Medical Education in Post-Katrina New Orleans: Title and subTitle BreakA Story of Survival and Renewal

The most costly national disaster in US history occurred on August 29, 2005, when Hurricane Katrina ravaged the Mississippi and Louisiana Gulf coasts, and the ensuing breaches in the New Orleans levee system resulted in flooding of approximately 80% of the city.¹ The survival of Tulane University School of Medicine and Louisiana State University School of Medicine at New Orleans (LSU), both located in downtown New Orleans, was severely jeopardized as every major educational and teaching facility flooded following the storm, closing both undergraduate and graduate medical training programs. However, both schools quickly moved their educational programs to new locations and reestablished training for students and residents 1 month later. Tulane and LSU have now returned their educational programs to New Orleans despite faculty losses, closure of some traditional training hospitals,² and a diminished population of greater New Orleans. The ability of both schools to survive and thrive has significant long-term implications for the delivery of health care in the region and the ability to train future physicians for the state of Louisiana.

Tulane and LSU are situated almost adjacent to each other in downtown New Orleans, but because of the differences in the private and public nature of the 2 schools, the impact of Katrina and the solutions to recovery differed.^{3 - 7} The effects of Katrina on the educational programs of both schools are summarized in the Table. Immediately following Katrina, Tulane moved its medical student programs to Houston, Texas, using facilities at Baylor College of Medicine while LSU moved its preclinical classes to LSU's Pennington Biomedical Research Center near the main campus in Baton Rouge, Louisiana. Both schools resumed classes within 4 weeks.

Communication was one of the earliest challenges. For 6 weeks, Tulane's electronic communications were unavailable, so students telephoned school administrators and provided notification of a student-created listserv. Baylor College of Medicine subsequently provided a Web site for Tulane to use to disseminate information. LSU installed a new data center with preexisting backup tapes.

Housing was another immediate concern. Tulane used an online housing registration system created by Baylor College of Medicine, primarily with housing donated from the Houston community. In Baton Rouge, many LSU students were able to make living arrangements, but others had no access to affordable housing. With support from the Federal Emergency Management Agency, a Baltic ferry at the Port of Baton Rouge served as home to hundreds of LSU students, residents, staff, and faculty.

The emotional and financial toll had a significant effect on all students, but none experienced significant physical harm. Tulane students received mental health support from Baylor College of Medicine mental health personnel,⁸ while LSU provided counseling to its students and residents, prioritizing those who remained in hospitals during the evacuation. The DeBakey Foundation, private donors, and students from other medical schools provided more than $200 000 to Tulane students for property losses. Even so, financial losses were a factor in the transfer of 7 students. Similarly, the LSU Alumni Association established an emergency fund to help students and residents with major financial losses. Despite these issues, retention of students was excellent at both schools (Table).

Maintaining the admissions process was also challenging. For the first academic year following Katrina, Tulane had no change in applicant numbers and continued its medical school application process by interviewing applicants in Houston. The class of 2010 represented 32 states; however, Louisiana matriculants increased from 28% to 36%. At LSU, application records were lost in New Orleans and the process had to be restarted with an extended deadline; however, the size of the applicant pool, all of whom were Louisiana residents, did not change. There was no change in the quality of incoming matriculants at either school based on mean scores of Medical College Admission Tests and grade point averages (Table).

Both schools quickly resumed medical student education without compromising quality. Student performance, as measured by mean final course averages, standardized National Board of Medical Examiners course examination scores, and scores for United States Medical Licensing Examination Steps 1 and 2, was unchanged. The limited number of Tulane faculty who delivered the curriculum in Houston were responsible only for education; the preclinical curriculum contained 90% of the pre-Katrina contact hours and involved some modifications to curriculum delivery.^{3 ,5} Clinical training was more difficult. Thirty-eight students requested and were granted permission to complete their clerkships at other schools immediately following Katrina. Based on availability of patients and faculty, almost 400 clinical rotations were voluntarily created for Tulane students by the 4 Houston-area medical schools. Clinical training of LSU students resumed largely at the public hospitals in Baton Rouge, Lafayette, and Houma, Louisiana. Additional rotations for students, along with residents, were developed at private hospitals. The range of schools into which all fourth-year students at both schools were matched was no different than in previous years. At Tulane, more students than in previous years did not match, attributed to the reduction in number of Tulane residency positions. Between 2005 and 2006, the percentage of students remaining in Louisiana for residency training declined from 20% to 16% at Tulane and from 52% to 44% at LSU.

Both schools returned to New Orleans for the 2006-2007 academic year. Tulane's primary education building sustained extensive flooding damage on the first floor, but was renovated by March 2006 with students returning in July 2006. A planned move into adjacent educational and administrative facilities continued, along with completion of a new clinical skills training facility, auditorium, and small group rooms. The New Orleans Veterans Affairs Medical Center and the Medical Center of Louisiana at New Orleans, with a total of 1030 beds, remained closed, necessitating further involvement of traditional community affiliates for clinical training in New Orleans.² A greater number of community physicians have agreed to supervise students directly. While flexibility is limited, an adequate number of clerkship positions are available.

LSU faced its own challenges on returning to New Orleans in July 2006 because every campus building had sustained major flood damage. Medical student clinical skills laboratories and expensive simulation equipment were destroyed. Despite these problems, preclinical teaching resumed with little change from the pre-Katrina curriculum (Table). With the help of alumni and corporate donations, simulation equipment was replaced and installed in temporary facilities, with plans to rebuild and significantly expand clinical skills teaching laboratories on higher floors. Clinical teaching resumed with greater dependence on public hospitals outside of New Orleans and additional sites that were developed for residency training (Table). To ensure similar levels of competence at all sites, the importance of clearly defined educational objectives for each clinical rotation was emphasized. A critical shortage of psychiatric beds and mental health training sites in New Orleans has been a major problem for both schools.

Residents and fellows at both schools experienced the same issues as the students. House staff were more likely to have families and own homes, creating additional personal challenges in dealing with the extended evacuation of the area. The closure of hospitals and lack of opportunities for performance of procedures took a significant toll on both programs. At Tulane, residents were relocated to temporary affiliates around the country; 200 went to Baylor College of Medicine, and many eventually transferred (Table). By July 1, 2006, Tulane University Hospital and Clinic had reopened, and most residents were distributed to facilities within greater New Orleans.

Similarly, 87% of LSU's residents had been located in the metropolitan New Orleans area prior to Katrina, because Medical Center of Louisiana at New Orleans provided the bulk of the training. Immediately after the storm, the inpatient census at public hospitals in Baton Rouge, Lafayette, and Houma nearly doubled and many residents resumed their training in these hospitals. Some residents moved temporarily to the LSU-Shreveport program or to out-of-state programs. As of August 2007, 75% of LSU residents have returned to the New Orleans area. However, many programs have forged and maintained new relationships with private hospitals that have diversified and enhanced the resident training experiences. These new sites, along with most programs, underwent review during formal Accreditation Council for Graduate Medical Education accreditation visits in July and August 2006.

The transfer of residents created significant financial challenges. Payments from long-standing affiliates stopped because almost all Tulane residents were transferred to new sites, many out of state, whereas LSU was able to transfer most residents to other state hospitals. The financial burden of payment was borne by the schools until the Centers for Medicare & Medicaid Services provided temporary waivers to transfer positions from Medical Center of Louisiana at New Orleans to new sites until 2008. The re-deployment of residents created unique opportunities for both schools to partner with community physicians who were keen on supervising residents, adding high-volume practices and outpatient training sites that had either limited or no previous role in medical education. Despite these additional sites, almost all residency programs were forced to downsize due to fewer patients, procedures, and faculty. In the first residency/fellowship match after Katrina, almost all positions filled, but both programs had significantly reduced the number of positions available (Table). This reduction in graduate training positions at both schools is likely to affect the future supply of physicians for the area.

Dramatic changes in the health care environment occurred in the New Orleans area during the year after Katrina, resulting in significant voluntary and involuntary reductions of faculty at both schools (Table). Data from several sources suggest that by July 2006, the population in Orleans Parish had decreased 40%, accompanied by a 73% decrease in physicians, an 89% reduction in staffed hospital beds, and a 10% to 14% increase in uninsured adults.⁹ The area is now well below the national average for hospital, mental health, and nursing home beds. These changes have had a disproportionately adverse affect on the uninsured, many of whom received care in facilities supported by both medical schools that remain closed. The decline in population, loss of hospitals, and the increase in uncompensated medical care contributed directly to the financial hardships of both institutions, which also sustained hundreds of millions of dollars in financial losses due to lost clinical income, relocation costs, lost research assets, and facility damages. Both schools have struggled to restore financial stability by downsizing and rebuilding their clinical enterprises while financially supporting the remaining faculty and staff. Tulane has relied heavily on support from the university for salaries while LSU has relied on continued state support. A greater proportion of resident salaries is now supported at newly developed training sites provided through the Centers for Medicare & Medicaid Services' waiver for both schools.

Despite the catastrophic effect of closed facilities and displaced faculty, staff, residents, students, and patients immediately following Katrina, both schools remained committed to their undergraduate and graduate medical education programs and were determined to reopen as quickly as possible following the storm, ensuring the survival of medical education in New Orleans. Both schools have always been the region's major suppliers of health care for underserved individuals, the major training sites for future local physicians, and major sources of economic development for the city. As the city of New Orleans rebuilds and repopulates, the need to resume these primary functions has never been greater. However, fewer residency positions are available and more students are leaving the state for residency training. Strong medical education programs are therefore essential for the faculties and residency programs to grow to meet physician supply needs as the population returns.

The process of reestablishing strong medical education programs has already started. Both schools have benefited from the development of new affiliations that provide higher patient and procedure volumes in more supervised settings than the traditional programs. Every educational program has been under intense scrutiny by the respective accreditation agencies and extensive documentation has been provided to show that program quality and patient population is adequate for medical training. Plans are under way for a new US Department of Veterans Affairs hospital and a new state-run hospital. Retention of faculty has largely stabilized and both schools have already begun to successfully recruit new physicians to their faculties.

While Tulane and LSU appeared to be on life support immediately following Katrina, the immediate actions of both schools were vital in saving and resuming high-quality undergraduate and graduate medical education to meet the needs of students, residents, and patients. Reduced faculty and clinical facilities have created unique opportunities that could not have been foreseen before the storm, and both schools are rebuilding their educational programs in a dynamic health care environment. Doing so will ensure the ability to attract outstanding students, residents, and new faculty to replenish the diminished physician supply of the region and serve the health care needs of the people of New Orleans.