**2.1 History of residency mergers**

The first reported residency merger was between two psychiatry residencies, one from The Institute of Living, and the other from the University of Connecticut [5]. In 1989, leaders from each program came together to discuss what the combined program would look like and how they would implement the changes; in July 1990, the combined program began. Both programs had their own set of strengths. The Institute of Living, which is located in downtown Hartford, Connecticut, is one of the oldest private psychiatric hospitals in the US; its reputation and location provide a diverse patient base and the opportunity for long term follow up. On the other hand, the University of Connecticut Health Center, which is located in a Hartford suburb, is an academic institution with a strong commitment to the education of both medical students and residents.

Based on these complementary characteristics, the respective institution leaders were hopeful that the merger would be successful. A task force to construct the new residency program was assembled and was comprised of both faculty and residents from both institutions. Salaries of the residents had differed between residency programs, so once merged, all salaries were standardized. Similarly, call requirements differed, so those too were standardized. Overall the merger was successful; both institutions used the merger to improve their educational experience as one cohesive unit.

There is limited literature available regarding residency mergers, but the most widely referenced specialties include pediatrics [6], psychiatry [5], family medicine [7], and surgery [8]. For the most part, the publications generally present the process behind the merged programs, the challenges they faced throughout the process, and the advice they offer for future mergers. Success of the merger is very subjective and is not typically measured objectively, with the exception of some literature which follow residents' perspective of the process through surveys evaluating how positively or negatively they felt about the merger.

Unfortunately, the limited amount of information available about residency programs that have merged or are undergoing a merging process is compounded by the fact that there is no official record or list which is published by the Accreditation Council for Graduate Medical Education (ACGME). Not only does the ACGME not keep records of this, but previous personal communication with ACGME administrators have revealed that no data on residency mergers is maintained [9].

Although not specifically a merger, a well-publicized closure of a large academic institution made national news in the United States in 2019. Hahnemann University Hospital, a 500-bed teaching hospital in Philadelphia, Pennsylvania, announced its closure abruptly in June 2019, soon after it had recently welcomed 140 new residents to its varied residency programs. This chaotic sudden closure suddenly displaced more than 550 residents and fellows, who then had to quickly find residency positions elsewhere. Fortuitously, all trainees were able to find educational opportunities within 43 days [10]. This is a worst-case scenario result of financial pressures placed upon teaching hospitals. The goal of raising this discussion about residency mergers and collaboration is to avoid a similar unfortunate event.

#### **2.2 Guidelines for residency mergers**

Rider and Longmaid, both of Harvard Medical School, have had personal experience with mergers as well as conflict resolution and therefore published an article in 2003 detailing their advice for merging residency programs [9]. They identified 10 specific guidelines to keep in mind while going forward with the merging process, which we will discuss briefly.

#### *2.2.1 Lead with vision*

The success of any merger is dictated by having a definitive plan that is effectively carried out. This can only be achieved with establishment of a leader who is capable of not only creating this plan but also putting it into action. Whether that is one of the previous residency program directors (PDs), a combination of individuals, or even another individual entirely, the leader should be clearly identified and communicated to all involved parties.

A plan should be established which addresses a few particular issues for the new program: goals of education and training, educational philosophy, governance of combined program, institutional cultures, and the impact of merger on faculty and trainees. The vision of the leader should be used to formulate a plan for these issues as well as a timetable for that plan to be fully operational. A more rapid timetable for the enactment of the plan is preferable, as the goal is of course to minimize the amount of disruptions during the process of combining programs.

The importance of a dynamic leader is not to be neglected, either. Although the leader may have his or her own vision, it should be combined with the input of faculty and residents from both institutions. Differing opinions will allow for the creation of an ideal program, to which all faculty will then be motivated to contribute. A suggestion based on previous successes in other health care mergers would be to create a committee of involved individuals who are dedicated to shaping the goals and vision for the future residency program. This would be a concrete way to incorporate the influence of all departments interested, as well as those of the residents. Flexibility is a necessary characteristic of a leader to establish a plan that not only fits the original vision but combines with the constructive input of others.

#### *2.2.2 Establish and reinforce communication links early*

Communication is key! While the vision and plan are put into action by the leader, obstacles that challenge the success of that plan will always be encountered. Having clear channels of communication already established can be helpful when trying to address some of these obstacles. Frequent updates via multiple modes of

communication will ensure that a communication link is available should any issues arise. Email would be the easiest, but not always the preferred method for everyone. An in-person meeting that is scheduled either weekly or bi-weekly could be helpful in making sure that all parties remain involved in planning and enacting change.
