Sudden closure of residency programs creates chaos – and opportunity

Members of the Accreditation Council for Graduate Medical Education's (ACGME) Residency Review Committee (RRC) in March 2021 visited the plastic surgery residency programs at Case Western Reserve University (CWRU) in Cleveland and University of Tennessee Health Science Center (UTHSC) in Memphis, presumably to discuss with officials topics such as work hours, case details and other phases of those residency programs.

But without warning, the RRC on April 9, 2021, announced that it was withdrawing accreditation from both programs. As neither program had been placed under probation, this announcement came as a shock to many – and created exceptional career and personal turmoil as well as uncertainty for the 22 active and three prospective trainees who were suddenly displaced from their systems – and therefore separated from their support.

They were left to find positions at other programs that would allow them to continue training, some were unable to communicate with their program director and/or chief and others were pulled from their rotations.

Eleven days after the RRC announcement, the ASPS Residents Council held a meeting that resulted in a position statement released in May 2021 to the leaders of ASPS, American Council of Academic Plastic Surgeons (ACAPS), RRC and Internal Review Committee (IRC) of the ACGME.

The challenges faced by the displaced residents brings to light myriad questions:

• How can such events be prevented in the future?
• Can the process of withdrawal of accreditation be improved?
• Can there be a streamlined process for displaced residents to find another program?
• Do the ramifications surrounding a loss of accreditation influence residents to conceal serious issues in their program?

A perfect solution for such a disruptive event may never be found. In the meantime, in an effort to provide takeaways from which to learn and to improve the process, two leaders of the ASPS Residents Council who've become immersed in gathering data and finding solutions, and two residents displaced by program closures, have agreed to share their insights and experiences with Plastic Surgery Resident.

Cristin Coquillard, MD

PGY-5, now at Northwestern University

More than a year has passed since the closure of my plastic surgery residency program at CWRU – and I view it as one of the best things that happened to me. However, the period of April-August 2021 was the most stressful time I've ever experienced.

My co-residents and I discovered our accreditation was withdrawn when we checked the ACGME website on my son's first birthday – coincidentally, April 9, 2021. Questions and speculation about our futures dominated our thoughts, and most conversations seemed to lack any good (or reliable) information. Would we be able to find new spots? How would we find them? Would we keep our funding? Would we have to repeat any time? How would this affect our graduation and ability to apply to fellowships? Our whole lives were in a state of upheaval.

Several days passed before we received any official notification of our closure – and more than a week passed before any meetings occurred with the hospital or GME leadership. To its credit, CWRU did the best thing they possibly could for us – they let us keep our funding, which made finding new positions infinitely easier for the Case Western residents. However, we were essentially told that we were on our own when it came to finding new spots. It was a tumultuous time for all of us by any and all measures.

The ASPS Residents Council stepped in after learning of the issues being faced by our program and at UTHSC. We soon began to hold meetings between all the displaced residents and the Residents Council. The most helpful thing that came out of these meetings was a list of and contact information for programs that could accommodate an additional resident. For the first time since the news broke, we felt supported and heard.

Given how late we were notified of our loss of accreditation, I didn't officially have a spot in another program until mid-May. My husband, 1-year-old son and I had less than six weeks to sell our house in Cleveland, buy a house in Chicago, physically move, figure-out childcare in a new state and complete the onboarding and licensing for a new hospital – all while both working full-time in our current jobs.

My husband had to stay in Cleveland for an extra month, which meant we couldn't get a house in Chicago by my July 1 start date. My son and I lived alone for a month in temporary housing more than 30 minutes away from the hospital. This challenge came on top of the already unnerving situation of navigating an entirely new hospital system in the absence of the support one normally receives as an intern. I also lost all my research projects that were in progress at my old program because I no longer had access to the EMR and faculty support there. It was an incredibly stressful time and a huge financial burden. Looking back, I still don't know how my family got through it. Still, the story has a happy ending. I'm extremely pleased with my current situation and feel fortunate for the opportunity to train at one of the best programs in the country.

However, the journey to this point was something that I wouldn't wish upon my worst enemy. I hope that no other plastic surgery programs close in the future, but I appreciate the steps the Residents Council is taking to make the process easier in the future and to protect the residents who must go through it.

The most important of those initiatives are to ensure that displaced residents keep their funding, and for programs to receive notification of accreditation withdrawal much earlier – so that prospective residents do not match into closed programs and are allowed ample time to find other spots to relocate.

Megan Fracol, MD

Immediate-Past Chair, ASPS Residents Council

When I began as chair of the Residents Council, our first group meeting occurred in Atlanta during Plastic Surgery The Meeting 2021. The majority of the meeting, which was one of the highest-attended Residents Council gatherings ever, was devoted to discussing the recent program closures – and we've spent the time since initiating several efforts to combat issues faced by many of the residents displaced by program closures.

Three major projects are currently underway:

1. Interviews of displaced residents for information gathering. These are being conducted largely by Residents Council members Matthew Pontell, MD, and Arya Akhavan, MD, under the faculty guidance of Brian Drolet, MD. There are multiple purposes to these interviews, including understanding the challenges displaced residents faced in finding new programs, how the events affected their families – and what resources would be useful to streamline the process. We also hope to describe the experience of displaced residents in order to emphasize to governing bodies how much the program closures affected them, such that the gravity of these closures can be better-understood and anticipated in the future.
2. An ACGME Residency Review Committee petition. The goal of this petition is to request that the timeline for RRC meetings be moved earlier in the year, such that decisions on program closures or suspensions can be available earlier in the year. This would allow sufficient time for displaced residents to find new positions and prevent prospective residents from matching to a program that's about to be shut down.
3. Develop a resource book for displaced residents. Prior to the program closures in 2021, it had been a long time since the last program closure. Many of the displaced residents felt there was a lack of guidance on how to go about finding new programs and how to navigate the transition phase. To that end, we're working on a resource guide that includes point-people for various steps of the transition process.

Although we hope that no one ever has to endure the process of a plastic surgery residency program closure, we're nevertheless working to ensure the process is smoother, should it occur. I would like to send a huge thank you to the Residents Council members who have helped in these efforts this year. Particular thanks goes to Drs. Pontell and Akhavan; Pablo Padilla, MD; Janak Parikh, MD; Anthony Colon, MD; Avra Laarakker, MD; Sameer Massand, MD; and Eugene Zheng, MD; for their time on the program closures working group. Also a big thank you to the residents from CWRU and UTHSC for giving us insight into their experiences.

Brandon De Ruiter, MD

PGY-3, now at University of Washington

One of the most daunting aspects of the transition after closure of my CWRU residency program was the lack of protocol. I think anyone who has reached this point in their medical training has done so following a predictable process of working through college, medical school and residency. Applications for each step are done in an orderly process and, while working through it, you always had a sense for what was to come next and what contingencies were available should things not fall into place.

The closure of a residency program is a massive departure from this paradigm – in large part because they are rare occurrences. When we first received the news of the CWRU closure, I performed a Google search to find examples of others that had been through similar situations. There wasn't much information to be found. My fellow residents had a lot of questions on how to reach out to programs, what to do with incoming interns that had matched but not started, how to navigate funding, how to navigate leases on homes and how to logistically handle the process of moving and onboarding over the span of several months.

The ASPS Residents Council intervened and, as Dr. Fracol noted, began holding meetings with us to troubleshoot problem areas (including reaching out to programs to identify points of contact for programs that had availability and disseminating this information to us via ACAPS, social media and program contacts). The council also initiated advocacy efforts with the AMA to help ensure that resident funding followed us; submitted proposals to ensure the earlier notification of program closures in the future, in order to avoid having medical students match into programs that may be closing; and proposed a host of solutions for travel logistics, training requirements and several other areas of impact.

Much of this work is ongoing. Still, having these protocols in place in the event this should ever happen to another program – regardless of specialty – is immeasurably important.

Arya Andre Akhavan, MD

ASPS Residents Council's Program Closures Subcommittee

Every year, residents across the United States send information to the ACGME regarding their residency programs and any potential issues that may exist. Programs are often able to address these issues, but in some cases, repeated issues or direct resident reports might result in programs receiving warnings or probationary status. A direct program closure, however, is rare.

That's why the ASPS Residents Council called an emergency meeting in April 2021 in the wake of the sudden closure of the CWRU and UTHSC residency programs. Even a single program closure within plastic surgery is exceedingly rare, but two at the same time is unheard of. Given that there are 5,380 residency programs in 31 specialties, one would expect that some type of resource or guide exists for displaced residents; therefore, we were surprised to find that no such thing exists. How exactly were these displaced residents supposed to know what to do?

The ASPS Residents Council formed a subcommittee specifically targeting program closures and these displaced residents, and then began work on several fronts – the first of which was navigating the placement process. The funding behind a position is complex and transferring this funding from one institution to another is byzantine. As it turns out, hospitals aren't even obligated to transfer the positional funding when a program closes, and the receiving GME offices often are unsure of how to accept the funding.

Our original plan to create a "safety net" fund – a backup to cover one year's funding for up to 12 displaced trainees – turned out to be untenable, although additional efforts are ongoing. As there's no pre-existing guide for displaced residents – no explanation of what the processes are, no core points of contact, no established group within ACGME – the Residents Council is also working to build such a resource, but further work with the ACGME along with standardized pathways and guidelines would certainly go a long way in fortifying that effort.

Our second front was focused on the incoming but displaced interns who suddenly found themselves without a place to train. The ACGME's Review Committee is responsible for program evaluation and closures, but their announcements of program closures occurs after the rank-list submission deadline. To address this at a more systemic level, the Residents Council and the Program Closures Subcommittee drafted a petition to the ACGME requesting that the timeframe for program probationary status and closure be moved up, in order to occur prior to applicants' submission of rank lists. That way, applicants can be fully informed in their rankings.

Last, and possibly most importantly: Displaced residents told us that many of them felt unsupported and unheard, and that these program closures levied a steep toll on mental health, personal finances and their relationships with significant others and children. The Residents Council wanted to make sure that residents not only had a voice, but also could share their experiences.

Hence, we launched a study whereby the subcommittee sent an IRB-approved survey to displaced trainees, asking them to describe how these program closures personally affected them, their families, their mental health and finances. We also asked them to identify their greatest sources of support in this process.

Our study findings were concerning. However, we did receive reports that the most helpful organization was ACAPS – and we thank the organization for all of its efforts. Given the recommendations for improvement from displaced residents and the Residents Council, as well as the concerning findings, we submitted the data to ACAPS and hope to discuss with program directors at the upcoming ACAPS Winter Meeting.

Residents whose programs close should feel supported by their national societies, and finding a new position should not be a herculean ordeal. We hope that the efforts of the Residents Council will bear fruit and help ease the way should something like this happen again.