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RESIDENTS’ AND FELLOWS’ COLUMN

After the Storm: Eight Unexpected Benefits toRadiology Resident Education at NYU LangoneMedical Center After Hurricane SandyLaura Heacock, MD, Sheryl Tulin-Silver, MD

Hurricane Sandy, the “super storm”

of 2012, battered the East Coastfrom the evening of Monday,October 29, through Tuesday,October 30, 2012. Although mil-lions of lives in the New Englandregion were affected by the storm,the people living in the coastalareas of New Jersey and seasideboroughs of New York City suf-fered some of the most severe con-sequences of the storm. The wind,rain, flooding, and fire broughtthese communities to a standstill.In the midst of the storm, New

York University (NYU) LangoneMedical Center, Bellevue HospitalCenter, and the Veterans AffairsNew York Harbor HealthcareSystem Manhattan Campus, alllocated on the southern coast of theisland of Manhattan, sustainedcatastrophic damage from once-in-a-century flooding and failedgenerators, which required thetemporary relocation of patients,employees, and services. The med-ical staff and volunteers heroicallyeffected the safe evacuation ofhundreds of patients to nearbyhospitals. Many NYU administra-tive and research facilities were alsoseverely damaged. After the windand rain ceased, our stunned com-munity regrouped to assess thedamage and begin the recoveryefforts.Among the challenges our

institution faced was ensuring theintegrity of its graduate medicaltraining programs while the hos-pitals were largely closed for inpa-tient clinical care. Most residencyprograms were forced to reassign

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house staff to nearby hospitals,which welcomed NYU trainees totheir programs during the recovery.The department of radiology,however, strongly felt that it wasmost beneficial to keep our resi-dents at NYU with our own facultymembers. With our extensive out-patient imaging facilities networkremaining operational after thestorm providing clinical care andwith creative adjustments to theprogram, we seamlessly continuedour training within the NYU hos-pital system. Thus, while learningradiology, we had a unique insideview of the recovery efforts andwere witness to the perseveranceand dedication required to pull adepartment out of a disaster.The challenges confronted by

the institution and the departmentof radiology after the hurricanealtered many aspects of our day-to-day experience as residents. Wedescribe our experience, empha-sizing measures initially imple-mented to address temporarydeficiencies in the training programbut that ultimately improved ourresidency program and positivelyaffected our educational experience.

CREATIVE COMMUNICATIONAND SOLUTIONSIn the immediate aftermath ofHurricane Sandy, communicationwithin the department of radiologyand between the radiologists andreferring clinicians faced multipleobstacles. The institutional e-mailservice and intranet were down,most hospital phone lines werenot operational, and many staff

.2013.08.020

members did not have accessto computers. The mass relocationof most radiology reading roomsand administrative and leadershipoffices to a nearby “off-campus”building, as well as the relocation ofreferring clinicians’ offices, renderedthe previous departmental phonenumbers useless even after phonelines were reestablished.

Creative teamwork overcamethis shared challenge. Personal cellphone numbers exchanged amongattending physicians reestablishedcommunication among the spe-cialties, fostering new relationships.This timely and reliable commu-nication was vital in maintainingcontinuity of care for our patientsduring the recovery period. As abonus, many clinicians and radi-ologists now find that they preferto use the contact numbers pro-vided after the storm.

Medical specialties were allo-cated precious space at outpatientsites, and our surgical colleaguesused staggered time during non-traditional hours in the operationalsurgical suites. Extended hours atoutpatient imaging sites wereidentified as critical to continuityof the NYU clinician-patient re-lationships. As a result, outpatientscanning centers began to offerlater hours, with residents andfaculty members shifting their callschedules and working expandedhours to offer radiology coverage.Initially launched to provide ser-vice with limited facilities, theseextended hours continue after therecovery because of patient andreferring clinician popularity.

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ENHANCED ATTENDINGRADIOLOGIST TEACHINGBoth formal and informalattending radiologisteled teachingsessions increased in frequencyafter Hurricane Sandy. Initiallydecreased case loads after the stormprovided the attending radiologistswith additional academic time forresident education. Formal dailyresident didactic and case confer-ences resumed on the first dayback to work, 1 week after thestorm, a measure deemed criticalto maintaining our educationalmission. The return to relativenormalcy in this very un-normalsetting proved important for oursense of security in the programand solidarity with our coresidents.Many subspecialty attending radi-ologists also informally presentedadditional lectures or case confer-ences to residents in the readingroom between dictations.Creative solutions supplemented

the temporarily limited inpatientand trauma case volume whilethe emergency department andinpatient wards were closed. Forexample, the pediatric imagingsection created modules fromteaching files to simulate dailyimage interpretation for practicedictation exercises, which wasparticularly important for juniorresidents with respect to neonatalintensive care unit imaging.Initially low CT volume affordedjunior residents early exposure toMRI 1 to 2 years earlier thanallowed by the traditional resi-dency curriculum. The attendingemergency radiologists offered one-on-one teaching sessions while theemergency department was closed,enhancing first-year residents’preparation for the daily spectrumof a busy level I trauma center.Overall, we were able to takeadvantage of the increased teachingtime to accelerate our learning andimplement innovations to ourteaching programs.

RESIDENTS TEACHINGRESIDENTSIn the posthurricane period, resi-dents were given greater respon-sibility and flexibility in teachingone another. During multiple sub-specialty rotations, residents createdbrief educational presentations indidactic format, interesting caseformat, or a combination of both.Attending radiologists, fellows,and coresidents assigned to therotation attended the presentationsand participated in brief discus-sions. Examples include the evalu-ation of bowel wall thickeningduring a body rotation or the dif-ferential diagnosis of cavitary lunglesions during a chest rotation.Both the presenting residents and

their coresidents benefited from thisform of “peer teaching.” The pre-senting residents gained in-depthknowledge and experience in small-group teaching and creating effec-tive presentations. The recipientresidents benefited from additionaleducational material supplementingthe regularly scheduled attendingradiologisteled conferences. Thepresentations were an excellentacademic use of time during theinitial lag before case volume wasrestored.

APPRECIATION OF QUALITYIMPROVEMENT INITIATIVESThe residents witnessed the hospi-tal administration and radiologysubspecialty section leaders eval-uate the performance of ourdepartment and strategize oppor-tunities for improvement revealedin the storm’s aftermath. Weobserved the quality improvementprocess in action as the adminis-tration identified shortcomings,gathered and analyzed data,designed and implemented solu-tions, and reanalyzed the results[1]. It comes as no surprise thatcurrent resident quality improve-ment projects address the issue ofreliable communication methods

during natural disasters and otheremergencies.

Practice-based learning andquality improvement are key com-petencies set by the ACGME forradiology residency education [2].The challenges stemming fromHurricane Sandy created excitingopportunities for residents to workas a team and join in the qualityimprovement process.

DEDICATED TIME FORSCHOLARLY WORKIn the first few weeks afterHurricane Sandy, residents wererelocated from rotations with in-sufficient teaching volume becauseof damaged equipment or closedfacilities. At the same time, redir-ected case volume to spared outpa-tient facilities required expandednontraditional hours, unique after-hours coverage, and new call re-sponsibilities for the residents.Postcall days therefore becameelective academic days, allowingresidents to share quality teachingtime at rotation sites or concentrateon research projects, while satisfyingduty-hour requirements. Manyresidents dedicated this academictime to RSNA presentations orprojects with winter abstractdeadlines.

The department’s emphasis ondedicating this unexpected time toscholarly work was broadly applied.Radiology faculty members wereencouraged to take advantage oftheir new proximity to biomedicalscientists because of the relocationof offices and reading rooms to theCenter for Biomedical Imagingresearch building. Multiple sym-posia and working groups werearranged, facilitating collaborationand dissemination of new ideas.Residents took advantage of theseunique opportunities to learnabout new translational research,increasing research participationat a key startup time for manyprojects.

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RESIDENT EXPOSURE TONEW CLINICAL SITESWith the temporary closure ofinpatient hospital training sites, off-campus imaging centers increasedpatient volume and became viableclinical teaching venues. Many ofthese NYU ambulatory centers (theClinical Cancer Center, the Centerfor Musculoskeletal Care, and theCenter for Women’s Imaging)offered a unique look at the out-patient practice of radiology withina major academic center. This un-expected increased exposure tooutpatient care provided an expe-rience that helped residents developa deeper understanding of post-residency career choices.Harnessing technological ad-

vances facilitated communicationamong the various sites. Telecon-ferencing the resident didactic andcase conferences allowed resident“attendance” and participationregardless of rotation assignmentacross the geographically dispersedcampus. The instant messagingfunction in our PACS allowed real-time attending radiologist andresident interactions regardingcases from any location throughoutthe day.The positive educational experi-

ence that many residents had atthese new outpatient sites has af-fected our curriculum. The futurerotation schedule will likely in-clude some of these outpatient sitesas rotation assignments.

LEADING BY EXAMPLE:TEACHING FLEXIBILITY AND APOSITIVE ATTITUDEFor several months after the hurri-cane, the normal routine wasdisrupted. In a staged reopeningsequence, the Bellevue HospitalCenter emergency department andoutpatient facilities reopened inNovember 2012; Tisch Hospital,the main university hospital, reop-ened in January 2013 (outpatientfacilities were closed only during

the week of the hurricane); and theVeterans Affairs New York HarborHealthcare System ManhattanCampus inpatient facilities reop-ened in May 2013. The NYUradiology community was copingwith new schedules, call, rotations,and locations for conferences andreading rooms at work even asmany residents’ and faculty mem-bers’ home lives were equally dis-rupted. The key to our successfulrecovery was to maintain a positiveattitude, be flexible, be grateful forwhat we had each day, and focus onthe progress made.In the immediate aftermath and

resulting displacement, our depart-ment chairman, Michael Recht, MD,and department administratorswere committed to keeping thecommunity informed. Dr Rechtconducted daily walking rounds inwhich he touched base with eachsubspecialty section; Vice Chairof Education and Academic AffairsGeorgeann McGuinness, MD,e-mailed concise daily bulletins,which reported our progress butalso pulled the department to-gether. There were weekly interac-tive staff meetings at whichquestions were welcomed andencouraged. As residents, we hadencouragement and support fromour tireless program director andassociate program director, MichaelAmbrosino, MD, and CeciliaMercado, MD.Flexibility and sensitivity to the

needs of our colleagues and patientshelped guide the successful recoveryefforts. We stayed positive, andworking within the imposed con-straints, the department managedto provide the level of outstandingpatient care and commitment toeducation established before thehurricane. The residents learnednot only radiology but also themind-set needed to overcomeadversity and the importance ofvisible, communicative, and opti-mistic leadership [3].

CAMARADERIEAfter the storm, many residents’apartments, especially in southernManhattan, were uninhabitable.Residents with apartments northof the power outage opened uptheir doors to their colleagues fordays to weeks, offering electricityfor phone charging, bathrooms forshowering, and sofas and sparebedrooms for sleeping. Our chiefresidents contacted each residentto make sure they knew these re-sources were available and orga-nized social events to keep moralehigh. We bonded and felt closerthan ever by helping one anotherthrough this challenging time.

Months after the storm, ourmajor core training institutions areback up and running at full volumein a way we will never again takefor granted. We were thrilled towelcome back our colleagues andinvaluable support staff membersas wards and clinics opened upweek by week. We admired thepristine hallways as we moved backinto our reading rooms. We expe-rienced increasing excitement witheach new bump in volume andaddition to the case mix, as hos-pital services came back online. Asa residency program, we are proudof what our department and ourhospitals have achieved in such ashort time.

Radiology residency interviewseason flew by, while the mainhospitals were still closed, andmany of our applicants, not sur-prisingly, were curious to knowhow our training had been affectedby the storm. “You may have heardof a little storm called Sandy,” oneof our senior residents joked dur-ing his tour. It was a moment ofreflection: only a few months ago,our institution faced an unimag-inable challenge. But with thehospitals reopened, night float infull swing, and the memories of allwe accomplished during this time,we were able to confidently tell our

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future residents that Sandy onlymade us stronger.

ACKNOWLEDGMENTS

We gratefully acknowledgeDrs Michael Recht, GeorgeannMcGuinness, Michael Ambrosino,Cecilia Mercado, and Nancy Fef-ferman for their editorial assistance

and support during the hurricanerecovery.

REFERENCES

1. Kruskal JB, Eisenberg R, Sosna J, Yam CS,Kruskal JD, Boiselle PM. Quality initia-tives: quality improvement in radiology:basic principles and tools required toachieve success. Radiographics 2011;31:1499-509.

2. Accreditation Council for Graduate MedicalEducation. Program requirements forgraduate medical education in diagnosticradiology. Available at: http://www.acgme.org/acgmeweb/tabid/148/ProgramandInstitutionalGuidelines/HospitalBasedAccreditation/DiagnosticRadiology.aspx.Accessed June 26, 2013.

3. Wiese JG. Leadership in graduate medicaleducation: eleven steps instrumental inrecovering residency programs after adisaster. Am J Med Sci 2008;336:168-73.

Laura Heacock, MD, and Sheryl Tulin-Silver, MD, are from NYU Langone Medical Center, New York, New York.

Laura Heacock, MD, NYU Langone Medical Center, Department of Radiology, 550 1st Avenue, New York, NY 10016; e-mail:

laura.heacock@nyumc.org.