Merging Cultures and Curriculum: An Anonymous Survey of Army and Navy Physicians Before the New Walter Reed Bethesda Internal Medicine Residency Program

Abstract

In 2005, the Base Realignment and Closure Commission (BRAC) recommended Walter Reed Army Medical Center be closed and that its operations be merged with the National Naval Medical Center to createWalter Reed NationalMilitaryMedical Center Bethesda , which became operational in September 2011. This provided an opportunity in 2010 to study premerger physician attitudes and preferred curriculum elements. Mergers of civilian academic medical centers are common and driven by potential advantages of operating cost savings, economies of scale, decreased duplication of services, and increased patient base. Unfortunately, mergers are frequently unsuccessful, providing “lessons learned” for our BRAC process. COL De Lorenzo reviewed organizational issues citing Greenberg’s work on potential barriers to change, including (1) structural and group inertia, reinforced by both top–down military structure and identification with one’s parent service, (2) Maslow’s hierarchy of needs, when there is more competition for fewer leadership posts, and (3) previous failures, such as failed efforts to create a Joint Military Medical Command. At the residency program level, merger benefits may include more diverse patients, enhanced academics, sufficient numbers of learners, and cost savings given less duplication of services. In one study of medical students, satisfaction and national standardized exam performance did not appear to suffer when military obstetrics and gynecology residencies combined. Potential graduate medical education (GME) merger challenges include conflicting cultures, schedule disruptions, decreased teacher–learner collegiality, faculty and resident morale, and recruitment concerns. One qualitative study using focus groups after a merger of family practice residencies identified themes of unmet potential in the curriculum, blending of two cultures resulting in feelings of loss, and a sense of rapid policy change and lack of resident and faculty accountability. The dilution of contact between a given resident and faculty within the larger program was noted to be an impediment to resident competency evaluation. All of these studies are retrospective (postmerger) and none consider two different military cultures; so, we anonymously surveyed all faculty and trainees at both of our internal medicine programs. Respondents included 136 physicians (minimum response rate 39%). A majority were active duty Army (54.3% (69)), followed by active duty Navy (29.1% (37)), and Army and Navy civilians (9.4% (12) and 7.1% (9), respectively). Half were attending physicians (53.5% (68)), whereas the remainder were interns (9.4% (12), junior residents (11.0% (14)), seniors (13.4% (17)), and fellows (12.6% (16)).Although outlined below, more information is available in an online supplement at https://sites.google.com/site/bracimmerger/.