What happens when an academic hospital closes?

The program director of Hahnemann University Hospital's IM residency tells the story.

Hahnemann University Hospital had served the heart of Philadelphia since 1848. But on June 26, 2019, its new for-profit owner, American Academic Health System, announced that the 500-bed teaching hospital would soon be closing its doors for good.

The institution's closure was a major loss for not only many of the city's poorest and sickest patients, but also its more than 570 residents and fellows, said David Jacob Aizenberg, MD, FACP, who at the time was program director for the internal medicine residency at Drexel University, for which Hahnemann was the main teaching hospital.

The rapid closure will go down in history for its impact on graduate medical education, he said. “From what we could find, and we dug relatively deeply, this is the largest displacement—or orphaning, which is what Medicare and ACGME [Accreditation Council for Graduate Medical Education] call something like this—in terms of number of trainees,” said Dr. Aizenberg, who was lead author of an article about the ordeal, published in the June 16 Annals of Internal Medicine.

Dr Aizenberg
Dr. Aizenberg

With 148 internal medicine residents to place in new programs, last summer was a whirlwind of emotions and hard work for him and his colleagues. But it paid off. “Every single trainee found a spot, or we helped them find a spot. . . . Some had a delay by a couple of weeks or a month, but everyone found a spot,” said Dr. Aizenberg, who is now an associate professor of clinical medicine and associate program director of the internal medicine residency at the University of Pennsylvania Perelman School of Medicine in Philadelphia.

In an interview on June 23 with ACP Hospitalist, almost exactly one year after the announcement of Hahnemann's closure, he discussed trainees' reactions and responses to this challenge, as well as why he thinks other program leaders may find themselves in similar situations in the future.

Q: Why did you decide to write about the closure?

A: First off, while we were going through this, I was keeping pretty detailed notes, just because I thought I would have to refer back to them, depending on how things developed. When the dust started settling, when everyone had a position and we were all starting to look ahead for our own personal jobs, a couple people came up to me and said, “We're really curious to know what actually happened, and you should write something.” So I was actually motivated by a couple of mentors to write something. And then my coauthors and I realized that this is probably going to happen again, with how hospitals are being run now and overall the way that funding works, and we expect more and more hospitals to close. We figured our experience could potentially be valuable for people going through something like this. And then finally, we hoped that our paper would also stimulate some discussion and possibly even some reform in how this takes place for the residents.

Q: What was your reaction to learning that the hospital was going to close?

A: There were definitely rumors floating around for months, and the rumors were concerning for a lot of reasons. One of them is, unfortunately, we heard the rumors through the media rather than through other channels, so that was a little disconcerting. But when it was finally announced on June 26, it was still pretty shocking because we were told again and again by people who were at Hahnemann for decades that “This happens every now and then, and it's really scary, but Hahnemann has pulled through every time.” So when it was finally announced, I think most people were pretty shocked, as was I.

Q: How did your trainees react?

A: Everyone was shocked, and there was a lot of sadness because I would say most of our residents were really looking forward to finishing their training at Hahnemann. They came to the program specifically to have an academic setting that cared for a patient population that was underserved. I had just been on the job for less than a year as program director, and we were in the process of actually restructuring the program and making significant changes that, at least in my opinion, were really positive, and I think a lot of the residents were looking forward to that. We had five or six big things that we were going to roll out in the first couple months of the academic year in 2019.

And then there was clearly uncertainty. We had no idea whether everyone would be able to be placed, where they would be placed, what the process was. There were a lot of people who were scared, as well. A lot of the residents just didn't know where they would be in a few months, and it was really a rollercoaster of emotion. Thankfully, it didn't really fester, and I think that's the silver lining to things moving so quickly. We thought we had a lot of time, but in the end, it was 41 days from the announcement to closure. That actually helped people process things a little bit better, even though it was more challenging to move [to another city for a new job] and things like that, but at least they just found out quickly where they were going and they could start moving forward. If you think about it, a lot of hospitals close much more deliberately than this one did. And, frankly, when I took the job, there was some question about the finances already back then. And I spoke to a lot of mentors about the safety of taking a job like this, and not one actually expressed concern that it would close so quickly. Everyone said if a hospital was going to close, it would take years and it would be a long process. I was extremely surprised how fast it all happened.

Q: All of your trainees were able to find new residency spots after the closure. What do you think contributed most to that success?

A: The way that programs are incentivized to actually take residents is in our favor because they all come with a significant amount of funding. The overall clarification of the funding occurred pretty late in the game, but once it occurred, it smoothed a lot of things out. When the hospital confirmed that residents would be going with around 80% of their funding from Medicare, a lot of people were able to finally sign and formalize their commitments to transfer to programs. That one thing probably allowed most of this to happen eventually. The program directors also worked really hard, and there were many programs, not just internal medicine, and we basically worked nonstop from the end of June to early August to make sure that all of this happened.

Q: How did the closure affect Hahnemann's hospitalists?

A: One of our hospitalists, Kevin D’Mello, MD, FACP, wrote about this [in the May Journal of Hospital Medicine]. The census plummeted. Even a week after the announcement, the hospital turned into a ghost town relatively quickly. And our hospitalists had to really be creative in how to continue teaching our residents. Even though all of them were focused on finding a new spot, we still had some patients to take care of, and we all still had the obligation to keep teaching [the residents] because otherwise they were going to miss out on more than a month of their training. And so [the hospitalists] had to be really creative on how they did rounds, how they taught, and we had to be creative as a program. We had to shift some duties more toward outpatient and reorganize services as the census continued to go down. That was something that we didn't even give any thought to until it started happening. We had to really make those decisions on the fly.

Q: What were the most surprising or difficult challenges?

A: At first, I thought that a challenge would be just finding the number of spots. I thought there may not be enough spots, and that actually turned out not to be the case. There were plenty of programs that were willing to take residents across the country, which was a huge relief. The greatest challenge, actually, was a little surprising. . . . I found there's no rulebook about how residents were supposed to find these programs or how we were supposed to help them find these programs. And it was really stressful for the residents because we started reaching out to programs, and all of the programs were on different timelines, and there was no Match. . . . You're interviewing in a place, and that program could actually give you an offer to join their program right on the spot and give you a deadline to respond yes or no, when [the residents] may have had other interviews later that week or the following week. And if they declined the offer or declined to respond to the offer, that slot was lost and went to someone else. I was surprised that there were no rules surrounding that, and the residents really didn't have too many protections when it came to that. There were a lot of meetings that I had with residents really trying to help them make the right decision for themselves, whether or not to take an offer or to delay for something else that would meet their career goals better.

The timing of it was also really odd because this was June, and our new interns had just finished orientation and they were three days on the job. So we didn't really have a finger on the pulse of how they were doing from a mental health point of view; we were just getting to know them. So there was all this uncertainty with that class, who just arrived in Philadelphia to start their training and now they're being told that their program is closing. . . . Timing for interns was pretty bad because they had just all signed leases and they all came and they were just starting out. But [different timing] could have been worse for some of the third-years who were applying in fellowship, for example. About half of our residents applied to fellowship that year.

Q: What could have made this process easier for you and your trainees?

A: It would have been very helpful for there to be some sort of system that we could activate when a large academic institution like this closes and everyone across the country knows that there are 570 trainees about to start looking for positions, and it would have been really great to actually have some sort of system, whether it be like a mini-Match or a [Supplemental Offer and Acceptance Program] that happens for people who don't match in the initial Match, something that the ACGME and the [National Resident Matching Program] could have had in place for us to activate and just give the whole interview and offer process a little bit of structure. That would have been really great to have. I don't know if it will ever happen, but it's something that I hope to continue to advocate for. And then there are other things. Obviously, it would have been nice to have some warning and to have some time to message this appropriately and make sure that we could have avoided some of the chaos and anxiety. But I don't know if that would ever happen with this kind of a for-profit organization that keeps their cards close to their chest.

Q: Going back to a point you alluded to earlier, do you think other program directors might find themselves in a similar position in the future?

A: I hope not, but I think that they will. It'll be interesting how this pandemic actually impacts some of this, because a lot of hospitals are really struggling financially because of the pandemic. And I hope that this won't be the reason that some actually end up going under, but I wouldn't be surprised if that were to happen.

Q: What would be your advice for them on preparing for this contingency?

A: If there's an inkling that a hospital is going to go under, I think it would be important to just start figuring out how the administrative burden is going to be handled in someone's program. We could have saved a lot of time by having our files for each resident ready to go, as to what to send to programs they apply to. We spent many, many days to a week or so working to organize our filing system and figuring out what we can and should send to programs that people are interviewing in.

Other than that, I think it's really hard to prepare logistically for this until it actually happens because a lot of the work actually happens once the announcement is made and people start applying for transfers. I would suggest that program leaders meet with their residents and address rumors up front. Even if a hospital ends up not closing, talking through the process of closing and finding programs could alleviate some of the resident anxiety. Ignoring the rumors is not helpful.