The Journal of Pediatrics
Volume 153, Issue 6 , Pages 731-732.e1, December 2008

The Merger of Two Pediatric Residency Programs: Lessons Learned

  • Frederick H. Lovejoy Jr, MD

      Affiliations

    • Department of Medicine, Children's Hospital Boston, Boston, MA
    • Corresponding Author InformationReprint requests: Frederick H. Lovejoy, Jr., M.D., Children's Hospital, Department of Medicine, 300 Longwood Ave, Hunnewell 2, Boston, MA 02115
    • ,
  • David G. Nathan, MD

      Affiliations

    • Children's Hospital Boston and Dana-Farber Cancer Institute, Boston MA
    • ,
  • Barry S. Zuckerman, MD

      Affiliations

    • Department of Pediatrics, Boston Medical Center, Boston MA
    • ,
  • Philip A. Pizzo, MD

      Affiliations

    • Department of Medicine, Children's Hospital Boston, Boston, MA
    • Stanford Medical School, Palo Alto, CA
    • ,
  • Gary R. Fleisher, MD

      Affiliations

    • Department of Medicine, Children's Hospital Boston, Boston, MA
    • ,
  • Robert J. Vinci, MD

      Affiliations

    • Department of Pediatrics, Boston Medical Center, Boston, MA

Article Outline

 

The last 20 years have seen many mergers in business, law, and banking, as well as in medical schools and hospitals, generally for economic reasons.1, 2 Mergers of residencies for educational purposes are less common3, 4, 5, 6, 7, 8, 9 and even more infrequent for pediatric programs.10, 11 The most carefully studied residency mergers have involved family medicine,3 pediatrics,10 surgery,5 and psychiatry7 and have evaluated resident and faculty opinions in such areas as institutional culture, governance, educational curriculum and teaching, programs costs, and resident career directions.3, 5, 7, 10 Key benefits from these mergers have included increasingly diverse populations of patients for clinical and educational purposes and academic enhancement.5, 7, 10 Challenges have included resolving conflicts between differing cultures, decreased resident–faculty collegiality, and resident morale challenges.5, 10

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The Residency Program 

The Boston Combined Residency Program (BCRP) was formed in 1996 from the merger of 2 existing pediatric residencies, Boston Medical Center (BMC) (33 residents) and Children's Hospital Boston (CHB) (87 residents). The goals of the merger were to create a broader and more varied clinical experience, to create more opportunities for independence and learning, to enrich career opportunities through broader educational experiences, and to enhance the training of pediatric academic leaders. The program involved the joining of a municipal hospital with a private children's hospital. A shared leadership structure of the 2 program directors responsible to the 2 department chairs, a single program (BCRP) with 2 tracks (categorical and primary care), and a fully integrated program of 120 residents (40 each year) characterized the program.

Rotations occurred either at CHB or BMC or were joint rotations, with time spent at both sites. The new curriculum was introduced in each succeeding year commencing with the intern year. In the aggregate in the first 2 years, categorical residents spent 70% of their time at CHB and 30% of their time at BMC, and spent 90% of their supervisory time at CHB in their senior year. Primary care residents spent 40% their time at BMC and 60% of their time at CHB in the first 2 years, and spent 90% of their supervisory time at BMC in the third year. Electives could be taken at either hospital. International electives and research experiences emanating from BMC or CHB were available to all residents irrespective of track.

From the onset, residents viewed themselves as members of the BCRP (not a specific track), but for purposes of salary, benefits, and administrative matters, primary care residents are assigned to BMC, and categorical residents are assigned to CHB. Residents' salary and benefits are adjusted to be comparable in both institutions. Financial benefits (eg, support for academic meetings, international travel, research projects) are equally available for all residents in the program. The education curriculum and program is reviewed by a combined Residency Program Training Committee (RPTC) composed of faculty and residents from both tracks and hospitals.12 Administratively, the program is run by a joint Executive Committee composed similarly. All committees (Internship Selection, RPTC, Resident and Program Evaluation Committees, and the Advisor Committee) are co-chaired (shared governance) and staffed by residents and faculty from both hospitals and tracks. Chief residents are selected jointly by department chairs and program directors. The salaries of program directors and coordinators are paid by each hospital. Administrative costs are shared (2/3 CHB, 1/3 BMC). The total cost of the program (resident and administrative) has remained expense-neutral for each hospital.

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Lessons Learned 

As a result of implementation of our joint program over the past 12 years, 5 important lessons have been learned.

Goals for the Merger 

Widespread knowledge and acceptance of the rationale for the merger became a critical stabilizing force. The department chairs saw this best accomplished through the combining of 2 different academic cultures, hospitals, and departments. They also saw greater autonomy in resident responsibility accomplished more easily for less medically complex patients at BMC, coupled with extensive teaching and in-depth subspecialty education achieved at CHB. Strong subspecialties coupled with a primary care emphasis across the 2 sites enhanced the program for all residents.

One program with 2 tracks became a second core philosophy. Two tracks, both focused on producing academic leaders, with one focused on urban primary care and the second on subspecialty training, allowed for a diverse class of residents and curricular enhancements that advanced individualized learning and career goals. The core philosophy of a single program but with the advantages emanating from 2 tracks came to be central to the program's success.

Governance 

The program was conceptualized by the 2 department chairs, planned by a joint transition committee from CHB and BMC, and jointly managed by the program directors. The lines of authority were clear. Within the BCRP, governance was always shared. (The Residency Review Committee required single institutional sponsorship, which was assumed by CHB and its program director.) The BCRP, not the CHB or the BMC residency program, became central. The program directors were in daily communication and resolved every issue together.

Second, 5 tenets of effective organizational leadership were instituted: commitment, collaboration, communication, trust, and conflict resolution.13 Leadership of the program was collaborative, with transparent committee structures used to enhance open communication with faculty and residents. Careful attention to process and fairness became guiding principles. The resident community knew that disputes could and would be resolved in a transparent manner by the program directors and, when necessary, the department chairs.

Effect on the Institutions 

The residency program at each institution changed in major ways. The institutions, departments, divisions, and faculty did not. Their differing core mission and values of patient care and education remained constant and were used to enhance education for the residency. Program directors and faculty did not lose their jobs. Departments and divisions did not close.

Through multiple joint retreats, 2 very different departments learned from each other and thus were enhanced. Similarly, the residency selected the best administrative practices from each of the 2 programs to incorporate into the BCRP. The energy involved in the creation of the BCRP resulted in positive change for both institutions.

Facilitating Structures 

To accomplish the program merger, the department chairs formed a small transition committee of faculty and residents, chaired by the program directors, to advise as to the nature of rotations, process for internship selection, timetable, and innumerable operational issues.14 Once the program was in place, 2 additional committees, 1 for educational issues (RTPC) and the other for administrative issues (Executive Committee) met monthly at alternate sites (CHB or BMC) to discuss operational issues. These committees, which proved essential for accomplishing programmatic and educational change, received input from faculty and residents, resolved potentially divisive issues in a transparent manner, and provided feedback regularly to all constituencies. Both committees are still operational 12 years later.

Curriculum and Education 

The residency was enhanced through a richer educational curriculum. First, when strengths existed at both institutions (eg, adolescent medicine, behavioral developmental pediatrics), the best educational aspects at each site were retained in the new rotation and the less valuable ones were eliminated. When differing strengths existed at the 2 institutions (eg, emergency medicine, neonatal intensive care), the separate clinical experiences were maintained but combined educationally in a complementary manner. When a rotation existed at 1 site only (eg, endocrinology, pulmonary medicine), residents from both tracks were afforded the opportunity to participate.

Second, the increased focus generated by the new program resulted broadly in multiple educational innovations and improvements. Rotations were evaluated longitudinally and graded each year. Educational innovations (eg, career development block,15 bimonthly basic and clinical journal clubs,15 bioethics curriculum,16 resident as teacher curriculum,17 senior rounds,18 international rotations,19 leadership seminars) proliferated as a result of constant attention to education and curriculum emanating out of the RPTC, often using faculty from both sites.

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Outcomes and Challenges 

The primary goals of the merger were accomplished. First, the melding of 2 very different cultures was clearly synergistic. CHB benefited from primary care exposure; BMC benefited from a subspecialty, research-oriented environment. Greater autonomy in resident responsibility (at BMC) and the vast array of specialty teaching (at CHB) were broadly recognized and appreciated. Second, the merger enhanced resident education through broader patient exposure and faculty teaching, as well as through curricular and educational innovations. Third, the goal of training academic leaders was met, with 75% to 80% of the each graduating class entering academia.20

Four challenges required the constant attention of the department chairs and program directors. First, a major change was needed in faculty, resident, and institutional thinking at both BMC and CHB. The traditionalists from both institutions were slow to accept the merged program and required persistent demonstration of the value of the joint program. Also, institutional wishes had to be adjusted periodically to meet educational needs. Second, although educational benefits and individualized learning were enhanced by 2 tracks, inequalities in resident workload, patient exposure, and education could and did occur. This required a unified voice of the 2 program directors, a transparent decision making process, and a balanced approach with absolute fairness. Third, with the program based at 2 busy academic medical centers, program directors needed to balance the growing service needs of the 2 institutions to avoid duplicative training experiences. As service needs have increased, new models for patient care delivery have become a high priority for the program directors. Finally, constant educational change, although threatening to the residency at first, became part of the culture. Full participation through the RPTC allowed the residents to become more educationally knowledgeable and committed to curricular change.

References available at www.jpeds.com

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References 

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PII: S0022-3476(08)00621-5

doi:10.1016/j.jpeds.2008.07.036

The Journal of Pediatrics
Volume 153, Issue 6 , Pages 731-732.e1, December 2008

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