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Introduction

Matching into an accredited surgical residency program is the ultimate goal for medical students who have embarked on the long and arduous path toward becoming a surgeon. For most trainees, the certainty of being locked into a residency program for the duration of their training is associated with tremendous relief and a sense of accomplishment. However, periodically, a hospital will close or lose accreditation, and several residents are faced with this seemingly impossible and uncertain scenario: closure of their surgical training program.

The transition of trainees from resident to “orphan” is unique and uncommon, but unfortunately one that the authors of this chapter have personally experienced. For most surgical residents, the details of the financial and legal aspects dictating residency administration do not have to be considered during training. However, in this chapter, we aim to unveil the legal underpinnings of residency funding and to share practical tips for finding a new residency program. While we hope that no others meet this fate, we endeavor to create a guide for the few trainees who may face a similar situation of hospital or residency program closure in the future.

Allocation of Funding for Residency

The funding of individual residency spots is something that most residents have little interest or need to learn. However, in the case of threatened or pending closure of a training program, understanding the process for funding ACGME-accredited residency seats is crucial in allowing a trainee to best face the challenges of finding a position in a new residency program. While the situation in every hospital is unique, funding for residency positions comes from a blend of federally appropriated funds, private donors, hospital funds, and additional state-based funding sources [1].

The federal government is the largest single contributor to GME funding nationally, contributing nearly $16 billion annually (estimated FY 2015), with the bulk of this funding originating from the Centers for Medicare and Medicaid Services (CMS) [2]. This funding is supplemented at the hospital level by private donors, state funding, and individual hospital system contributions. Residency staffing at hospitals is largely determined by the needs of an individual hospital; however, federal funding for these spots is limited by the “cap” established by the Balanced Budget Act of 1997, which froze the number of federally funded training positions at hospitals with established programs [3].

While CMS is the primary stakeholder that funds Graduate Medical Education, it does not regulate the allocation of these funds. The ACGME accredits training programs, allowing them to receive this funding. In training programs operating at or below their “cap,” individual programs are responsible for distributing federally received funds to each resident. This per-resident amount (PRA) determines the total dollar amount distributed to each hospital per resident. The sum of money distributed per resident is greater than a trainee’s salary, providing supplemental funding for the institution to maintain the overall infrastructure of the training program. In training programs operating above their “cap,” institutions supplement federally received money with money from any of the abovenamed sources in order to achieve funding for their full complement of residents. In this situation, the institution often uses its own funding or nonfederal sources of funding to support the infrastructure of its residency program(s).

From the perspective of a trainee whose program is closing, the allocation of residency funding becomes crucial information. While the circumstances of every program closure are different, any and all funding a resident can bring with them to a new program greatly increases their chances of obtaining a new residency training spot. In cases of programs operating at or below their “cap,” all federal funding should be transferred with a resident to their new training location. In programs operating above their cap, institutions may be less willing or able to provide nonfederally appropriated funds for residents they are no longer training. While closing programs are encouraged to provide above-cap supplemental funding for all orphaned residents, they are not financially or legally obligated to do so [4].

For example, when examining the closure of Hahnemann University Hospital, residents from surgical specialties with funding were highly desirable to other training programs as adding residents with funding provided the potential for an overall increase in GME’s budget. The process of transferring GME funding does theoretically have some uncertainty. When Hahnemann closed, the for-profit parent corporation attempted to claim ACGME-accredited and CMS-funded spots as an asset and sell them at auction. This did not eventually happen as the programs voluntarily resigned accreditation and ACGME reallocated the spots and CMS redistributed funding accordingly. It is unclear if there is no scenario where a hospital and program could try to retain resident funding as a resource even after stopping training.

Additionally, the PRA for each hospital is different and the receiving institutions may have a higher PRA for their own residents in comparison with those they are receiving. This funding discrepancy may leave a gap in the funding of an orphaned resident that will often need to be covered by the new institution. While the entire funding process for residents is beyond the scope of this text, the purpose of this discussion is to highlight the complexity of factors underlying the decision-making process of programs taking on newly orphaned residents.

What to Do in the Immediate Aftermath of Closure

In situations of either an impending closure or a closure that occurs suddenly, the most important first step for residents is to recognize that there is only one stakeholder who truly is invested in their success: themselves. In an ideal situation, the resident’s current program director, administrative staff, and teaching faculty are similarly invested in finding a new training spot for their displaced residents. However, due to the varied reasons for program closures, this is not always the case. Faculty and administrative staff are often under pressure to find new jobs themselves, and many have other trainees in different disciplines that are similarly in a difficult situation.

There are a few critical steps that we believe orphaned surgical residents should take in the immediate aftermath of a program closure to best prepare themselves for finding a new training position:

  1. 1.

    Prepare electronic records of residency application and current credentialing.

There are significant administrative challenges that are associated with a program closure, and it is important that you have a personal record of your initial ERAS application, an updated curriculum vitae, and an updated ACGME case log record. This last point is of utmost importance, as there is a chance that the electronic case log system may lock out while you are searching for a new program.

  1. 2.

    Contact the GME office for a description of their role in the process.

There will be an avalanche of misinformation and conflicting guidance on how to approach the process of finding a new training program. Accordingly, residents should work together to request a written statement regarding the role the GME department will have in assisting trainees as they find new positions. GME will often provide conflicting statements regarding their role in finding new training positions for residents, so obtaining a written statement about GME’s plan for facilitating residents’ contact with new programs is critical. If GME pledges to make contact for residents at new programs on their behalf, residents should ensure that this process happens swiftly and is well organized. In situations where GME offices are unable to efficiently contact new programs or residents perceive the GME office to be a hindrance to the process, residents should feel empowered to contact potential programs on their own.

  1. 3.

    Contact the ACGME and local surgical societies.

While the local GME and hospital administration are important, residents should also reach out to the ACGME and local surgical societies with the assistance of their training faculty. While the ACGME may not be helpful to individual residents, they may be able to provide guidance to local and distant residency programs on the logistical aspects of transferring residents to new positions. They have a national presence allowing them to inform potential residency programs about orphaned residents that they otherwise may not be aware of. In addition, if a program would like to take on a new trainee beyond their ACGME-approved number of positions, the program may need to appeal to ACGME for a temporary increase in their complement of residents in order to accommodate the orphaned resident in their program. Similarly, contacting the local and national surgical societies with the help of faculty may alert other residency programs of the orphaned trainees.

Above all, an orphaned trainee must remember that they are their best and greatest advocate in the process of finding a new training position. They should be prepared to humbly reach out to any contacts they have in the surgical world, and program directors at places they are interested in, to secure themselves a new position. At the same time, they should remember that as residency training funding is severely limited, and surgical subspecialty residents often do significant labor for a hospital further increasing their value, they do have strength in their position. Many Hahnemann residents did end up transferring to programs that they felt were more prestigious and had more resources for training than our original program. Orphaned residents should beware of programs that try to lock them in for transfer quickly and work with a mentor to make sure that once their funding is secured, they are able to transfer to the best possible program for them.

What to Do If You Do Not Find a Spot

While the goal is for every orphaned resident to find a new permanent training location, the reality is that this may not be possible. It is the experience of these authors that with persistence and open horizons, most residents should be able to find a new training location. It is possible, however, that this may not be the case for all involved.

Due to the challenges associated with finding a new position, residents should be prepared to do whatever is necessary to continue their surgical training including relocation, repeating a year of training, or completing a remediation program. Ideally, a candidate would be able to continue training in a geographically convenient location in a positive or consecutive year; however, this may not always be possible depending on the circumstances of a program’s closure.

One group that had difficulty finding new programs were residents just beginning their chief year. They brought only 1 year of additional funding with them, and most programs prefer chief residents that know their program’s preferences and policies well. In our experience, many of these rising chief residents found success working with the hospitals where they were already matched, or interviewing, for fellowship.

If these measures fail, orphaned surgical residents who remain without a training position may consider taking an unplanned research year or search out positions in other, less competitive, specialties.

The Impact of Residency Closure on Fellowship and Job Prospects

For orphaned residents who can find positions at new surgical training programs in successive years, fellowship and job prospects should not be greatly affected. In fact, residents who can thrive after closure of their initial training program demonstrate resilience that may be viewed favorably during future applications for fellowship or permanent jobs.

As only a few years have passed and we have no controls, we cannot comment objectively on this. However, it has been our observation that all our fellow orphans have been matching as well as we had hoped prior to the program’s closure.

Closure of a surgical residency program should never be in the 5–7-year plan of a medical student who has just matched in the surgical training program of their choice. However, if faced with the reality of a program closure, orphaned residents can employ the guidelines above to empower themselves on their journey toward finding a new program at which to complete their surgical training.

Pearls

  • An understanding of residency funding processes can be helpful to consider when a program closes.

  • In the setting of a program closure, it is critical to collect a record of your residency experience including case logs and credentialing information.

  • Contacting academic societies may be helpful to find available programs and increase visibility of your program closure.

  • Be prepared to reach out to any previous mentors and colleagues for assistance during this process.

  • Ultimately, transitioning to a new residency likely will not affect your fellowship and career goals.