When Florida State University began lobbying the state Legislature for a new medical school in 1998, it triggered a near-revolt among the big players in the state's turf-conscious medical establishment.
A formidable array of institutions lined up to oppose the plan-including the deans of the state's three existing allopathic medical schools, the university's own powerful board of regents and the Florida medical society.
But the wall of opposition quickly crumbled. The Legislature, in a flurry of 11th-hour horse-trading brokered by a close associate of FSU's longtime president, approved $50 million to build a medical school that many believe is unnecessary.
Too many or too few?
Whether the creation of a new medical school was good public policy or pork-barrel politics, it helped reignite the longstanding national debate over whether America's 125 medical schools are producing too many physicians-or too few.
"This situation is not unique," says Jack Ginsburg, director of Health Policy Analysis and Research with the American College of Physicians-American Society of Internal Medicine. "Oral Roberts University got a medical school (it operated for 12 years after opening in 1978) despite recommendations against it from the state health planning agency. It went bankrupt. Parents want to send their sons and daughters to medical school. People want to have more doctors. But when you look at the actual requirements, the objective data show that there is no need for any more physicians (than existing schools produce)."
The new program is set to debut in May. When it gains its accreditation-and no one expects otherwise-the FSU facility in Tallahassee will become the nation's first new U.S. allopathic medical school since 1982, when Mercer Medical School opened in Macon, Ga.
Mercer's accreditation came at the end of a building boom in medical schools. From 1956 to 1980, about 40 new medical schools opened in the U.S. in response to concerns about a potential physician shortage.
By the time Mercer opened, however, fears of an oversupply of doctors led to an "effective voluntary moratorium" on future expansion in allopathic medical education, according to a July 2000 report in the New England Journal of Medicine titled "The Case for More U.S. Medical Students."
Scrambling to fill residencies
The number of U.S. medical school graduates has remained fairly consistent in the past decade, at about 16,000 per year. At the same time, the number of first-year graduate residencies has grown to about 24,000 per year, forcing many of the nation's 1,200 teaching hospitals to rely more and more on graduates of foreign medical schools.
Fitzhugh Mullan, M.D., former director of the federal Bureau of Health Professions and the author of the Journal article, says teaching hospitals could easily fill many of those positions by expanding medical training in this country. In fact, American medical schools reject more than two times the number of students they accept, an unnecessarily restrictive enrollment policy that robs many highly qualified students of a career in medicine and leads to a reliance on foreign medical school graduates, Mullan says.
"Given the large and consistent shortfall in the supply of medical school graduates available to fill residency positions and a pool of qualified applicants eager to enter medical school, it might be appropriate once again to expand enrollment in U.S. medical schools," Mullan wrote.
Mullan also rejects the notion that more U.S. medical schools would saturate the market. "There is no unemployment in the medical community," he noted in the article.
Yet the Institute of Medicine, a national advisory group affiliated with the National Academy of Sciences, issued a report in mid-1997 that called for a moratorium on new medical schools and a reduction in graduate residency programs. The government funds those programs at the rate of more than $6 billion per year-an increase of nearly $2 billion since 1990. The number of residencies has swelled in recent years, rising to more than 97,300 in 1998-1999 from about 82,800 in 1988-1989.
"With no cap on the number of residency positions funded," according to the report, "there is an incentive for cash-strapped hospitals to increase residency positions in order to bring in more federal funds."
In 1996, one year before the release of the IOM report, the Pew Health Professions Commission called for a reduction in medical school residency positions through the closing of some schools.
Jordan Cohen, M.D., president of the Association of American Medical Colleges, believes that the real problem is an overabundance of medical residencies-not an excess of medical school graduates.
"Many experts believe we are training too many physicians," Cohen says. "But I think the problem is at the level of graduate medical education. That's the level at which there is a surplus of physicians being trained. We believe that the graduates of accredited medical schools are sufficient in numbers-ample enough to meet any projected need for physicians as far as we can tell in the future."
The AAMC, which represents all of the accredited U.S. allopathic medical schools, has declined to take an official position on FSU's proposal.
"In the AAMC's view, it's not a question of a need for more or fewer medical schools," says David Stevens, M.D., the group's vice president of medical school standards and assessments. "It's a question of whether a school meets the standards for accreditation. We evaluate schools based on their compliance with standards, apart from physician supply and political considerations."
FSU's new medical school will be Florida's fifth. The state has public medical schools at the University of Florida in Gainesville and the University of South Florida in Tampa. It also has one private allopathic medical school at the University of Miami in Coral Gables. Together with an osteopathic medical school at Nova Southeastern University near Fort Lauderdale, the schools graduate about 500 students per year for a state that must import about 90% of the doctors who work there.
Myra Hurt, acting dean of the FSU medical school, defends the creation of a new school in Florida, where about 40% of all licensed doctors are graduates of foreign medical schools. She says FSU's new school will provide another 120 graduates per year to a state with a burgeoning population, a growing pool of elderly and huge swaths of rural areas lacking even the most basic health services.
"Our state has taken a passive strategy of allowing other states and countries to train our doctors," says Hurt, who holds a doctorate in molecular biology and serves as chairman of the search committee for a permanent dean. "We have never kept up with the training of professionals for a state the size of Florida."
FSU, a national football powerhouse accustomed to winning, scored a major off-the-field victory when it finally secured funding for the medical school in June 2000 for a venture that appeared so improbable just two years earlier. That was when the school's own 14-member board of regents voted unanimously to oppose an initial plan that called for about $220 million in state funding.
A little help from some friends
The school's victory in the Legislature was secured with the assistance of a handful of powerful political friends-including retiring Republican House Speaker John Thrasher, an FSU alumnus and a close associate of the university's president, Sandy D'Alemberte.
In a legislative bargain struck on the final day of the session, Thrasher won approval for the FSU medical school in a trade-off with his counterpart in the Assembly's other chamber, Senate President Toni Jennings, who championed new law schools at Florida A&M University and Florida International University.
"I believe there are still people who believe this is a political thing," Hurt says. "Unfortunately, in Florida as elsewhere there is an air of competition for state dollars. The natural fear is that (a new medical school) is going to hurt (other medical schools). Actually, I think, a lot of people have softened their stances."
After all the posturing and politics, FSU won a commitment of about $39 million per year in state funding, with an additional $50 million earmarked for the construction of a new science building on its campus in Tallahassee, the state capital. Since 1971, FSU has operated a first-year-only medical school program that feeds about 30 students per year to the University of Florida.
"The Legislature created it-and once the Legislature funds something, it's up to the board of regents to make sure it works," says Keith Goldschmidt, a spokesman for the board of regents.
Yet, Goldschmidt adds, the regents "did not feel (the new medical school) was necessary."
Although many observers agree that there's a shortage of doctors in some areas of Florida, others believe there were less-expensive ways to address the problem than creating a new medical school. Among the options: expanding FSU's first-year program, admitting more students to the existing medical schools or increasing the number of residency posts at teaching hospitals in Florida.
"The state Legislature, kind of out of nowhere, ignored all of these recommendations and opinions, and came along and, in a surprising way, said, `No, we're going to build a whole new medical school in Tallahassee,' " says one top official at the University of Miami who asked not to be identified.
Under the new program, FSU's community-based medical school will teach first- and second-year students on campus before sending them to clinical training sites in different cities for the third and fourth years of their education.
Targeting the underserved
Proponents of FSU's medical school say it will increase the supply of physicians willing to provide care to two increasingly neglected groups in Florid: rural residents and the elderly. More than a dozen Florida counties meet the federal definition of "underserved areas"-those with fewer than 33 physicians per 100,000 residents. Meanwhile, about one-fifth of the state's residents are older than 65, a number that will continue to grow.
"I am completely convinced we do not have a population of physicians that has been trained to meet the unique needs or our state," Hurt says.
Of course, even Hurt acknowledges that there's no guarantee that the graduates of FSU's program will serve in rural areas or, for that matter, specialize in geriatrics.
Steve Uhlfelder, a Tallahassee lawyer who is a member of the state board of regents, ultimately supported the new school despite early misgivings about the absence of any pre-established conditions to compel FSU graduates to live in underserved areas or practice geriatric medicine.
"The people I trust (at FSU) say they'll recruit students who will make this commitment (to rural areas and geriatric care)," Uhlfelder says. "FSU will look foolish if, down the road, 10 years from now, they have graduates who are all living in Chicago and practicing plastic surgery. This is a case where, just like everybody wants a football team in Florida, everybody would like to have a medical school. But (medical schools are) costly. And if FSU is wrong (about the students it recruits), only the taxpayer will suffer."