AAMC Reporter: August 2006

One Year Later, Katrina Still Lingers

LSU medical students boarding a ferry docked in Baton Rouge, La., that served as temporary student housing; students have since returned to New Orleans

In a world of 24-hour media coverage, where even major stories can be unceremoniously forgotten within days, it is easy to leave tragedy behind.

But the individuals who work in New Orleans' academic medical centers hope Americans never forget Hurricane Katrina.

"Just because it's not on the news every night doesn't mean people aren't still suffering," said Nicole Giambrone, M.D., who began her medicine-pediatrics residency with Louisiana State University Health Sciences Center (LSUHSC) in July after graduating from Louisiana State University School of Medicine in New Orleans (LSUSOM-New Orleans).

"It's easy to forget if you don't see it all the time. But we see it," Giambrone said.

And while there is certainly much to celebrate as he region approaches the one-year anniversary of the storm, people in New Orleans' academic medical institutions — including LSUSOM-New Orleans, Tulane University School of Medicine, and Ochsner Health System — still see plenty of obstacles ahead.

Much teamwork and investment, however, has forged many victories. Residency programs returned to New Orleans in July. LSU and Tulane facilities are almost fully reopened. LSU's University Hospital is tentatively scheduled to begin seeing patients again by this fall.

And, as Paul K.Whelton, M.D., M.Sc., senior vice president for health sciences of Tulane University Health Sciences Center, professor of medicine and dean of Tulane School of Medicine, and epidemiology professor at Tulane University School of Public Health and Tropical Medicine, puts it, the city's "esprit de corps" is stronger than ever.

But, of course, challenges are never far from the surface. Clinical care is struggling to help droves of uninsured patients. And in general, much of the city and the surrounding region remains in ruins. Some places — such as Charity Hospital, part of LSUHSC's hospital network — will likely remain shuttered indefinitely. Nevertheless, as residents mark one year since the Category 3 storm hit the Gulf Coast, academic medical centers are taking the opportunity to reflect on their progress.

"August 29 is a big psychological hurdle," Whelton said. "To get past that first anniversary and to not only be surviving but thriving, that will be a huge morale booster."

LSU School of Medicine graduate André Mouledoux Jr. reacting to his match assignment

Residents, Research Renewed

Also buoying spirits this summer was the return of medical residents to the city, and a relief that many are still willing — and even eager — to practice in the area.

However, major barriers had to be addressed for GME programs to continue, including which programs would have to be discontinued, where displaced residents and programs could be relocated, and who would compensate residents and the new and temporary institutions and faculties training them.

LSUHC Chancellor Larry H. Hollier, M.D., said that for his institution, the latter was perhaps the largest concern. However, state legislators helped the school by providing a $50 million federal social services block grant in so-called bridge funding to continue operations through the end of the fiscal year. The emergency allocation included reimbursement for the costs of placing residents and supervising faculty in hospitals not designated as teaching hospitals and therefore not qualified for federal GME reimbursement.

"We were paying the salaries of the residents and faculty but weren't getting any reimbursement," Hollier said. "There was a potential crisis there. But our state legislature realized that LSU trains 75 percent of the health care professionals in Louisiana. Our graduates tend to stay in Louisiana and practice. Our big concern was that… we'd lose the health care workforce of the state of Louisiana."

In order to help retain that workforce, the state also carved out a portion of its federal hurricane relief funds for $10,000 grants to Louisiana medical students graduating from Louisiana medical schools who matched residency programs based at the Medical Center of Louisiana at New Orleans.

Hollier said all LSUHSC residents are permanently placed in various program sites — many of them new — around the area. However, some program downsizing was unavoidable.

"All our residents are reassigned with new agreements, and I'm as happy as a clam right now," Hollier said.

"We're getting everything in place. Our medical school only takes students from the state of Louisiana, and they're used to hurricanes.We filled our residency programs, but we did have a reduced number. For example, we closed our radiology residency. They all worked in Charity Hospital, and that's gone," Hollier said.

Whelton said that while Tulane downsized its residency programs by about 30 percent, it did fill all 155 of the available slots.

Charles Hilton, M.D., LSUSOM-New Orleans' associate dean for academic affairs, said, "We reduced our quota by only 10 percent; we filled positions in all but four of our 15 programs and then rapidly filled the remaining slots in the scramble."

William Pinsky, M.D., Ochsner Health System's executive vice president and chief academic officer, said Ochsner's resident capacity actually increased five slots this year to 68 (a move decided pre-Katrina). Even though application were down 25 percent, all Ochsner residency positions were filled on Match Day thanks in part, Pinsky said, to concerted communications efforts and to the fact that, for some, the situation presented a desirable opportunity.

"There are individuals out there who recognize that this might be something different," Pinsky said. "This is a city restructuring its health system. There are all these changes going on that they could maybe be a part of."

Whelton said Tulane officials also deliberately approached and selected applicants they thought would have an interest in serving the city.

"We went after kids who have that driving passion to be leaders and who want to help rebuild public health infrastructure," Whelton said.

"It's been unbelievably reassuring to have the residents come back. They're putting their careers on the line during residency — would they feel comfortable doing that in New Orleans? As it turns out, they do."

For one resident, the decision to stay in New Orleans was an easy one.

"This is home," Giambrone said. "Some people got scared off, but the people who stayed are my heroes. They taught me how to pick myself back up in the face of adversity. I can't get that anywhere else. I love the people here so much, and there's nowhere else I'd rather be."

On the research side of academic medicine, things are also faring well. At Tulane, researchers earned a total of $130 million in 2006 grants, just $10 million less than their 2005 record number. Whelton admitted faculty and research personnel have not stayed the course in New Orleans as diligently as students and residents, but said the school was able to retain key staffers with help from a $20 million investment from the university, which in part guarantees salaries for two years after Katrina.

"We've lost some very strong people, but we've been able to maintain most of our best and brightest," he said. "And we're recruiting. The integrity and quality of our faculty is very much intact. We need a stable, long-term workforce here."

Hollier said grant applications at LSUHSC are 40 percent higher this year than last, and researchers have secured $40.7 million in NIH funding since Katrina.

"Our faculty has been great," he said.

Stubborn Challenges

Orleans Parish, where New Orleans is located, had 4,600 health care providers before Katrina and now has only 1,400.

Many larger concerns still exist. Chief among these are the huge numbers of uninsured patients taxing every facet of the centers' clinical care facilities.

Pinsky estimated that the number of "indigent care" patients seen at Ochsner has quadrupled since Katrina, with the emergency room experiencing a 30 percent spike in "no pay" visits.

Whelton said Tulane is "awash" in uncompensated cases, with as many as 47 percent of patients having no ability to pay on some days.

They attribute the rise not only to an increase in regional poverty but also to an influx of uninsured construction workers and laborers and a decline in provider availability due to the loss of Charity Hospital and a host of other providers.

Whelton noted that Orleans Parish, where New Orleans is located, had 4,600 health care providers before Katrina and now has only 1,400. He recommended that federal grants aimed at revitalizing the region and its economy should also focus on relieving the problem of caring for thousands of uninsured patients.

"We have an enormous challenge with uncompensated care," Whelton said.

"Some people had a job that disappeared, or they lost their homes and elected not to keep taking health insurance.Many workers who come into the city are Mexican-Americans with no health insurance. Many here worry that federal money may be used to create jobs, but then that still leaves [health care providers] with a problem."

Additionally, Hollier said that while the LSUHSC is largely restored, problems with housing shortages, cleanup, and related matters persist in affecting every aspect of New Orleans life.

"We're still having issues with the city," he said. "There are problems with housing, and there are infrastructure problems."

A Stronger Place

While residents still face many obstacles, the city of New Orleans is stronger in some areas than it was pre-Katrina. Schools say that academic and financial programs are streamlined, disaster preparedness plans have been drafted and refined, and remaining students and faculty are more dedicated.

In late 2005, The RAND Corp., an international nonprofit institution that helps improve policy and decision making through research and analysis, established the RAND Gulf States Policy Institute, which is assisting in long-term recovery efforts by providing evidencebased policy guidance to facilitate and speed regional recovery and growth, re-establish services, and make wise investments in infrastructure. Seven universities, including Tulane, are collaborating with RAND on the effort.

LSU and the Department of Veterans Affairs are developing plans for a $1 billion collaborative complex of teaching hospitals and medical research facilities in downtown New Orleans. Many leaders at local academic medical centers have been asked to speak around the nation and offer their own insights into local, state, and federal disaster planning.

But everyone agrees the city still has a long way to go.

"People here go home, and they still don't have homes to go to," Whelton said. "But people have bonded. We have certainly learned things and helped to change some things that will help everybody in the nation. But this is going to take time. People have to continue to be supportive."

— By Scott Harris

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