Emerg Radiol (2006) 13: 57–59DOI 10.1007/s10140-006-0506-8

EDITORIAL

Stephen R. Baker

Radiology residencies: disasters and preparedness

Published online: 25 August 2006# Am Soc Emergency Radiol 2006

For the past decade now, residency positions in radiologyin America continue to be highly sought. The competitionis fierce but when the match is published and the applicanthas gained a place for training after internship, it is a causefor celebration as the stresses of the months longapplication process is finally relieved. However, enteringa residency is no guarantee that it can be completed,independent of the enthusiasm and capabilities brought tothe program by the trainee himself.

Externalities can affect the 4-year residency interval.There is no guarantee that the quality of the program willcontinue indefinitely as decline is as likely as improve-ment, although maintenance of the status quo is probablymore frequent. The job market for radiologists is so strongin the United States today that prized faculty members areapt to be recruited away from the program, leaving theresidents with fewer teachers of quality. The administrationof the hospital may no longer be interested in maintaining aresidency program, and may choose to end it after only ashort transition period. This is not merely a theoreticalconcern as program closure has happened several times inthe past few years. Worse, the program or the hospital maybecome bankrupt and then may no longer value the benefitsof continuing to maintain a graduate medical educationprogram. Under such a drastic scenario, trainees will thenbe compelled to seek other positions elsewhere and onlyget them if they are lucky. In these circumstances, there islittle protection for the residents when the program declinesor disintegrates.

Ad hoc procedures must be found to help residents inthese unfortunate circumstances. Yet the record of the past3 years is such that mechanisms are not always im-mediately successful in linking existing programs withdisplaced trainees even if the resident and his family has to

relocate without delay. Moreover, the Radiology ResidencyReview Committee, an arm of the ACGME, meets onlytwice a year. When it convenes, it may conclude that aparticular residency no longer passes muster and as a firstwarning, places it on probation. This is a good and badthing at the same time. It is bad because it tarnishes thereputation of the program. Perhaps such a report card willencourage the sponsoring agency to close the program ornot make necessary investment to support it. Yet, it can alsobe good because it could be a wake-up call for the hospitalor the medical school to now sustain the residencysufficiently after a period of decline and neglect. TheRadiology Residency Review Committee could also opt toterminate the program immediately if the educationalcontent is so wanting improvement that nothing can bedone to fix it, an eventuality that is rare but not impossible.Here, too, the resident now must find another place tocomplete his training. However, a director of the disac-credited program may not be strongly motivated to help thedisplaced resident. So neglect, lack of investment, andeconomic vicissitudes can all contribute to a small but notnegligible risk to any resident in any program.

One might ask—How do these educational misfortunesrelate to the focus of the contents of Emergency Radiology?The mission of this journal is to present facts and opinionsrelated to imaging of the emergently ill and injured. Mattersof trauma have and will continue to occupy a central placein the content of every issue. In the past, attention has beenprimarily directed to case reports and series involved withmanifestations of traumatic damage to persons. But analo-gously, the unexpectedness and devastating effect of anabrupt disruption to well-being can afflict institutions aswell as individuals. Residents and residencies alike mayhave to contend with programmatic dislocations as a resultof a calamity, be it natural or manmade, and be forced toconfront the attendant consequences to equipment, build-ings, communication, and transportation. Each of which isvital to the maintenance of a clinical enterprise and avibrant learning program. The past year, unfortunately, hasshown that worried musings about such eventualities canbe reified as actualities.

S. R. Baker (*)Department of Radiology,UMDNJ-New Jersey Medical School,150 Bergen Street, UC C-320,Newark, NJ 07103-2406, USAe-mail: bakersr@umdnj.edu

Hence, we have lessons to learn from the effect ofKatrina on New Orleans programs. Also, we can postulaterectifying responses, some of which have been instituted,and others as yet are not implemented or even not con-templated. The Centers for Medicare-Medicaid services,otherwise known as CMS, is the major paymaster forgraduate medical education in the United States. It hasrecently recognized that when programs are disrupted,there needs to be a policy to transfer personnel funding,either temporarily or permanently to a new host hospitalfrom the old home hospital so that training can continue forthat resident, even though the physical components of thedamaged program have been placed in abeyance byadverse circumstances. Until last August, there had beenthree radiology residencies in the city of New Orleans.Ochsner Clinic, which stayed dry during the hurricane,nonetheless suffered considerably in the aftermath ofKatrina. Its patient load went down and residency trainingwas disrupted almost entirely for almost 6 weeks. Yet,Ochsner has been able to reconstitute itself. The disruptionof clinical training, its severity abbreviated, has not resultedin such a marked decrement in education that the quality ofthe program could not be restored.

Tulane Hospital which became nonoperative afterKatrina continued its radiology program after the transferof residents to Houston. That necessitated the reposition-ing of the residents from New Orleans to another cityhundreds of miles away with its associated difficulties interms of maintenance of both quality of education andquality of life. In worse shape still was the LSU programwhich had been based for decades at the now flooded andpermanently closed Charity Hospital. The LSU residentswere initially distributed to various clinical sites through-out Louisiana. Yet, that response was ineffectual from thestandpoint of adherence to the standards of specialtytraining as prescribed in the Requirements for GraduateMedical Education in Radiology as well as by the GeneralRequirements for all training programs under the aegis ofthe ACGME. Thus, the LSU program has been terminatedby the RRC, perhaps to be reconstituted at a later date.The trainees there have been made to search quickly forother places to provide education for them. Not all maysucceed in finding a suitable program.

One other difficulty brought to light by the Katrinadisaster was that while Medicare through CMS reimbursesmost residency positions in the United States, the BalancedBudget Act of 1997 requires there to be a cap of trainingslots at each facility, providing postgraduate medical edu-cation supported by federal funds. So, a hospital potentiallywilling to accept a resident in a program displaced by thedisaster might then become reluctant to take on anothertrainee because it would have to shoulder the entire burdenof payment for that individual. CMS has responded to thispredicament with the following newly proposed rulesissued in a recent document. It is a revision of existingregulations allowing home hospitals that have closedtemporarily to transfer their full time equivalent residentswho are paid for under Medicare to the new host hospitals,so that the receiving facility already training residents

could obtain payment for the newly installed trainee whowould join them either temporarily or permanently. Eventhough that means that such facilities would then exceedthe level of the predetermined cap, further payment couldbe received by them in accordance with the number of newpositions they would take from the New Orleans program.Under this arrangement, payment would be retroactive tothe day of the disaster to incorporate new members at hosthospitals, even if the host hospital is far away. Thisaccommodation would be limited to no more than 3 years,which creates a potential later issue for radiology with its4−year-residency requirement if a first year resident trans-fers particularly.

Under preexisting conditions, it used to be that thehospital would be paid in its current year based upon a3-year rolling average count of residents when they take ona new resident if the number of residents increased. Then,the hospital would only get a portion of that increase basedupon a prorated average. Under the new affiliation optionsrelated to Katrina and other anticipated disasters, as an-nounced by CMS, payment for displaced residents occupy-ing new positions will be excluded from the rolling average.The computation would instead simply be that the hosthospitals will get the full amount of reimbursement for theresident and the home hospitals will get 2/3 of the re-imbursement as well. Sounds great! However, rememberreimbursement through Medicare in some institutions paysthe full amount of the trainee salary and fringe benefits. Yetin others, especially those in which the Medicare compo-nent of the patient population is low, CMS only pays afraction of such costs. It does not matter what the Medicarefraction was at the home hospitals new host hospitalsincreased payment would reflect indigenous Medicare ratesfor them, not the Medicare rate of the hospitals hit by thedisaster. For example, in our institution, only 18% of totalsalary for each line is received from CMS because theproportion of elderly patients in our institution is meager.Hence, if you wish to take on another resident, CMS willpay for it to the extent it has paid for other lines under thecap and no more.

So much for accommodating present residents in adisaster area and new residents who may be affected byfuture disasters. What should a program do in expectationthat the next disaster may be knocking at its doorstep?Well, in this regard the lesson learned by the threeLouisiana hospitals so far has been that a lesson has notactually been learned. Therefore, I make a suggestion.Either your institution with legal support, or your programitself, of course with legal support, should seek to develop apartnership arrangement with some other residency inradiology, located a distance away so that during theinterval in which your hospital is disabled and cannotprovide clinical and didactic experience for trainees, thoseresidents could be transferred to the partner hospital undera preexisting agreement made before the cataclysmic eventto allow for orderly transfer of trainees and enable therelatively uninterrupted continuance of education. Mostlikely, a temporary accommodation consequent to such apartnership will gain the advantage afforded by the afore-

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mentioned rule of CMS which permits transfer payments tosupport displaced residents. Luck, as Branch Rickey onceexclaimed, is “preparation meeting opportunity.” We haveinsurance to protect us from untoward events related toinjury or health. Similarly, we should create our own in-surance for residency training. A partnership agreementwould be a good first step to give some measure of comfortso that for residents affected by the aftermath of the nextdisaster will be able to maintain a continuation of educationeven though everything else is disrupted or destroyed.

Another approach is to deny that these things will everhappen again, and for most of you, that will be sensible andrequire no effort. The odds are surely in your favor. How-ever, we owe it to our residents to protect their education.They are innocents here; they enter a program not knowingwhether its educational value will decline because of lackof money, lack of interest, lack of teachers, lack of clinicalmaterial, or lack of hospitals beds and clinic visits. It is ourduty to protect them from these eventualities. Disasterpreparedness is part of that responsibility.

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