Letter from New Orleans FREE

It's 19 September 2005. We are getting things done in a whole new way, and we're making terrific progress. The same rules don't really exist anymore, hierarchies have broken down, and responsibility goes to people who are willing to work. The local motto is “ask for forgiveness, not permission.” Even the dress code is different. You can't tell who the CEOs are because everyone is wearing jeans.

The city itself is becoming more livable each day. The storm damaged trees, billboards, and anything else that served as a good sail, but in the areas that the flood spared, streets are clear and crews are working at a Herculean pace to restore power, sewerage, and other vital systems. Today, Entergy connected our downtown hospital and other buildings to emergency-level power. Crews can now get in and clean effectively.

Connections to the outside world are still limited. The only reliable media source is radio station WWL870 AM, with 90% of people tuned in. In some outlying areas, newspaper and mail delivery is starting slowly. Cellular and other telephone service is improving daily, but dropped calls, redialing, and recorded messages of “all circuits are busy” are routine. Most of us walk around with 2 cellular telephones, 1 with an out-of-state area code. Internet access is spotty but invaluable.

Those of us at Tulane University are focusing on rebuilding our city and its health care infrastructure. The opportunity to develop health care services and medical education from the ground up is, literally, energizing. Since the first week of September, I have been involved in the complex and rewarding process of jump-starting our university, medical school, training programs, and clinical care settings. In doing so, we are helping to jump-start the economy of New Orleans, as Tulane is the largest private employer here.

I haven't worked this hard since I was an intern. Workdays are 18 hours long and come with the continual stimulation and interruption—telephones ringing, e-mails popping up, and people approaching. Good thing I thrive on chaotic environments and change. Without reliable roads and lines of communication, work is difficult and there are many impromptu interactions. For example, I had a series of meetings with a variety of folks on the ramp of Charity Hospital on Wednesday. This chaos makes me worry about duplicate efforts and about not working efficiently and rapidly enough to meet the needs of our citizens. Nonetheless, I am convinced that we will successfully rebuild Tulane and New Orleans, and I believe that what we rebuild will be better than what we had before and perhaps will be better than any other health care system.

Tulane's plan is to keep our faculty and housestaff in the greater New Orleans area to provide services to patients. We hope to be in the medical school building by November, so that we can start recruitment for the next residency season, using the motto “Tulane, where heroes are made.”

Our primary training and clinical sites were the New Orleans Veterans Administration (VA) Medical Center, Charity Hospital, and Tulane University Hospital and Clinic. We intend to reopen Tulane University Hospital and Clinic as soon as possible. We are lobbying the state to reopen Charity or University Hospital as a site for care for the underserved, but we don't know whether we'll win that one. Even if we do, we'll probably be able to only provide emergency and ambulatory care. However, ambulatory training and research opportunities would be available at the least.

The VA hospital is setting up mobile clinics that my faculty, and hopefully residents, will staff. These mobile clinics will care for the same patients our residents and faculty cared for when the VA was open. The VA hospital appears to be in good shape, although I am not an engineer. I hope that they can reopen quickly, given the generally high needs for services among veterans, most of whom are low-income.

Until our New Orleans cluster sites are open, we are temporarily placing our faculty and medicine residents at sister hospitals here (Lakeside and Lakeview). Both are for-profit hospitals historically not focused on care for the underserved, unlike Tulane University Hospital and Clinic. Nonetheless, there should be ample inpatient training opportunity. We are also operating existing sites in the community, which we hope to develop into intermediate-term facilities for vulnerable patients. One of these sites is at the foot of Canal Street, under a cement awning where we have set up card tables and some chairs (Figure). The USS Comfort hospital ship may serve as a temporary Charity Hospital. Tulane has a sister public hospital in Alexandria, Louisiana, near the Alexandria VA and another private hospital. The juxtaposition of these institutions will provide a very similar training experience for housestaff who end up in Alexandria. We'll place a few residents in Houston, Texas, to work with Baylor faculty. Baylor's motto is like that of the 82nd Airborne: “We can make that happen.”

All of this is intended to be temporary so that we can bring everyone back together when we have the capacity from a housing and patient care standpoint. We remain committed to the city. All faculty and residents requested New Orleans as their first-choice site. In fact, despite the difficulties and uncertainties, not a single member of my general medicine faculty or a single resident has quit. They are tenacious and loyal to the people of this city.

I am sure you can imagine that this is a logistic nightmare, given how limited our telephone and Internet access is and how everyone is spread out around the country. There are lots of special needs, and there are many who provide revenue streams and who regulate us to pass our ideas by. To their credit, all faculty, residents, and regulatory bodies have been incredibly understanding and flexible.

In her devastation, Hurricane Katrina has provided an unprecedented opportunity to New Orleans. Never before has a city had the chance to completely rebuild its health care system. My fervent hope is that we don't retreat to comfortable ways but that we seize the day and develop a fully integrated health care system for the underserved that is supported by an electronic health record. I dream of multispecialty clinics in communities that provide on-site mental health care and social work services, clinics that aren't housed in clinics but in community centers that also have resources, such as exercise facilities, child care, and Internet access. Maybe we'll scrap the old way of one-on-one physician–patient visits for all occasions, and we'll use innovative formats, such as group visits, which have shown great promise in improving patient self-care and satisfaction. I also hope that we take advantage of the complete lack of appointment schedules by using open access and other scheduling innovations to make the services friendly to patients rather than to providers. The post-hurricane health care system should be proactive (as it could be if electronic medical records were used) and should identify at-risk patients before their conditions deteriorate. It should measure and monitor the quality of care in an open and positive way that will lead to continuous improvement. It could be a showcase.

This rebuilding will take money, creativity, and huge amounts of sheer will. Many of us have the will; few have the money. My hope is that the money meets those who have the interests of the patients, not their own revenue stream, in mind.

My personal message to you is that you should see Tulane as a viable university with a general internal medicine section that will be strengthened by the storm. People around the country have been incredibly supportive and have offered to take me in immediately at their institutions. However, I could not possibly leave. Not only do I have a responsibility to the city and to my faculty to get us running again, I also would never miss this unprecedented learning and leadership-building opportunity.

I will try to write again soon to give you more information as it evolves. We will continue working until we get this going again. Stubborn Louisianans we are.