Impact of Hurricane Katrina on Medical

Student Academic Performance: The Tulane

Experience
BYRON E. CRAWFORD, MD; MARC J. KAHN, MD; JENNIFER W. GIBSON, PHD;
ANNE J. DANIEL, PHD; N. KEVIN KRANE, MD

ABSTRACT: Background: Hurricane Katrina forced the

temporary closure of Tulane University School of Medicine requiring relocation to the Texas Medical Center in
Houston, Texas. This required curricular restructuring,
and resulted in faculty/student challenges. The effect of
these stresses on student performance was studied.
Methods: A pre-Katrina and post-Katrina comparative
analysis of all Tulane medical students performance on
standardized exams, internal examination and United
States Medical Licensing Examination (USMLE) step exams was performed. A one-way analysis of variance was
used to determine if mean examination scores differed
from pre-Katrina to post-Katrina. Results: Internal exam-

ination scores did not differ significantly. National standardized examination grades significantly decreased
pre-Katrina to post-Katrina in Biochemistry, Pharmacology, Pathology, Medicine, Pediatrics and Psychiatry
(P 0.05). There was no statistical change in USMLE
scores. Conclusions: Tulane students had a statistically
significant decline in performance on many course and
clerkship examinations, though overall performance on
licensing examinations was unchanged. Many stresses
may have affected students ability to perform. KEY
INDEXING TERMS: Disaster; Learning; Medical Students; Assessment. [Am J Med Sci 2008;336(2):142
146.]

administration. Though the ability to resume medical education so quickly was remarkable, this was
an especially challenging period for students, faculty, and their families as reflected in Table 1.3,4 The
faculty were very concerned about the effect of additional stresses on student performance and implemented new programs and policies to minimize student stress as outlined in Table 2.3,4
There are very few studies on the effects of disastrous events on learning, and little is known about
the specific effects on medical students.57 We therefore studied the effect of abruptly moving the educational programs to Houston, after Hurricane Katrina, on the academic performance of the first,
second, and third-year Tulane students.

urricane Katrina forced the closure of Tulane

University School of Medicine and its affiliated
hospital on August 29, 2005.1,2 As a result, the
undergraduate medical education program moved to
Houston, Texas, and 1 month later, using its original curriculum, resumed first and second year
classes at Baylor College of Medicine (BCM) and
clerkships at BCM, University of Texas, Houston,
University of Texas, Medical Branch in Galveston,
and Texas A&M School of Medicine. The basic science curriculum, taught by almost all Tulane faculty, required some restructuring but maintained
the same predisaster objectives, teaching methodologies, learning assessment methods, and resources.1
Despite relocating, student retention was over 95%,
and most students quickly adjusted. Maintaining
the quality of the educational experiences was of
concern to students, faculty, and accreditation agencies, which also monitored and worked with Tulanes
From the Department of Pathology (BEC), Department of Medicine (MJK, KK), Department of Medical Education (JWG, AJD), Tulane University School of Medicine, New Orleans, Louisiana.
Submitted April 29, 2008; accepted in revised form May 13,
2008.
Correspondence: Byron E. Crawford, MD, 1430 Tulane Avenue.,
SL-79, Department of Pathology, New Orleans, LA 70112 (E-mail:
bcrawfo@tulane.edu).

142

Methods
Participants
This study met Internal Review Board (IRB) exemption criteria. The population consisted of first, second, third, and fourthyear students enrolled at Tulane School of Medicine during the
2004 2005 (pre-Katrina), 20052006, (Katrina), and 2006 2007
(post-Katrina) academic years. Each class was compared with the
previous class, and the fourth year class was used as a control
group for previous clerkship exams and United States Medical
Licensing Examination (USMLE), Step 2Clinical Knowledge
(CK) scores. Class profiles of all years were similar, with equivalent Medical College Admission Test (MCAT) class means, average student age of 28 and similar demographics.
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Crawford et al

Table 1. New Stresses

Evacuation from New Orleans

Returned, commuted from New Orleans
Loss of life, missing persons
Change in lifestyle
Property loss
Sense of group loss
Family/individual resettlement
Separation from family/friends
Pre- and post-Katrina housing issues
Financial obligations
Adjusting to new schedules
Adjustment to new faculty
Rumors and uncertainty
Unknown return date
Transference of student/faculty stress

Materials
The National Board of Medical Examiners (NBME) produces
standardized, objective discipline-based exams that can be
used to assess knowledge in the basic and clinical sciences
throughout the medical school curriculum known as shelf
exams.
USMLE is a 3-step standardized examination that must be
passed to practice medicine in the United States. Step 1 assesses
the ability to understand and apply concepts of the sciences to the
practice of medicine and is usually taken at the end of their
second year. Step 2CK, measures application of medical knowledge, skills, and understanding of clinical sciences and is usually
taken during their fourth year.
Pre-Katrina and post-Katrina students took the NBME basic
and clinical sciences shelf exams at Tulane School of Medicine
during their regularly scheduled examination time. Results on
the basic sciences exams were available in the content areas of
Biochemistry, Pathology, and Pharmacology. Internal examination grades were used in basic science courses that did not
utilize NBME standardized exams including Anatomy, Histology, and Physiology. For the clinical science exams, results
were available in the following subject areas: Medicine, Pediatrics, Psychiatry, Surgery, and Obstetrics/Gynecology. Results were also available for the USMLE Step 1 and Step
2CK exams. NBME and USMLE test results were available
to senior administrators.
Design and Data Analysis
For NBME and internal exams in the basic sciences, a one-way
analysis of variance (ANOVA) was used to determine if mean
examination scores differed from pre-Katrina to post-Katrina.
For NBME clinical science shelf exams, 2-tailed unpaired Students t tests were used for the same purpose. For USMLE

Table 2. Support Programs

Maintenance of similar curriculum

Pass/fail grading system
Elimination of all attendance requirements
Peer-assisted tutoring programs
Student/faculty meetings
Counseling services
Legal services
Housing assistance
Financial support
Maintenance of Tulane identity
Development of listservs
Stress-reduction retreat
Support of the Texas Alliance institutions

THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES

results, a 2 analysis was used to determine if differences existed

in percent passing rates from pre-Katrina to post-Katrina. All
data were analyzed using SPSS 11.0 (Chicago, IL) statistical
software.
An alpha level of 0.05 was used for all statistical tests. Analyses
were conducted to examine whether student performance on
national and internal exams were impacted by Hurricane Katrina. Analyses compared pre-Katrina (2004/2005) examination
scores with Katrina (2005/2006) and post-Katrina (2006/2007)
scores.

Results
In the basic science comparison, post-Katrina students (first- and second-year students) who took
these examinations (basic science NBME Shelf Exams and USMLE, Step 1) on a post-Katrina date
were compared with students who took these exams
pre-Katrina. In the clinical rotations, third- and
fourth-year students who took the exams (clinical
clerkship shelf and USMLE, Step 2CK) post-Katrina were compared with students who took these
examinations pre-Katrina.
Basic Sciences (NBME)
A one-way analysis of variance (ANOVA) was
calculated on student NBME shelf examination
scores in the basic science content areas of Pathology, Biochemistry, and Pharmacology. For the
NBME Pathology examination, the main effect
was significant, F(2,455) 3.12, P 0.04. Planned
comparisons revealed that Pathology grades declined from pre-Katrina to post-Katrina, t(455)
2.44, P 0.02. For Pharmacology, the main effect of
year was again significant, F(2,444) 5.50, P
0.05. Specifically, when compared with pre-Katrina
scores, student performance was significantly lower
in the Katrina academic year, t(444) 3.21, P
0.004. In Biochemistry, the main effect yielded significant results, F(2,467) 7.88, P 0.001. Planned
comparisons revealed that when compared with preKatrina scores, student performance significantly
declined during the post-Katrina academic year,
t(467) 3.47, P 0.001. These findings are summarized in Figure 1.
Basic Sciences (Internal Exams)
Mean examination scores in Histology, Anatomy,
and Physiology did not differ from pre-Katrina to
post-Katrina time periods (P 0.05).
Clinical Science Exams (NBME)
Two-tailed unpaired Students t tests were performed on the NBME clinical sciences shelf examination scores. In the subject area of Medicine, the
comparison revealed that student grades declined
significantly from pre-Katrina to post-Katrina,
t(317) 2.42, P 0.02. For Pediatrics and Psychiatry, the same held true; there were significant
declines in mean scores from pre-Katrina to postKatrina, t(301) 2.06, P 0.04 and t(290) 2.99,
143

Academic Performance Post-Katrina

Figure 3. Percent passing rates on the USMLE Step 1. P-values

represent significance levels obtained when comparing Tulane pass
rates to those of the national average.
Figure 1. Tulane mean performance on NBME basic science
shelf exams. P-values represent significance levels obtained when
comparing Tulane pre-Katrina to Katrina scores () and Tulane
pre-Katrina to post-Katrina scores (*). National average mean
scores are provided as a reference.

P 0.003, respectively. In contrast, Obstetrics/Gynecology student test scores showed a significant

increase from pre-Katrina to Katrina, t(271) 2.01,
P 0.04 and an increase from pre-Katrina to postKatrina, t(323) 2.29, P 0.02. Surgery examination scores showed an increase from pre-Katrina to
Katrina, t(295) 2.30, P 0.02. These findings are
summarized in Figure 2.
United States Medical Licensing Examination
A 2 goodness of fit test was used to determine
whether USMLE pass rates during the Katrina

and post-Katrina academic years were as expected

given Tulane passing percentages in the pre-Katrina academic year. Student pass rates were also
compared with the national average for each year.
For the USMLE Step 1 examination, there were no
differences in pass rates comparing pre-Katrina
with Katrina and post-Katrina testing periods
(P 0.05) nor did they differ from the national
average (see Figure 3).
For the USMLE Step 2CK examination, Tulane
pass rates declined from pre-Katrina to Katrina,
2(1, n 147) 12.75, P 0.01 but not from
pre-Katrina to post-Katrina (P 0.05). Tulane student pass rates were significantly higher than the
national average during the pre-Katrina year, 2 (1,
n 158) 4.71, P 0.03, but did not differ significantly from the national average during the Katrina and post-Katrina years (see Figure 4).
Discussion

Figure 2. Tulane mean performance on NBME clinical science

shelf exams. P-values represent significance levels obtained when
comparing Tulane pre-Katrina to Katrina scores () and Tulane
pre-Katrina to post-Katrina scores (*).

144

Shortly after Katrina, internal examination mean

grades did not show measurable differences from
previous years. This study was devised to learn how
the students performed on national standardized
exams comparing the class means with national
means, and also internally comparing the class
means with previous years.
Tulane University School of Medicine did a remarkable job by resuming the entire undergraduate
medical curriculum in Houston 1 month after Hurricane Katrina. Changes were necessary to account
for lost time and to adjust to faculty availability.
However, the pre-Katrina basic science curriculum
hours were delivered over the ensuing academic
year, and all pre-Katrina clerkships were available.
Modifications to the curriculum were also necessary
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Crawford et al

also considered new learning. Problems with explicit memory have been associated with traumatic/
stressful events along with dissociative amnesia
that involves breaks of memory that occur for limited time because of hippocampus damage.8 Studies
have not shown that implicit memory is affected by
stress or trauma. This study did not measure hippocampal damage.

Figure 4. Percent passing rates on the USMLE Step 2 (CK).

P-values represent significance levels obtained when comparing Tulane pass rates to those of the national average.

as faculty attempted to mitigate the stresses this

move placed on students. The affect of anxiety disorders, depression, and post-traumatic stress syndrome on students and faculty, was also of concern.4
All of these issues were considered in reconstructing
the curriculum. However, it was essential that all
students received the expected education necessary
to achieve curriculum goals for their roles in patient
care and residency training. This concern was also
expressed by accreditation agencies at both the undergraduate and graduate medical education levels.
It was therefore important to demonstrate that student outcomes did not suffer despite this unprecedented relocation of the entire medical school.
Pathophysiology of Stress and Learning
Past reports show that traumatic or stressful
events may result in disturbances of memory and
problems with concentration.8,9 These possibly result from hippocampus damage that links to problems with memory and new learning. Studies also
show that stress inhibits neurogenesis in a damaged
hippocampus, an effect that is reversed by antidepressants.8,10 Stress hormones like norepinephrine
and cortisol have been reported to act on the hippocampus either strengthening memory (norepinephrine) or inhibiting memory formation (cortisol).8 Recent studies also show a close relationship of
the hippocampus and the medial prefrontal cortex
with stress-induced damage. Dysfunction of one or
both can result in problems with learning.11,12
Memory can be divided into implicit (nondeclarative, episodic)-conditioned responses, and explicit
(declarative, procedural)memory easily brought to
consciousness. An example of explicit memory is
learning lists of words or facts. Explicit learning is
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES

Comparative Analysis
The comparative analysis revealed a significant
decline in the clinical subject exams (Pediatrics,
Psychiatry, and Medicine). In the clinical years, students are applying knowledge learned in the preclinical years. Although students are still developing
explicit memory, they apply previous knowledge reflexively. It is proposed that previously learned
knowledge might be affected by stress and traumatic events explaining the decline in grades.
Grades in Obstetrics/Gynecology (Ob-Gyn) significantly increased, possibly secondary to other unmeasurable factors.
Results of the analysis from the basic science
courses are similar to the clinical clerkship exams.
Standardized examination grades significantly declined in Biochemistry post-Katrina. Even though
postdisaster class means significantly dropped in
Pharmacology and Pathology, when compared with
predisaster class means, they remained above the
national means in both topics. Learning content in
these 2 courses requires extensive explicit memory.
In addition, it requires recall of recently learned
material or new learning. It has been estimated
that approximately one-third of the students exhibited some degree of post-traumatic stress syndrome
or depression post-Katrina.4 One might hypothesize
that the reduction in the class means in these exams
result from hippocampus/medial prefrontal cortex injury and/or dysfunction of explicit type memory. Further research is needed to determine if the reduction in
class means is due to memory dysfunction.
Review of the comparison analysis of the USMLE,
Step 1 scores reveals no significant difference in the
Tulane pass rate and the national average for the
Katrina year or in the after post-Katrina year. Comparison of USMLE Step 2CK also reveals no difference in the pass rate. Step 2 pass rates exceeded
or were equal to national pass rates.
Study Limitations and Strengths
Determining the etiology of the changes in students
grades is multifactorial. Additional stress plays a role,
but there are many other variables that were not
measured including qualitative and quantitative postdisaster faculty variability, disaster timing in particular students curriculum (first year versus second year
versus third year), and the move back to New Orleans
with the repetitive process of reorganizing personal
lives, the curriculum and clinical rotations.
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Academic Performance Post-Katrina

Because this study only compared 1 class to another class, it did not evaluate individual students
that may have revealed additional variables affecting student learning. However, this study did involve 3 separate classes and compared them to standardized exams with national data instead of only
limited internal data.
In conclusion, the effects of Hurricane Katrina
resulted in additional student stress that did not
alter internal examination scores. This study evaluated and compared national standardized exams to
determine if there was significant reduction in academic achievement of these students. The results
support that there were significant class differences
in learning/test performance in multiple areas including Biochemistry, Pharmacology, Pathology,
Medicine, Pediatrics, and Psychiatry. The results
support the hypothesis that some students may
have experienced stress-related events that affected
their ability to perform utilizing explicit memory or
declarative memory resulting in lower basic science
scores. Despite the changes in individual course
scores, overall performance was not significantly
altered for the students in the Katrina year in the
basic sciences or during the clinical clerkships based
on these NBME shelf exams, USMLE Step exams,
and internal examinations.
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146

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