Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2725_Библиотеки_им_академика_М_И_Перельмана.pdf
470
I. A. Gutierrez et al.
The planning and establishment of a sustainable family
medicine residency program requires a symphony of diverse
collaborators. Beginning with the community, identifying a
program director and coordinator, naming a core leadership
group early in development, and then going on to involve
other essential collaborators in iterative fashion over time are
the key steps. As these collaborators join forces and interact
in mutually respectful ways, their collective commitment
forms the bedrock of a sustainable family medicine residency program that meets the highest standards of medical
education and embodies the values, adaptability, and
community and patient-centered focus necessary for the
ever- evolving landscape of healthcare.
How Do WeContinuously Improve
theProgram Design?
Designing a program should precede and continue parallel to
implementation. Iterative design—and the questions we have
used to organize this chapter—need to be revisited regularly
during development as well as upon implementation and in
the years thereafter. Continuous program improvement represents an ongoing commitment to excellence and adaptability. Embracing a mindset of continual renement allows the
program to respond effectively to the evolving landscape of
healthcare and to the unique needs of the community it
serves. Iterative design also means you can start almost anywhere and build from there.
While mission, vision, and goals are too often conducted
as a point-in-time pro forma exercise in the development of a
business or educational venture, continuing to think critically about design and re-design is necessary to the new program’s next steps. Where does the program want to go? A
community-oriented program that seeks to build a primary
care workforce for a particular geographic area will have a
different strategic focus than an academic research-oriented
program. As described in a roadmap published for rural programs and adapted to Teaching Health Center programs [13],
continuous program improvement should include a periodic
environmental scan to identify and assess local resources and
lengthy conversations with community collaborators to get
their perspectives and buy-in [10]. Engaging the community
in a capacity and asset inventory at the beginning of the process can set an empowering tone and should complement the
usual decit-based approach, building for sustainability.
What Are theProgram’s Anticipated Risks/
Demands?
As the program’s shape and goals begin to form, developers
will identify important organizational relationships, as well
as the risks and demands that invariably come about as those
relationships develop [6]. Essential questions include:
• Who will the program’s Sponsoring Institution (SI) be?
Consider whether joining an existing sponsoring institution would be more or less advantageous than establishing a new one.
• Where will the residents’ primary training site be located?
Common considerations in this decision include adequacy
of existing facilities, initial and potential patient volume,
ease of access by the local population, meeting the needs
identied in the community needs assessment, and availability of faculty to provide ACGME-required learning
experiences.
• From where will initial and ongoing funding come?
Administrative costs of starting a new residency begin to
accrue years before revenue appears from traditional
funding streams. It is critically important to understand
how funding will be allocated to the new program and
how nancial decisions are made, since funding often
ows directly to the primary training site and not to the
program directly.
• Continually ensure that the program’s vision is aligned
with the sponsoring institution, hospital, academic department, and any other afliated organizations.
• Consult early and often with peers, other similar programs, and experts in residency design, accreditation,
funding, and governance, as recommended by a workshop group of rural residency planning and development
grantees (Table40.3).
Are theRisks/Demands Acceptable?
As the exploration phase concludes, initial leaders will
need to decide whether the risks and demands of the new
program are acceptable, and whether to proceed onward
into the design phase. This requires an objective review of
strengths, opportunities, and resources, vs. anticipated
needs and risks. The predominant reasons for the closure of
family medicine residency programs include inadequate
nancial support, inadequate political support, and institutional leadership changes [11]. Other factors identied as
either risks (if absent) or assets (if present) include faculty
and teaching resources, resident recruitment, program attributes, program mission, and patient-related clinical experiences [20].
For example, a corporate merger that results in a change
in leadership for the residency program’s primary training
site or sponsoring institution, or a loss of grant funding easily
threatens the viability of either a developing or existing program. Although not all these factors can be easily identied,
being aware of them can help the development team ask dis-
40 Starting aNew Program: Asking Good Questions
471
Table 40.3 Consulting Wisely. Through a World Café processa and a
subsequent workshop at The RTT Collaborative Annual Meeting, on
April 27, 2022,b a group of consultants and grantees from the Rural
Residency Planning and Development Programc considered the following question, “How do I determine the best time to seek or recom-
mend a consultation for program design and development?”
Following is a summary of the key points that emerged, including group
comments
1 Join a peer network informed by deep experience, and take each
bit of counsel with a grain of salt. Your situation may be unique
“Create a network and ask questions.”
“Ask three people from three stages of program development:
before, during, and after successful program startup”
2 Consult early and often—before you “need” it, when you don’t
know what you don’t know. If you wait till you “need” it (e.g.,
disagreements among local leaders, when you’re “stuck”) or when
the money’s available, it may be too late
“The best time to seek consultation is before you need it! …before
things are really on re!”
“If you think you need one, it is probably past time.”
“There is no bad time.”
3 Be prepared to answer these four questions:
• Why are you seeking this consultation?
• What key questions would you like to have answered?
• What do you expect as deliverables?
• What is the time frame for this work?
4 Pursue a consultation or series of consultations that ts the stage
of program development, e.g., a single 2-hour online diagnostic
consultation with the leadership team, a site visit early in the
process of exploration for the purpose of initial program design,
and/or a later longitudinal consultation conducted an hour a
month for mentored problem solving or program implementation
“(Consider) ‘consultation light’ (brief and inexpensive)”
“(Consider a comprensive consult) when there is a critical mass”
(a core leadership group committed to proceed)”
5 Establish a primary consultant you can trust, preferably a
generalist (as in “primary care”), and do not judge the value of a
consultation by how much it costs
“Like in much of life, the sticker price does not reect quality.”
a
Process as described in a World Café toolkit, available at: https://
theworldcafe.com/tools- store/hosting- tool- kit/
b
The RTT Collaborative Annual Meeting archive, available at: https://
rttcollaborative.net/meetings/annual- meeting- archives/
c
Health Resources and Services Administration (HRSA) Rural
Residency Planning and Development program, described at: https://
www.hrsa.gov/rural- health/grants/rural- health- research- policy/rrpd
cerning questions and make wise decisions to proceed or
abandon the effort.
Is theStrategy Sustainable?
New programs face many obstacles, one of which is
attracting talented employees. Founders of new programs
often nd themselves performing many tasks themselves,
which is not sustainable in the long term. These program
leaders should ambitiously seek administrative staff and faculty who have the skills and qualications to take on some of
these tasks. Questions that often arise as programs seek and
nd possible team members include: Should the program
recruit individuals for specic slots? Should the program
create positions for promising candidates? [7].
One of the most critical resources for a new residency
program is residents. How will the program market itself to
potential applicants? And conversely, how will the program
ensure selection of candidates prepared to further the program’s mission? Recruitment into a new program is very
challenging. Many of the qualities of programs and their
residents as well as outcomes data, which applicants usually
consider are not yet available for new programs. As program
development is underway, the program director and design
team should think strategically about the program’s market
niche and what will be its biggest selling points [6].
How Strong Is theOrganization?
Organizations have “hardware,” such as organizational structure and systems, and “software,” such as culture and norms.
Implementation of a residency is a “disruptive innovation,”
revealing weaknesses in institutional structure and processes
and necessitating timely solutions [8]. The addition of rotations, recruitment schedules, and educational activities complicate administrative processes. This systemic stress may be
viewed as an opportunity for growth (by some) even if it
legitimately burdens other parts of the system.
How will the program’s design team shape the program’s
culture? Culture emerges from the aggregate behavior of
individuals and groups and lls in the gaps that an organization’s written rules do not anticipate. Inevitably, there will be
both expected and unexpected challenges in a new program,
and culture determines how the program will respond to
those challenges. Actively recruiting people whose personalities and values align with the vision and goals of the program helps build culture intentionally, rather than by chance.
Once accreditation is achieved, the program’s attention
turns toward proof of concept and building for sustainability. How will the program’s leaders evaluate the program,
assess resident clinical competency, and ensure the quality
and safety of the clinical learning environment? Are the program’s goals too conservative? Too aggressive? Are the
right resources and relationships in place to execute the
strategy?
How Will theProgram Evolve toMeet
theQuintuple Aim ofHealth Care
Improvement?
“Learning organizations” prioritize learning at all levels and
are working to continuously transform themselves. Medicine
is a rapidly evolving science, while medical organizations
are generally slow to change [2]. This leads to a gap between
472
I. A. Gutierrez et al.
what is known and what is practiced clinically. Training the
next generation of family physicians to be prepared to signicantly impact the quintuple aim of health care (improving
population health, enhancing the care experience, reducing
cost, reducing workforce burnout, and advancing health
equity) requires that programs evolve on pace with the science of medicine [18]. How will the new program prepare
proactively to meet the needs of its intended population?
How will the program optimize the experience of its patients
in the healthcare environment? Is the program teaching costs
of care to its residents, and controlling cost to patients and
the healthcare system? Is the program using its funding and
resources wisely? How is the program caring for its caregivers? Are staff, residents, and faculty satised with their work
and well-being? Do patients, staff, residents, and faculty feel
respected? How is the program improving health equity in its
community? Ultimately, the successful family medicine residency program is not simply aiming to become accredited;
accreditation is a means to an end and assists the program to
make a difference in the health of patients, families, and
communities it serves. These questions help the new program remain oriented to achieve that end.
What Pitfalls Should WeAvoid?
The establishment of a new Family Medicine Residency program is an ambitious undertaking, laden with the promise of
cultivating future generations of procient and compassionate healthcare providers. However, amidst the optimism, it is
crucial to navigate the potential pitfalls that can impede the
program’s trajectory. These potential stumbling blocks
underscore the importance of meticulous planning, continuous evaluation, and strategic adaptability to ensure the program’s resilience and long-term success (Table 40.4). By
proactively mitigating these challenges, institutions can
establish a Family Medicine Residency program that not
only meets accreditation standards but also thrives in preparing residents for successful and impactful careers in family
medicine, setting the program on a path of sustained excellence in medical education and training.
What Do IDo inSpecial Circumstances?
Residency program development in a rural community or an
urban facility caring for the historically marginalized (e.g., a
Federally Qualied Health Center) requires a creative
approach to working with limited resources. If you nd yourself in these circumstances, get help early. Successfully
designing, developing, and implementing a program in rural
and under-resourced places requires an adaptive approach,
engaging the community and building on assets [15] (See
Table 40.4 Common pitfalls when developing a new family medicine
residency program
Area Potential issue
Program design and
governance
Needs assessment
and community
asset and capacity
inventory
Faculty recruitment Recruiting faculty with insufcient experience
Curriculum design Developing a curriculum that lacks a balance
Infrastructure and
resources
Community
engagement
Assessment and
evaluation
Financial challenges Underestimating the nancial resources
Flexibility and
adaptability
Communication and
collaboration
Failing to develop the program governance
beyond the organizational chart, to include
functioning procedures and timeline.
Failing to identify the appropriate program
sponsor.
Failing to conduct a thorough asset and needs
assessment may result in a mismatch between
the program’s design and the actual healthcare
needs and capabilities of the community and
the available resources at the hospital and
clinic. This can hinder the program’s
relevance and sustainability.
in both clinical practice and medical education
can compromise the quality of instruction.
A lack of diversity in faculty members may
limit the program’s ability to provide a
well-rounded educational experience.
among clinical experiences, didactic sessions,
and research opportunities can lead to an
incomplete education for residents.
Failure to integrate emerging trends in family
medicine may hinder the program’s
competitiveness.
Inadequate facilities, technology, and
resources may impede the delivery of quality
healthcare education.
Insufcient partnerships with clinical sites can
limit the variety of experiences available to
residents.
Failing to establish strong ties with the local
community can result in a lack of
understanding of the specic healthcare
challenges and needs and diminish the
community’s investment in the sustainability
of the program. This can impact the program’s
ability to train residents effectively for
community-based practice.
Neglecting to implement robust assessment
and evaluation mechanisms may hinder the
program’s ability to track and improve
resident performance, faculty effectiveness,
and overall program quality. Iterative design
requires iterative assessment.
required for the successful launch and
sustained operation of the residency program
can lead to nancial strain and potential
program discontinuation.
Failing to build exibility and adaptability
into the program design may hinder the ability
to adapt to changes in ACGME rules,
advancements in medical knowledge, or shifts
in community needs.
Failing to build in time for iterative processes
to review program.
Inadequate communication and collaboration
among faculty and program administrators can
hinder the development of a cohesive and
supportive learning environment.
(continued)
40 Starting aNew Program: Asking Good Questions
473
Table 40.4 (continued)
Area Potential issue
Overambitious
timeline
Resident recruitment Having an unrealistic timeline for recruitment
Clinical experiences Overestimating the commitment from faculty
Setting unrealistic timelines for program
development and accreditation may lead to
rushed decision-making and compromise the
quality of the program.
Ensuring that the program is developed with
enough time to participate in medical student
recruitment season that starts with the AAFP
Family Medicine National Conference is
necessary.
(e.g., not being able to advertise the program
because accreditation is obtained in October
or January with a plan to take a class in July)
Recognizing challenges the program might
have with resident recruitment and having
plans to address them or at least acknowledge
that there may be issues.
in the community in providing clinical
experiences.
Overestimating clinical volume to support the
required clinical experiences.
Overestimating clinical experiences available
in the community.
Chap. 34). Since 2010, rst through the RTT Technical
Assistance Program and then, in 2012, led by the emergent
nonprot cooperative The RTT Collaborative (RTTC), a free
tool, TREES, was developed that can be used as a general
guide to residency program development https://rttcollabora-
tive.net/about/tools- and- assistance/. In 2019, the Rural
Residency Planning and Development Technical Assistance
Center (RRPD-TAC) created a portal and toolbox of webinars, tools, and seminal articles that can be accessed by anyone who registers at https://ruralgme.org. In 2021, the
Teaching Health Center Planning and Development Technical
Assistance Center (THCPD-TAC) developed a parallel
library of tools at https://thcpd.sirs.unc.edu/login. The latter
two technical assistance centers are currently grant-funded,
but the RTTC, recently renamedThe Rural Medical Training
Collaborative (RMTC), remains a self-funded cooperative
that has now been sustained for more than a decade and
hopefully will sustain into the future. Though much of the
information available from these resource centers was originally designed for rural residency program development, the
concepts are transferable for use by urban programs.
There are good reasons to pursue separate accreditation
and other reasons to pursue expansion of an existing program through a “track.” This is a decision not to be made
lightly. Taking the easy route in the short term may jeopardize the program in the long term. Consult early and often
with peers and organizations who have deep experience
(Table40.3).
Development of a residency in a rural community or a
facility caring for the historically marginalized also requires
special attention to funding. For example, rural hospitals
receive graduate medical education (GME) funding from the
federal government and from many states under slightly different rules than urban hospitals. Teaching Health Center
funding, through a grant-funded mechanism called THCGME requires periodic authorization by Congress. Although
funding should not drive initial residency program design, it
is an important and essential piece of the puzzle and cannot
be approached in the template-driven manner that often characterizes input from large consulting rms. Get advice from
consultants with deep expertise in rural and under-resourced
settings.
Good Questions Are Key toBeginning Well
Beginning well requires that programs be armed with a roadmap, relevant questions, curious minds, a communityengaged and collaborative approach, a commitment to
excellence, innovation, and continuous program improvement in the cultivation of compassionate, well-rounded family medicine physicians. Each is essential in shaping a
program that not only meets national standards but also
addresses the unique healthcare challenges of the
community.
With this holistic approach, a new residency program is
poised not just to meet expectations but to exceed them.
References
1. Agency for Healthcare Research and Quality. National healthcare
quality and disparities report. 2023. https://www.ahrq.gov/research/
ndings/nhqrdr/nhqdr23/index.html. Accessed 28 Dec 2023.
2. Alonazi WB. Building learning organizational culture during
COVID-19 outbreak: a national study. BMC Health Serv Res.
2021;21(1):422.
PMID: 33947380; PMCID: PMC8094974.
3. Alweis R, Donato A, Terry R, Goodermote C, Qadri F, Mayo
R. Benets of developing graduate medical education programs
in community health systems. J Community Hosp Intern Med
Perspect. 2021;11(5):569–75. https://doi.org/10.1080/20009666.20
21.1961381. PMID: 34567443; PMCID: PMC8462840.
4. Association of American Medical Colleges. Physician supply and
demand, a 15-year outlook: key ndings. 2021. https://www.aamc.
org/media/10886/download
5. Ayanian JZ, Weissman JS.Teaching hospitals and quality of care: a
review of the literature. Milbank Q. 2002;80(3):569–93. https://doi.
org/10.1111/1468- 0009.00023.
6. Barajaz M, Turner T.Starting a new residency program: a step-bystep guide for institutions, hospitals, and program directors. Med
Educ Online. 2016;21:1. https://doi.org/10.3402/meo.v21.32271.
7. Bhide A. The questions every entrepreneur must answer. Harv
Bus Rev. 1996.
entrepreneur- must- answer. Accessed 24 Dec 2023.
https://doi.org/10.1186/s12913- 021- 06454- 9.
https://hbr.org/1996/11/the- questions- every-
474
I. A. Gutierrez et al.
8. Bush RW, LeBlond RF, Ficalora RD. Establishing the rst residency program in a new sponsoring institution: addressing regional
physician workforce needs. J Grad Med Educ. 2016;8(5):655–61.
https://doi.org/10.4300/JGME- D- 15- 00749.1. PMID: 28018527;
PMCID: PMC5180517.
9. California Department of Public Health (CDPH-Substance and
Addiction Prevention Branch (SAPB)). California Overdose
Surveillance Dashboard. 2022. https://skylab.cdph.ca.gov/
ODdash/?tab=Home. Accessed 24 Dec 2023.
10. Forrest LL, McHugh D, Marquis-Eydman T.Insights for new and
developing rural family medicine residency programs. Fam Med.
2023;55(2):81–8. https://doi.org/10.22454/FamMed.2022.810495.
Epub 2023 Jan 7. PMID: 36689447; PMCID: PMC10614542.
11. Gonzalez EH, Phillips RL Jr, Pugno PA.A study of closure of family practice residency programs. Fam Med. 2003;35(10):706–10.
PMID: 14603401.
12. Green LA, Miller WL, Frey JL, et al. The time is now: a plan
to redesign family medicine residency education. Fam Med.
2022;54(1):7–15. https://doi.org/10.22454/fammed.2022.197486.
13. Hawes EM, Weidner A, Page C, etal. A roadmap to rural residency program development. J Grad Med Educ. 2020;12(4):384–7.
https://meridian.allenpress.com/jgme/article/12/4/384/445472/A- Roadmap- to- Rural- Residency- Program- Development
14. Kupersmith J. Quality of care in teaching hospitals: a literature
review. Acad Med. 2005;80(5):458–66.
15. Longenecker R.An organic approach to health professions education and health equity: learning in and with underserved communities. J Health Care Poor Underserved Suppl. 2020;31(4):114–9.
16. Longenecker R, Hawes E, Page C.Cultivating healthy governance
in rural programs. J Grad Med Educ. 2021;13(2):174–6. https://doi.
org/10.4300/JGME- D- 20- 00825.1.
17. Morris CG, Chen FM.Training residents in community health centers: facilitators and barriers. Ann Fam Med. 2009;7(6):488–94.
https://doi.org/10.1370/afm.1041.
18. Nundy S, Cooper LA, Mate KS.The quintuple aim for health care
improvement: a new imperative to advance health equity. JAMA.
2022;327(6):521–2. https://doi.org/10.1001/jama.2021.25181.
19. Ozarks Health Commission. Joplin community summary regional
health assessment. 2022. https://www.mercy.net/content/dam/
mercy/en/pdf/chna/joplin- chna- 2022.pdf. Accessed 28 Dec 2023.
20. Patterson DG, Schmitz D, Longenecker RL. Family medicine rural training track residencies: risks and resilience.
Fam Med. 2019;51(8):649–56. https://doi.org/10.22454/
FamMed.2019.769343. PMID: 31509216.
21. Patterson DG, Shipman S, Pollack SW, etal. Growing a rural family physician workforce: the contributions of rural background and
rural place of residency training. Health Sys Res. 2023;59:e14168.
https://doi.org/10.1111/1475- 6773.14168.
22. Savoj J, Mikhail C, Ayutyanont N, etal. The effect of starting
a new residency program on the quality of care measures at a
community hospital: a 2-year follow-up. HCA Health J Med.
2021;2(3):223–8.
23. Stajduhar T. Physician recruitment: the costs to hire and return
on investment. Jackson Physician Search; 2018. https://www.
jacksonphysiciansearch.com/wp- content/uploads/2018/11/
Jackson- Physician- Search- Physician- Recruitment- The- Cost- toHire- and- Return- on- Investment.pdf
24. Stavros JM, Hinrichs G. The thin book of® SOAR. Bend: Thin
Book Publishing; 2009.
25. Strasser R, Worley P, Cristobal F, etal. Putting communities in the
driver’s seat: the realities of community-engaged medical education. Acad Med. 2015;90(11):1466–70.
Preparing forandSurviving aDisaster
inYour Program
TaraScott
41
Key Points
• Many of the key components required to prevail during a
disaster are important for your program at any time.
• Preparing for disaster ahead of time will position your
program well to pivot to a number of lesser challenges.
• Annual review of disaster readiness, including orientation
for onboarding interns, will help to prepare your program
and will highlight transparency and communication as a
key organizational strategy.
• Communication platforms for rapid and efcient communication with your residents, staff, and faculty are key
during disasters and work well for day-to-day operations
as well.
• Ideally, programs will prepare to accommodate a range of
risk tolerance, readiness to serve among the residents,
faculty, and staff.
• Persistence of Family Medicine residency programs
through disaster is crucial for the primary care
workforce.
Introduction
Unless you have experienced a natural disaster in your community, you are not likely to be thinking about preparing
your program for disaster or leading your program during
existential times when you rst become a residency program
director. Especially at the beginning, there are so very many
things to learn: American Council of Graduate Medical
Education (ACGME) requirements, accreditation, budgeting, relationships with leaders, behavior management to
T. Scott (*)
Sutter Santa Rosa Family Medicine Residency,
Santa Rosa, CA, USA
University of California, San Francisco’s Department of Family
and Community Medicine, San Francisco, CA, USA
e-mail: Tara.Scott@sutterhealth.org
name just a few. It is natural not to focus on the “maybes”
when you have so many must-do tasks before you.
You are probably right to hope that you are never in the
unfortunate position to be leading your program through a
natural disaster and, with any luck, you will be fortunate to
serve your time as program director without facing one.
However, in recent years, an increasing number of residency
programs have been existentially threatened by res, oods,
and hurricanes. When you see images on the nightly news of
another community hit by outsized weather events, how
often have you thought about whether there was a residency
program that was taken out of commission by the event?
When an area that relies on its Family Medicine residency
program to provide care for the community is hit by a natural
disaster, the ability to keep the program running becomes
essential not only for providing care during the disaster but
also for training experience of residents and fellows as well
as the long-term primary care workforce of the area.
The specialty of Family Medicine, it turns out, is undeniably useful in responding to the needs of communities during
times of disaster. Both trainees and faculty are uniquely
suited to see people of all ages and to move from makeshift
community care sites to the hospital with ease. Few other
specialties have the breadth of practice to serve the community so well in makeshift settings such as mobile vans, evacuation shelters or hospital expansions. Should you ever be in
such a position, you can be assured that you will see a side of
Family Medicine that will make your dedication to the specialty even deeper.
Many of the systems you need to have in place to be prepared for a disaster will serve you well in day-to-day operations or during smaller events such as a new pandemic, a
change in sponsorship or accreditation status or another type
of unexpected event within your residency community.
Investing a small amount of time now to prepare yourself and
your program to be nimble during a disaster is well worth the
time, especially if the payoff will be that you keep your program in operation for the long run. Leading an organization
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
R. Kellerman, G. Irwin (eds.), Graduate Medical Education in Family Medicine, Excellence in Medical Education 2,
https://doi.org/10.1007/978-3-031-70741-4_41
475
476
T. Scott
during a disaster can be both incredibly demanding and an
irreplaceable growth opportunity for you personally. This
chapter will help you think through some of the basic planning you can do now to familiarize yourself with the systems
and processes that may help things run more smoothly
should a disaster strike.
Preparing Yourself andtheProgram
toRespond toDisaster
Anticipate Common Disasters
The most likely disaster scenarios to affect your program and
community will vary by geographic location. Certain parts
of the United States will be more prone to res or earthquakes, and others may be more prone to hurricanes and
ooding. Depending on how long you have been in the community, where your program is, and whether you have experienced a major environmental event there, you may or may
not be personally familiar with your county’s emergency
evacuation zones and routes. Your rst step should be to
learn about your town’s emergency planning infrastructure,
so you can include it in your program’s plan. Some cities and
counties have instituted a county-wide alert system that will
let residents of different areas know if there is a threat in their
zone by cellular phone alert. Trainees, who are often new to
a community, will not automatically think to learn about
things like evacuation zones or routes when they move to a
new town; thus, incorporating education during orientation
about such items can prove important to the health and safety
of your trainees.
Learn About Your Regional Emergency Infrastructure
City and county governments often have a department that is
specically focused on Emergency Management and usually
creates an Emergency Operations Plan (EOP) for the region.
Your city or county website will hopefully have their EOP
available online. Many EOPs include planning for multiple
different types of community impacts such as extreme heat,
power shut-offs, storms and ooding, earthquakes, and res
depending on your region. In addition, your community may
already have a blueprint for mass care and shelters. In the
event that care is needed in the community due to closure of
some of the usual health care sites, members of your healthcare system may be called upon to provide care in alternative
care sites. There are numerous issues to think through in
advance to be well prepared to deploy residents and faculty
to provide healthcare services where they are needed.
Learn Your Organization’s Command Center Structures
In a community wide disaster, there will likely be multiple
interlocking Command Centers within the public health
department, the county, the hospital, the clinics as well as the
residency program. It is likely that you and your residents
and faculty are situated somewhere in the middle of these
interacting Command Centers. If you have never been a part
of an active or simulated Command Center, you may not
know how your residency program and you as Program
Director t into the command center organizational plan. In
some settings, especially if you are in a smaller community
or if you also serve as the Designated Institutional Ofcial or
the Chair of a Medical Department, you may play a key role
in the Command Center Operations at your hospital. If you
have never been oriented to your role and the expectations
for your position in the Command Center structure, inquire
about the organizational chart for the command center within
your clinic or hospital system. Once you have understood
your command center structure, it is important to share it
with your co-leaders including other faculty, lead residents,
and staff.
Questions toExplore
1. Is your sponsoring institution already part of a county
health system or military branch that will be expected to
deploy to mass care or shelter sites? Some programs are
connected to county health systems, and faculty and residents may be required to deploy to such sites in the event
of emergency.
2. If you are not a part of the county health system or the
military, how will your sponsoring institution approach
malpractice risk if residents and faculty are deployed to
nontraditional care settings or hospitals other than your
sponsoring institution where emergency privileges may
be granted?
3. In some systems, faculty may receive a salary, and in oth-
ers they may be compensated based on productivity in the
ofce or hospital. Will salaried faculty and residents continue to receive their salary while working in alternative
care settings? Will there be a way for faculty who are not
salaried, to be compensated for work outside the traditional settings or will they be working on a volunteer
basis? You may need to speak with leaders in your institu-
41 Preparing forandSurviving aDisaster inYour Program
477
tion or within your medical group or county to get the
answers to these questions.
Prepare aPhone Tree
A phone tree is a structured hierarchical communication
model that is used to contact specic individuals within an
organization and verify their location and safety. In the
event of a large-scale emergency, one of the rst things you
and your program will need to do is to contact all residents,
staff, and faculty to ascertain their well-being, location, and
level of safety. Although your program likely uses
MedHubTM, New InnovationsTM or similar management
software to manage personnel data, it is wise to create some
redundancy in your system. For instance, consider a contact
list of your personnel in paper form that you keep in your
home ofce, or a digital form you store on your laptop in
such a way that internet service is not required. There may
be situations where the servers that run your organization’s
platform are out of commission, internet access is absent or
poor for a period of time, and old-fashioned paper will serve
you well in these circumstances. Create redundancy in the
roles for those who will be responsible for contacting personnel. Your program leadership may nd itself in the position where at least one of the members of the leadership
team is unable to perform the duties of the phone tree due to
the need to deal with their own personal safety. For additional redundancy, involve resident leaders in the plan for
the phone tree and let them know about this expectation in
advance. This is another way to teach about how organizations respond to disaster. If you create a disaster briefcase or
backpack, make sure to give one to at least one of your resident leaders. If they do not ever experience a disaster, they
will have absorbed the concept of the phone tree for their
future leadership positions.
deciding who is at the highest risk of threat from the event,
and how to prioritize your phone tree contact calls. An individualized map, such as those you can make on the GoogleTM
platform, allows you to enter the addresses of your personnel
onto a single personalized map when your program onboards
new residents and/or faculty. If there is an event impacting a
certain part of your town or county, such as the activation of
evacuation zones, this type of map allows you to quickly nd
those to contact rst.
Establish Communication Channels
andMeeting Locations fortheProgram
By now, many programs have created fast and efcient ways
to communicate news and updates to everyone at once that
do not involve phone calls and emails. During a disaster,
many people will be away from their computers and may
not be monitoring emails in real time. There are numerous
phone-based platforms such as TigerconnectTM,
WhatsAppTM, SlackTM, and more that allow you to send
messages to a large group of people at once. For a number
of reasons, people may not be checking email during a
disaster and using a platform that is not behind an organizational rewall is ideal. Many of these programs are used in
the everyday operations of a residency program and can be
very helpful. When disaster strikes and it is difcult to be
physically present with members of your group for some
periods of time, a group messaging app becomes crucial. As
a leader, you may become very busy during a disaster, and
you need to be able to communicate to everyone quickly and
reliably.
Anticipate Program Work andPatient Care
During Disaster
Action Step Create a disaster plan briefcase or backpack
for you and a few co-leaders in your program. This will contain any key documents and contact lists for the program.
The plan will need to be updated annually and the contact
information for all employees updated. (open-source image
from freepic.com).
Create aContact Map
Due to the nature of environmental events, understanding
where your personnel live in your town can be crucial for
You may want to consider in advance what activities your
residents do that are nonessential, so you can focus resources
where they are most needed during a disaster. For instance,
you may designate certain electives as rotations that are, in
essence, a reserve if higher patient loads are seen or if additional care at remote sites is necessary.
Working in Your Own Hospital Depending on how a
disaster impacts your community, your hospital may remain
open and functional, and your faculty and residents may be
needed at higher stafng levels for a period of time.
Alternatively, your residents and faculty may nd themselves
unable to leave the hospital in certain situations where there
is not a clear evacuation route in a re or a massive ood.
478
T. Scott
Here Are Some Alternative Care Site Scenarios That May Arise
1. Your residents and/or faculty are called upon to transfer
hospital patients to a nearby hospital and continue to provide care. Emergency privileges are usually granted in
this scenario if the receiving hospital is overwhelmed by
the number of patients needing care. In these scenarios,
residents may work under physicians who are not usually
supervisors or faculty may also be present to provide
supervision.
2. Your residents and faculty are called upon to help provide
medical care in alternative care sites such as mass evacuation shelters where neither you nor your faculty have
experience providing care.
3. Your residents and faculty are called upon to provide
medical care via a mobile clinic such as an RV or van
where there are no agreements in place for the provision
of care.
4. Your residents and faculty are called upon to assist at a
mass triage site such as a shelter or outside a hospital that
is over capacity.
In each of these circumstances, you will need to assure
that the residents and faculty are able to rest and have time to
debrief frequently with a leader about their experience.
One of your rst tasks to prepare to lead during a disaster
is to review your Sponsoring Institution’s Graduate Medical
Education Policy relating to how it will support residents
during a substantial interruption in training. According to the
ACGME, each Sponsoring Institution must maintain a policy “that addresses support for each of its ACGME-accredited
programs and residents/fellows in the event of a disaster or
other substantial disruption in patient care or education” [1].
Program andHospital-Specic Emergency Plans
Describe your hospital, clinic, or program’s command center
structure and location and let residents know what will be
happening in the minutes, hours, and days following a
disaster.
Regional Emergency Infrastructure
Since many residents will be new to your city or county, it is
likely they will not know about emergency systems such as,
ood or storm warning systems, evacuation zones and routes,
and city or county alert systems.
Expectations ofResidents
Emphasize that you expect residents, faculty, and staff to
attend to their own safety rst and foremost and that any
work they are expected to do will follow once their safety
and that of their families has been established. Beyond
that, explain how your program will determine who will
be required to work, and who may need to be excused
from duty due to evacuation and personal safety. If your
region has an escalating level of warnings such as “voluntary evacuation” versus “mandatory evacuation,” let them
know how this will affect your expectations for coming to
work.
Responsibilities oftheProgram
Share your sponsoring institution’s ACGME-required policy
around “Substantial Disruptions in Patient Care or Education”
[1]. This policy should let them know what they can expect
in terms of salary support and assistance nding alternative
training locations in the event that the program can no longer
continue to provide patient care or meet the ACGME requirements for training and supervision.
Preparation Tip Have a conversation with your hospital
leadership about how long they would be willing to continue
salaries and benets in the event of a major disaster that
causes closure of the hospital, both temporary and permanent. Convey this to all residents upon entering the
program.
Orient Your Team toOrganizational Readiness
andExpectations Annually
Many residents have only recently moved to your town or
city to start their training and may be unfamiliar to the unique
landscape, weather events, and state or county systems that
relate to their safety. One easy way to introduce them to your
residency’s emergency plan is to create a 1-hour session for
orientation.
Teach theSkills ofDisaster Response
If you are lucky, you attended a residency program where
there was some explicit preparation or training for disaster,
or perhaps you participated in a mock or a real disaster. For
a good number of us, however, that will not be the case. The
American Academy of Family Physicians (AAFP) has a curriculum outline for any program to consider working Disaster
Medicine into their overall curriculum: AAFP Recommended
Curriculum Guidelines for Family Medicine Residents:
Disaster Medicine [2]. It may be hard to prioritize this cur-
riculum given, the vast array of requirements programs must
all meet in just three short years. Even if you do not have
formal time set aside in the curriculum to teach the elements
of disaster response, some of the resident’s learning can happen just through your role modeling including an annual orientation for new interns and a refresher for residents, faculty,
and staff who are not new to the program.
41 Preparing forandSurviving aDisaster inYour Program
479
If you are interested in more guidance on how approach to
disaster preparation into your program’s curriculum, the
National Consensus Guidelines on Disaster Training [3]
denes a set of concrete competencies for disaster preparedness and response in addition to a variety of “levels” at which
individuals at different levels of training and experience and
in different roles within an organization may be operating
during a disaster response. This can serve as a framework
upon which to build different activities and expectations
within your program.
Managing Your Program During Disaster
Attend toYour Own Safety
One of the more challenging elements of facing a disaster as
a leader is the need to balance the dual responsibilities of
attending to you and your family’s safety and attending to
the safety of your residents, faculty staff, and patients. There
are multiple layers of threat to manage simultaneously, and if
you are uncertain about your own safety or that of your family, it may impact your ability to help and lead others. You
will have to determine your capacity to serve your organization and its community members and strategize with coleaders to see who among your senior leadership has the
capacity to execute the initial phases of your disaster
response. Throughout the disaster, you and your co-leaders
may experience waxing and waning ability to focus your
attention on the larger organization. It is crucial to remember
that you must attend to your own well-being so that you can
continue to make good decisions in the face of a high stakes
and high stress event that will likely ip you into a high
adrenaline mode. You do not how long it will be necessary to
stay in this high adrenaline state so self-care and delegation
of responsibilities based on varying levels of capacity should
be considered a necessity.
Communicate withYour Team Frequently
During theDisaster
property or if the future of the program is uncertain, “reside
texts” that communicate gratitude, updates or information
about the wellbeing of the program may be very appreciated.
Residents are uniquely vulnerable, in that, in addition to the
trauma of a disaster, a signicant impact on the program
could mean changing programs midway through training or
even repeating some time in a new program to meet certain
ACMGE requirements.
Education andPatient Care During Disaster
There are numerous scenarios you and your program may
nd yourselves in during a disaster in terms of where patient
care, and therefore education, can happen. If your hospital
remains open, there may be a need to continue the usual
patient care as well as triage injuries from the disaster. In
other cases, the hospital may be damaged or evacuated for
safety and alternative sites for care may become necessary.
Evacuation shelters and mobile care units are two common
care “sites” you may be involved with. Additionally, other
area hospitals may be functional while your own hospital is
not. While contracts or letters of agreements are usually
required for privileges, some hospitals use a system of emergency privileging to avoid unnecessary delays in patient care
and allow physicians who are not already on the medical
staff to perform care.
In the immediate aftermath of a disaster in your community, providing patient care at various sites where it is needed
will likely sufce to meet ACGME expectations for ongoing
training at least for a short while. Even in emergency scenarios, however, it is important to remember that the ACGME
still requires that residents be supervised appropriately and
that their work hours still comply with clinical and educational work hour requirements. There may be a need to curtail activities such as didactics for a short period due to
personnel shortage and demand for patient care. However,
you will want to restore as much of the non-patient care educational programming as soon as possible to ensure that your
residents are not exclusively providing patient care under
high-stress circumstances.
Beyond the initial telephone tree, ongoing communication
with your entire team, and to subgroups, is essential. As a
leader, you will likely be bombarded with questions, concerns and decisions making, and the ability to communicate
with many people rapidly from your cell phone or laptop is
key. Ideally, you will appoint someone other than yourself on
the leadership team who can eld calls, questions, and texts
for you since these important and well-meaning communications can become overwhelming in volume.
In the early days of a disaster, especially if it is challeng-
ing for you team to gather, if there is signicant damage to
Anticipate Dierent Levels ofRisk Tolerance
andReadiness toServe
In any group of family doctors, whether they are residents or
faculty, there will likely be a spectrum of tolerance for working in risky or unfamiliar settings. While faculty will generally feel they have more agency to decide what they can and
can’t do, residents may feel less empowered to speak up due
to the nature of their training obligations and their position in
the medical hierarchy. While we often hope for our residents