum issues, and beyond. As one of our associate deans often reiterated, The main thing is that the main thing is the main thing.
Finally, we have all come to appreciate the personal strength of individuals during a crisis. Many faculty and staff continued to work even though their homes had been destroyed and they were completely rebuilding their own lives. Many had commutes of several hours until they could make housing arrangements in Baton Rouge. Residents and students remained confident that we would provide a quality education despite rumors that we would close. They resumed clinical training or preclinical studies in the face of displacement, tremendous personal loss, and an uncertain future. Preparedness and leadership are the cornerstones of success but, ultimately, institutions will depend on the resilience of their faculty, staff, residents, and students to survive in the aftermath of disaster.
References