Gulf Coast Hurricane Sinks New Texas Emergency Medicine Residency

Abstract

Everything fell nicely into place for Brad Silver last summer. Having earned a medical degree from The University of Texas Medical Branch (UTMB) in Galveston, TX, the native Texan had just begun his first year as an emergency medicine resident at UTMB. He was one of 8 inaugural members of the 118-year-old university's new emergency medicine residency program. Silver said he felt he was making history, laying the groundwork for future residents who would seek their emergency medicine training on a Gulf of Mexico island that The New York Times had recently described as “an emerging Lone Star equivalent of the Hamptons.”1Shevory K. Texans find their own Hamptons equivalent.2007Google Scholar It also didn't hurt that he also got to remain close to his girlfriend, a medical student at UTMB.Then came Hurricane Ike, making landfall directly over Galveston Island in the early morning hours of September 13.Silver evacuated to Plano, TX, a day before the storm struck the shore as an outsized Category 2 hurricane, driving 10- to 15-foot waves onto the island. He hasn't been back to UTMB to work since. Two months after the hurricane UTMB officials decided they could no longer support their emergency residency program.“What I've learned is that things can change really quickly, and sometimes in life that's going to happen, and you just have to deal with it,” Silver said. “It's going to be tough, and it's not going to be what you wanted, but you have to deal with it.”Unlike New Orleans, Galveston Island stands 8 to 12 feet above sea level and has a smaller population, so the human tragedy–there were 37 deaths in Texas from the storm–was small compared to that of Hurricane Katrina in 2005. And many buildings on the island were salvageable once the waters receded, including many facilities on UTMB's campus, which overlooks sandy beaches and the Gulf's muddy waters.A Devastating BlowAll the same, university officials estimated the storm caused $710 million in damage and business losses, and caused it to lose an additional $40 million each month after the storm. Even prior to Ike, the hospital, with its emergency department (ED) as a key provider of care to the island's uninsured population, had already stood on shaky ground.“The (financial) model at UTMB was not working before the hurricane,” regents vice chairman Robert B. Rowling told the Houston Chronicle at the time. “There were going to have to be some drastic changes.”So cuts were made. In November Rowling and other University of Texas regents laid off 3,800 of UTMB's 12,500 employees. Among the cuts were 5 emergency physicians.Prior to the storm, UTMB's primary health care facility, John Sealy Hospital, had 528 beds and a Level 1 trauma center, providing an ideal training ground for its emergency medicine residents. The American College of Surgeons had rated the UTMB ED in October as having the best survival rate for a big hospital in the country.Yet as a result of the storm and subsequent financial cuts the ED's capacity dropped from about 200 patients a day to 30. And now, instead of 2 to 4 doctors available at all hours, just one emergency physician would be available 24 hours a day. UTMB lost its Level 1 trauma center designation, and no longer met the requirements for an emergency medicine residency program.“The hospital as a whole has gone through some pretty dramatic cuts,” said Brian Zachariah, MD, medical director of John Sealy Hospital's ED, and the director of the new emergency medicine residency program. “Most programs here have had to cut half of their residency programs. But our residency program is the only one that's actually been cut entirely. It's hard on all the people who worked to make it happen, and it's hard on the pioneering class of residents who thought they were going to be a bright part of the future of emergency medicine on the island.”The loss of UTMB's emergency medicine residency program goes beyond just a simple tale of a tragedy due to a natural disaster, but rather it highlights 2 of the most critical issues facing the specialty of emergency medicine: the financial peril of hospitals that provide care to large uninsured populations in their EDs, and the shortage of emergency medicine residency programs at a time there has been a severe shortage of board-certified emergency physicians in US hospitals.2Kever J. Latson J. Regents blame Hurricane Ike for UTMB layoffs.2008Google ScholarPrior to Ike's arrival, UTMB had been making a concerted effort to strengthen its emergency medicine program. In the 5 years since Dr. Zachariah arrived on the island from Dallas, the department increased its staff from one board-certified emergency physician to 9. To further the medical school's ability to recruit faculty, Dr. Zachariah said consultants told university administrators they should begin a residency program.After 2 years of preparation, UTMB received approval for a 3-year program consisting of 8 residents per year. The first class started in July, 2 months before Ike.“It's just been unfortunate for everyone involved,” said Angela Gardner, MD, an assistant professor at UTMB who is ACEP's President-Elect. “Most of us are still waiting to see what's going to happen with the university's overall plan for the hospital. Right now we've got 200 beds. I've been told they would like to restore the hospital to a Level 1 trauma center, but in my experience that would be very hard to do with 200 beds. What is comforting is, given the way the emergency medicine community works, when and if the university is up and running we can reapply and reestablish the residency program. But I think that's probably at least a couple of years away.”Chaos in the AftermathThe storm's aftermath left UTMB in chaos. The medical school had reasonable plans for dealing with the actual hurricane, providing for the closure of facilities, evacuation of patients and essential staffing to ride out the storm. Its brand-new, $176 million biosafety-level-4 laboratory, survived with nary a scratch.Yet because much of the island was devastated–homeowners weren't allowed back on for 2 weeks, and power outages lasted much longer–the hospital was forced to close for 2 months. Much of UTMB's campus was functioning, but the larger community around it simply was not.“I sat around my parents' house for a couple of weeks as we residents were told to hold on,” Silver said.After 2 weeks Silver received word that he would be temporarily assigned to a residency program at Christus Spohn Hospital Memorial in Corpus Christi, about 220 miles south along the Texas coast. The 7 other residents were assigned to locations around the state. The move was supposed to last one month.Two weeks later the residents were told they needed to spend a second month at their new locations. Finally, at the end of November the residents learned that UTMB's emergency medicine program had been canceled. The university has since been working with the residents to find permanent programs and funding for their second and third years of residency.“I've interviewed at a number of places now, and I'm pretty confident I'll be able to work something out. But I'll miss UTMB. We were treated well, and I enjoyed good camaraderie with the rest of the class. I really enjoyed my time, and I'm really bummed that it's not going to work out in Galveston.”It won't be as easy for the emergency physicians at UTMB to return to a sense of normalcy. Months after the storm there remains a sense of uncertainty about what the future holds. Both Dr. Zachariah and Dr. Gardner cited a lack of planning for the long-term aftermath following a natural disaster as a lesson other medical institutions can learn.“After 9/11 and Hurricane Katrina a lot of institutions, including UTMB, have developed good plans for responding to disasters,” Dr. Gardner said. “But the real question for us has become: What happens after the first 3 weeks? After you've lost infrastructure do you have longer term plans? Do you have insurance to cover for these losses? Plans for how to ramp your services back up when they've been cut drastically? Unfortunately for us this has been a learn-as-you-go process.”“The New Normal”For inspiration UTMB can look to another institution, the Tulane University School of Medicine. Hurricane Katrina closed Tulane and scattered its students across the Gulf Coast, with some even finding a temporary home in Galveston.“The term here became the ‘new normal,’” said N. Kevin Krane, MD, the Vice Dean for Academic Affairs of Tulane's medical school.“Based on our experience, as hard as it is, you really have to look at the direction you're going. It really becomes more of a marathon than a sprint. If you're comfortable that things are moving in the right direction, even in a small way, then you have to develop a certain degree of patience with the overall situation. As long as you're making some progress, at some point the pace of progress will pick up.”Dr. Krane said the storm forced Tulane to consider new partnerships that probably would not otherwise have been available. After the storm Tulane formed a partnership with Our Lady of the Lake Regional Medical Center in Baton Rouge, LA, sending students to a community much less affected by Katrina. In that sense there were new opportunities to be mined amid the turmoil.Yet the challenges were often greater. Immediately after Katrina the entire Louisiana state hospital system in New Orleans closed, and it has only slowly been opening back up, Dr. Krane said. That has meant financial difficulties for Tulane as it has had to absorb larger numbers of uninsured and under-insured patients.The Tipping PointIt has been those kind of financial pressures that have proven most acute for UTMB, even prior to Ike's landfall.“I think it has to be made clear that the issues here are bigger than the hurricane alone,” Dr. Zachariah said. “It was a tipping point. But it did not physically damage our emergency department in a significant way. We lost the pharmacy, some labs, and some operating rooms. But a big part of the reason why the hospital has scaled down is UTMB was already struggling because of its role as a safety net hospital.”Dr. Krane said Tulane worked with the greater New Orleans community to bring its residents back to the rebuilding city as soon as possible, recognizing the importance of such programs to providing a long term supply of physicians to the region.The closure of UTMB's emergency medicine residency program leaves just 7 in Texas, the country's second largest state in population. According to the American Board of Emergency Medicine, which published a task force report in Annals last year,3Perina D.G. Collier R.E. Thomas A.H. et al.Report of the Task Force on Residency Training Information (2007-2008).Ann Emerg Med. 2008; 51: 671-679Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar New York has the most residency programs (20), followed by California (13), Pennsylvania (11) and Michigan (10). There are now 142 residency programs in the United States, with much of the growth in new programs coming in East Coast states while the country's population growth has been elsewhere, particularly the Southern and Western United States.The landmark Institute of Medicine reports in 2006 on the future of emergency medicine4Institute of Medicine Committee on the Future of Emergency CareHospital-based emergency care: at the breaking point. National Academies Press, Washington, DC2006Google Scholar said EDs should ideally be staffed by physicians who had spent their residency training in emergency medicine and earned board certification.Yet a recent report in Academic Emergency Medicine notes that there simply are not enough residency programs to meet present and future needs in emergency departments.5Camargo Jr. CA, Ginde AA, Singer AH, Espinola et al. Assessment of emergency physician workforce needs in the United States, 2008. Acad Emerg Med. 151317-1320.Google Scholar The authors found that, unrealistically assuming the loss of no current doctors from the system, it would take until 2019 to find enough fully trained, board-certified emergency physicians to work in the country's 4,828 EDs that are open 24 hours a day. Only about 55% of these needs are being met today.The present economic crisis may have the same effect on other EDs that Ike did on UTMB, a financial tsunami that sends some programs permanently into the red.“If the economic crisis continues we'll see more hospitals close, more people lose insurance, and in turn more people will be coming to the remaining emergency departments,” said Dr. Gardner. “But if we keep losing residency programs we're simply not going to be able to meet our manpower needs.” Everything fell nicely into place for Brad Silver last summer. Having earned a medical degree from The University of Texas Medical Branch (UTMB) in Galveston, TX, the native Texan had just begun his first year as an emergency medicine resident at UTMB. He was one of 8 inaugural members of the 118-year-old university's new emergency medicine residency program. Silver said he felt he was making history, laying the groundwork for future residents who would seek their emergency medicine training on a Gulf of Mexico island that The New York Times had recently described as “an emerging Lone Star equivalent of the Hamptons.”1Shevory K. Texans find their own Hamptons equivalent.2007Google Scholar It also didn't hurt that he also got to remain close to his girlfriend, a medical student at UTMB. Then came Hurricane Ike, making landfall directly over Galveston Island in the early morning hours of September 13. Silver evacuated to Plano, TX, a day before the storm struck the shore as an outsized Category 2 hurricane, driving 10- to 15-foot waves onto the island. He hasn't been back to UTMB to work since. Two months after the hurricane UTMB officials decided they could no longer support their emergency residency program. “What I've learned is that things can change really quickly, and sometimes in life that's going to happen, and you just have to deal with it,” Silver said. “It's going to be tough, and it's not going to be what you wanted, but you have to deal with it.” Unlike New Orleans, Galveston Island stands 8 to 12 feet above sea level and has a smaller population, so the human tragedy–there were 37 deaths in Texas from the storm–was small compared to that of Hurricane Katrina in 2005. And many buildings on the island were salvageable once the waters receded, including many facilities on UTMB's campus, which overlooks sandy beaches and the Gulf's muddy waters. A Devastating BlowAll the same, university officials estimated the storm caused $710 million in damage and business losses, and caused it to lose an additional $40 million each month after the storm. Even prior to Ike, the hospital, with its emergency department (ED) as a key provider of care to the island's uninsured population, had already stood on shaky ground.“The (financial) model at UTMB was not working before the hurricane,” regents vice chairman Robert B. Rowling told the Houston Chronicle at the time. “There were going to have to be some drastic changes.”So cuts were made. In November Rowling and other University of Texas regents laid off 3,800 of UTMB's 12,500 employees. Among the cuts were 5 emergency physicians.Prior to the storm, UTMB's primary health care facility, John Sealy Hospital, had 528 beds and a Level 1 trauma center, providing an ideal training ground for its emergency medicine residents. The American College of Surgeons had rated the UTMB ED in October as having the best survival rate for a big hospital in the country.Yet as a result of the storm and subsequent financial cuts the ED's capacity dropped from about 200 patients a day to 30. And now, instead of 2 to 4 doctors available at all hours, just one emergency physician would be available 24 hours a day. UTMB lost its Level 1 trauma center designation, and no longer met the requirements for an emergency medicine residency program.“The hospital as a whole has gone through some pretty dramatic cuts,” said Brian Zachariah, MD, medical director of John Sealy Hospital's ED, and the director of the new emergency medicine residency program. “Most programs here have had to cut half of their residency programs. But our residency program is the only one that's actually been cut entirely. It's hard on all the people who worked to make it happen, and it's hard on the pioneering class of residents who thought they were going to be a bright part of the future of emergency medicine on the island.”The loss of UTMB's emergency medicine residency program goes beyond just a simple tale of a tragedy due to a natural disaster, but rather it highlights 2 of the most critical issues facing the specialty of emergency medicine: the financial peril of hospitals that provide care to large uninsured populations in their EDs, and the shortage of emergency medicine residency programs at a time there has been a severe shortage of board-certified emergency physicians in US hospitals.2Kever J. Latson J. Regents blame Hurricane Ike for UTMB layoffs.2008Google ScholarPrior to Ike's arrival, UTMB had been making a concerted effort to strengthen its emergency medicine program. In the 5 years since Dr. Zachariah arrived on the island from Dallas, the department increased its staff from one board-certified emergency physician to 9. To further the medical school's ability to recruit faculty, Dr. Zachariah said consultants told university administrators they should begin a residency program.After 2 years of preparation, UTMB received approval for a 3-year program consisting of 8 residents per year. The first class started in July, 2 months before Ike.“It's just been unfortunate for everyone involved,” said Angela Gardner, MD, an assistant professor at UTMB who is ACEP's President-Elect. “Most of us are still waiting to see what's going to happen with the university's overall plan for the hospital. Right now we've got 200 beds. I've been told they would like to restore the hospital to a Level 1 trauma center, but in my experience that would be very hard to do with 200 beds. What is comforting is, given the way the emergency medicine community works, when and if the university is up and running we can reapply and reestablish the residency program. But I think that's probably at least a couple of years away.” All the same, university officials estimated the storm caused $710 million in damage and business losses, and caused it to lose an additional $40 million each month after the storm. Even prior to Ike, the hospital, with its emergency department (ED) as a key provider of care to the island's uninsured population, had already stood on shaky ground. “The (financial) model at UTMB was not working before the hurricane,” regents vice chairman Robert B. Rowling told the Houston Chronicle at the time. “There were going to have to be some drastic changes.” So cuts were made. In November Rowling and other University of Texas regents laid off 3,800 of UTMB's 12,500 employees. Among the cuts were 5 emergency physicians. Prior to the storm, UTMB's primary health care facility, John Sealy Hospital, had 528 beds and a Level 1 trauma center, providing an ideal training ground for its emergency medicine residents. The American College of Surgeons had rated the UTMB ED in October as having the best survival rate for a big hospital in the country. Yet as a result of the storm and subsequent financial cuts the ED's capacity dropped from about 200 patients a day to 30. And now, instead of 2 to 4 doctors available at all hours, just one emergency physician would be available 24 hours a day. UTMB lost its Level 1 trauma center designation, and no longer met the requirements for an emergency medicine residency program. “The hospital as a whole has gone through some pretty dramatic cuts,” said Brian Zachariah, MD, medical director of John Sealy Hospital's ED, and the director of the new emergency medicine residency program. “Most programs here have had to cut half of their residency programs. But our residency program is the only one that's actually been cut entirely. It's hard on all the people who worked to make it happen, and it's hard on the pioneering class of residents who thought they were going to be a bright part of the future of emergency medicine on the island.” The loss of UTMB's emergency medicine residency program goes beyond just a simple tale of a tragedy due to a natural disaster, but rather it highlights 2 of the most critical issues facing the specialty of emergency medicine: the financial peril of hospitals that provide care to large uninsured populations in their EDs, and the shortage of emergency medicine residency programs at a time there has been a severe shortage of board-certified emergency physicians in US hospitals.2Kever J. Latson J. Regents blame Hurricane Ike for UTMB layoffs.2008Google Scholar Prior to Ike's arrival, UTMB had been making a concerted effort to strengthen its emergency medicine program. In the 5 years since Dr. Zachariah arrived on the island from Dallas, the department increased its staff from one board-certified emergency physician to 9. To further the medical school's ability to recruit faculty, Dr. Zachariah said consultants told university administrators they should begin a residency program. After 2 years of preparation, UTMB received approval for a 3-year program consisting of 8 residents per year. The first class started in July, 2 months before Ike. “It's just been unfortunate for everyone involved,” said Angela Gardner, MD, an assistant professor at UTMB who is ACEP's President-Elect. “Most of us are still waiting to see what's going to happen with the university's overall plan for the hospital. Right now we've got 200 beds. I've been told they would like to restore the hospital to a Level 1 trauma center, but in my experience that would be very hard to do with 200 beds. What is comforting is, given the way the emergency medicine community works, when and if the university is up and running we can reapply and reestablish the residency program. But I think that's probably at least a couple of years away.” Chaos in the AftermathThe storm's aftermath left UTMB in chaos. The medical school had reasonable plans for dealing with the actual hurricane, providing for the closure of facilities, evacuation of patients and essential staffing to ride out the storm. Its brand-new, $176 million biosafety-level-4 laboratory, survived with nary a scratch.Yet because much of the island was devastated–homeowners weren't allowed back on for 2 weeks, and power outages lasted much longer–the hospital was forced to close for 2 months. Much of UTMB's campus was functioning, but the larger community around it simply was not.“I sat around my parents' house for a couple of weeks as we residents were told to hold on,” Silver said.After 2 weeks Silver received word that he would be temporarily assigned to a residency program at Christus Spohn Hospital Memorial in Corpus Christi, about 220 miles south along the Texas coast. The 7 other residents were assigned to locations around the state. The move was supposed to last one month.Two weeks later the residents were told they needed to spend a second month at their new locations. Finally, at the end of November the residents learned that UTMB's emergency medicine program had been canceled. The university has since been working with the residents to find permanent programs and funding for their second and third years of residency.“I've interviewed at a number of places now, and I'm pretty confident I'll be able to work something out. But I'll miss UTMB. We were treated well, and I enjoyed good camaraderie with the rest of the class. I really enjoyed my time, and I'm really bummed that it's not going to work out in Galveston.”It won't be as easy for the emergency physicians at UTMB to return to a sense of normalcy. Months after the storm there remains a sense of uncertainty about what the future holds. Both Dr. Zachariah and Dr. Gardner cited a lack of planning for the long-term aftermath following a natural disaster as a lesson other medical institutions can learn.“After 9/11 and Hurricane Katrina a lot of institutions, including UTMB, have developed good plans for responding to disasters,” Dr. Gardner said. “But the real question for us has become: What happens after the first 3 weeks? After you've lost infrastructure do you have longer term plans? Do you have insurance to cover for these losses? Plans for how to ramp your services back up when they've been cut drastically? Unfortunately for us this has been a learn-as-you-go process.” The storm's aftermath left UTMB in chaos. The medical school had reasonable plans for dealing with the actual hurricane, providing for the closure of facilities, evacuation of patients and essential staffing to ride out the storm. Its brand-new, $176 million biosafety-level-4 laboratory, survived with nary a scratch. Yet because much of the island was devastated–homeowners weren't allowed back on for 2 weeks, and power outages lasted much longer–the hospital was forced to close for 2 months. Much of UTMB's campus was functioning, but the larger community around it simply was not. “I sat around my parents' house for a couple of weeks as we residents were told to hold on,” Silver said. After 2 weeks Silver received word that he would be temporarily assigned to a residency program at Christus Spohn Hospital Memorial in Corpus Christi, about 220 miles south along the Texas coast. The 7 other residents were assigned to locations around the state. The move was supposed to last one month. Two weeks later the residents were told they needed to spend a second month at their new locations. Finally, at the end of November the residents learned that UTMB's emergency medicine program had been canceled. The university has since been working with the residents to find permanent programs and funding for their second and third years of residency. “I've interviewed at a number of places now, and I'm pretty confident I'll be able to work something out. But I'll miss UTMB. We were treated well, and I enjoyed good camaraderie with the rest of the class. I really enjoyed my time, and I'm really bummed that it's not going to work out in Galveston.” It won't be as easy for the emergency physicians at UTMB to return to a sense of normalcy. Months after the storm there remains a sense of uncertainty about what the future holds. Both Dr. Zachariah and Dr. Gardner cited a lack of planning for the long-term aftermath following a natural disaster as a lesson other medical institutions can learn. “After 9/11 and Hurricane Katrina a lot of institutions, including UTMB, have developed good plans for responding to disasters,” Dr. Gardner said. “But the real question for us has become: What happens after the first 3 weeks? After you've lost infrastructure do you have longer term plans? Do you have insurance to cover for these losses? Plans for how to ramp your services back up when they've been cut drastically? Unfortunately for us this has been a learn-as-you-go process.” “The New Normal”For inspiration UTMB can look to another institution, the Tulane University School of Medicine. Hurricane Katrina closed Tulane and scattered its students across the Gulf Coast, with some even finding a temporary home in Galveston.“The term here became the ‘new normal,’” said N. Kevin Krane, MD, the Vice Dean for Academic Affairs of Tulane's medical school.“Based on our experience, as hard as it is, you really have to look at the direction you're going. It really becomes more of a marathon than a sprint. If you're comfortable that things are moving in the right direction, even in a small way, then you have to develop a certain degree of patience with the overall situation. As long as you're making some progress, at some point the pace of progress will pick up.”Dr. Krane said the storm forced Tulane to consider new partnerships that probably would not otherwise have been available. After the storm Tulane formed a partnership with Our Lady of the Lake Regional Medical Center in Baton Rouge, LA, sending students to a community much less affected by Katrina. In that sense there were new opportunities to be mined amid the turmoil.Yet the challenges were often greater. Immediately after Katrina the entire Louisiana state hospital system in New Orleans closed, and it has only slowly been opening back up, Dr. Krane said. That has meant financial difficulties for Tulane as it has had to absorb larger numbers of uninsured and under-insured patients. For inspiration UTMB can look to another institution, the Tulane University School of Medicine. Hurricane Katrina closed Tulane and scattered its students across the Gulf Coast, with some even finding a temporary home in Galveston. “The term here became the ‘new normal,’” said N. Kevin Krane, MD, the Vice Dean for Academic Affairs of Tulane's medical school. “Based on our experience, as hard as it is, you really have to look at the direction you're going. It really becomes more of a marathon than a sprint. If you're comfortable that things are moving in the right direction, even in a small way, then you have to develop a certain degree of patience with the overall situation. As long as you're making some progress, at some point the pace of progress will pick up.” Dr. Krane said the storm forced Tulane to consider new partnerships that probably would not otherwise have been available. After the storm Tulane formed a partnership with Our Lady of the Lake Regional Medical Center in Baton Rouge, LA, sending students to a community much less affected by Katrina. In that sense there were new opportunities to be mined amid the turmoil. Yet the challenges were often greater. Immediately after Katrina the entire Louisiana state hospital system in New Orleans closed, and it has only slowly been opening back up, Dr. Krane said. That has meant financial difficulties for Tulane as it has had to absorb larger numbers of uninsured and under-insured patients. The Tipping PointIt has been those kind of financial pressures that have proven most acute for UTMB, even prior to Ike's landfall.“I think it has to be made clear that the issues here are bigger than the hurricane alone,” Dr. Zachariah said. “It was a tipping point. But it did not physically damage our emergency department in a significant way. We lost the pharmacy, some labs, and some operating rooms. But a big part of the reason why the hospital has scaled down is UTMB was already struggling because of its role as a safety net hospital.”Dr. Krane said Tulane worked with the greater New Orleans community to bring its residents back to the rebuilding city as soon as possible, recognizing the importance of such programs to providing a long term supply of physicians to the region.The closure of UTMB's emergency medicine residency program leaves just 7 in Texas, the country's second largest state in population. According to the American Board of Emergency Medicine, which published a task force report in Annals last year,3Perina D.G. Collier R.E. Thomas A.H. et al.Report of the Task Force on Residency Training Information (2007-2008).Ann Emerg Med. 2008; 51: 671-679Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar New York has the most residency programs (20), followed by California (13), Pennsylvania (11) and Michigan (10). There are now 142 residency programs in the United States, with much of the growth in new programs coming in East Coast states while the country's population growth has been elsewhere, particularly the Southern and Western United States.The landmark Institute of Medicine reports in 2006 on the future of emergency medicine4Institute of Medicine Committee on the Future of Emergency CareHospital-based emergency care: at the breaking point. National Academies Press, Washington, DC2006Google Scholar said EDs should ideally be staffed by physicians who had spent their residency training in emergency medicine and earned board certification.Yet a recent report in Academic Emergency Medicine notes that there simply are not enough residency programs to meet present and future needs in emergency departments.5Camargo Jr. CA, Ginde AA, Singer AH, Espinola et al. Assessment of emergency physician workforce needs in the United States, 2008. Acad Emerg Med. 151317-1320.Google Scholar The authors found that, unrealistically assuming the loss of no current doctors from the system, it would take until 2019 to find enough fully trained, board-certified emergency physicians to work in the country's 4,828 EDs that are open 24 hours a day. Only about 55% of these needs are being met today.The present economic crisis may have the same effect on other EDs that Ike did on UTMB, a financial tsunami that sends some programs permanently into the red.“If the economic crisis continues we'll see more hospitals close, more people lose insurance, and in turn more people will be coming to the remaining emergency departments,” said Dr. Gardner. “But if we keep losing residency programs we're simply not going to be able to meet our manpower needs.” It has been those kind of financial pressures that have proven most acute for UTMB, even prior to Ike's landfall. “I think it has to be made clear that the issues here are bigger than the hurricane alone,” Dr. Zachariah said. “It was a tipping point. But it did not physically damage our emergency department in a significant way. We lost the pharmacy, some labs, and some operating rooms. But a big part of the reason why the hospital has scaled down is UTMB was already struggling because of its role as a safety net hospital.” Dr. Krane said Tulane worked with the greater New Orleans community to bring its residents back to the rebuilding city as soon as possible, recognizing the importance of such programs to providing a long term supply of physicians to the region. The closure of UTMB's emergency medicine residency program leaves just 7 in Texas, the country's second largest state in population. According to the American Board of Emergency Medicine, which published a task force report in Annals last year,3Perina D.G. Collier R.E. Thomas A.H. et al.Report of the Task Force on Residency Training Information (2007-2008).Ann Emerg Med. 2008; 51: 671-679Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar New York has the most residency programs (20), followed by California (13), Pennsylvania (11) and Michigan (10). There are now 142 residency programs in the United States, with much of the growth in new programs coming in East Coast states while the country's population growth has been elsewhere, particularly the Southern and Western United States. The landmark Institute of Medicine reports in 2006 on the future of emergency medicine4Institute of Medicine Committee on the Future of Emergency CareHospital-based emergency care: at the breaking point. National Academies Press, Washington, DC2006Google Scholar said EDs should ideally be staffed by physicians who had spent their residency training in emergency medicine and earned board certification. Yet a recent report in Academic Emergency Medicine notes that there simply are not enough residency programs to meet present and future needs in emergency departments.5Camargo Jr. CA, Ginde AA, Singer AH, Espinola et al. Assessment of emergency physician workforce needs in the United States, 2008. Acad Emerg Med. 151317-1320.Google Scholar The authors found that, unrealistically assuming the loss of no current doctors from the system, it would take until 2019 to find enough fully trained, board-certified emergency physicians to work in the country's 4,828 EDs that are open 24 hours a day. Only about 55% of these needs are being met today. The present economic crisis may have the same effect on other EDs that Ike did on UTMB, a financial tsunami that sends some programs permanently into the red. “If the economic crisis continues we'll see more hospitals close, more people lose insurance, and in turn more people will be coming to the remaining emergency departments,” said Dr. Gardner. “But if we keep losing residency programs we're simply not going to be able to meet our manpower needs.”