Anyone knows about what to do when a residency tells you they will close in a few months? What was done in the past and what can be done now as an individual?
Thank you
Thank you
Residency closing
- Thread starter Warof1812
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ACGME or AOA?
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Well, if it's an ACGME residency (not fellowship!) then you are in luck, sort of. This happened to a few residents I worked with earlier in my training. If your program is truly closing down you'll gain something like "orphan" status but maintain your funding from your school. Surrounding programs will be given the option of adding some of these residents - many will jump at it since they won't have to pay your salary and essentially gain an extra worker for minimal cost as long as they have the workload to support it.
The downside is you will likely have no input on where you end up, and you may have to move hours away or even to a different state. Depending on what your specialty is, it is unlikely that any one institution will be able to absorb all of the orphan residents so you'll likely have to split up between several different programs. Some ended up at much higher level programs, and some didn't. Note this doesn't apply if you are a prelim resident as you only have a one year contract anyway.
There is some precedent here as the general surgery program in Daytona Beach, FL and the anesthesiology program in Tampa, FL both shut within the past decade or so. To my knowledge all residents found a spot, but some had to move as far away as Atlanta (~4-6 hour drive).
This is an ACGME accredited residency program. Open for decades. They have their reasons to close the program but it was closed abruptly and with little notice. The decision came out of nowhere. Everyone has a few months to find a new place but the support of program as of now looks somewhat reliable.
How true is this fact of maintaining your funding from your program because of orphan status? So orphan status qaulifies you for this fund from home program that is transferable per ACGME?
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It's not that the home program transfers funds, it's that the CMS money that pays for you can follow you to a new program so that they can afford to offer you a position, even though they may not have the funding themselves for another position.
Is it possible that the CMS money can be 1. inadequate and not cover every resident and 2. nontransferable to a created residency position in a different state?
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EDIT: This post is not exactly correct. Rather than try to fix it, read further down this thread for a more accurate description.
This is a very complicated issue. I'll try to summarize as best as possible.
Also, look at this presentation for details: http://aodme.org/wp-content/uploads/What_Happens_When_A_Program_Closes_2.pdf
It doesn't matter if this is an ACGME or AOA program, as CMS funds both.
In general, if a program closes, the residents are called "orphan residents" and the funding that previously was flowing to the program for those residents now is attached to the resident.
If the resident can find a new position, their new program gets the funding, even if the program is at their "cap" (i.e. maximum amount of funding allowed).
This additional funding only lasts as long as the resident's training. Once the resident completes their training, then the funding slot reverts back to the original hospital (who could use it for a different program). If an entire hospital closes, all of the slots revert back to CMS and then there is a redistribution process.
BUT
It's possible that the original hospital is over it's cap. In that case, they have a subset of residents who get no funding. I don't actually know what happens in that case. The hospital files a report every month claiming how many residents are training for funding -- I don't know if that Medicare Cost Report is itemized by resident, or if it just gives totals. So I don't know if a program can claim that all, or some percentage, of terminated residents actually have no funding.
Last, even if a resident has full funding, whether or not that funding actually pays all of the costs of training is a controversial topic.
So, to answer your questions as best I can:
1. Yes, maybe, if a program is over their training cap. In that case, I'm not sure what happens.
2. Probably not an issue. CMS is federal. Doesn't matter what state. (Except that some states help pay for GME costs, so if you're in one of those states and move to a state that doesn't, part of your funding would disappear)
Note that if you don't take your funding with you, the hospital gets to keep it. Hence, it's in their best financial interest (unfortunately) not to help you with this. Most PD's I would hope would take the high road and help.
This is a very complicated issue. I'll try to summarize as best as possible.
Also, look at this presentation for details: http://aodme.org/wp-content/uploads/What_Happens_When_A_Program_Closes_2.pdf
It doesn't matter if this is an ACGME or AOA program, as CMS funds both.
In general, if a program closes, the residents are called "orphan residents" and the funding that previously was flowing to the program for those residents now is attached to the resident.
If the resident can find a new position, their new program gets the funding, even if the program is at their "cap" (i.e. maximum amount of funding allowed).
This additional funding only lasts as long as the resident's training. Once the resident completes their training, then the funding slot reverts back to the original hospital (who could use it for a different program). If an entire hospital closes, all of the slots revert back to CMS and then there is a redistribution process.
BUT
It's possible that the original hospital is over it's cap. In that case, they have a subset of residents who get no funding. I don't actually know what happens in that case. The hospital files a report every month claiming how many residents are training for funding -- I don't know if that Medicare Cost Report is itemized by resident, or if it just gives totals. So I don't know if a program can claim that all, or some percentage, of terminated residents actually have no funding.
Last, even if a resident has full funding, whether or not that funding actually pays all of the costs of training is a controversial topic.
So, to answer your questions as best I can:
1. Yes, maybe, if a program is over their training cap. In that case, I'm not sure what happens.
2. Probably not an issue. CMS is federal. Doesn't matter what state. (Except that some states help pay for GME costs, so if you're in one of those states and move to a state that doesn't, part of your funding would disappear)
Note that if you don't take your funding with you, the hospital gets to keep it. Hence, it's in their best financial interest (unfortunately) not to help you with this. Most PD's I would hope would take the high road and help.
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Wayne State had a bunch of residencies temporarily shut down around 2007. St Vincent Hospital completely closed in 2010(?) so you saw residents from both places scattered around the country during those years.
what about the case where there is more than one entity funding to cover what is not covered by CMS e.g. a hospital corporation, and academic insitution? With CMS alone only a few positions are covered. Also a complicated case.
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It's not really that complicated.
CMS funding goes with the resident if s/he finds a new spot. All other money is forfeited.
If you have a residency spot that is completely institutionally funded, and that institution closes...you're pretty f***ed.
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Agreed. But if a program has 4 residents x 3 years = 12 spots, and 6 are funded by CMS and 6 are funded some other way, it's not clear what happens. Do 6 people get full orphan funding and 6 people get nothing? Or does everyone get half funding? Looking into it further, it appears that either can happen. The program can release the positions to a new program -- in that case, a single resident gets the full funding. Or, the program can keep the positions and work out a financial deal with other institutions -- that would allow partial funding.
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I hadn't considered that issue. Which is a good point since a lot of programs (most?) have more residents than they have CMS money for.
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I decided to try to find out how this process works. I figured, it has to be in the CMS statutes somewhere, so how hard could it really be to find, right?
Wrong. And that's twice this week. So I'm definitely slipping.
It turns out that it's not in the law at all. When hospitals close, or when programs close and hospitals don't refill residency spots, then empty spots are reallocated to existing programs. Turns out some of that law is in the ACA, unclear if the repeal attempt will affect that at all. But it has nothing to do with this issue.
After much searching, it turns out the answer is in the Federal Register. The FR is documentation of how each gov't agency interprets the laws. So nowhere in the law does Congress say this can happen, but CMS decided it was a good idea and wrote rules around it. It's in 66 FR 39828. Ready to come down the rabbit hole?
First, about the FR. Its basically like a medical journal. 66 is the volume number. The issue we want is 148, but what the FR does is sequentially number the pages of all of it's issues, so the reference "39828" is actually the page number of the 1st page of this issue. We want page 39899 -- which is on page 73 of the PDF linked above.
Reading the FR is somewhat entertaining. OK, not really. As you'll see, it's like a legal brief where questions are asked, and answers are summarized. The process for orphan residents getting their funding transferred is fully described starting at the top of the middle column. And here's where it becomes really fun.
Residents don't actually "own" their funding, like I thought. The program closing needs to VOLUNTARILY give up it's funding slots to a receiving program. I see nothing in this document that forces anyone to do anything. Hence programs over cap will hold onto as many slots as they need. Even if an institution is left with "unused" slots, they might decide to hold onto them and reallocate them to existing programs (i.e. let those programs grow) -- although they will eventually get those slots back, they may not want a delay or a lack of flexibility.
If anyone disagrees with my interpretation, feel free to chime in. This FR is from 2002, it's possible there have been updates and the FR is horrible to search.
Wrong. And that's twice this week. So I'm definitely slipping.
It turns out that it's not in the law at all. When hospitals close, or when programs close and hospitals don't refill residency spots, then empty spots are reallocated to existing programs. Turns out some of that law is in the ACA, unclear if the repeal attempt will affect that at all. But it has nothing to do with this issue.
After much searching, it turns out the answer is in the Federal Register. The FR is documentation of how each gov't agency interprets the laws. So nowhere in the law does Congress say this can happen, but CMS decided it was a good idea and wrote rules around it. It's in 66 FR 39828. Ready to come down the rabbit hole?
First, about the FR. Its basically like a medical journal. 66 is the volume number. The issue we want is 148, but what the FR does is sequentially number the pages of all of it's issues, so the reference "39828" is actually the page number of the 1st page of this issue. We want page 39899 -- which is on page 73 of the PDF linked above.
Reading the FR is somewhat entertaining. OK, not really. As you'll see, it's like a legal brief where questions are asked, and answers are summarized. The process for orphan residents getting their funding transferred is fully described starting at the top of the middle column. And here's where it becomes really fun.
Residents don't actually "own" their funding, like I thought. The program closing needs to VOLUNTARILY give up it's funding slots to a receiving program. I see nothing in this document that forces anyone to do anything. Hence programs over cap will hold onto as many slots as they need. Even if an institution is left with "unused" slots, they might decide to hold onto them and reallocate them to existing programs (i.e. let those programs grow) -- although they will eventually get those slots back, they may not want a delay or a lack of flexibility.
If anyone disagrees with my interpretation, feel free to chime in. This FR is from 2002, it's possible there have been updates and the FR is horrible to search.
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In the midst of searching, I also found this really nice explanation of GME funding: GME Financing - Graduate Medical Education That Meets the Nation's Health Needs - NCBI Bookshelf
This has nothing to do with orphaned residents, and is completely off topic. But it's a really nice summary of GME funding and controversies. Somewhat dated but I don't think much has changed. Not for the faint of heart, but if you want to see how the sausage is made, dive right in.
This has nothing to do with orphaned residents, and is completely off topic. But it's a really nice summary of GME funding and controversies. Somewhat dated but I don't think much has changed. Not for the faint of heart, but if you want to see how the sausage is made, dive right in.
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This is incredibly impressive that you researched this to such a degree! Beyond respect.
I wonder if anyone out there has actually read this stuff other than the people that wrote it
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This is the most telling paragraph in the document cited by aProgDirector:
THE BLACK BOX OF GME COSTS AND BENEFITS
Remarkably little is known about the individual, institutional, and societal costs of residency training. There are also considerable conceptual challenges in defining and identifying the costs and cost savings related to residents' presence within an institution. The most significant information gaps relate to the impact of GME on the costs of care, particularly regarding the indirect costs and cost savings (and/or revenue) associated with GME. This dearth of information exists, in part, because CMS requires only minimal reporting from teaching hospitals as a condition of receiving funding, despite the nearly $10 billion annual Medicare investment in GME. Federal GME regulations are nearly silent regarding transparency and accountability for use of Medicare GME funds. Medicare statute requires teaching hospitals to report only aggregate DGME costs, the number of FTE trainees (with limited specificity regarding specialty and whether the residents are in their initial residency period),25 the amount of time residents spend on hospital and non-hospital rotations, and the intern and resident-to-bed ratio (CMS, 2012; Wynn et al., 2006). Sponsors of teaching programs have little incentive to maintain detailed documentation of GME-related expenses because Medicare and Medicaid payment regulations do not require it.
This is the result when you have politicians and physicians conjuring up a vehicle to throw around $15 billion a year. Some of you have no respect for people who manage private enterprises but I can tell you that no one in a competitive business would last 15 seconds if he or she were unaware of the benefits and underlying costs of a program he or she managed that threw around that amount of cash every year. The healthcare economists are just as bad. Economists completely ignore these issues due to their ineptitude and political cowardice. To my knowledge no one knows what an efficient residency program or undergraduate medical education looks like. Nobody knows what efficient education or residency training costs. Based on what I've read on these boards no one even cares about efficiency in any medical context.
THE BLACK BOX OF GME COSTS AND BENEFITS
Remarkably little is known about the individual, institutional, and societal costs of residency training. There are also considerable conceptual challenges in defining and identifying the costs and cost savings related to residents' presence within an institution. The most significant information gaps relate to the impact of GME on the costs of care, particularly regarding the indirect costs and cost savings (and/or revenue) associated with GME. This dearth of information exists, in part, because CMS requires only minimal reporting from teaching hospitals as a condition of receiving funding, despite the nearly $10 billion annual Medicare investment in GME. Federal GME regulations are nearly silent regarding transparency and accountability for use of Medicare GME funds. Medicare statute requires teaching hospitals to report only aggregate DGME costs, the number of FTE trainees (with limited specificity regarding specialty and whether the residents are in their initial residency period),25 the amount of time residents spend on hospital and non-hospital rotations, and the intern and resident-to-bed ratio (CMS, 2012; Wynn et al., 2006). Sponsors of teaching programs have little incentive to maintain detailed documentation of GME-related expenses because Medicare and Medicaid payment regulations do not require it.
This is the result when you have politicians and physicians conjuring up a vehicle to throw around $15 billion a year. Some of you have no respect for people who manage private enterprises but I can tell you that no one in a competitive business would last 15 seconds if he or she were unaware of the benefits and underlying costs of a program he or she managed that threw around that amount of cash every year. The healthcare economists are just as bad. Economists completely ignore these issues due to their ineptitude and political cowardice. To my knowledge no one knows what an efficient residency program or undergraduate medical education looks like. Nobody knows what efficient education or residency training costs. Based on what I've read on these boards no one even cares about efficiency in any medical context.
So we now have an idea of it. So what's next for a program (which will abruptly close soon) that is saying they do not have enough CMS funding for all their residents who now need spots? There is too much evading the question.
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Are you implying that people in this thread are evading the question? If so, I'd read the post by @aProgDirector again. There is a lot of useful data there, and the answer is that it is unclear. There is no hard and fast rule. If the program has no unfunded slots, they may choose to give away your funding to another program who can then take you. They may decide to be dinguses and keep your funding (I believe this is what happened to the rads program in NYC that recently closed. They kept the residents' funding and used it to enlarge their FM program). They may have funding for some of you but not all in which case they may divvy what funding they have among all of you so you're partially funded and another program needs to foot the rest of the bill, or some of you get all and some get none, or as above, they just keep the money.
The short answer is: ask your PD/head of GME at the hospital. They have a lot of options and unless you get it straight from the source, you won't know for sure.
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Actually your question has been directly answered already. If this is really happening you need to hammering down the door of the PD and the GME office to see what your options are.
Also, ACGME programs don’t just get shut down out of the blue usually these things are readily apparent for months giving the institution and the residents time to plan. Time to figure out what your program plans to do.
Assuming I'm at the same (closing) residency as Warof1812, then no, there was no "heads-up" from the program that it might close. We were totally blindsided from this, and it seems like the funding institution was as well. The entire faculty of the program resigned; the program was not forced to shut.
The program announced its closure 6 days ago and the PD is on vacation right now... GME office rep and our DIO are both new at their jobs and fairly clueless from what I can tell. Program coordinator is trying hard to help, but overwhelmed and in over her head.
My corollary question is this: the program is contractually obligated to help us find new programs, but how much are they actually required to do? I don't have a lot of confidence in this group of people right now.
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What specialty is this in, if we may ask. There are different resources based on what you are training to do.
As for what's the next step, if I were you I would talk to everyone you knew from med school and see if they know of any openings in your field at their institutions. There are some lists out there that advertise positions as well.
Oh, and this is a wonderful time for the PD to be on vacation...
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Trust me, your institution knew. It’s a hugely big deal for the ACGME to shutter programs and takes a lot of documentation - they almost always have to place a program on probation/warning first. Then they have a year to respond, make changes and the such.. Now whether they shared this information that you were struggling with you or not, that is up to them. That’s questionable ethics, but not surprising if they are getting shut down. That’s likely why your GME office has had so much turnover.
This whole situation sounds very fishy and I am sure we are only getting the tip of the iceberg here. An entire faculty resigning? That’s not done routinely, most can’t just afford to just up and quit their jobs unless they are close to retiring. There was the issue with the EM program in Ohio shut down when Summa replaced all the EM faculty abruptly, but that’s a separate and thankfully rare.
Finally, I don’t usually recommend this but I’d consider outing this place publicly. Current applicants need to know about an institution’s instability, and if they aren’t sharing the information with current residents it’s doubtful it is getting shared with applicants. You can probably do this more anonymously through a moderator, if you’d prefer.
For anyone wondering about the ACGME status of your program, it’s available online via the official site - ACGME - Accreditation Data System (ADS)
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I don't know anything about this situation other than what has been said here, but it doesn't sound like the ACGME shut the program down from what the residents have shared so far. It almost sounds like the department/hospital decided it no longer wanted that residency.
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Your institution/program is only obligated to help find you find a new program if your contract or their policies state so. The GME office should have a policy regarding programs that close. I just looked at our policy, and all it says is that the PD "must assist displaced residents in finding a new position". There's nothing about funding, etc. Assuming the language is vague, they can "assist" you as much or as little as they want.
I was not referring to this thread answering/ evading questions rather it is the program not trying to address what is discussed here. Much thanks.
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I was thinking this as well. We all assumed (not unwarranted) that it was ACGME shutting it down. But perhaps the hospital just decided it was too much trouble.
The OP is being cagey with actual information so it's hard to tell, but this sounds like a community based program with a (loose?) university affiliation. Maybe the parent institution wanted it's funding back.
Something along these lines. The ACGME has nothing to do with the closure, except for maybe causing the PD to be afraid of probationary status.
That's what I figured and what I was afraid of.
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There has to be more to the story than that. The OP says it's closing in "a few months." No one shuts a program down mid-year. Every program dissolving I've ever heard of (except when the hospital got destroyed by weather event or something) graduates their last class and transitions their people out in the summertime.
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It could totally happen. I know nothing of the situation, but one of the posters mentioned that "all of the faculty resigned". I expect the trigger for their resignation wasn't something residency specific, but some other disagreement with the hospital. If that were to happen in the middle of a training year, the program would be forced to close with little to no warning.
I could imagine a scenario like this: Docs work for the hospital. Hospital announces that everyone is taking a pay cut, or that their nursing staff is being slashed, or that productivity will be increased by 50%, or that the residency program will be phased out. Docs say that this is unacceptable. Hospital says "that's too bad". All docs quit in protest. Any affiliated residency program would be stuck.
I could imagine a scenario like this: Docs work for the hospital. Hospital announces that everyone is taking a pay cut, or that their nursing staff is being slashed, or that productivity will be increased by 50%, or that the residency program will be phased out. Docs say that this is unacceptable. Hospital says "that's too bad". All docs quit in protest. Any affiliated residency program would be stuck.
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Almost happened to a program here in my state. Decent sized FM program that had 5 faculty quit within a 3 month period over changes in how they were being paid. That was out of 8 full time faculty.
Luckily they got recent grads to do clinic precepting and speed hired 2 new people to manage inpatient and did OK but that was almost 2 years ago and they still aren't back to full steam yet.
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This is basically what happened wit the Summa Health EM residency in Akron last Spring. If the contract timing had been off from the academic calendar, they would have closed mid-year because all of the docs left when the hospital gave the contract to USACS.
So, completely believable that this could happen as stated.
Also a total s***show and the residents are kind of in a bad place unfortunately.
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Also, just another scenario, but some residencies cannot continue with others...like you can have a general surgery residency without an anesthesia program, but an anesthesiology program has to have a general surgery program, too. I am sure there are other dependencies, (especially with IM).
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What?
You can't have an anesthesiology residency in a hospital unless you also have a general surgery residency? Because of the ICU experience? That doesn't make any sense to me.
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Its true for fellowships - you cant have a pulm crit fellowship without three other core (not sure what defines core) fellowships (like cards, gi, nephro) And an IM residency and GS residency at the same institution
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Yeah, this isn’t necessarily true. In fact one of the cross town hospitals where I did my residency is opening a program in 2-3 years and there isn’t a GS program there. They will, however, need to have rotations and exposure to ample cardiac, peds, neuro, vascular etc... Which is why just about every (all?) program has a GS program as well.
ICU exposure needs to be at least 2/3-3/4 supervised by an Anesthesiology intensivist, per ACGME rules.
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for medicine subspecialty fellowships there has to be an IM residency in place...its the core specialty since you have to have done an IM residency to then be eligible for the fellowship (need to be BC in IM to sit for any subspecialty board).
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I.A.1. The sponsoring institution must also sponsor or be affiliated with ACGMEaccredited residencies in at least the specialties of general surgery and internal medicine. (Core)
The above is directly from the ACGME requirements for Anesthesiology
The above is directly from the ACGME requirements for Anesthesiology
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“Affiliated” GS institution is 2 hours away at the main sponsoring institution’s campus.
... did you really go back to check this?
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AdmiralChz, yes I did. It bugs me when someone questions me like that, because that makes me start wondering that maybe I remembered it wrong! 😛
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IM/Peds fellowships require a residency program to ground them. But I can't think of any other reason IM would depend on another residency program. I guess you would need an ED that accepts residents to rotate, so it's easier to have an EM residency as well, but I'm sure there exist community IM programs that are alone in the hospital. Now, they have to have certain faculty to remain open, but not necessarily other residency programs...
Except this one, with only 90 days advanced notice. Hence OP's post and the devastation among its residents.
Exactly.
Haha
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Well I'm in a Dental Anesthesiology residency that was informed on December 19th that the program will no longer be open after June 30th of this year, which strands 5 of us without positions. There was no teach-out discussed, and we certainly only got news of this after the decision was long made. We had NO clue that this was happening; we'd just taken new residents via PASS Match as well. Our program director was caught completely off guard. The institution apparently made the decision entirely on their own.
So...it definitely does happen.
So...it definitely does happen.
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Not sure how that's relevant to us
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The posts above were showing doubt that this scenario could play out. I'm just demonstrating that I'm someone in a same situation it definitely does happen.
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Dental residencies and medical ones are presumably quite different situations.
What does the "md" in your name refer to, anyway?
What does the "md" in your name refer to, anyway?
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It's DMD, doctor of medical dentistry...
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Why are these residencies so different to your mind?
Mine is a hospital based general anesthesia program attended by a mix of MD and DMD anesthesiologists, primarily MD, where we do cases involving general surgery, neuro, cardiothoracic, vascular, OBGYN, podiatry, and orthopedics on top of OMFS and general dental cases. We work very closely with the surgery residencies. Our accrediting agency has similar requirements to ACGME in many instances.
Either way, summarily shutting down a residency in the middle with little to no warning is a really ****ty move.
