Acad Psychiatry 31:205-210, May-June 2007
doi: 10.1176/appi.ap.31.3.205
© 2007 Academic Psychiatry
Medical Student Education in Psychiatry After Katrina: Disaster and Renewal
Mark H. Townsend, M.D.
Received September 10, 2006; revised November 13, 2006; accepted December 15, 2006. Dr. Townsend is affiliated with the Department of Psychiatry, Louisiana State University, New Orleans, Louisiana. Address correspondence to Dr. Townsend, Louisiana State University Health Sciences Center, 3450 Chestnut Street, Third Floor, New Orleans, LA 70115; mtowns{at}lsuhsc.edu (e-mail).
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INTRODUCTION
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Hurricane Katrina had a catastrophic effect on the medical schools of both the Louisiana State University Health Sciences Center, New Orleans, and Tulane University (1). Massive flooding, the result of levee failures, damaged the majority of structures in Orleans Parish and has greatly hindered the restoration of psychiatric services to the region (2). As of May 2007, however, medical student education has largely returned to New Orleans (3). Although LSU’s iconic art deco Charity Hospital remains quarantined and unused, classes are being held for first- and second-year students in the same buildings and classrooms as before, and the psychiatry clerkship is once again being taught entirely within the New Orleans metropolitan area.
Medical education is, in fact, regularly interrupted by natural disasters. Medical schools and teaching hospitals are built along dangerous coastlines, in floodplains or seismic zones, and in politically unstable areas. Understandably, the presence of academic medical centers is seen as necessary for the recovery of affected regions (4). Despite this, relatively little is written about either the immediate effects on or the long-term outcome of disasters for these institutions.
Internationally, two medical schools seem especially likely candidates for study: Kobe University, affected by the January 17, 1995, Hyogo-Ken Nanbu earthquake, and the medical school of Syiah Kuala University in Banda Aceh, Indonesia, flooded by tsunami from the enormous Sumatra-Andaman earthquake of December 26, 2004. Little information is available about the impact of these events on the schools. For example, the psychiatric effects of the earthquake on Kobe have been well-studied, including those of hospital workers (5), but not the earthquake’s effect on psychiatric medical education itself. Similarly, although the Banda Aceh medical school was reduced to a virtually empty building, and numerous students and faculty were killed (6), no reports describe how medical education continued until the school reopened in April of 2006 (7).
U.S. medical schools that experience disasters are also rarely the subject of study. Education at the Medical University of South Carolina was disrupted by Hurricane Hugo, but this information is gleaned from reports from individual hospitals or specialties (8). The October 30, 1997, flooding of the John A. Burns Medical School of the University of Hawaii has been described (9), but the story of its rebirth has not. Similarly, the 1989 Loma Prieta earthquake affected medical care throughout the San Francisco Bay Area (10), but little information exists about the earthquake’s effect on medical student education. Because of the relative paucity of information, it may be especially useful to learn about Louisiana State University Health Sciences Center’s (LSUHSC’s) experience.
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Hurricane Katrina and Its Immediate Effects
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A good outline of what has transpired at LSU can be found at its Web site, www.lsuhsc.edu, where "emergency notices" have been archived since August 29, 2005, the day operations were officially suspended. Most LSU medical students, residents, and faculty safely evacuated the city, but many of those who remained worked in hospitals that were flooded. Their stories are being told (11), but no doubt much information about the effects of the storm and flood on individual teaching hospitals will not be recorded. In New Orleans, as in Kobe, communication and mobility were severely compromised both during and after the disasters (12, 13), and many people who left the region did not return (14, 15), making it difficult to gather data retrospectively.
In New Orleans, LSU’s medical school class has approximately 180 students, and psychiatry clerkships are offered in 6-week "blocks," the modal length for a psychiatry clerkship (16). Both LSU and Tulane shared Charity Hospital with its 92 psychiatric beds, 56 of them staffed by LSU psychiatry faculty. Before the storm, Charity was, after New York’s Bellevue, the oldest continually operating public hospital in the United States, although its most recent building was erected in 1939 (17). Charity shared some services with the newer and smaller University Hospital, also on LSUHSC’s campus. Charity’s psychiatric emergency room, the Crisis Intervention Unit, or CIU, had approximately 600 patient encounters each month.
Prior to the storm, medical student education in psychiatry occurred largely within the confines of four city blocks. First- and second-year classes, whether in small groups or lecture halls, were taught in adjacent buildings. The library was in a third building, connected to the others by a second-floor walkway from which students could travel the three blocks to Charity Hospital by another elevated walkway. About 20 of our medical student clerks were assigned to Charity each block, and only two others, at the suburban Ochsner Foundation Hospital. Students assigned to Charity also spent 1 day each week in community mental health centers, mainly within the city or in the neighboring St. Bernard Parish. Each student, whether assigned to Charity or Ochsner, performed on-call duties in the CIU.
The storm’s effect on LSU’s physical plant was savage. Charity, with its inpatient beds and busy psychiatric emergency room, remains closed 20 months after Katrina due to the effects of flooding in its basement. The first floors of the remaining buildings also flooded, ruining state-of-the-art medical education technology, including simulated patients and specialized audiovisual equipment. These have since reopened. The dental school, however, on a separate campus closer to Lake Pontchartrain, suffered even worse flooding and it remains based in Baton Rouge while the campus is renovated. Only two of the five New Orleans area mental health centers used as teaching sites survived the storm.
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Resuming Education
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The LSUHSC Chancellor, then Dr. John Rock, now Dr. Larry Hollier, directed that medical education be quickly resumed from Baton Rouge: the clerkships on September 19 and preclinical, classroom-based education on September 26. Baton Rouge was a logical place to resume medical education. The city is home to the largest LSU campus and was the first major city westward-bound New Orleans evacuees encountered. Therefore, many students and faculty found themselves there, living with family or friends, or in hotels. Most expected to spend a few days away, then return to New Orleans after the storm passed (18). Furthermore, the LSU Health Sciences Center operates Earl K. Long Hospital, which, with the destruction of Charity, became the state’s largest public hospital. More importantly, the hospital had a 48-bed acute-care unit in nearby Greenwell Springs, La., which was to become an important medical student training site.
The department’s task was twofold: to continue the first- and second-year courses in classrooms provided by LSU Baton Rouge and to place 22 third-year students, only 1 week into their clerkship, into appropriate sites. Classroom space was quickly identified by the medical school. The department’s job was to locate faculty and secure hospitals and clinics. Remarkably, all fell together quickly. Key faculty members were, indeed, within driving distance from Baton Rouge, but our four clerkship sites, three of them untried, were determined by a variety of factors.
Ochsner Foundation Hospital, just over the city limits in Jefferson Parish, remained open during the storm, and had been educating two students during each block with both full-time and clinical faculty. They continued their efforts and took in an additional student. Our three other Louisiana sites were new to us, although to varying degrees: Lafayette, Greenwell Springs, and Pineville. Our ability to work with students at these new sites was the result of both generosity and happenstance.
The city of Lafayette is approximately 60 miles west of Baton Rouge and contains Joseph Henry Tyler, Jr., Mental Health Center, a free-standing community psychiatric hospital affiliated with LSU. Fortunately, the hospital is administered by the Louisiana Office of Mental Health (OMH) and was capable of communicating with other OMH facilities by telemedicine. Its medical director, Dr. George Diggs, is a member of LSU’s clinical faculty and for many years taught students rotating from foreign medical schools. Dr. Diggs happily and quickly agreed to create a separate track for eight LSU psychiatry students.
Greenwell Springs has had a long role in the state’s public health system. It began as a spa, providing lodging and other amenities to travelers who hoped to gain medical benefits from drinking and bathing in the area’s mineral springs; then it became the home of a tuberculosis hospital and, most recently, the site of the acute-care psychiatric facility associated with LSU’s Earl K. Long Hospital, 15 miles to the southwest (19). Greenwell Springs Hospital had not trained medical students and, furthermore, was run by clinical faculty from the Tulane Department of Psychiatry and Neurology. Just as at Henry Tyler, the medical directors—Drs. John Thompson and Clay Kelly—not only welcomed 10 of our students but also allowed three of our faculty to practice there. The hospital is also administered by the Louisiana OMH, which linked it to Henry Tyler by videoconferencing.
Our third new site was Central Louisiana State Hospital in Pineville, a suburb of Alexandria. Pineville was the final destination of those Charity Hospital patients too ill to be discharged prior to Katrina. They, along with physicians, nurses, and other staff, endured 5 days in hot, locked inpatient units until they were transported by bus. Although Charity employees and LSU psychiatry faculty and residents were and remain grateful for the many opportunities offered to them at Central, the hospital became peripheral to medical education due to a lack of student housing. While 10 students could have been accommodated each block and taught by full-time faculty living in Alexandria as evacuees, only four students were trained there the entire 2005–2006 academic year.
Thus, our clerkship: every 6 weeks we placed students in Jefferson Parish, Lafayette, Greenwell Springs, and Pineville. Our lecture series continued with the same faculty, but by telemedicine, originating from the videoconference studio closest to the faculty member. The office manager for medical student education, Patricia Reed, became proficient in organizing lectures by faculty personally unknown to her who taught from classroom-studios many of us would never actually see. We maintained an evolving list of contact numbers for each student, and communicated regularly by e-mail and cell phone. Handouts and PowerPoint presentations were sent out each week, and faculty kept in touch with one another by departmental meetings held in Baton Rouge. Rough patient logs were kept by monitoring the types of illnesses seen by students at each site: essentially similar numbers of patients with mood, psychotic, and anxiety disorders. Students met in person at the end of each block, in a classroom on the LSU Baton Rouge campus. The reward for our efforts was twofold: final exam scores were unchanged from pre-Katrina, and the students themselves reported that their educational experiences gave them a favorable impression of psychiatry.
Resuming our preclinical courses for the September 29 deadline held other challenges. Although classroom space was provided for us at LSU Baton Rouge’s Pennington Biomedical Research Center, all first- and second-year students needed housing nearby. The Health Sciences Center accomplished that by leasing a passenger ship, which was docked on the Mississippi across the river from the university. Our second-year class is taught only in the spring semester, buying us some time, but our first-year class is taught in 16 small groups, each with its own faculty member and co-led with colleagues from the medicine and family medicine departments. Although some faculty were never able to secure housing in Baton Rouge, and others—including tenured faculty—were furloughed in November (20), we were nevertheless able to provide at least one leader for each group. We had a Liaison Committee on Medical Education (LCME) interim site visit on December 13 and were told we had, in fact, remained on track.
Keeping and maintaining our footing in this new situation was difficult at times. Sudden homelessness was a shocking and unusual experience for most of us, and the dual challenges of rebuilding homes in New Orleans while locating new, temporary arrangements were complicated and varied. Several endured the cruel predicament of knowing they had "lost everything"—a phrase often repeated and literally true—while they worked at hospitals far away from their ruined homes, which the insurance adjusters needed to assess and contractors needed to rebuild.
In retrospect, 20 months after the hurricane, it is surprising how quickly the needs of medical education drove us from providing direct care at shelters to brick-and-mortar hospitals. In the weeks between the storm and the September 29th resumption of the clerkship, students and faculty in Baton Rouge worked together in an informal fashion from the downtown Baton Rouge Mental Health Center. The regional medical director, Dr. David Post, provided daily briefings on the composition and needs of area shelters. Some convention centers and sports arenas had thousands of residents, while others, schools and churches throughout metropolitan Baton Rouge, had fewer. Largely under the direction of Dr. Margaret Baier, the associate training director, students and residents formed teams to identify and treat patients in the many Baton Rouge shelters. However, because OMH hospitals became available and were willing to accept our students and residents, on September 29 we had largely returned to acute-care hospital settings.
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Returning Home
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Although each of us wanted to return to New Orleans quickly, and the Health Sciences Center pledged to return by August—and ultimately did—the timing of our return was dictated both by the academic calendar and the lack of suitable hospitals and clinics in New Orleans. National Board "shelf tests," used as our final exams, are ordered well in advance and have to be given in specific ways. At one point in March 2006, for example, we were able to move faculty and students from Greenwell Springs to another state hospital closer to New Orleans in Mandeville, but we needed to wait several weeks until the end of the block.
Our faculty outpatient practice resumed operations in October 2005 from the same building as before, which gave us an early base in the city. From there, however, we quickly realized that the region had vast mental health needs and fewer resources to meet them. Our New Orleans clinic lost three psychiatrists, a psychologist, and a clinical social worker in the November 2005 furloughs. As a department, we felt a mandate to assist the city while meeting LCME standards for psychiatric education. We developed a five-student outpatient track, based in emergency rooms and community clinics, which allowed students to assist in treating patients who were in many cases more acutely ill than those seen in existing hospitals.
Ultimately, though, we did not have the resources to relocate every student to metropolitan New Orleans by the July 1 start of the 2006 academic year. We continued operations at the state hospital in Mandeville, where we are currently training residents and students alongside Tulane’s. In early August 2006, the Office of Mental Health opened a 20-bed inpatient unit in the city, the first new psychiatric hospital since Katrina, and reopened a 15-bed child and adolescent hospital. We placed students in both the adult and adolescent units. And as for the preclinical classes, in newly renovated classrooms downtown, we began to teach human development in small groups again on August 22, 2006. The Health Science Center’s role in acute psychiatric treatment is reduced, however: University Hospital reopened on November 20, 2006, without psychiatric beds, and Charity Hospital remains closed. On February 14, 2007, the Medical Center of Louisiana at New Orleans, which had previously run Charity Hospital, announced that an abandoned New Orleans psychiatric hospital would open this summer with 33 new inpatient beds and a temporary regional psychiatric emergency room (Appendix 1).
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Conclusions
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The department, as well as the rest of the medical school, has developed a wealth of information regarding disaster response. However, we were victims of the same disaster as our patients, and we experienced an unusual sort of loss, no doubt similar to what our colleagues experienced at Tulane. Many of our patients were evacuated to distant cities, where they remain still, while we trained LSU residents and students among patients who had no direct experience with the city’s trauma. After returning to New Orleans, we became active, often exhausted participants in the effort to rebuild mental health infrastructure, while treating patients with increased anxiety and depression (21). At this time, May of 2007, the region still lacks a psychiatric emergency room and no university-affiliated psychiatry beds have been restored.
Numerous warnings about the ability of a hurricane to flood the city were given over the years, and the department and the Health Sciences Center had developed comprehensive evacuation plans. In fact, the New Orleans Adolescent Hospital, which currently houses our 20-bed adult unit, successfully evacuated prior to Katrina’s landfall. However, we did not have a ready plan to preserve the department during an extended evacuation from the city. Although accomplished with a combination of hard work, some serendipity and much generosity on the part of others—particularly the Louisiana Office of Mental Health and the faculty and administration of LSU Baton Rouge—our strategy was simple and was completed within the 3 weeks given to us by the chancellor.
Our recommendations for other academic medical centers are straightforward. Because the Midwest’s New Madrid and California’s San Andreas faults will someday shift again; because tornadoes will occur every spring and fall; because the oceans are warmer and rising; and because other horrifying events, unimaginable to us now, will occur at any time, each medical center must be prepared to relocate and rebuild itself. Planning for that eventuality can perhaps strengthen the institutions even as it lowers the anxiety of those who work within them.
Clinical faculty members must be made aware of their possible role in a catastrophic event. Each department should strive to make its entire faculty feel valued and to communicate with them frequently and candidly. Gratis and part-time, paid faculty are repositories of institutional memory. They may be the backbone of any rebuilding effort and should not require postdisaster instruction about their role in furthering the department’s goals and objectives.
In addition, regional networks and alliances of medical schools, such as the one that nurtured and sustained Tulane’s, must be fostered everywhere. The rationale for increased interdepartmental planning lies in the relative fragility of academic psychiatry itself. Psychiatry is a shortage specialty (22), and faculty and trainees should not be idled by local traumatic events. Furthermore, academic psychiatrists, like colleagues in other fields, are encouraged to develop narrow and divergent lines of research. Medical schools working as a consortium, however, allow faculty who are specialists in one area to be available to multiple institutions. Additionally, if one school is affected by an extreme event, the others can help continue, or at least preserve, its distinct identity. Both Tulane and LSU have become experts in disaster psychiatry and will themselves be capable of advising and assisting other medical schools, just as Kobe University has been helpful in Banda Aceh (23).
Finally, departments of psychiatry must be aware of their schools’ overall disaster response plan and be prepared to articulate the needs not only of psychiatry faculty and trainees, but also the patients they treat. Anxiety and depression increase globally in traumatized populations, but increase most among people with preexisting psychiatric illnesses (24). Psychiatric services, such as inpatient units, psychiatric emergency rooms, outpatient clinics, and outreach teams, should be rebuilt quickly. This can only occur if the public and private agencies that constitute the mental health care system have agreed to their roles well before any emergency. If the effects of Hurricane Katrina teach us anything, it is that nothing can be left to chance.
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REFERENCES
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- Howell WLJ: Displaced by the storm, researchers struggle to continue their work. AAMC Reporter, Nov 2005
- Weisler RH, Barbee JG, Townsend MH: Mental health and recovery in the Gulf Coast after hurricanes Katrina and Rita. JAMA 2006; 296:585–588[Free Full Text]
- Simon F: Doctors without quarters. Tulanian 2006; 78:42–47
- Ramsey W, Bridgford LR, Lusby RJ, et al: The Australian medical support force in Rwanda. Med J Aust 1995; 163:646–651[Medline]
- Uemoto M, Inui A, Kasuga M, et al: Medical staff suffered severe stress after earthquake in Kobe, Japan. BMJ 1996; 313:1144[Free Full Text]
- Davidson JRT: After the tsunami: mental health challenges to the community for today and tomorrow. J Clin Psychiatry 2006; 67(suppl 2):3-8
- Uplift International [Online]. Aceh Update April 27, 2006: Restoration of Syiah Kuala Medical School. http://www.upliftinternational.org/aceh_update.htm
- Norcross ED, Elliott BM, Adams DB, et al: Impact of a major hurricane on surgical services in a university hospital. Am Surg 1993; 59:28–33[Medline]
- Cadman EC: The flood at John A. Burns School of Medicine. Hawaii Med J 2005; 64:22[Medline]
- Pointer JE, Michaelis J, Saunders C, et al: The Loma Prieta earthquake: impact on hospital patient care. Ann Emerg Med 1992; 21:1228–1233[CrossRef][Medline]
- Leder HA, Rivera P: Six days in charity hospital: two doctors’ ordeals in Hurricane Katrina. Compr Ther 2006; 32:2–9[CrossRef][Medline]
- Franco C, Toner E, Waldhorn R, et al: Systemic collapse: medical care in the aftermath of Hurricane Katrina. Biosecur Bioterror 2006; 4:135–146[CrossRef][Medline]
- Ukai T: The Great Hanshim-Awaji Earthquake and the problems with medical emergency care. Ren Fail 1997; 19:633–645[Medline]
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- Shaw R, Katsuihciro G: From disaster to sustainable civil society: the Kobe experience. Disasters 2004; 28:16–40[CrossRef][Medline]
- Rosenthal RH, Levine RE, Carlson DL: The "shrinking" clerkship: characteristics and lengths of clerkships in psychiatric undergraduate education. Acad Med 2005; 29:47–51
- Kaiser RM: Reviews and notes: New Orleans’ Charity Hospital: a story of physicians, politics and poverty. Ann Intern Med 1994; 120:253–254[Free Full Text]
- Long A: A flood of fear. APA Med School Newsletter 2006; 14:5–6
- Fairchild JL: A historical sketch of Greenwell Springs 1850-1950. Greenwell Springs, La, JL Fairchild, 1993
- Infectious Diseases Section, Louisiana State University Health Sciences Center: Eight months later: Hurricane Katrina aftermath challenges facing the Infectious Diseases Center of the Louisiana State University Health Sciences Center. Clin Infect Dis 2006; 43:485–489[CrossRef][Medline]
- Kessler RC, Sandro G, Jones RT, et al: Mental illness and suicidality after Hurricane Katrina. Bull World Health Organ 2006; 84:930–939[CrossRef][Medline]
- Thomas CR, Holzer CE: The continuing shortage of child and adolescent psychiatrists. J Am Acad Child Adolesc Psychiatry 2006; 45:1023–1031[CrossRef][Medline]
- Sumargono E, Hayashi Y, Tamura Y, et al: How to help Acehnese helping themselves?—a note after a visit with Kobe University medical team. Kobe J Med Sci 2005; 51:29–34[Medline]
- Smith EM, North CS, McCool RE, et al: Acute postdisaster psychiatric disorders: identification of persons at risk. Am J Psychiatry 1990;147: 202-206
This article has been cited by other articles:
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W. S. Griffies
Post-Katrina Stabilization of the LSU/Ochsner Psychiatry Residency Program: Caveats for Disaster Preparedness
Acad Psychiatry,
September 1, 2009;
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418 - 422.
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E. J. Conrad, M. H. Townsend, and N. Buccola
Restoration of Mental Health Services in New Orleans
Am J Psychiatry,
January 1, 2008;
165(1):
33 - 33.
[Full Text]
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R. J. Ursano, C. S. Fullerton, D. M. Benedek, and D. A. Hamaoka
Hurricane Katrina: Disasters Teach Us and We Must Learn
Acad Psychiatry,
June 1, 2007;
31(3):
180 - 182.
[Full Text]
[PDF]
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INTRODUCTION
Hurricane Katrina and Its...
