medical student education in psychiatry after katrina: disaster and renewal

Perspective

Academic Psychiatry, 31:3, May-June 2007 http://ap.psychiatryonline.org 205

Medical Student Education in PsychiatryAfter Katrina: Disaster and Renewal

Mark H. Townsend, M.D.

Received September 10, 2006; revised November 13, 2006; acceptedDecember 15, 2006. Dr. Townsend is affiliated with the Departmentof Psychiatry, Louisiana State University, New Orleans, Louisiana.Address correspondence to Dr. Townsend, Louisiana State UniversityHealth Sciences Center, 3450 Chestnut Street, Third Floor, New Or-leans, LA 70115; [email protected] (e-mail).

Copyright � 2007 Academic Psychiatry

Hurricane Katrina had a catastrophic effect on themedical schools of both the Louisiana State Univer-

sity Health Sciences Center, New Orleans, and TulaneUniversity (1). Massive flooding, the result of levee fail-ures, damaged the majority of structures in Orleans Parishand has greatly hindered the restoration of psychiatric ser-vices to the region (2). As of May 2007, however, medicalstudent education has largely returned to New Orleans (3).Although LSU’s iconic art deco Charity Hospital remainsquarantined and unused, classes are being held for first-and second-year students in the same buildings and class-rooms as before, and the psychiatry clerkship is once againbeing taught entirely within the New Orleans metropolitanarea.

Medical education is, in fact, regularly interrupted bynatural disasters. Medical schools and teaching hospitalsare built along dangerous coastlines, in floodplains or seis-mic zones, and in politically unstable areas. Understand-ably, the presence of academic medical centers is seen asnecessary for the recovery of affected regions (4). Despitethis, relatively little is written about either the immediateeffects on or the long-term outcome of disasters for theseinstitutions.

Internationally, two medical schools seem especiallylikely candidates for study: Kobe University, affected bythe January 17, 1995, Hyogo-Ken Nanbu earthquake, andthe medical school of Syiah Kuala University in BandaAceh, Indonesia, flooded by tsunami from the enormousSumatra-Andaman earthquake of December 26, 2004.Little information is available about the impact of theseevents on the schools. For example, the psychiatric effectsof the earthquake on Kobe have been well-studied, includ-

ing those of hospital workers (5), but not the earthquake’seffect on psychiatric medical education itself. Similarly,although the Banda Aceh medical school was reduced toa virtually empty building, and numerous students andfaculty were killed (6), no reports describe how medicaleducation continued until the school reopened in Aprilof 2006 (7).

U.S. medical schools that experience disasters are alsorarely the subject of study. Education at the Medical Uni-versity of South Carolina was disrupted by HurricaneHugo, but this information is gleaned from reports fromindividual hospitals or specialties (8). The October 30,1997, flooding of the John A. Burns Medical School of theUniversity of Hawaii has been described (9), but the storyof its rebirth has not. Similarly, the 1989 Loma Prietaearthquake affected medical care throughout the SanFrancisco Bay Area (10), but little information exists aboutthe earthquake’s effect on medical student education. Be-cause of the relative paucity of information, it may be es-pecially useful to learn about Louisiana State UniversityHealth Sciences Center’s (LSUHSC’s) experience.

Hurricane Katrina and Its Immediate Effects

A good outline of what has transpired at LSU can befound at its Web site, www.lsuhsc.edu, where “emergencynotices” have been archived since August 29, 2005, the dayoperations were officially suspended. Most LSU medicalstudents, residents, and faculty safely evacuated the city,but many of those who remained worked in hospitals thatwere flooded. Their stories are being told (11), but nodoubt much information about the effects of the storm andflood on individual teaching hospitals will not be recorded.In New Orleans, as in Kobe, communication and mobilitywere severely compromised both during and after the di-sasters (12, 13), and many people who left the region didnot return (14, 15), making it difficult to gather data ret-rospectively.

In New Orleans, LSU’s medical school class has ap-

PSYCHIATRY EDUCATION AFTER KATRINA

206 http://ap.psychiatryonline.org Academic Psychiatry, 31:3, May-June 2007

proximately 180 students, and psychiatry clerkships are of-fered in 6-week “blocks,” the modal length for a psychiatryclerkship (16). Both LSU and Tulane shared Charity Hos-pital with its 92 psychiatric beds, 56 of them staffed by LSUpsychiatry faculty. Before the storm, Charity was, afterNew York’s Bellevue, the oldest continually operating pub-lic hospital in the United States, although its most recentbuilding was erected in 1939 (17). Charity shared someservices with the newer and smaller University Hospital,also on LSUHSC’s campus. Charity’s psychiatric emer-gency room, the Crisis Intervention Unit, or CIU, had ap-proximately 600 patient encounters each month.

Prior to the storm, medical student education in psy-chiatry occurred largely within the confines of four cityblocks. First- and second-year classes, whether in smallgroups or lecture halls, were taught in adjacent buildings.The library was in a third building, connected to the othersby a second-floor walkway from which students couldtravel the three blocks to Charity Hospital by another el-evated walkway. About 20 of our medical student clerkswere assigned to Charity each block, and only two others,at the suburban Ochsner Foundation Hospital. Studentsassigned to Charity also spent 1 day each week in com-munity mental health centers, mainly within the city or inthe neighboring St. Bernard Parish. Each student, whetherassigned to Charity or Ochsner, performed on-call dutiesin the CIU.

The storm’s effect on LSU’s physical plant was savage.Charity, with its inpatient beds and busy psychiatric emer-gency room, remains closed 20 months after Katrina dueto the effects of flooding in its basement. The first floorsof the remaining buildings also flooded, ruining state-of-the-art medical education technology, including simulatedpatients and specialized audiovisual equipment. Thesehave since reopened. The dental school, however, on aseparate campus closer to Lake Pontchartrain, sufferedeven worse flooding and it remains based in Baton Rougewhile the campus is renovated. Only two of the five NewOrleans area mental health centers used as teaching sitessurvived the storm.

Resuming Education

The LSUHSC Chancellor, then Dr. John Rock, now Dr.Larry Hollier, directed that medical education be quicklyresumed from Baton Rouge: the clerkships on September19 and preclinical, classroom-based education on Septem-ber 26. Baton Rouge was a logical place to resume medicaleducation. The city is home to the largest LSU campus

and was the first major city westward-bound New Orleansevacuees encountered. Therefore, many students and fac-ulty found themselves there, living with family or friends,or in hotels. Most expected to spend a few days away, thenreturn to New Orleans after the storm passed (18). Fur-thermore, the LSU Health Sciences Center operates EarlK. Long Hospital, which, with the destruction of Charity,became the state’s largest public hospital. More impor-tantly, the hospital had a 48-bed acute-care unit in nearbyGreenwell Springs, La., which was to become an importantmedical student training site.

The department’s task was twofold: to continue the first-and second-year courses in classrooms provided by LSUBaton Rouge and to place 22 third-year students, only 1week into their clerkship, into appropriate sites. Classroomspace was quickly identified by the medical school. Thedepartment’s job was to locate faculty and secure hospitalsand clinics. Remarkably, all fell together quickly. Key fac-ulty members were, indeed, within driving distance fromBaton Rouge, but our four clerkship sites, three of themuntried, were determined by a variety of factors.

Ochsner Foundation Hospital, just over the city limitsin Jefferson Parish, remained open during the storm, andhad been educating two students during each block withboth full-time and clinical faculty. They continued theirefforts and took in an additional student. Our three otherLouisiana sites were new to us, although to varying de-grees: Lafayette, Greenwell Springs, and Pineville. Ourability to work with students at these new sites was theresult of both generosity and happenstance.

The city of Lafayette is approximately 60 miles west ofBaton Rouge and contains Joseph Henry Tyler, Jr., MentalHealth Center, a free-standing community psychiatric hos-pital affiliated with LSU. Fortunately, the hospital is ad-ministered by the Louisiana Office of Mental Health(OMH) and was capable of communicating with otherOMH facilities by telemedicine. Its medical director, Dr.George Diggs, is a member of LSU’s clinical faculty andfor many years taught students rotating from foreign medi-cal schools. Dr. Diggs happily and quickly agreed to createa separate track for eight LSU psychiatry students.

Greenwell Springs has had a long role in the state’s pub-lic health system. It began as a spa, providing lodging andother amenities to travelers who hoped to gain medicalbenefits from drinking and bathing in the area’s mineralsprings; then it became the home of a tuberculosis hospitaland, most recently, the site of the acute-care psychiatricfacility associated with LSU’s Earl K. Long Hospital, 15miles to the southwest (19). Greenwell Springs Hospital

MARK H. TOWNSEND, M.D.


had not trained medical students and, furthermore, wasrun by clinical faculty from the Tulane Department of Psy-chiatry and Neurology. Just as at Henry Tyler, the medicaldirectors—Drs. John Thompson and Clay Kelly—not onlywelcomed 10 of our students but also allowed three of ourfaculty to practice there. The hospital is also administeredby the Louisiana OMH, which linked it to Henry Tyler byvideoconferencing.

Our third new site was Central Louisiana State Hospitalin Pineville, a suburb of Alexandria. Pineville was the finaldestination of those Charity Hospital patients too ill to bedischarged prior to Katrina. They, along with physicians,nurses, and other staff, endured 5 days in hot, locked in-patient units until they were transported by bus. AlthoughCharity employees and LSU psychiatry faculty and resi-dents were and remain grateful for the many opportunitiesoffered to them at Central, the hospital became peripheralto medical education due to a lack of student housing.While 10 students could have been accommodated eachblock and taught by full-time faculty living in Alexandriaas evacuees, only four students were trained there the en-tire 2005–2006 academic year.

Thus, our clerkship: every 6 weeks we placed studentsin Jefferson Parish, Lafayette, Greenwell Springs, andPineville. Our lecture series continued with the same fac-ulty, but by telemedicine, originating from the videocon-ference studio closest to the faculty member. The officemanager for medical student education, Patricia Reed, be-came proficient in organizing lectures by faculty personallyunknown to her who taught from classroom-studios manyof us would never actually see. We maintained an evolvinglist of contact numbers for each student, and communi-cated regularly by e-mail and cell phone. Handouts andPowerPoint presentations were sent out each week, andfaculty kept in touch with one another by departmentalmeetings held in Baton Rouge. Rough patient logs werekept by monitoring the types of illnesses seen by studentsat each site: essentially similar numbers of patients withmood, psychotic, and anxiety disorders. Students met inperson at the end of each block, in a classroom on the LSUBaton Rouge campus. The reward for our efforts was two-fold: final exam scores were unchanged from pre-Katrina,and the students themselves reported that their educa-tional experiences gave them a favorable impression ofpsychiatry.

Resuming our preclinical courses for the September 29deadline held other challenges. Although classroom spacewas provided for us at LSU Baton Rouge’s PenningtonBiomedical Research Center, all first- and second-year stu-

dents needed housing nearby. The Health Sciences Centeraccomplished that by leasing a passenger ship, which wasdocked on the Mississippi across the river from the uni-versity. Our second-year class is taught only in the springsemester, buying us some time, but our first-year class istaught in 16 small groups, each with its own faculty mem-ber and co-led with colleagues from the medicine and fam-ily medicine departments. Although some faculty werenever 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 oneleader for each group. We had a Liaison Committee onMedical Education (LCME) interim site visit on Decem-ber 13 and were told we had, in fact, remained on track.

Keeping and maintaining our footing in this new situationwas difficult at times. Sudden homelessness was a shockingand unusual experience for most of us, and the dual chal-lenges of rebuilding homes in New Orleans while locatingnew, temporary arrangements were complicated and varied.Several endured the cruel predicament of knowing they had“lost everything”—a phrase often repeated and literallytrue—while they worked at hospitals far away from theirruined homes, which the insurance adjusters needed to as-sess and contractors needed to rebuild.

In retrospect, 20 months after the hurricane, it is sur-prising how quickly the needs of medical education droveus from providing direct care at shelters to brick-and-mor-tar hospitals. In the weeks between the storm and the Sep-tember 29th resumption of the clerkship, students and fac-ulty in Baton Rouge worked together in an informalfashion from the downtown Baton Rouge Mental HealthCenter. The regional medical director, Dr. David Post,provided daily briefings on the composition and needs ofarea shelters. Some convention centers and sports arenashad thousands of residents, while others, schools andchurches throughout metropolitan Baton Rouge, hadfewer. Largely under the direction of Dr. Margaret Baier,the associate training director, students and residentsformed teams to identify and treat patients in the manyBaton Rouge shelters. However, because OMH hospitalsbecame available and were willing to accept our studentsand residents, on September 29 we had largely returned toacute-care hospital settings.

Returning Home

Although each of us wanted to return to New Orleansquickly, and the Health Sciences Center pledged to returnby August—and ultimately did—the timing of our return



was dictated both by the academic calendar and the lackof suitable hospitals and clinics in New Orleans. NationalBoard “shelf tests,” used as our final exams, are orderedwell in advance and have to be given in specific ways. Atone point in March 2006, for example, we were able tomove faculty and students from Greenwell Springs to an-other state hospital closer to New Orleans in Mandeville,but we needed to wait several weeks until the end of theblock.

Our faculty outpatient practice resumed operations inOctober 2005 from the same building as before, which gaveus an early base in the city. From there, however, wequickly realized that the region had vast mental healthneeds and fewer resources to meet them. Our New Orleansclinic lost three psychiatrists, a psychologist, and a clinicalsocial worker in the November 2005 furloughs. As a de-partment, we felt a mandate to assist the city while meetingLCME standards for psychiatric education. We developeda five-student outpatient track, based in emergency roomsand community clinics, which allowed students to assist intreating patients who were in many cases more acutely illthan those seen in existing hospitals.

Ultimately, though, we did not have the resources torelocate every student to metropolitan New Orleans by theJuly 1 start of the 2006 academic year. We continuedoperations at the state hospital in Mandeville, where weare currently training residents and students alongside Tu-lane’s. In early August 2006, the Office of Mental Healthopened a 20-bed inpatient unit in the city, the first newpsychiatric hospital since Katrina, and reopened a 15-bedchild and adolescent hospital. We placed students in boththe adult and adolescent units. And as for the preclinicalclasses, in newly renovated classrooms downtown, we be-gan to teach human development in small groups again onAugust 22, 2006. The Health Science Center’s role in acutepsychiatric treatment is reduced, however: University Hos-pital reopened on November 20, 2006, without psychiatricbeds, and Charity Hospital remains closed. On February14, 2007, the Medical Center of Louisiana at New Orleans,which had previously run Charity Hospital, announcedthat an abandoned New Orleans psychiatric hospital wouldopen this summer with 33 new inpatient beds and a tem-porary regional psychiatric emergency room (Appendix 1).

Conclusions

The department, as well as the rest of the medicalschool, has developed a wealth of information regarding

disaster response. However, we were victims of the samedisaster as our patients, and we experienced an unusualsort of loss, no doubt similar to what our colleagues ex-perienced at Tulane. Many of our patients were evacuatedto distant cities, where they remain still, while we trainedLSU residents and students among patients who had nodirect experience with the city’s trauma. After returning toNew Orleans, we became active, often exhausted partici-pants in the effort to rebuild mental health infrastructure,while treating patients with increased anxiety and depres-sion (21). At this time, May of 2007, the region still lacksa psychiatric emergency room and no university-affiliatedpsychiatry beds have been restored.

Numerous warnings about the ability of a hurricane toflood the city were given over the years, and the depart-ment and the Health Sciences Center had developed com-prehensive evacuation plans. In fact, the New Orleans Ad-olescent Hospital, which currently houses our 20-bed adultunit, successfully evacuated prior to Katrina’s landfall.However, we did not have a ready plan to preserve thedepartment during an extended evacuation from the city.Although accomplished with a combination of hard work,some serendipity and much generosity on the part of oth-ers—particularly the Louisiana Office of Mental Healthand the faculty and administration of LSU Baton Rouge—our strategy was simple and was completed within the 3weeks given to us by the chancellor.

Our recommendations for other academic medical cen-ters are straightforward. Because the Midwest’s New Ma-drid and California’s San Andreas faults will someday shiftagain; because tornadoes will occur every spring and fall;because the oceans are warmer and rising; and becauseother horrifying events, unimaginable to us now, will occurat any time, each medical center must be prepared to re-locate and rebuild itself. Planning for that eventuality canperhaps strengthen the institutions even as it lowers theanxiety of those who work within them.

Clinical faculty members must be made aware of theirpossible role in a catastrophic event. Each departmentshould strive to make its entire faculty feel valued and tocommunicate with them frequently and candidly. Gratisand part-time, paid faculty are repositories of institutionalmemory. They may be the backbone of any rebuilding ef-fort and should not require postdisaster instruction abouttheir role in furthering the department’s goals and objec-tives.

In addition, regional networks and alliances of medicalschools, such as the one that nurtured and sustained Tu-lane’s, must be fostered everywhere. The rationale for in-

MARK H. TOWNSEND, M.D.


APPENDIX 1. Hurricane Katrina and LSU Health Sciences Center Timeline

Date Event

August 29, 2005 Health Sciences Center officially closes for hurricaneAugust 30, 2005 Orleans Parish levees fail and campus floodsSeptember 1, 2005 Evacuation of Charity and University HospitalsSeptember 19, 2005 Clerkship resumes in scattered sitesSeptember 26, 2005 First- and second-year lectures relocate to LSU Baton RougeSeptember 29, 2005 Mandatory evacuation lifted for parts of New OrleansOctober 3, 2005 LSU psychiatry clinic reopens in uptown New OrleansNovember 22, 2005 Force majeure exigency plan declaredNovember 30, 2005 150 tenured and non-tenured medical school faculty are furloughedMarch 28, 2006 First clerkship site reopens in New OrleansJuly 1, 2006 Clerkship instruction resumes entirely within metropolitan New OrleansAugust 7, 2006 20 public psychiatry beds reopen in New OrleansAugust 10, 2006 First-year teaching resumes in renovated downtown campusNovember 20, 2006 University Hospital reopens without inpatient psychiatry; Charity Hospital remains closedFebruary 14, 2007 Health Sciences Center announces a psychiatric ER and 33 beds opening in New Orleans this summer

creased interdepartmental planning lies in the relative fra-gility of academic psychiatry itself. Psychiatry is a shortagespecialty (22), and faculty and trainees should not be idledby local traumatic events. Furthermore, academic psychia-trists, like colleagues in other fields, are encouraged to de-velop narrow and divergent lines of research. Medicalschools working as a consortium, however, allow faculty whoare specialists in one area to be available to multiple insti-tutions. Additionally, if one school is affected by an extremeevent, the others can help continue, or at least preserve, itsdistinct identity. Both Tulane and LSU have become expertsin disaster psychiatry and will themselves be capable of ad-vising and assisting other medical schools, just as Kobe Uni-versity has been helpful in Banda Aceh (23).

Finally, departments of psychiatry must be aware oftheir schools’ overall disaster response plan and be pre-pared to articulate the needs not only of psychiatry facultyand trainees, but also the patients they treat. Anxiety anddepression increase globally in traumatized populations,but increase most among people with preexisting psychi-atric illnesses (24). Psychiatric services, such as inpatientunits, psychiatric emergency rooms, outpatient clinics,and outreach teams, should be rebuilt quickly. This canonly occur if the public and private agencies that consti-tute the mental health care system have agreed to theirroles well before any emergency. If the effects of Hurri-cane Katrina teach us anything, it is that nothing can beleft to chance.

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medical student education in psychiatry after katrina: disaster and renewal

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