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A Major Hospital Announces It Is Closing
The Fallout for Neurology Residents and Patient Services

Article In Brief

After Hahnemann University Hospital in Philadelphia announced it is closing, neurology departments scrambled to place neurology residents in other positions. Neurologists discuss the likely fallout for neurology patients.

It is too soon to predict how the closing of a major medical center in Philadelphia in September—Hahnemann University Hospital—will affect neurology services in the city. But the fallout will likely be significant, neurologists interviewed for this article told Neurology Today.

One concern—the placement of neurology residents—has been assuaged, however. At press time, all 17 of the “orphaned” neurology residents who lost their training slots when Hahnemann University Hospital announced that it would be closing its doors had been officially accepted into other residency programs, according to Jyoti Pillai, MD, FAAN, associate professor and vice chair of neurology and director of the neurology residency program at Drexel University College of Medicine.

Twelve of the neurology residents have matched with new programs in the Philadelphia area: six to Temple University, four to Thomas Jefferson, and two to the University of Pennsylvania.

Others were placed at University of Pittsburgh Medical Center, Columbia University, Oregon Health State University, Penn State Health, Milton S. Hershey Medical Center, and Yale University School of Medicine. One clinical neurophysiology fellow has been accepted at University of Pennsylvania, and the other fellow withdrew her application.

But the process was not easy. The neurology residents—along with their more than 550 colleagues in many other specialties—waited in limbo after Hahnemann shocked its employees with the closure news during a town hall meeting on June 26, citing “unsustainable financial losses.”

Nathalia Figueiredo, MD, a second-year resident, had completed her PGY1 year at AtlantiCare Regional Medical Center in New Jersey before relocating to Philadelphia for PGY2.

“I got here on Monday night, June 24, expecting to start my residency on July 1. On Wednesday morning, less than two days later, we got the news,” she said.

“We were all really freaking out. There's no other way to describe it. Fortunately, all the programs here in Philadelphia and elsewhere in Pennsylvania started reaching out to us very quickly after the news came out.”

By the first week of July, Dr. Figueiredo had completed promising interviews with three other institutions and received an offer from Temple, where her husband is also a medical resident.

But she couldn't accept yet. As part of Hahnemann's bankruptcy proceedings, Tower Health, which operates six hospitals in the region and has an academic partnership with Drexel, offered to buy the Medicare provider number and hospital license, which includes the residency slots, and the corresponding state certificates associated with being a teaching hospital, for $7.5 million.

Because Tower's hospitals do not have the breadth of approved residency programs that Hahnemann had, about one-fifth of the Hahnemann residency complement, and not nearly as many specialties, Tower's offer included the right of all current residents to be released to accept offers from other teaching hospitals.

So as they interviewed with other residency programs, Hahnemann's residents still didn't know when the funds attached to their residencies would be released, allowing them to accept residencies elsewhere.

“We went through all of July without knowing if the funding would be released or not, whether they would release 100 percent of it, if so, and whether programs would agree to accept us if the funding was not 100 percent,” said Dr. Figueiredo. “It was very stressful, but we were all so grateful for Dr. Pillai and all of our attendings, who gave us all the help they possibly could.”

Reduced Funding for Residency Program

On July 24, however, after weeks of protests, Hahnemann's parent entity, Philadelphia Academic Health System, announced it would officially release the funds attached to its residents by withdrawing from accreditation. Under the release agreement, the residents would only travel with 80 percent of their allotted funding from the Centers for Medicare and Medicaid Services (CMS) to be distributed to the receiving hospital; fortunately, all of those hospitals agreed to accept the reduced funding.

It was a huge relief for all of Hahnemann's residents, but particularly for foreign medical graduates like Dr. Figueiredo. “Being here on a visa, you cannot have any gaps in your training,” she said. “We had asked the Educational Commission for Foreign Medical Graduates (ECFMG) if, for example, the program closed on August 1 and the next program was only ready to accept us on August 15, would that gap be too much? They told us we would probably have a 30-day grace period in order to adjust everything, but we were still waiting on official information.”

The neurology residents' last day at Hahnemann was August 6, and most—including Dr. Figueiredo—began their new residencies on August 7. Although admissions to Hahnemann's emergency department officially ended on July 17 and inpatient admissions on July 19, there were still patients on the floor for residents to manage through the third week in July.

“For the last week of July and the first week of August, we didn't have any patients in the hospital, but we were working in the outpatient clinics, so there will be no gaps in our training on the record,” she said.

“It's been heartbreaking to watch these accomplished trainees, who have done so much to get where they are, stuck in limbo in a situation that was entirely out of their control,” said Jill Farmer, DO, MPH, assistant professor of neurology at Drexel and director of the Parkinson's Disease & Movement Disorder Program at Drexel Neurosciences Institute.

“The amount of camaraderie among what usually are competing institutions to get people placed as quickly as possible was heartening to see. But the overall environment and the context in which it all happened was devastating for a lot of people.”

One institution that wanted to accommodate the orphaned Hahnemann neurology residents was unable to. St. Luke's University Health Network in the Lehigh Valley, which operates 11 hospitals—soon to be 12—has a neurology department with more than 40 practicing neurologists, and recently launched psychiatry and neurology residency programs.

“We were approved for 24 psychiatry and 16 neurology residents over four years, and beginning on July 1 of this year, we started with four neurology PGY1 and six psychiatry PGY1 residents at St. Luke's Anderson Campus, a brand-new facility on 400 acres,” said Jonathan P. Hosey, MD, FAAN, chairman of the St. Luke's Center for Neuroscience and himself a 1983 graduate of Hahnemann. “We felt that we could take a substantial number of PGY2, PGY3, and PGY4 residents from Hahnemann.”

It seemed like a perfect solution—but CMS regulations require organic growth to a new residency program, and the agency was not willing to make an exception for emergency action to bring in orphan residents.

“I've learned that these regulations are in place to discourage new residency programs from raiding other programs, but in extreme circumstances, wouldn't it be nice to be able to accommodate people in distress?” Dr. Hosey said.

Temple University, which accepted six Hahnemann neurology residents, hopes to permanently expand its neurology residency program going forward.

“We would like to apply to the ACGME for a permanent expansion,” said Paul M. Katz, MD, professor and interim chairman of the department of neurology at the Lewis Katz School of Medicine at Temple and director of the Temple Comprehensive Stroke Program.

“We will enhance our services to accommodate the residents as well as patients, and hopefully that will be sustainable, which is really what we need for the further development of our neurology program to begin with. It will free up time for the residents to have better educational experiences and give them protected time for their electives and for research projects.”

The Impact on Services

The impact of the closure may soon be felt at the emergency departments of the other local hospitals, said Dr. Pillai. “Their ED wait times may increase and may possibly impact acute neurological care. For chronic disorders, the wait times to see a neurologist in the outpatient clinic, especially subspecialty clinics is already long.”

Raymond Price, MD, FAAN, associate professor of clinical neurology and director of the neurology residency program at Penn Medicine, estimates that the neurology resident clinic at Hahnemann cared for approximately 1,600 patients over the previous 18 months.

“Of those, they were anticipating transitioning only about 20-30 percent to Drexel faculty practices,” Dr. Katz said. “About 70 percent of neurology patients who had been receiving care in their outpatient clinics will need care elsewhere—that's more than 1,000. And that's all just chronic outpatient care, and does not include inpatient stroke or neuro-trauma volume.”

Temple's stroke service has been somewhat busier than normal since Hahnemann's emergency department closed, Dr. Katz said, but the full impact of the closure is not yet clear. “For right now, we've been able to accommodate any increases there. But I think the biggest problem is going to be in outpatient neurology,” he predicts.

“As it is, there's a very long wait in the Philadelphia area for outpatient neurology appointments—a couple of months or more. We've talked about expanding office hours or having attendings put in another session, but my solution, which I wanted to do even prior to Hahnemann's closing, is to develop a division of general neurology with four full-time neurologists to tackle this issue.”

“The amount of camaraderie among what usually are competing institutions to get people placed as quickly as possible was heartening to see. But the overall environment and the context in which it all happened was devastating for a lot of people.”

—DR. JILL FARMER

The program has already hired three and is negotiating with a fourth, he said.

What About the Patients?

The neurology residents, in the midst of their worries about their own futures, are also equally concerned about their patients. One PGY-3 neurology resident, who asked that her name not be used, had just reunited with her husband after he relocated his own radiology residency from Chicago to Philadelphia—only to have her own status put in jeopardy. (She was ultimately accepted at Temple.)

“When I was in the outpatient clinic, my patients kept asking if they could follow with me and if I could continue to be their doctor,” she said. “I had no choice but to tell them no, that they would have to find another physician. It was very stressful for these people, who are already dealing with so much stress related to their medical conditions.”

“Doctors put patients first, so we will try and help them navigate options for continuity of care the best we can, preferably at the other local institutions, so that they get easy local access,” Dr. Farmer said.

Dr. Hosey said other institutions should consider Hahnemann as a cautionary tale. “If it happened here, at an institution with an over 100-year legacy, my fear is that it could happen anywhere,” he said. “If it does, we shouldn't put patients or residents through what they've gone through at Hahnemann. Institutions need to be prepared to take care of displaced patients and protect their trainees.”

Link Up for More Information

• Redford G. What happens when a teaching hospital closes? https://news.aamc.org/medical-education/article/what-happens-when-a-teaching-hospital-closes. Accessed August 8, 2019.
    • Brubaker H. Hahnemann University Hospital to close. https://www.inquirer.com/business/hahneman-hospital-philadelphia-closing-20190626.html. Accessed August 8, 2019.