ORIGINAL REPORT

Resident and Faculty Perceptions of aSurgical Residency Program Merger

John Mellinger, MD, Bruce Bonnell, MD, William Passinault, MD, Richard Wilcox, MD,Wayne Vanderkolk, MD, Randal Baker, MD, Alan Davis, PhD, and Bruce Brasser, MSN

Grand Rapids/Michigan State University General Surgery Residency Program, Grand Rapids, Michigan

PURPOSE: To evaluate resident and faculty perceptions of aresidency merger process.

METHODS: Survey of faculty and residents of a recentlymerged general surgical residency. Nineteen separate programcharacteristics were evaluated via a numerical scoring system,and additional written commentary regarding dominant per-ceived benefits and detriments of the merger was solicited. Sta-tistical significance was evaluated on numerically scored itemsby applying the Mann-Whitney U test to median values ex-pressed with interquartile ranges, comparing resident and fac-ulty responses.

RESULTS: Scoring system responses from faculty and resi-dents were generally similar. The merger was seen as neutral topositive in its impact on academic issues, but it had more neg-ative effects on issues related to overall program atmosphere andmorale. Statistically significant differences between residentand faculty responses were noted in 2 areas: teaching conferencetiming and overall program effectiveness in preparing for prac-tice. Both of these areas were more favorably impacted by themerger from the residents’ perspective, and more negatively asjudged by the faculty (p , 0.05). Written commentary by bothgroups similarly emphasized areas of academic strengthening asa positive effect of the merger, and relationship and moraleissues as being more negatively impacted.

CONCLUSIONS: As reflected by resident and faculty percep-tions, program mergers may provide opportunities tostrengthen and enhance the academic and clinical foundationof residency. This may, however, occur at the expense of moraleand relational issues, which may be negatively impacted byprogram administrative and geographic expansion. (Curr Surg58:223-226. © 2001 by the Association of Program Directorsin Surgery.)

KEY WORDS: hospital mergers, resident education, resi-dency mergers

INTRODUCTION

Hospital mergers have become commonplace events in recentyears.1 The organizational and fiscal pressures fostering suchevents may also dictate residency program restructuring in in-stitutions so affected. Although the effect of mergers on healthcare systems has become a topic of some interest, little investi-gation has been done on the impact of such events on residenteducation. A Medline search over the last 35 years revealed onlya single article focusing on the educational impact of mergers onresidency training, which in that instance involved a psychiatryprogram.2

Historically, 2 separate general surgery residency programshave existed in Grand Rapids, Michigan. Both programs havehad a strong track record of accreditation and educational suc-cess, as well as of mutual cooperation on educational issues.Discussions regarding merger of the programs had been ongo-ing for several years, and beginning in 1998, rotation integra-tion at the junior levels was commenced. Merger discussionswere further stimulated by the official merger of the separatesponsoring institutions into a single health care system in 1998.A combined curricular and conference schedule was begun in1999, with only chief resident rotations being kept separate. InOctober 1999, the new combined program received ResidencyReview Committee approval.

The present study is an attempt to evaluate the impact of asurgical residency merger on resident education as assessed byresident and faculty perceptions of that process in the recentGrand Rapids experience.

METHODS

A survey was sent to all surgical residents and faculty. Respon-dents were asked to score 19 separate program characteristics ona numerical scale from 1 to 5 (1 5 very negative impact ofmerger, 2 5 somewhat negative impact, 3 5 no impact, 4 5positive impact, 5 5 very positive impact). The 19 characteris-tics evaluated are listed in Table 1. Because no previously de-veloped models for this assessment existed, the survey used wasnovel. The survey was not pretested nor scrutinized for evidenceof validity or reliability. Additional written commentary was

Correspondence: Inquiries to John D. Mellinger, MD, 245 Cherry Street, SE, Suite 102,Grand Rapids, MI 49503; fax: (616) 456-7955; e-mail: jdmellinger@gateway.net

CURRENT SURGERY • © 2001 by the Association of Program Directors in Surgery 0149-7944/01/$20.00Published by Elsevier Science Inc. PII S0149-7944(00)00452-9

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solicited regarding perceived dominant positive and negativeeffects of the merger on the residency. All responses were sub-mitted anonymously.

The data were analyzed by computing mean and medianscores for each of the program characteristics, the latter beingexpressed with interquartile range calculation as well. Compar-isons between resident and faculty median responses were madeusing the Mann-Whitney U test. Written commentary was col-lated, and areas of most-frequent emphasis were noted for bothresidents and faculty.

RESULTS

Twenty-five resident surveys were returned (30 categorical res-idents in program) and 26 faculty responses (90% faculty re-sponse rate). The mean scores, and median scores with associ-ated interquartile ranges, are depicted in Table 1. Statisticallysignificant differences between resident and faculty median re-sponses were noted in 2 of the 19 areas: teaching conferencetiming and overall preparation for practice. In both areas, theresidents perceived a more positive impact of the merger thandid the faculty. Generally higher scores were noted in areasreflecting the academic climate of the program, with lowerscores in areas indicative of program support and atmosphere.Overall, resident and faculty responses were largely concordant.

Written commentary responses are recorded in Table 2. Ar-

eas of academic strengthening were again perceived as being themost positively impacted by the merger, and atmospheric andrelational issues as being more negatively impacted.

DISCUSSION

Hospital and health care system mergers and acquisitions havebecome a major business and even judicial issue in recent years,

TABLE 1. Survey Responses

Program characteristicResident score

[mean/median (IQ range)]Faculty score

[mean/median (IQ range)]

Curricular issuesCase mix 3.44/4 (3,4) 3.24/3 (3,3.8)Conference timing* 3.48/3 (3,4) 2.77/3 (2,3.5)Conference content 3.56/4 (3,4) 3.38/4 (3,4)Rotation structure 3.56/4 (3,4) 3.15/3 (2.45,4)

Administrative issuesProgram director

Qualifications 3.52/4 (3,4) 3.42/3 (3,4)Approachability 3.44/3 (3,5) 2.88/3 (2,3)

Secretarial support 2.88/3 (2,3.5) 2.8/3 (3,3)Hospital support 2.36/2 (2,3) 2.73/3 (2.5,3)

Teaching issuesOperative teaching 3.48/4 (3,4) 3.12/3 (3,3)Nonoperative teaching 3.24/3 (2,4) 3.19/3 (3,3)Faculty conference participation 3.6/4 (3,4) 3.27/3 (2.5,4)

Atmosphere issuesCall schedule 2.96/3 (2,3) 2.7/3 (2,3)Academic climate 3.42/3 (3,4) 3.46/3(3,4)Uncertainty regarding program future 3.32/3 (2,4) 2.96/3 (2.3,3)Supportive atmosphere 3.24/4 (2,4) 3.15/3 (2.5,4)Competitive atmosphere 2.88/3 (2.5,3) 3.08/3 (2.5,4)

End issuesFellowship preparation 3.27/3 (3,4) 3.35/3 (3,4)Practice preparation* 3.72/4 (3,4) 3.38/3 (3,4)Overall resident satisfaction 3.08/3 (2,4) 2.8/2 (2,4)

* Statistically significant difference at p , 0.05.

TABLE 2. Written Commentary Responses

Resident responses (n)Benefits of merger

Improved operative case mix (9)Improved intensive care/trauma experience (8)Improved faculty base for program (7)

Detriments of mergerDecreased familiarity with individual attendings (5)Less desirable overall atmosphere, lifestyle issues (5)Decreased hospital support for program (3)

Faculty responses (n)Benefits of merger

Improved academic atmosphere (6)Improved faculty base for program (4)Improved case mix/rotation structure (3)

Detriments of mergerDecreased familiarity with individual residents (9)Decreased resident morale (4)

224 CURRENT SURGERY • Volume 58/Number 2 • March/April 2001

as dictated by the fiscal challenges of contemporary health care.As many as 20% of community hospitals nationwide havechanged hands in a single year in the last decade, with well over600 hospitals nationwide being involved in such processes an-nually.1 Although this has not had a dramatic effect on thenumber of surgical residency program mergers in the same timeframe, a continuation of this trend is perhaps likely to impacthospital-based residency training on a wider scale in the future.

The recent medical literature demonstrates very little atten-tion to the impact of program mergers on resident education.Over the past 35 years, a total of 6 publications focusing onhospital mergers were noted in response to a Medline query onmergers and residency.2-7 Most of these focused on fiscal andadministrative rather than on educational issues.4-7 A recentstudy evaluated the impact of a residency merger on studenteducational programs in obstetrics and gynecology, but it didnot focus on resident training.3 The only publication specifi-cally dedicated to an evaluation of the postgraduate educationalimpact of a residency merger involved a psychiatry program.2

The authors of that study emphasized several key issues in thenegotiation of the merger process. These included developingan educational philosophy, assessing local resources, defininggoals for training, establishing program governance, evaluatingfaculty impact, deciding on the logistics of program implemen-tation, and being sensitive to institutional cultures.

In this study, surgical resident and faculty perceptions of aresidency merger process were assessed via a program-wide sur-vey. The results suggest that to a large degree, residents andfaculty perceive similarly the leading benefits and detriments ofsuch a process on resident education. Taken collectively, aca-demic issues were perceived as being neutrally to somewhatfavorably impacted by the merger process. This was largelybecause of the expanded clinical and faculty base for the pro-gram provided by the merger, including the availability of ro-tations and interactions with faculty previously limited by asmaller program structure. Program atmosphere and lifestyleissues were perceived as being more negatively impacted, causedin part by the loss of frequent contacts with a smaller andthereby more familiar working group. Perceptions regardinghospital support also were negative as support staff downsizingand fiscal tightening affected the formation of the new programstructure. Heightened call pressures dictated by broader servicestructure also became a source of negative perception.

In reflecting on this process and the perceptions reflected inthe data presented, the following suggestions could be offered.On the positive side of the equation, residency programs facinga merger can anticipate perceived academic and educationalbenefits from the process. Early commitment of the residentsand faculty to educational priorities can facilitate a proper con-duct of the merger process. In the Grand Rapids situation, thiswas facilitated by proactive discussion and approval of the pro-gram merger concept by residents and faculty before the hospi-tal merger. Keeping educational priorities at the forefront of theprocess can also alleviate many of the pitfalls encountered inmerging programs. In our experience, challenges were encoun-

tered in selecting a new program director, agreeing on confer-ence timing and location, establishing a combined clinical ro-tation plan, defining resident coverage in the expandedprogram structure without significantly increasing call and clin-ical load, and in establishing a variety of policies in which therewere programmatic differences to reconcile. Examples of thelatter included vacation and meeting policy, outpatient clinicadministration, evaluation procedures, conference format, andservice expectations. Approaching such potentially contentiousissues with a commitment to what is educationally optimal canfacilitate consensus and allow the successful negotiation of theminefield of past commitments, aspirations, and expectationsheld by both residents and faculty in such a process. In addition,representation of both residents and a full compliment of fac-ulty in all major decision making is critical in overcoming per-ceptions of parochialism and in establishing a new and inclusiveprogram culture.

Negatively, a merger process certainly is disruptive to well-established working relationships, roles, expectations, and theusually understood but perhaps rarely articulated relational“glue” that governs the day-to-day conduct of a residency pro-gram. In this area, several suggestions might be offered as well.Clear communication regarding policy and personnel respon-sibility in critical areas of program administration, such as caselogs, scheduling, and evaluations, helps to avoid duplication ofefforts and a continued perception of prior differences in pro-gram identity and governance. Ideally, the most qualified indi-viduals from the prior separate programs can be blended into anew working group, retaining the strongest personnel fromeach of the preexisting entities, rather than eliminating an entireteam of individuals en bloc. The latter approach certainly cre-ates the perception of an absorption or takeover of the weakerby the stronger, rather than a blending or merging of respectedpartners. Gracious recognition and affirmation of those whoseprior roles must change to avoid an unnecessary duplication ofeffort in the new program structure is critical here. This can bechallenging, particularly when such change is not desirable tothe individuals involved. Again, the priority of what by consen-sus appears to be in the program’s best educational interest isperhaps the safest guiding principle in such situations.

A significant relational stress perceived in the data presentedinvolved the dilution of contact between a given resident andfaculty member in the larger program structure. This was highlyperceived by both residents and faculty not only as a relationalstressor, but also as an issue that impacted the reliability ofevaluation mechanisms and the monitoring of resident progressin the program. In this regard, merging programs may need todevelop other mechanisms to oversee resident development andprogression and facilitate close faculty and resident contact.Possibilities we have considered or employed in this area in-clude an expanded faculty evaluation committee and the devel-opment of a faculty-mentoring program. Formal and informalopportunities for faculty and resident interaction off rotation,including conferences, dinner lectures, journal clubs, welcomeparties, and graduation events, may also be critical to overcom-

CURRENT SURGERY • Volume 58/Number 2 • March/April 2001 225

ing the loss of frequent individual personal contact, which isinherent to a merger-dictated expansion.

Certainly, it is difficult, on the basis of a relatively small andnonvalidated survey, to comprehensively analyze something ascomplex as a residency merger process, including all its admin-istrative, fiscal, educational, and interpersonal ramifications.Nevertheless, the dirth of published material on this issue, andthe likelihood that it will continue to challenge educators in thefuture as postgraduate medical education and its financing aregovernmentally reviewed and sponsoring hospitals fiscally chal-lenged, make it worthy of consideration. Based on the pre-sented experience, the authors would hope that others con-fronted with the necessity of a program merger could benefitfrom the perceptions herein presented, and the lessons providedin the process.

REFERENCES

1. Bellandi D. A year of more and less. Mod Healthc. 1999;29(2):48-62.

2. Tasman A, Riba M. Strategic issues for the succesful mergerof residency training programs. Hosp Community Psychiatry.1993;44:981-985.

3. Hines JF, Satin AJ, Browne M, Armstrong AY, HaffnerWH. Effect of a residency program merger on undergradu-ate medical student education in obstetrics and gynecology.Obstet Gynecol. 1999;94:144-147.

4. Besaw L. Merger mania: it’s feeding time, is your hospitalon the menu? Texas Med. 1996;92:38-44.

5. Cannon N. What merger has accomplished for three com-munity hospitals. Int Surg. 1969;51(6):6-7.

6. Shortliffe EC. Program organization following corporatemerger of community hospitals. JAMA. 1968;206:109-111.

7. Englehard HH, Grant J, Ciric IS, Wetzel NC, Batjer HH.The history of neurological surgery at Northwestern Uni-versity. Neurosurgery. 1998;43:914-925.

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