By BARRY KLEIN
© St. Petersburg Times, published April 2, 2000
TALLAHASSEE -- State Rep. Durell Peaden Jr. is a proud product of rural Florida, a country doctor born and raised in DeFuniak Springs, one of the many communities he says has been badly neglected by Florida's medical establishment.
So when he hears that most of the state's medical school deans think his bill to create a medical college at Florida State University is unneeded and impractical, he gets very cranky.
"What do they know? Most of them don't even practice medicine," roars the Crestview Republican, who says he wouldn't be pushing a new school if the deans had done a better job of producing doctors willing to work in Florida's rural communities and inner cities.
"Let's face it," Peaden says. "Someone making $300,000 in a real nice dean's office could care less whether someone dies of a heart attack in Chipley."
So goes another reasoned discussion of the legislative push that, for better or worse, could soon make Florida the first state in 20 years to open a new medical school.
Many experts, including the deans at the state's three largest medical schools, think that effort is misguided.
They note that medical schools across the country are struggling financially. And while they acknowledge isolated shortages of doctors, the deans say Florida has more than enough physicians overall, a stance supported by the American Medical Association and the American Association of Medical Colleges.
They doubt a new school would even be under discussion if it weren't backed by powerful FSU alumni in the Legislature, especially House Speaker John Thrasher.
"People need to remember that medical education is an expensive proposition," says Robert Watson, a senior associate dean for educational affairs at the University of Florida medical school.
So is providing all Floridians with adequate health care, say FSU officials, who are asking for $34-million annually to operate the school. They say it will serve as a model for the future.
The school will have no teaching hospital -- the traditional training ground for fledgling physicians. That plan had to be abandoned last year after the price tag blew up to more than $200-million annually.
Instead, FSU medical students will spend much of their time training in nursing homes and rural clinics. The goal is to produce a steady supply of primary care physicians willing to treat the elderly and people in isolated communities, including 12 Florida counties the federal government says are medically underserved.
The deans say that approach, however well-intended, is going to have problems. They point out that FSU has no means of compelling its students to stay in those areas once they graduate.
"It is very difficult to force professionals to practice in a certain locale," says John Clarkson, dean at the University of Miami medical school.
"They are going to have a tough time," says Martin Silbiger, the University of South Florida medical school dean.
FSU provost Larry Abele, who is heading up the effort to land a medical school, says it wouldn't be fair to force only FSU students into post-graduate service.
"Not when taxpayers are paying the same amount to subsidize the education of medical students at the other schools," he says.
That position seemed to startle supporters who learned about it last week.
"What is going to prevent their students from moving to New York and becoming plastic surgeons?" asks Steven Uhlfelder, a Tallahassee lawyer and the only member of the state Board of Regents who has publicly supported FSU's plan. He says his support is conditioned on some form of compulsory service.
Peaden promises such a provision will be in the final bill.
"FSU can say what they want," he says, "but the Legislature has the final say."
The political pressure that has driven this issue for more than two years has had one indisputable effect: deterring opposition.
The deans, for example, have reservations about the proposal but are nervous about the consequences of being public with their concerns. Lawmakers, after all, have a lot to say about the size of their budgets.
They are much more comfortable pointing at the numbers.
A $250,000 study conducted for FSU indicates that Florida has 201 doctors for every 100,000 residents. That puts the state well below the national average, which the study cited as 221 doctors per 100,000 residents.
But the American Medical Association says there are 283 doctors per 100,000 residents in Florida, or slightly more than the national average, which the AMA pegs at 280. The American Association of Medical Colleges says its numbers are very similar.
Ken Boutwell, the president of MGT of America, the Tallahassee-based consultants who did the study for FSU, say their statistics are different because of a calculation he calls "age-weighting."
Every Florida resident aged 65 or older was counted at least twice in the MGT study, Boutwell says. The goal was to reflect the disproportionate impact older people have on the health care system.
Abele says that is a legitimate calculation. It also is a convenient calculation, and one critics say raises questions about how much the medical school proposal is being shaped to make it easier to sell to politicians in Tallahassee.
Thrasher did not return calls seeking comment. But his backing of a project that would greatly benefit his alma mater falls comfortably within a long Florida tradition of House speakers who bring home the bacon.
Former Speaker Jon Mills helped land a performing arts center for his Alachua County district. The mammoth classroom complex that wraps around FSU's football stadium came courtesy of T.K Wetherell, a former speaker and Seminole wide receiver.
Ralph Haben was speaker-designate in the early 1980s when his colleagues okayed a civic center for his hometown of Palmetto. One legislator was so impressed with that effort that he paid to have a platter with an entire roast pig on it brought into the House chamber.
Boutwell winces when he hears such comparisons. He knows they are inevitable, but says much of the same talk was floating around when USF proposed creating the state's third medical school 35 years ago.
"It's really just turf guarding," says Boutwell, who was a university system vice chancellor at the time.
Silbiger also noted parallels between FSU's proposal and the one that led to USF's medical school.
"Our school also started on the cheap because Gainesville didn't want it to thrive," he says.
But it grew. And so will FSU's, Silbiger says, regardless of what its plan says now.
"Twenty years from now," he says, "that school will look just like everyone else."
In higher education circles, the phenomenon is referred to as "mission creep."
University system Chancellor Adam Herbert, who thinks it makes more sense to expand the state's existing medical schools than create a new one from the ground up, says he has no intention of letting it happen at FSU.
Last year, Herbert recommended against creating a medical school for FSU. The Board of Regents concurred.
But if the Legislature overrides their recommendation, Herbert says, FSU will be expected to stay within its proposed budget, which is a fraction of the more than $200-million spent annually by the state's three largest medical colleges.
"To do otherwise would be irresponsible from a taxpayer perspective," Herbert says.
Abele, the FSU provost, says that's fine with him.
"We have no intention of straying from our very well-publicized mission," he says.
Right now, the state has four medical schools: at USF, the University of Florida, the University of Miami and at Nova Southeastern University, a college of osteopathic medicine in Fort Lauderdale.
In addition, FSU operates a first-year medical program known as PIMS. Those students typically move on to UF for the rest of their education.
The Florida schools graduate about 500 new physicians every year, which isn't many for a state of 15-million people. About 90 percent of the state's physicians are imported, either from out of state or from foreign schools.
Peaden considers that unconscionable.
"How can you justify that when our medical schools are turning away upward of 300 qualified applicants every year?" he asks.
Neither Herbert nor the deans dispute the numbers.
"But is the state obligated to educate everyone who is qualified?" asks Clarkson, the UM dean. "I think not."
Clarkson notes that only about half of UM's medical students practice in Florida after they graduate.
FSU officials are confident their school can beat that record. The key, Abele says, is recruiting.
"Studies show that if you recruit students from rural and inner-city areas, they are more likely to return to those areas and practice," he says.
Kathy Thomas, an administrator at Madison County Memorial Hospital in North Florida, says most physicians won't stay in rural areas unless they already are familiar with the lifestyle.
"It can be a real culture shock for doctors who come here," she says. "It can be a very difficult adjustment."
People who have been watching the efforts of FSU's legislative supporters on this issue love to talk conspiracies.
One scenario involves the proposal's likely role as a bargaining chip in upcoming budget negotiations between the House and Senate. The Senate hasn't put any money for the medical school in its proposed spending plan.
The theory supposes that Thrasher will get his medical school in exchange for state Senate President Toni Jennings getting a performing arts center for her home district.
"That is absolutely not true," says Edie Ousley, an aide to Jennings, who says her boss is more concerned with problems in public schools than possible deficiencies in medical education.
"If that's what she is supposed to be trading for," Ousley says, "she is obviously getting the bad end of the deal."