Few residency directors have faced the challenges that Jeffrey G. Wiese, FACP, internal medicine residency director at Tulane University Hospital in New Orleans, took on after Hurricane Katrina struck in August 2005.
In addition to helping his team of 105 residents cope with the immediate disaster, Dr. Wiese continued the residents' training offsite for six months after the hurricane until all were able to move back to New Orleans in January 2006. What kept him going? His own training during residency, an Internet chat room that brought the residents together and the compassion of the residents to dig in and help the community through one of the worst disasters in U.S. history. Dr. Wiese spoke to ACP Hospitalist about how he responded to the disaster and managed to keep his residency team together.
Q: Before Katrina struck New Orleans, had Tulane University Hospital and Clinic made any plans for how to respond to a major disaster?
A: There's a standard code gray (hurricane) policy, but it was based on certain erroneous presumptions. You count on electricity and cell phones. You count on the team being there for one day or two, but not for five. We have redesigned our disaster teams. All our code gray policies are ready for the next one, should the next one occur.
The Tulane internal medicine residency now has its own elite “code gray” team. Residents are selected from a pool of volunteers, who have received endorsement from their peers, and who undergo psychological profiling to ensure they are equipped to handle the potential stress. After selection, this elite team undergoes training in conflict resolution, stress management, disaster protocols and advanced topics in disaster medicine. The team trains year round. Should a hurricane cross the specified latitude/longitude markers to prompt a code gray, this elite team comes in and relieves all of the medical residents on the wards, in the ICU, etc.
Q: Did the IM residents stay in New Orleans or evacuate?
A: All of the 42 residents assigned to the wards and ICUs stayed until the last patient was evacuated from the city; the remainder of the 105 residents evacuated prior to the storm as instructed. By five days after the storm, we had assurance that everyone had been evacuated from the city. On the sixth day we set up a Yahoo! chat room and announced our 10-point plan for recovery. The plan called for 30% of the residents to stay in New Orleans to build makeshift clinics for city residents and rescue workers; 30% went to Alexandria, La., to care for VA and Charity Hospital patients at a residency program started there, 20% went to Houston and operated a service at the VA hospital and the remaining 20% temporarily transferred back to their home medical schools. By January 2006, all of the residents returned to New Orleans.
Q: How did you continue to oversee the residents and ensure that they were being properly trained while they were in other cities?
A: I would drive from New Orleans to Houston every Monday and work with the residents there. Then on Tuesday night or early Wednesday morning, I would drive to Alexandria. I would stay there Wednesday and Thursday, and then I would return to New Orleans on Thursday night. I did that every week. They had to have their curriculum, and I wanted to make sure they were getting the right clinical training. Of course each site had great local leaders, including Dr. Bill Merrill (Houston), Dr. Michelle Guidry (Alexandria), and Dr. Eboni Price (New Orleans). Our Chair of Medicine, Lee Hamm, was making similar trips—he was inspirational.
In the year prior to the storm, the Tulane residency had moved to a novel Friday School curriculum in lieu of the standard noon-conference curriculum. Every Friday morning, every resident in the program is relieved of their clinical duties, and they report to one conference room where they have 3.5 hours of protected learning time. The attending physicians hold their pagers and work with the interns to continue patient management. The residents work as teams in solving mystery vignettes that address not only four to five important areas of medical knowledge, but also each of the six competencies. At noon, there is an all-residency/faculty conference and the pagers are handed back. The residents take the interns' pagers and return to the wards, while the interns have their own 3.5 hours of protected learning time.
Once the storm hit, we continued the Friday School concept, except that it was Tuesday School at Houston, Thursday School at Alexandria and Friday School in New Orleans. Making the move to Friday School was a serendipitous move, since we did not have to rely upon five different faculty members each week running a noon-conference curriculum at each clinical site.
In the setting of a crisis, people crave the security of the way things used to be. I tried to recreate what we did in New Orleans so the residents could have some semblance of normalcy. I think I drove 36,000 miles in six months. I know I drank a lot of coffee.
Q: What about the Tulane medical students?
A: All of the Tulane medical students went to Houston. Dr. Mark Kahn and Dr. Kevin Krane oversaw that contingent. Many of our residents made the trip from New Orleans to Houston to help with the clinical diagnosis curriculum there.
Q: What prepared you to keep the residency program running during this crisis?
A: Some of the leadership training I had in prior life experiences, but mostly the character of the residents that we recruited to this team. I studied a lot of philosophy and leadership in college, and this background was essential to the writings that were disseminated to the residents. Perhaps the most important leadership principle in the setting of a crisis is recognizing that people want you to answer the question: “Why, when I did nothing wrong, did this happen to me?” Peter Berger's notion of “bad faith,” Kant's categorical imperative and Marx's notion of “false control” were instrumental. When they asked the big question (“Why did this happen to me?”), I reminded them that most of us live in the middle-class mentality (Marx) laden with a notion that everything is under our control. I reminded them that few if any defining moments are truly under our control.
Defining moments (like Hurricane Katrina) in life are what happen to you, and you don't control them. What you can control is how you respond to them. So when the residents asked, “What should I do?,” I replied, “What would you want every person of your ability and talent to do? Well, do that.” And that they did, maintaining service to the relief shelters and continuing to care for their patients, whether it was in Houston, Alexandria or New Orleans.
Q: Were you able to interview and recruit residents to Tulane following the storm?
A: We have filled two years now in the match. We did not compromise our admissions standards. Despite the loss of some amenities, the character of our residents and the strength of our team have been a huge draw for prospective recruits. It's inspiring to see medical students drawn to the admirable virtues that have made our profession noble.
Q: Are prospective residents drawn to Tulane because they want to provide care for the underserved?
A: I think so. As Martin Luther King Jr. said, health is the grand fundamental right, for you can have no other rights without it. A devotion to the underserved is our mission statement. Sure, we do all the things that other residency programs do, but there's the added aspect that this is a program that embraces the care of low-income people. That's the glue that holds this team together. The 12,000 hours we gave in the month following the storm in relief shelters is testament to our devotion to this mission statement, and the continued service since that point is as well.
Q: Has this experience changed the career plans of the residents?
A: We had about the same percentage of people who chose to do a fellowship, and all of them found a fellowship position. But more people stayed in New Orleans. They felt tied to the city. We have more residents than normal go into primary care and hospital medicine in the New Orleans area.
Q: How has the aftermath of Katrina affected the medical students?
A: Their medical training was very fragmented. We saw a big decline in students who chose internal medicine. I think if we could have had the students with us the whole time, we could have had more influence in showing them the grand and noble features of internal medicine as a career.
Q: Did you lose any faculty after Katrina?
A: The department of medicine lost 16 faculty members out of 137. All of these positions have been hired back, but with younger physicians. You hate to see anybody let go, but it's a better and younger faculty now.
Q: When will health care in New Orleans recover?
A: One of the things that we did right was moving more of our clinics to the community instead of asking people to come to the medical district. I think this is an important first step. But the thing about health care is it's not separated from other public institutions, schools in particular, but also opportunities for gainful employment. Going forward, our resident team is going to play more of a role in the public schools. Educating kids about health and disease is the most meaningful way to make a difference in a community's health.