THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
SOCIO-ECONOMIC IMPACT STUDY
TABLE OF CONTENTS
PROGRESS IN FULFILLING WORK FORCE & SOCIAL IMPACT MISSIONS
ADDITIONAL EDUCATIONAL & SOCIAL IMPACTS 52
About this report Physicians, patients, hospital administrators, community leaders and others often tell us about the impact the Florida State University College of Medicine is making in their community. Until now, we’ve never tried to formally measure that value. This report was prepared by MGT of America, Inc., with the intent of accurately describing the College of Medicine’s contributions to improving the health and welfare of Florida’s residents. If you are reading this report online and would like a copy mailed to you, please contact our Department of Public Affairs, Communications and Alumni Relations at (850) 645-9698.
In its brief 10-year history, the Florida State University College of Medicine has developed rapidly in accordance with its founding plan. This report assesses the impact of the new medical school over its first decade, and this chapter provides background information about its history and structure.
Development of the FSU College of Medicine Medical education at Florida State University has its origins in the late 1960s, when the Program in Medical Sciences (PIMS) was initiated. With initial sponsorship from the National Institutes of Health, PIMS was a joint effort of FSU and the University of Florida College of Medicine to contribute to the supply of physicians in rural northwest Florida. Beginning in 1970-71, 30 jointly selected students pursued their first year of study at FSU each year before moving to Gainesville for the remaining three years of the UF medical school program. In addition to considering the typical medical school admissions criteria, PIMS emphasized selection of older and nontraditional students who were more likely to be interested in working in underserved areas. After observing nearly three decades of success by PIMS in fostering interest in primary care and rural health, members of the Florida Legislature grew interested in expanding the stateâ€™s efforts to train physicians likely to practice in underserved rural and inner-city areas across the state. In 1998, the Legislature directed the Florida Board of Regents, in cooperation with FSU, to assess the capacity of Floridaâ€™s medical education system. In addition to documenting the already apparent shortages of physicians in rural areas of the state and in primary care specialties, the findings from that assessment contradicted the then-conventional wisdom about an overall physician surplus and concluded the state and the nation would face a significant shortage of physicians of all types in the coming decade. In 1999, the Legislature directed FSU to develop a proposal and implementation plan for establishing a new medical school with special characteristics to target the areas of highest need. The Legislature endorsed the FSU proposal in 2000 and passed House Bill 1121 creating the FSU College of Medicine. HB 1121 was signed into law by Gov. Jeb Bush on June 15, 2000. The FSU College of Medicine was never intended to be just another medical school. Rather, with its origins in the PIMS program and its special legislative mandate, it was designed as a high-quality medical school that addressed several specific social needs of the state through an innovative, community-based model of program delivery and training. The stateâ€™s goals for the new medical school were captured in the following statement of mission:
The Florida State University College of Medicine will educate and develop exemplary physicians who practice patient-centered health care, discover and advance knowledge, and are responsive to community needs, especially through service to elder, rural, minority, and underserved populations.
Enrollment Expansion The College of Medicine enrolled its charter class of 30 students in May 2001. Over the following several years, the enrollment of each entering class grew incrementally until the first class of nearly 120 entering students began study in 2007. When this cohort graduates in 2011, the College of Medicine will achieve its original goal of producing approximately 120 new physicians per year. Details of the 10-year enrollment build-out are summarized in Exhibit 1, which also depicts enrollment in transitional (i.e., the Bridge Program) and graduate programs.
EXHIBIT 1 ENROLLMENT EXPANSION OVER FIRST 10 YEARS FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Overview of the FSU College of Medicine One distinguishing feature of the College of Medicine is its communitybased, distributed model of medical education. A “community-based” medical school is one that does not operate its own university-affiliated teaching hospital. In a “distributed” model, portions of the training program are offered in more than one geographic location. In the case of the College of Medicine, the first two years of the four-year instructional program occur primarily on the main campus in Tallahassee. The second two years of the program take place in a community setting through the auspices of a regional medical campus, with more than 60 percent of student training time spent in doctors’ offices, clinics and other ambulatory settings. The College of Medicine has grown into a network composed of the main campus in Tallahassee and six regional campuses across Florida. The first three regional campuses, in Orlando, Pensacola and Tallahassee, received their first groups of third-year students in July 2003. Two years later, the first students reported to the Sarasota Regional Campus. The full complement of six regional campuses was achieved in July 2007 with the opening of the Daytona Beach and Fort Pierce regional campuses. The map in Exhibit 2 shows the geographic distribution of the six regional campuses, along with two special rural training sites and a clinical training site in Thomasville, Ga. EXHIBIT 2 REGIONAL CAMPUSES, RURAL TRAINING SITES, & CLINICAL TRAINING SITE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
With the financial support of the Florida Legislature, FSU developed state-of-the-art facilities for its new medical school. After several years of operation in temporary on-campus facilities, the John Thrasher Building opened in November 2004 as the new main-campus home of the College of Medicine. This 156,000-square-foot structure contains lecture halls, small classrooms, class laboratories, study space, a clinical skills center and an e-library, as well as faculty and administrative offices. A companion Research Building was completed in spring 2006, with 132,200 additional square feet of specially designed space for biomedical research by students, faculty, and postdoctoral researchers. The third component of the medical school complex is an auditorium with a seating capacity of 300. To support the regional medical school campuses, the College of Medicine has leased or partnered in construction of seven facilities across the state. The six regional campus sites, which are approximately 5,000 square feet each, provide space for lectures, video conferencing, study and administration. Students and clinical faculty members at the regional medical school campuses spend most of their time in physiciansâ€™ offices, clinics and hospitals in their respective communities. In addition to the six regional campus sites, the College of Medicine owns the Collier Clinic facility in Immokalee, which has 42,700 square feet of patient care and office space. Overall, the College of Medicine occupies 376,600 square feet of space. Summary details of the buildings and their locations are listed in Exhibit 3. EXHIBIT 3 FACILITIES OCCUPIED BY LOCATION AND SIZE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Partners and Affiliated Institutions In fulfillment of the directives in HB 1121, the community-based, distributed model employed by the FSU College of Medicine depends on strong partnerships with a variety of affiliated health-care institutions. Statewide, the College of Medicine has affiliation agreements with 46 hospitals that collectively encompass more than 8,000 acute-care beds. The College of Medicine also has affiliations with 45 county health departments, clinics and similar organizations. These critical partners are listed in Exhibit 4. EXHIBIT 4 PARTNERS AND AFFILIATED INSTITUTIONS FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Faculty Employment Expansion The College of Medicine has approximately 115 full-time faculty members on the main campus in Tallahassee and approximately 1,700 part-time clinical faculty members across the state. As is common in medical schools across the nation, most members of the clinical faculty devote the majority of their time to patient care, while serving as instructors for third- and fourth-year medical students. Exhibit 5 provides counts of the College of Medicine faculty over its first decade of existence. The faculty members are supported by more than 500 full- and part-time technical and support staff. EXHIBIT 5 EXPANSION OF FACULTY EMPLOYMENT FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
The College of Medicine is fully accredited by the Liaison Committee on Medical Education (LCME). In October 2002, the College of Medicine received “provisional accreditation,” which was the first step in the then two-step process. When it was granted “full accreditation” in February 2005, it became the first new fully accredited medical school in the United States in more than 20 years.
Purpose of Socio-Economic Impact Study On June 15, 2010, the College of Medicine observed the 10th anniversary of the enactment of House Bill 1121, which established the school. A few days earlier, the fourth class of 120 entering students had begun study, marking the attainment of the full enrollment capacity planned for the College of Medicine after 10 years of scheduled growth. While the founding goals related to enrollment growth have now been achieved and are easily documented, the medical school’s leaders also wanted to assess whether it is fulfilling its special mission and having its intended social impact on the state. In an effort to address its qualitative progress, it developed plans for a socio-economic impact study. MGT of America Inc., the planning and consulting organization that assisted in the development of the original plan for the College of Medicine, was commissioned to perform the socio-economic impact study. As planned, the study had four goals: 1.
Evaluate the impact to date in fulfilling the college’s work force and social missions – What impact has the College of Medicine had on the state’s shortage of physicians, especially in primary care, elder care, and rural and underserved areas?
Measure the economic impact of investments to date – What impact has the College of Medicine had on the economy of the state of Florida, and particularly on the six communities that host the medical school’s regional campuses?
Assess the educational and social impact of its programs – What additional impacts has the College of Medicine had on its students and the quality of health care in Florida?
Identify future challenges and opportunities as it embarks on its second decade – Now that the College of Medicine has achieved its initial goals related to enrollment growth and has assessed progress on other aspects of its special mission, what priorities should be the focus as it enters its second decade?
MGT’s findings related to these four goals are the subject of the remainder of this report.
PROGRESS IN FULFILLING WORK FORCE AND SOCIAL IMPACT MISSIONS
The Florida State University College of Medicine was designed to address specific needs in Florida’s medical work force. This chapter reviews its founding mission and its growing impact on the size and composition of the state’s supply of physicians.
Overview of College of Medicine’s Social Impact Mission Beginning with its origins in the PIMS program, medical education at FSU has always been driven by a strong sense of mission to have a positive impact on society. When the College of Medicine was established by the Florida Legislature in 2000, the framework for its founding mission was defined in House Bill 1121. In particular, the College of Medicine and its programs are intended to: • • • • • •
Contribute to the overall supply of physicians practicing in Florida. Focus on promoting careers in primary care. Ensure training in the medical needs of the elderly. Serve the rural health-care needs of the state. Increase participation of students from previously underrepresented groups. Address the medical needs of the state’s underserved populations.
In the remainder of this chapter, we assess the impact that the College of Medicine is having on the people of Florida as it carries out its missions related to work force and social impact.
Impact on the State’s Overall Physician Shortage In the 1999 report An Assessment of the Adequacy and Capacity of Florida’s Medical Education System, several key findings addressed the then-growing lack of access to physician care in Florida. Not only was Florida found to rank poorly among the major states in physicians per capita at the time, but the situation was projected to worsen. The state’s population was growing at a rate faster than the nation’s increase in physician supply, and Florida would soon be unable to continue to rely on surpluses of medical graduates from other states to meet its own physician work force needs. The report concluded that Florida would face an additional shortage of 1,000 physicians per year by 2020 if no corrective action by the state was implemented. The need to increase the supply of physicians in the state became a major factor in building support for the proposed College of Medicine and was specifically addressed in the preamble to HB 1121. State leaders and College of Medicine planners recognized that solving the state’s physician shortage required a long-term solution. As noted in both the 1999 Assessment of Adequacy and Capacity report and the subsequent plan, more than a decade would be needed after legislative authorization for a new medical school before a significant increase in the stream of new physicians entering the state’s medical work force would be realized. After a brief period to plan and prepare for the charter class of medical students at the new school, significant blocks of time were needed for: • • •
College of Medicine leaders to build enrollment levels from the initial entering class of 30 students to the full planned capacity of 120 new matriculants per year. Students to pursue medical training over a four-year period. Medical graduates to continue training in residency and fellowship programs lasting three-five years or longer before entering practice.
After this extended training period, an additional challenge remains in retaining greater proportions of medical graduates to practice in the state.
“I witnessed great hardships for elderly community members [in my hometown of Crestview] because medical care was not available in our area. My heart is in serving the rural and geriatric populations, which is FSU’s mission. I believe FSU prepared me to serve these populations in my home community. Also, I fell in love with the 17 warm, friendly, upbeat atmosphere created by the faculty and staff.” -- Kara Brooks, M.D. 2006, Crestview Family Medicine
Exhibit 6 graphically depicts the times required for each phase of the medical training pipeline, beginning with a student pursuing a pre-med course of study before admission to medical school. EXHIBIT 6 YEARS OF REQUIRED TRAINING IN MEDICAL EDUCATION
The development of the College of Medicine has generally proceeded according to the schedule in its original planning documents, which called for the college to eventually enroll 480 students across four classes and thereby produce 120 graduates per year. As noted in the introductory chapter of this report, enrollments reached full capacity in May 2010 and the first class of approximately 120 students is scheduled to graduate in May 2011. Once these graduates complete residency training in 2014 and later, the collegeâ€™s full impact on the stateâ€™s physician work force can begin to be measured. Even in its relatively brief history, evidence is growing that the College of Medicine will become a major contributor to the Florida physician work force. As seen in Exhibit 7, the college now has produced 336 graduates with the Doctor of Medicine (M.D.) degree. Although six classes of graduates have completed the program since its inception, half of the graduates to date finished in the past two years.
EXHIBIT 7 GRADUATES BY YEAR FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
T h e C o l l e ge o f Medicine has maintained close contact with its alumni to monitor their progress in graduate medical education programs and entry into the profession. Of the 27 members of the first graduating class in 2005, 22 have completed r e s i d e n c y/ fellowship training and entered practice ( m o re t h a n 8 1 percent). Of those who have completed res i d e n cy, 14 (nearly 64 percent) are now practicing in Florida. The percentage capture rate is highest among the stateâ€™s medical schools and is more than 1.6 times greater than the national average of 39 percent for in-state retention of medical school graduates. Details on the status of the Class of 2005 and subsequent classes, most of whom are still in residency programs, are summarized in Exhibit 8. EXHIBIT 8 ANALYSIS OF STATUS OF GRADUATES TO DATE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Impact on Supply of Primary Care Physicians Numerous state and national studies have documented the long-term trend of increasing proportions of medical graduates pursuing careers in medical specialties rather than primary care fields, despite growing deficits in these areas. Concern about this trend was already evident as plans were being developed for the College of Medicine, and the need for primary care physicians is even greater today with the demands arising from federal health-care reform. The founding purpose of the College of Medicine, as stated in House Bill 1121, recognized Florida’s need for primary care physicians. It states that “The College of Medicine shall be dedicated to . . . preparing physicians to practice primary care. . . .” Building on the success of the preceding PIMS program, the College of Medicine has embraced the mission of contributing to the state’s supply of primary care physicians (that is, those specializing in family medicine, internal medicine, obstetrics & gynecology, or pediatrics) through both the processes used to select students and the design of its curriculum. The College of Medicine’s initial strategy in its efforts to emphasize primary care focused on the processes used to select each entering class. Admission policies have been mission-based, considering geographic and socio-economic background as well as evidence of community-based service. The success of the careful recruitment of the college’s students is seen when comparing responses of College of Medicine students with their peers nationally to questions on the Matriculating Student Questionnaire administered by the Association of American Medical Colleges (AAMC). When they were asked about career plans when they entered the program, 49 percent of Florida State College of Medicine students indicated the intent to pursue a primary care specialty upon graduation, compared with only 43 percent of their national peers. That is, the College of Medicine had admitted students who were about 14 percent more likely to pursue primary care medical careers than new students starting at other medical schools.
A second key element of the strategy to promote primary care careers is the curriculum. As compared with most programs nationally, College of Medicine students take more clerkship rotations in primary care under the supervision of carefully selected role models. Other curricular strategies include the three-week activity at the end of the first year sponsored by the Florida Area Health Education Centers (AHEC) and the community medicine clerkship in the third year, which both promote the primary care mission. Since students in medical schools do not declare a â€œmajorâ€? and all students in the same school follow nearly identical programs, the first opportunity to observe whether FSU is more successful than its peers in actually producing primary care physicians occurs on Match Day. The process by which all fourth-year medical students nationally make their initial determination of a medical specialty (for example, pediatrics or surgery) and seek acceptance into select residency programs for the required additional training takes several months, and culminates in March on Match Day each year. Students who match with a primary care residency program are more likely to become practicing primary care physicians.
EXHIBIT 9 GRADUATES IN PRIMARY CARE RESIDENCY TRAINING FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
The College of Medicine has demonstrated strong performance in graduates matching with primary care residency programs. In the most recent match (March 2010), 56 percent of its graduating class selected to pursue residency training in primary care, compared with only 43 percent nationally. This pattern has been similar throughout the brief history of the College of Medicine, with 55 percent of all its graduates pursuing residency in primary care â€“ a proportion that is 25 percent greater than the national proportion over the same period. The 56-percent match rate of College of Medicine graduates in 2010 is even more striking when compared with the 42-percent match rate for primary care in other Florida medical schools. According to the American Academy of Family Physicians, the College of Medicine now ranks fifth in the nation for production of family doctors as a proportion of total graduates. Exhibits 9 and 10 show the results for each of the six graduating classes of the College of Medicine, along with comparative national data.
EXHIBIT 10 PRIMARY CARE PROPORTIONS AT THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE VERSUS NATIONAL AVERAGES
As described above, the College of Medicine is just beginning to see the fruits of its efforts as graduates of the initial entering classes complete their residency training and enter practice. Of the 51 College of Medicine graduates who are known to have completed residency, 34 (or 67 percent) are practicing in a primary care specialty. Most important, 24 of these primary care physicians are practicing in Florida.
Impact on Access to Elder Care Florida is at the forefront of a significant national demographic trend of an aging population. Widely known for many years, an unusually high proportion of Floridians are over the age of 65 (17.6 percent in Florida compared with 12.4 percent nationally). Over the past decade, there has been growing awareness that the older age groups are among the fastestgrowing cohort both in Florida and nationally. The over-65 population in Florida grew from 2.4 million in 1990 to 2.8 million in 2000, rose to 3.3 million in 2010 and is projected to reach 4.6 million by 2020. Exhibit 11 shows the projected state and national growth in the over-65 population. EXHIBIT 11 GROWTH OF POPULATION OVER AGE 65 FLORIDA AND UNITED STATES
People live longer in the 21st century, in large part, because of advances in health care. Such advances, however, suggest that older people visit physicians at a much higher than average rate. The Assessment of Adequacy and Capacity report estimated that elder patients consume more than twice the volume of medical services per capita than do younger groups. The older population mix and accompanying/ correlated higher utilization rates create a significant demand for physicians in Florida to attend to the needs of elders. Historically, the medical needs of elders have been handled by internal medicine or family practice physicians for primary care, along with frequent referrals to specialists for other types of needed care. An alternative approach is for physicians to specialize in geriatrics, a primary care medical specialty that focuses on elders. Most geriatricians completed residency training in internal medicine or family medicine, and then pursued one to three years of additional fellowship training to specialize in the care of elders. Geriatrics is among the smallest specialty areas, with only 12,575 geriatricians nationwide (less than 2 percent of all physicians). The existing shortage of geriatricians is likely to become even more acute as the population of the nation ages. The American Geriatrics Society reported in 2005 that “a shortage of geriatricians exists in the United States and is projected to worsen over the next 20 years. Currently, there is one geriatrician for every 5,000 adults age 65 and older. In 2030, it is estimated that there will only be one geriatrician for every 7,665 older adults, representing a 50 percent decline over the next 25 years.” As directed in House Bill 1121, the College of Medicine has a separate Department of Geriatrics, one of only a few in the United States. The Department of Geriatrics has the express purpose of educating all medical students, no matter what their eventual area of specialty, in the care and treatment of seniors. College of Medicine students receive extra training with seniors in the continuum of doctoring courses as well as through the required geriatrics clerkship. As a result, they average 325 contact hours training in the diagnosis and treatment of elders – an exposure significantly higher than students in typical programs elsewhere.
“When I applied to the FSU College of Medicine, I was already interested in geriatrics. There has always been a soft spot in my heart for the elderly. Once our training began, I was excited to see a rotation in our fourth year dedicated to caring for geriatric patients. That training was also skillfully integrated into our doctoring courses throughout medical school. I am blessed to be able to use those skills daily in my current job as a hospitalist. On average, 75 percent of my patient load is 65 years of age and older. Hats off25 to the FSU College of Medicine for making geriatrics a priority in medical education!” -- Lorna Stewart, M.D. 2005, hospitalist, Tallahassee Memorial HealthCare
Robin Albritton, M.D. 2007, grew up in Marianna and now, having completed the Family Medicine Residency Program at Tallahassee Memorial Hospital, is practicing in his hometown. He explained how the rural training at the Florida State College of Medicine prepared him for his residency:
“You’ve got a group of physicians who have no other responsibility to teach anybody else. They don’t have to teach residents. Their only person to teach is that medical student. And they enjoy teaching, and they want to give them a phenomenal experience…. When I started my residency, I felt like I’d already completed a year of residency. I was ready to go see sick people in the ER. I was feeling confident in my skills. It was a huge advantage.”
Impact on Physician Access in Rural Areas Contributing to the state’s supply of physicians serving rural areas has been a long-standing goal of medical education at Florida State University. Rural health care was a major factor in the establishment of PIMS in 1970, and both the 1999 Assessment of Adequacy and Capacity report and the subsequent proposal and implementation plan for a new medical school at FSU emphasized Florida’s need for more physicians in rural areas. The preamble to House Bill 1121 noted that the Health Professional Shortage Areas in Florida were primarily in rural North Florida, and declared that one of the key purposes of the new medical school at Florida State was to prepare physicians to practice rural medicine. The College of Medicine has addressed its rural mission through both its admissions practices and its curricular design. One researchbased principle of medical school admissions is that students who come from rural backgrounds are more likely to pursue careers in rural medicine than their urban counterparts. Over time, a significant number of entering students at the College of Medicine have come from the 33 statutorily defined rural counties in Florida. As seen in Exhibit 12, 57 students from rural counties have enrolled in the College of Medicine over the past 10 years, accounting for 6.9 percent of all entering students. This compares with a 6.3-percent statewide representation of college-aged population from these same rural areas. The strength of the College of Medicine’s commitment to its rural mission is further evidenced by the fact that only 5.4 percent of its applicants, compared with 6.9 percent of its matriculants, indicate they have rural backgrounds. The validity of the College of Medicine’s recruiting strategy, which considers whether applicants have a rural background, is seen in the students’ plans for settings in which they intend to practice upon completion of training. On the AAMC Matriculating Student Questionnaire, 13.0 percent of 2009 matriculants at the College of Medicine indicated their plan to practice in a non-suburban community with population of 10,000 or less, compared with 5.1 percent of their counterparts nationally. EXHIBIT 12 ENTERING STUDENTS WITH RURAL BACKGROUNDS FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Perhaps the most visible feature of the College of Medicineâ€™s curriculum related to rural medicine is the presence of rural training sites in Marianna and Immokalee. The Marianna site, which is located in Jackson County with approximately 50,000 residents, provides a full complement of clerkships for students in the third year of the M.D. program through affiliations with local physicians, the 100-bed acute-care Jackson Hospital, and the nearby Florida State Hospital in Chattahoochee. Over the past several years, three to five students per class have elected to participate in the rural track during their third year before moving to one of the six regional medical campuses for their final year. The Immokalee Health Education Site operates in affiliation with Collier Health Services in a community with approximately 20,000 permanent residents and almost as many migrant workers during harvest season. Because of the smaller base of operations, the Immokalee site offers only third-year clerkships in family medicine and pediatrics. Like the Marianna site, the Immokalee site also serves College of Medicine students from any of the regional campuses who wish to seek an elective rotation in a rural setting.
Only 9 percent of doctors nationwide practice in rural areas, so expectations for rural placements of a young medical school must be realistic. Nevertheless, of the 51 College of Medicine graduates who have completed residency training and entered practice to date, seven (14 percent) are practicing in a predominantly rural area in Florida. These graduates are located in: •Arcadia •Marianna •Winter Haven
Numerous other graduates are in practices where a significant number of their patients come from rural areas. Other graduates nearing completion of their residency requirements have stated their intent to set up practice in other rural Florida communities.
In its search for potential students from rural settings, the College of Medicine has found the Florida Panhandle to be a strong source of qualified applicants. Recently, five Chipola College graduates from five different hometowns were accepted into College of Medicine programs.
“I completed my undergraduate career at Chipola College in rural Northwest Florida and at the University of Florida. Applying to medical school was definitely a challenge. Maintaining grades while trying to balance extracurricular activities and preparing for the MCAT were among some of my top stressors during this time. After interviewing at the Florida State University College of Medicine, I knew it was where I wanted 29 students to go. My interviewers were so sincere and welcoming. The had a positive attitude, and the camaraderie was like nowhere else.” --Rick Sims, Class of 2014, Marianna
Impact on Diversity of Medical Work Force Racial and ethnic minorities have long been underrepresented in the state and national physician work force. This disparity not only is a concern for social equity but also has direct impact on the capacity to provide needed care to medically underserved populations. As noted in the College of Medicine’s implementation plan, minority physicians have a greater propensity to practice in underserved areas. House Bill 1121 recognized the state’s need for greater diversity in the physician work force and directed the College of Medicine to provide “access to medical education for groups which are underrepresented in the medical profession.” One key element of the minority recruitment strategy for the College of Medicine (and its predecessor PIMS) has been to develop a pipeline of future applicants through the Science Students Together Reaching Instructional Diversity & Excellence program (SSTRIDE). The “pre-collegiate” component of SSTRIDE exposes middle and high school students to potential medical careers through tutoring, mentoring, enrichment activities and summer camps, where education in the basic sciences is reinforced. A corresponding undergraduate SSTRIDE component offers similar services to students in the three public colleges and universities in the Tallahassee area. A second element of the minority recruitment strategy is the Master’s Bridge Program. In this effort, the College of Medicine enrolls minority and rural students who were not successful applicants to the medical school program and provides additional training in the basic sciences alongside medical students. Students who meet academic and other criteria in both instructional and health-care settings are granted admission to the medical school and earn a master’s degree. As seen in Exhibit 13, the Bridge Program admitted 26 students over its first five years, and 22 became M.D. graduates of the College of Medicine. More than two-thirds of the physicians from the Bridge Program are in primary care. EXHIBIT 13 ENROLLMENT AND OUTCOMES OF BRIDGE PROGRAM FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE: 2001-2005
The evidence of the success of these programs is strong. Of the recently matriculated 120-member Class of 2014, approximately 20 (one-sixth of the class) were enrolled as a direct result of one of the College of Medicine outreach programs and contribute to a much more diverse student body. Exhibit 14 provides data on the ethnic diversity of the College of Medicine’s student body over the years along with comparison to the state’s population and physician work force. Over its 10-year history, 10 percent of College of Medicine students have been African-American and 16 percent Hispanic. The proportion of African-American and Hispanic students at the college far exceeds their representation in the state medical community and mirrors the overall mix of the state population more closely than most other professional schools. The representation of racial and ethnic minorities among the student body significantly exceeds their presence among Florida’s current M.D. population. The college’s success in serving minority students has been widely noted, and it was ranked seventh best in the nation for Hispanic students by Hispanic Business magazine in 2009. EXHIBIT 14 DIVERSITY OF THE STATE OF FLORIDA, ENTERING STUDENTS AT FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE, AND THE FLORIDA M.D. WORK FORCE
â€œAs an FSU medical student, I learned firsthand about the health-care needs in Florida and of underserved populations. I also participated in the International Medical Outreach Program, in which a group of us served in a mission in Panama. Two years earlier, as an undergrad at FSU, I served in a mission in Haiti. Now, I have started a solo practice in Clermont, Fla., where, with the help and support of the Southlake Hospital team, I have relocated as the first and only Spanishspeaking obstetrician/gynecologist. This is a growing area with a large Hispanic population.â€? 32
--Manny Herrera, M.D., Class of 2005
Impact on Medical Care for Other Underserved Populations In addressing its intent that the College of Medicine devote attention to medical needs of all types of underserved populations, House Bill 1121 included the directive that “Various short-term clinical exposures shall be programmed throughout the pre-clinical years, including . . . minority health.” The college has responded to this intent through the structure and location of its required courses. Full-time physician faculty members provide care to underserved populations at local facilities, including assignments at the local community health center, rural Department of Health facilities, a school-based health center and a domestic violence center. These sites also serve as clinical locations for first- and second-year students throughout the state to reinforce clinical skills and gain experience in caring for the underserved. Learning opportunities include: • • •
The yearlong Doctoring 1 course that teaches basic history and physical skills. The community preceptorship program, where students spend a half day every other week with a community-based primary care physician. A three-week clinical immersion course (the Summer Clinical Practicum) at the end of the first year, in which every first-year student is placed with a primary care physician. The College of Medicine especially seeks out those physicians who treat underserved populations for these courses.
The integrated curriculum has unifying goals to teach basic clinical skills, incorporate the bio-psychosocial model of illness, and emphasize the dynamic relationship between biological, psychological, social and cultural factors of human illness. Once students begin clerkships in the third year of the curriculum, the emphasis continues with students developing their understanding of and skills for meeting the medical needs of underserved populations. In particular, the third-year, three-week Community Medicine Clerkship is required for all students at the regional campus sites and is designed to broaden students’ understanding of the role played by community agencies in health promotion and disease prevention. Other opportunities include multiple rotations at the Immokalee Health Education Site, which draws much of its clientele from migrant populations. Also, College of Medicine faculty members sponsor trips to Panama and the Texas border through the student organization FSUCares to deliver health care to people who have little or no access to medical care.
Summary Observations on Mission Fulfillment A considerable amount of time is required to build and develop a new medical school, and especially to measure quantitative and qualitative results and impact. Nonetheless, 10 years after its legislative authorization, the FSU College of Medicine is a clear success. It has now reached its full enrollment capacity and will be producing a steady stream of new physicians for the state.
“Every medical school, every university has a mission statement. They’re all aspirational. Yours is focused, and you’ve been deadly serious about meeting it. You have the most focused mission statement I’ve ever seen for a medical school. And you’ve been relentless in every one of your programs to line up your activities with that mission statement. That’s the key ingredient…. I can’t say enough good things about what you’ve accomplished…. The problem is now we need to extend it to other medical schools and to the entire health-care system.” -- Darrell Kirch, M.D. President and CEO of the Association of American Medical Colleges 35
In addition to its role in expanding Florida’s physician work force and improving health care and educational access for underserved populations, the Florida State University College of Medicine also produces a tangible economic benefit for the state and for each of the communities in which it operates. This chapter of the report documents the expenditures in each region and across the state by the College of Medicine and its affiliates to estimate the economic impact of the medical school on the state and selected communities.
Overview of Methodology An economic impact analysis documents the direct and indirect dollars attributable to an organization’s operation within a community. Direct investments are defined as expenditures by the organization and affiliated entities – including capital investments, staff salaries, purchases of goods and services, and even peripheral spending by visitors brought to the area by the organization’s presence. Indirect investments trace the direct investments by the organization and its affiliates as they are spent again in the community, continuing to roll over between other organizations and individuals within the market. The phenomenon of the indirect expenditures continuing to roll over within the economy is referred to as a “multiplier effect,” in that each dollar invested in the community is eventually worth many times its original value. The value of multipliers varies based on definitions of the market.
Multipliers and Relevant Markets As stated, the total output or economic impact associated with an organization’s operation amounts to the sum of its direct impact (all attributed expenditures) plus its indirect impact, or the successive spending that is induced by the original investment. Indirect or induced spending is arrived at via application of a multiplier to the direct expenditure values. Multipliers are derived based on market-specific estimations of how much “leakage” occurs each time dollars are spent on particular goods or services, versus how many of those dollars are retained and spent again in the local economy. Exhibit 15 below presents a depiction of the flow of direct and indirect dollars into a community, and the associated derivation of the multipliers used to estimate total economic impact. For simplicity’s sake, the illustration assumes that, for every $1 invested in a community by the focus organization, the recipients of those funds will spend 60 cents in the local economy, while 40 cents is spent outside of the market area. The 60 cents that is reinvested into the local economy endures a second cycle of spending, losing another 40 percent in magnitude, and so on, until all the dollars have effectively leaked out of the local market. In this example, with 60 percent of funds being retained in each transaction, the multiplier has a value of 2.50, which is to say, every $1 spent in the market results in approximately $2.50 of output in the local economy.
EXHIBIT 15 ILLUSTRATION OF MULTIPLIER EFFECT
The magnitude of multipliers varies depending on the composition of what is defined as the local market. Central to this consideration is the notion that expenditures toward some industries have higher rates of retention or leakage than others; for example, a large proportion of utility expenditures are not likely to be retained locally, as a substantial share will leak to foreign commodity suppliers, while another large segment will be pulled out of the local economy by taxes, and another will presumably go to domestic companies that are located outside of the market. As an alternate illustration, large proportions of expenditures in construction typically remain within the local market, as most expenses go toward local laborersâ€™ wages and/or local construction companiesâ€™ profits. It follows that the definition of the market area included in an economic impact analysis determines the value of embedded multiplier effects. In concert with variations by industry or the type of good or service being purchased, the magnitude of the multiplier effect associated with an economic activity varies based on the scale and scope of the encompassed populations and industries. It follows that the more goods and services that are available within the defined local economy, the more times the directly invested dollars can roll over. Therefore, larger multiplier values are associated with larger focus economies or market areas.
For the purposes of this study, markets have been defined according to delineations of assorted constituent groups. The first delineation for this analysis encompasses the state of Florida, corresponding with the college’s primary funding source, the state taxpayer. The second analysis segments the impact across the six “local” economies corresponding with the College of Medicine’s regional campuses. These were defined as follows: •
• • • • •
Tallahassee Region (Leon, Gadsden, Jefferson and Wakulla counties in Florida, and Thomas County in Georgia). Orlando Region (Orange, Lake, Osceola, and Seminole counties). Pensacola Region (Escambia, Santa Rosa and Okaloosa counties). Sarasota Region (Sarasota and Manatee counties). Daytona Beach Region (Volusia and Flagler counties). Fort Pierce Region (St. Lucie, Martin and Indian River counties).
The areas defined above generally reflect the counties included in respective Metropolitan Statistical Areas (MSAs) for each of the regional campus locations, as defined by the U.S. Office of Management and Budget. The counties included in MSAs are characterized as having “a high degree of social and economic integration (as measured by commuting to work) with the urban core.” However, several of the MSAs corresponding with campus locations have been supplemented with additional counties to account for specific instances where an adjacent county houses partnering organizations where students are being trained; specifically, Thomas County, Ga., was added to the Tallahassee Region; Okaloosa County was added to the Pensacola Region; Flagler County was added to the Daytona Beach Region; and Indian River County was added to the Fort Pierce Region. It should be noted that – because of increasing magnitudes of the multipliers as market areas increase in size and scope – the sum of the six local impacts is less than the broader impact measured for the statewide analysis: a case where the whole is greater than the sum of its parts.
Categories of Expenditure Data Accounting for College of Medicine impact requires measures and estimations of a number of economic activities. The operations in this review include: • • •
Education & General. This category is composed of operating expenses including salaries, benefits, utilities and other expenses not documented separately in other categories. Contracts & Grants. Dollars are also expended on research and other projects funded by public and private sponsors external to the university. Capital Outlays. These include expenditures on physical structures and infrastructures associated with the college’s operation. Represented within this category are the Thrasher and Research facilities on the main campus in Tallahassee, as well as regional construction/renovation projects undertaken to establish operations in respective areas. Foundation. This category includes private gifts expended each year through the FSU Foundation in support of the college’s operations. Student Spending. This category accounts for the impact of students assigned to each campus who engage in economic activity, including room and board, the purchase of supplies, transportation, and other personal and recreational activities. Spending amounts for this component were estimated according to university assessments of cost of attendance across these categories. Visitor Spending. This category accounts for the dollars expended by official guests to the various campuses as well as personal visitors of the college’s students and staff. The impact of visitors was estimated conservatively on a per- student basis (assuming changes in student volume correlate with staffing levels) using reasonable expenditure levels and associated multipliers to account for lodging, food and retail activities.
Most of the information for these analyses was extracted from reports supplied by the college’s Finance and Administration unit; therefore, dollar values represent actual totals in most accounts. Some smaller expenditure categories were not explicitly available, so, instead, estimates were derived via conservative references to scales of other related operations.
Source of Multiplier Factors Multipliers used in this analysis were obtained from the Bureau of Economic Analysis’ Regional Input-Output Modeling System (RIMS II). The multipliers published through RIMS II include final-demand multipliers for output, earnings, employment and value added; and direct-effect multipliers for earnings and employment. The final demandoutput multiplier was utilized in this analysis as it provides the most comprehensive perspective among the available units.
Statewide Economic Impact The most important measure of impact is the College of Medicine’s influence on statewide economic activity, since it operates, in part, based on funds provided by taxpayers throughout Florida. In this section of the report we examine the cumulative impact of the college’s operations in the state from 2000-01 through the 2009-10 fiscal year, the last year for which actual data were available.
Ten-Year History The College of Medicine officially began development during the 2000-01 fiscal year, with its first class enrolled the following year, while construction and development of the full program capacities continued through the decade. The major advancements along this timeline include: • • •
• • •
Planning and recruitment expenditures were disbursed in 2000-01 before the first class enrolled. The first students (Class of 2005) enrolled in the summer of 2001, utilizing the existing (i.e., PIMS) facilities. Construction of the medical complex in Tallahassee (including Thrasher and Research buildings, as well as additional capital outlays) stretched between 2001-02 and 2006-07. Regional campus operation initiated in 2003-04 in Tallahassee, Pensacola and Orlando, as the inaugural (Class of 2005) students entered their third year. Two years later, in 2005-06, the Sarasota campus enrolled its first students. After two more years, the first third-year medical students enrolled at the Daytona Beach and Fort Pierce campuses (in 2007-08). Full operational capacity (approximately 480 medical students, as well as 10 Bridge Program and 34 graduate students) was attained at the beginning of the 2010-11 academic year.
Billion-Dollar Impact The total expenditures and impact of College of Medicine operations and related activities are displayed in Exhibit 16: • • •
More than $503 million has been expended by, or on behalf of, the college or its affiliates since its inception in 2000-01. Annual expenditure levels reached nearly $73 million in 2009-10, while still operating 26 students short of full capacity. Based on the most recent year’s (2009-10) estimates, more than $160 million in impact will occur on an annual basis each successive year of full-capacity operation. The most recent budget data (2010-11) suggest ongoing impacts at levels exceeding 2009-10 levels, particularly considering planned expansions to the research program (estimated to grow three times over in five years, and up to five times its current levels in 10 years). The cumulative investment into state and local economies over the first 10 years of College of Medicine operation is estimated to have exceeded $1 billion.
EXHIBIT 16 TOTAL EXPENDITURES & STATEWIDE ECONOMIC IMPACT OF THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Taxpayer Return on Investment An assessment of resource investments often entails an analysis to determine the return that is experienced on those funds. It can be demonstrated that state taxpayers’ contributions toward operation of the College of Medicine have yielded extremely fruitful results. The most recent accounts of operations include the following: • • •
The College of Medicine received about $39 million in public funds toward its operations in 2009-10. As demonstrated, the total economic impact for this same period totaled nearly $161 million. The annual return on investment (total benefits divided by funds invested) amounted to over 410 percent, exclusively in terms of economic benefit.
While any investment would be expected to roll over and multiply into a twofold impact, the quadrupling of public expenditures is a powerful testament to the significance of the college’s operation. Furthermore, when consideration is given to the immeasurably important contributions to the demonstrated need to expand the physician work force and improve the quality of health care throughout the state, the college’s value added relative to public contributions cannot be overstated.
Economic Impact on Six Communities While the operations of the six regional campuses are approximately equivalent, the context for their operations varies substantially with respect to the types of cities hosting the campus, the facilities utilized in the region, and the types of partnering organizations. While each campus has a capacity of 40 students (20 per class of third- and fourthyear medical students) operating within a facility of approximately 5,000 square feet, some variation exists in populations and other circumstances associated with each region: The Tallahassee campus is unique in that the regional campus is located in the same city as the main FSU campus. Thus, local impact entails the substantial capital investments involved in construction of the Thrasher and Research buildings, as well as each siteâ€™s ongoing operations. o
While the main campusâ€™s presence results in local expenditure levels that are much larger than the levels observed for other regions, the local multipliers associated with these expenditures are less substantial factors than those observed for most other regions. This is due to a smaller encompassed population in market area counties (just over 371,000 individuals reside in the four counties included in this region).
Similar to the Tallahassee regional campus, the Orlando and Pensacola campuses also operate in free-standing leased facilities that were renovated according to required specifications. Pensacola’s market area is close to the median value among regional locales, with about 654,000 residents across three counties. Alternately, market area population for the Orlando campus includes more than 2 million residents, as opposed to approximately 400,000-700,000 in the service areas of other campuses. This results in the largest multiplier effect for this campus. The Sarasota campus also operates within a free-standing, renovated facility located near the downtown of its home city. About 708,000 residents are included in the two encompassed market area counties. The Daytona Beach and Fort Pierce campuses are both located in newly constructed facilities built on the campuses of local community/ state colleges (Daytona State College and Indian River State College, respectively). FSU assisted in the construction of the facilities and maintains lease agreements with the colleges for ongoing use. The construction of these facilities results in substantial initial capital expenditures in each region. o
The market area population included in the Daytona Beach service area includes about 602,000 residents, while the Fort Pierce market encompasses about 558,000 residents. Though Fort Pierce’s market area population is larger than the Tallahassee region, the local multipliers for this region are actually the smallest effects observed among campuses, presumably because of the presence and mix of local industries.
A general rule of measuring economic impact is that the less industry encompassed by a study area, the smaller the associated multiplier. This correlates with smaller geographic areas as represented by each of the campus market areas.
“I love the faculty and staff and the small class sizes. The FSU College of Medicine is a family that I am proud to be a part of.” --Erin Connelly, M.D. 2007, pediatrics chief resident at Winnie Palmer Hospital in Orlando and recipient of a prestigious pediatrics/child abuse fellowship at 43 Riley Hospital for Children in Indianapolis
TALLAHASSEE EXHIBIT 17 FLORIDA STATE COLLEGE OF MEDICINE â€“ MAIN CAMPUS & TALLAHASSEE REGIONAL CAMPUS TREND IN LOCAL ECONOMIC IMPACT, FY2000-01 THROUGH 2009-10, JUNE 2010 CONSTANT DOLLARS
The trend in explicit impact in the Tallahassee market is depicted in Exhibit 17. The values include both expenditures and activities associated with the main campus as well as the regional campus. Planning expenditures in 2001-02 and initial enrollment in the PIMS facilities are reflected in 2000-01 through 2001-02, with construction of various components of the College of Medicine complex (including Thrasher and Research buildings) through 2006-07, and ongoing operations expanding through the most recent year. Cumulative expenditures have amounted to more than $426.5 million for the first 10 years of operation, resulting in an estimated economic impact of $746.7 million over this period.
ORLANDO EXHIBIT 18 FLORIDA STATE COLLEGE OF MEDICINE â€“ ORLANDO REGIONAL CAMPUS TREND IN LOCAL ECONOMIC IMPACT, FY2003-04 THROUGH 2009-10, JUNE 2010 CONSTANT DOLLARS
Operations in Orlando began in 2002-03 with renovation of the local facility, and expanded with a limited number of third-year students and a smaller contingent of faculty (relative to current capacities) in the subsequent year. Initial annual expenditure levels amounted to about $2.2 million in 2003-04, with an associated impact in excess of $4.4 million, and have grown to about $3.5 million, with an impact over $6.9 million. The cumulative impact to the area since the outset of operations amounts to more than $40.2 million. These figures are presented in Exhibit 18.
PENSACOL A EXHIBIT 19 FLORIDA STATE COLLEGE OF MEDICINE â€“ PENSACOLA REGIONAL CAMPUS TREND IN LOCAL ECONOMIC IMPACT, FY2003-04 THROUGH 2009-10,
The economic impact to the Pensacola area also began in 2002-03 with facility renovations, and expanded in 2003-04 with a partial class of third-year medical students, faculty and staff. Initial operating expenditures (2003-04) by the college and its affiliates also amounted to approximately $2.2 million, and have since expanded to more than $3.3 million on an annual basis. These spending levels equate to annual impacts ranging from $4.0 million to $6.3 million in this particular market (Exhibit 19). The cumulative total investment in the region has amounted to about $20.2 million in direct expenditures, which equates to an economic impact of nearly $37.5 million over its seven years of operations.
SARASOTA EXHIBIT 20 FLORIDA STATE COLLEGE OF MEDICINE â€“ SARASOTA REGIONAL CAMPUS TREND IN LOCAL ECONOMIC IMPACT, FY2003-04 THROUGH 2009-10, JUNE 2010 CONSTANT DOLLARS
As depicted in Exhibit 20, the annual impact in the Sarasota community has grown from very small levels (for initial planning efforts in 2003-04) to more than $5.4 million in 2009-10. Cumulatively, more than $13.3 million has been invested in this community, resulting in an impact of $23.4 million.
DAYTONA BEACH EXHIBIT 21 FLORIDA STATE COLLEGE OF MEDICINE â€“ DAYTONA BEACH REGIONAL CAMPUS TREND IN LOCAL ECONOMIC IMPACT, FY2006-07 THROUGH 2009-10, JUNE 2010 CONSTANT DOLLARS
Expenditures in Daytona Beach include assorted expenditure levels growing from about $2.5 million in impact to in excess of $5 million by 2009-10, with an additional investment of $2.1 million for the construction of the facility on the Daytona State College campus (impact of $3.6 million) occurring in 2007-08 (Exhibit 21). The cumulative effect has been an increase in local economic output of $19.3 million over four years.
FORT PIERCE EXHIBIT 22 FLORIDA STATE COLLEGE OF MEDICINE â€“ FT PIERCE REGIONAL CAMPUS TREND IN LOCAL ECONOMIC IMPACT, FY2006-07 THROUGH 2009-10, JUNE 2010 CONSTANT DOLLARS
Similar to the timeline demonstrated for Daytona Beach, the Fort Pierce campus impact peaks with the facility investment (on the Indian River State College campus), while other categories increase gradually over the period (Exhibit 22). The cumulative impact in this area has amounted to $17.3 million over four years.
SU MMARY EXHIBIT 23 TOTAL EXPENDITURES AND STATEWIDE ECONOMIC IMPACT OF THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE JUNE 2010 CONSTANT DOLLARS
A summary of individual campusesâ€™ impacts for the most recent year (2009-10) and their cumulative total impacts is depicted in Exhibit 23. As shown, operations in the Tallahassee area approach $100 million in their estimated annual impact, while regional campus activities in other locales drive between $4 million and $7 million of economic activity in their respective markets. Cumulatively, output has totaled nearly $750 million in the Tallahassee market while accounting for between $17 million and just over $40 million of activity in regional campus markets.
Future Economic Impacts Based on the most recent expenditures (approaching $73 million) and estimates of statewide impact, the Florida State University College of Medicine can be expected to contribute more than $160 million per year to the statewide economy, including $100 million in the Tallahassee market and in excess of $5 million in each of the regional campus markets. The activity totals nearly $1 billion every six years. In actuality, the figure could grow well beyond these levels, as research activity is expected to multiply significantly over the next five to 10 years. Realistically, this likely represents an underestimate of the actual future contributions of economic output to be made by the College of Medicine to state and local economies, as it does not account for the potentially substantial increases in research funding and activity anticipated in coming years. These research expenditures are of particular significance because the dollars typically do not represent state tax dollars that have been reinvested and successively multiply in the regions, but represent entirely new investments to the regions that also experience the multiplicative effect. Additionally, as the college’s mission is fulfilled and its graduates begin to bolster Florida’s physician work force, substantial benefits could be experienced by the state and campus localities in terms of economic development. The additional contingent of highly skilled professionals working throughout the state increases personal income levels and allows for more dollars to be retained as patients are able to seek treatment locally rather than outside the region or state. Furthermore, the locales become more attractive options for health care and related research businesses, as well as individuals and businesses from broader industries, based on quality-of-life enhancements resulting from the improved health-care infrastructures.
“When we recruited Torrey Pines [Institute for Molecular Studies] to the area, the FSU medical campus was one of our selling points.” --President Edwin Massey, Indian River State College
ADDITIONAL EDUCATIONAL AND SOCIAL IMPACTS
Not only has the Florida State University College of Medicine fulfilled its work force and social missions and produced significant economic impact, but it has had positive impacts on its students, the medical communities where it operates, and the university itself.
Overview In addition to successfully implementing its statutory mission over the first 10 years of its operation, the College of Medicine is having additional positive impacts for a variety of key stakeholders. In this section, we report our findings on the ways in which the college benefits: • • • • •
Its students as they prepare for advanced training and practice. The community-based clinical faculty members who continue to maintain active practices. The six host communities where campuses are located. Other programs of Florida State University. State and national policies and practices for medical education.
Our findings are based on interviews with numerous stakeholders, surveys sponsored by the Association of American Medical Colleges (AAMC), and analyses of various internal statistical reports prepared by FSU departments.
“Working with medical students has elevated the level of care in our practice and in the hospital.” --Kenneth Hurwitz, M.D., Sarasota clerkship faculty member
Impacts on Students As described in Chapter 2, the College of Medicine has already achieved its enrollment growth goals, and its intended impact on the size and composition of the stateâ€™s physician work force is starting to be realized. Just as important, the college is providing an educational program that surpasses the experience at many other medical schools. Its students and graduates report higher levels of student satisfaction, perform on national exams at better-than-expected levels, and exhibit strong performance in well-respected residency programs. Compared with their counterparts in other allopathic medical schools across the nation, College of Medicine graduates are significantly more satisfied with their educational experience. Data from the AAMC Graduation Questionnaire for the Class of 2009 (the most recent version available) reveal that the average response from College of Medicine graduates was higher than the national average on 117 of 125 key survey items relating to basic science instruction, clinical clerkships, and professional skills development. The mean response for College of Medicine graduating students was higher than the national average for 18 of 19 questionnaire items that addressed satisfaction with the content and structure of basic science courses and their value in preparing for clerkship training, and the overall mean score across all items was 10 percent above the average of counterparts nationally. For the 51 items related to clerkship experiences, College of Medicine graduating students were again much more satisfied than their national counterparts. Their average response was more positive in all but five instances. Four of those five were related to the quality of instruction provided by residents and fellows, which is not a key part of the College of Medicine instructional delivery model (unlike at most schools). Again, the mean response for clerkship experiences for the College of Medicine was 10 percent more favorable than the national average. College of Medicine graduating students were even more positive about their experiences in medical school when responding to the 47 items related to the development of a variety of doctoring and professional skills. Their overall mean response was 13 percent above the national average, with College of Medicine students rating 45 of the 47 responses higher than their national peers. Seven items on the questionnaire related to instruction in caring for elders, which is a special focus of the College of Medicine mission. On those seven items, the College of Medicine response was more positive in every instance, and the mean response was 13 percent above the national average.
On a single capstone question concerning satisfaction with the overall quality of the medical school experience, the mean College of Medicine response was 7 percent above the national average. A summary of our analysis of Graduation Questionnaire results is shown in Exhibit 24. EXHIBIT 24 EDUCATIONAL EXPERIENCES OF FSU COM GRADUATES COMPARED WITH NATIONAL AVERAGE OF ALL MEDICAL GRADUATES
Evidence of the strong performance of the College of Medicine instructional program also can be found in the performance of its students on the U.S. Medical Licensing Examination (USMLE). The USMLE is composed of four different assessments conducted at various points in a student’s educational program: •
Step 1 assesses student knowledge of the basic sciences and ability to apply key concepts to the practice of medicine. The Step 1 exam occurs at the end of the second year of the medical school program. Step 2 CK assesses a student’s clinical knowledge early in the fourth year of medical school. This assessment classifies test items along two dimensions: disease category and physician task. Step 2 CS, which also occurs early in the fourth year, assesses clinical skills through observation of student interactions with simulated patients. Step 3, at the end of the first year of residency, assesses the application of medical knowledge and understanding of biomedical and clinical science essential for the unsupervised practice of medicine, with emphasis on patient management in ambulatory settings.
Since the Step 3 assessment does not occur until the medical student is in residency training, its relevance to the performance of the College of Medicine instructional program is limited. The mean Step 1 score for College of Medicine students in the Class of 2011 was 218, compared with the national average of 221. Their performance is well above the 188 score necessary to “pass” the exam. College of Medicine students had a 96-percent pass rate on first attempt, compared with 94 percent nationally. All College of Medicine students attained a passing score on a retake of the exam. A 218 mean score may appear to reflect only average outcomes for the program. However, the College of Medicine results were higher than predicted based on national norms for entering students. Because of its efforts to admit students most likely to serve in rural and underserved areas, the College of Medicine accepts students with lower-than-average Medical College Application Test (MCAT) scores. Based on the welldocumented strong positive correlation between MCAT scores and USMLE test scores, the predicted response for College of Medicine test-takers was only 211. That is, the training received during the first two years of the College of Medicine curriculum has enabled its students to perform significantly better than expected on Step 1.
EXHIBIT 25 TRENDS IN STEP 2 CK SCORES FOR FSU COLLEGE OF MEDICINE GRADUATES ACTUAL AND PREDICTED SCORES COMPARED WITH NATIONAL AVERAGES
The value added by the College of Medicine curriculum is even more apparent in Step 2 CK results. The Class of 2010 had a mean score of 230, just above the national average of 229. When considering the performance of these same FSU students on the MCAT exam several years earlier, their expected performance was only 214. All test-takers (100 percent) in the Class of 2010 passed Step 2 CK. As seen in Exhibit 25, this pattern of significantly higher-than-predicted performance for College of Medicine students on Step 2 CK has prevailed since the second graduating class. The Step 2 CS assessment results are reported using a “pass-fail” designation and not a numeric score, so fewer comparisons are possible between the performance of the College of Medicine and all medical schools nationally. In the six years of USMLE testing at Florida State, 99 percent of students passed Step 2 CS on the first attempt, compared with 96 percent of all U.S. and Canadian students and 83 percent of international students. The high quality of the College of Medicine instructional program has become widely recognized by the graduate medical education (GME) community over the past few years. Directors of residency programs not only observe the strong USMLE scores attained by applicants from the College of Medicine but also openly express their satisfaction with the strong on-the-job performance of those graduates in their residency programs. As a result, residency program directors now actively recruit College of Medicine students for their programs. One faculty member observed that “FSU has gone from unknown to sought after in residency placements” in its first few years.
Two metrics demonstrate the College of Medicine’s success in preparing its students for GME – the ability of students to match with programs of their choice and their performance in their residency program. On the most recent residency program Match Day in March 2010, all College of Medicine students matched. This 100-percent overall match rate compares with the national rate of 93 percent. Not only are College of Medicine students successful in gaining entry to desired GME programs, but they exhibit superior performance while serving in their residency. Among the charter Class of 2005, the only class in which a majority of its members have completed residency training, 30 percent served as “chief resident,” generally considered to be the strongest performer in his or her cohort. Given that the typical residency program has four to eight residents per program year, College of Medicine graduates are attaining this leadership recognition at a rate far higher than predicted. During interviews with numerous students who were completing their third year of the program at the six regional campuses, MGT found further evidence of student satisfaction with their experiences at FSU COM. Throughout the remainder of this report, paraphrased statements drawn from interview notes are indicated by italics. Though they may not be accurate word for word, they faithfully reflect the intent of what was said. Students commented favorably on the overall design of the curriculum and the distributed, regional campus model. Students reported: • • • • •
Extensive patient contact on campus during Years 1 and 2 of the program made the third-year clerkships more productive for me. The Clinical Learning Center and standardized patients on the main campus are critical to student success in clinical training on the regional campuses. The community learning environment helps us prepare to function as a team. The FSU College of Medicine model fosters community building instead of competition. The FSU College of Medicine provided the opportunity for me to attend medical school near home for a major part of the program.
Students shared their experiences during their third-year clerkships and discussed the ways these experiences contributed to their professional development: • • • • • • • • • • • • • •
The community setting enabled me to realize I am already “making a difference” in the health of individuals and a community. I am pleased to find that patients and other community members have been very supportive of my presence and career goals. The FSU College of Medicine model enhances my personal interaction skills and independent thinking. I am developing excellent patient relationship skills. I was pleasantly surprised at the high level of patient interaction. Based on working with several physicians, I now have a more favorable view of private practice. I have become more familiar with outpatient work. I had an amazing OB experience with 10 deliveries and 40 assists. I have had more hands-on opportunities than my counterparts at other medical schools. The community faculty members are very impressive – they are great doctors, brilliant, want to teach, and embrace their roles in helping us. I have a good perspective on what it will be like to be in private practice in a specialty. I appreciate exposure to different practice management approaches, which I believe will help me make better career choices in the future. Working one-on-one with individual practitioners during Year 3 has helped me realize there are many different strategies for blending professional and personal life. The "quality time" I am able to spend with faculty is key to the success of the FSU College of Medicine model.
“I wanted to tell you about the extraordinary experience we had [when] we happened to interview three of your graduating students…. Each young woman was poised, articulate, and absolutely a delight to speak with. They all have outstanding records, excellent board scores, and, clearly, a passion for what they hope to do…. I realize you have a relatively young school. I think it is terrific what a good job you have done to recruit – and nurture – such talent…. [O]ur entire staff was so impressed by these applicants that I think you deserve to know how much we appreciate your efforts. We . . . hope more of your students apply to us in the future.” 59 --Director of Connecticut-based residency program
At the time of transition from their third to their fourth year of the program, College of Medicine students were becoming more aware of the superior preparation they had received to date: • • • • •
I’m starting my externship at another medical school and have found that I am far ahead of peers. Now that I’ve returned from my elective clerkship away from the College of Medicine, I can appreciate what our program offers. As an FSU College of Medicine clerk, I am functioning at the same level as residents trained elsewhere. I enjoy much greater access to attending physicians than my counterparts at other medical schools. When a student from a well-known private medical school came to Pensacola for one of his clerkship rotations, he told me his experience here was more productive than anything at his home institution. In sitting for the USMLE clinical skills assessment with students from other schools, I found I had logged far more hours working with patients than my counterparts.
Drawing on their own individual training and professional backgrounds, community faculty members also commented on the experiences they had observed that were benefiting the students training in their communities: • • • • • • • • • •
Based on my prior teaching experience at another medical school, I can tell you that the FSU model should be the model. Third- and fourth-year students from the FSU College of Medicine are ahead of residents I have worked with elsewhere. FSU clerks perform better than first-year residents from other programs. I’m very impressed with the scope and quality of the FSU College of Medicine program. I’m so proud that one of our local graduates was just accepted for a highly competitive vascular fellowship. FSU College of Medicine graduates perform well in residency training and are more personable. FSU College of Medicine students are “nicer human beings” than I find at other schools. FSU College of Medicine students are ahead of where I was at the same stage of my own medical education program. I wish I had been provided the same opportunities when I was a medical student. I’m a physician in Daytona Beach – and this is the way medical school should be done.
Students seemed uniformly pleased with their experiences and the education received at the College of Medicine. When asked what they advise friends and family members who are interested in going to medical school, typical answers were: • • •
I would absolutely recommend FSU – in fact, I just did so today. FSU will provide a great education that will give you clinical experience to go into whatever field you will pursue. I would recommend FSU. The curriculum is very well organized, and provides a perfect transition from undergrad to medical school. The clinical experience is perfect. My sister recommended FSU to me, and I in turn recommended it to my brother. All three of us have really been pleased with our experience – unlike friends who went to other schools.
“Coming from a lower-income family, I originally aspired to be a doctor based on expectations of wealth and prestige. My experience at the College of Medicine has helped me realize a successful career as a physician cannot be based on anything less than a sincere appreciation for helping others.” --Justin Deen, Class of 2011
Impacts on Community-Based Faculty The College of Medicine educational model relies on local practicing physicians to serve as clinical faculty members for the six regional medical campuses. These physicians were carefully selected for their excellent reputations and their expressed interest in medical education. Even though the individual faculty members already could be regarded as top physicians in their community, they report that they have been able to provide even higher-quality patient care in their practices since their affiliation with the College of Medicine. These faculty members are proud to serve and strongly endorse the FSU program. In interviews with clerkship directors and community faculty members across the six regional campuses, these physicians not only expressed their enthusiasm for the FSU program but also shared insightful observations about its impact on them, their practices and their communities. Members of the community clinical faculty feel strongly that the College of Medicine is having a significant impact on the quality of health care in their respective regions. Numerous comments were volunteered regarding: • • • •
Quality of care. Communications among health-care providers. Medical work force. Professional development and satisfaction.
Regarding quality of care, physician comments ranged from observations about how they conducted their own practices to impact on the community at large: • • • • • • • •
Serving as an FSU College of Medicine faculty member has contributed to improvements in the quality of health care in my practice. Serving as an FSU College of Medicine faculty member has contributed to improvements in the quality of health care in my community. Access to the FSU College of Medicine e-library has enhanced my ability to provide up-to-date, evidence-based diagnoses and medical care. Students have elevated the appreciation for and use of technology in private practices where they have been assigned. Our community has not had a strong medical library; the FSU College of Medicine e-library is great. With the encouragement of their students, faculty members now practice evidence-based medicine. Students keep the doctors on their toes. Other physicians in the community have asked FSU faculty to assist them with library research needs.
Poor communication among health-care providers is often cited as an impediment to improved quality of care. Serving on the medical school’s clinical faculty has provided value to the individual physicians through expanded communication networks. Faculty members observed: •
The opportunity to serve on the medical school faculty is building a greater sense of community among physicians – the fall faculty meeting has become a good professional opportunity for doctors. Some physicians felt professionally isolated before the FSU College of Medicine established the regional campus, but they now communicate more with other physicians in their community. Physicians now communicate more on professional matters with colleagues in neighboring counties, and not just in our own town.
As the top-quality residents and fellows near completion of their advanced training, many are torn between continuing their careers in an academic health center setting and focusing on patient care in a community environment. Current faculty members have observed that the potential role of serving as a community faculty member appeals to these young physicians since the position provides some of the best of both alternatives. College of Medicine community faculty reported that: • •
The presence of the regional campus is becoming a valuable factor in recruiting superior physicians to practice in the area. All three candidates for a recent opening in my practice asked about the opportunity for an FSU College of Medicine faculty appointment.
Every community faculty member interviewed was enthusiastic about the opportunity provided by their appointment. They felt a sense of pride and professional fulfillment and were invigorated by the challenges of passing on their knowledge to the next generation of physicians. They reported: • • • • • • • • • • •
Local residents seem more confident that their doctor is up-to-date if he or she serves as a member of the FSU College of Medicine faculty. Physicians are proud to serve on the FSU faculty and overtly make public their appointment on websites. The high rate of faculty retention indicates that the physicians feel they are gaining professionally from their role with the medical school. Practice is no longer rote, and is becoming fun again. Faculty members feel they have now gone to medical school twice, and learned more the second time. The FSU e-library was a big help when I was preparing for board recertification. Patients are impressed their doctor is good enough to be a faculty member. Working with students is like a shot of adrenalin. Physicians who serve on the faculty are now more satisfied with their careers. Students are starting to invite their faculty to take part in research projects. Many community physicians were skeptical of the FSU model at first, but now strongly endorse the program after seeing the results firsthand.
All members of the community faculty that we met expressed strong support for the College of Medicine, but their commitment to the program can be further documented by the high levels of faculty retention at the regional campuses. Some medical schools suffer from lack of continuity in their community-based educational experiences because of high levels of faculty turnover. For the FSU College of Medicine regional campuses, however, members of the community faculty seem to value their roles as mentors for the next generation of physicians. As seen in Exhibit 26, more than 88 percent of the more than 2,200 community physicians who have been appointed to the FSU College of Medicine faculty since 2002 have retained their affiliation. A majority of those who left the faculty indicated their reason was either retirement or relocation. EXHIBIT 26 TRENDS IN FACULTY RETENTION FSU COM REGIONAL CAMPUSES
Impacts on College of Medicine Host Communities The College of Medicine partners with 88 hospitals and health-carerelated organizations in the six communities where the regional medical campuses are located. According to hospital administrators and community leaders in these six locations, the college is having a positive impact on the quality of medical care in their respective regions. Additionally these communities value the College of Medicine’s presence for its economic and social impact. During site visits to the six regional campuses, the MGT team had the opportunity to interview members of the community board in each location. The members included executives of hospitals and other health care organizations, leaders of physician groups, government and education officials, and business leaders in the respective communities. Their enthusiasm for the FSU distributed model of medical education and the presence of a College of Medicine regional medical campus related to: • • • • •
Serving as a valued community asset. Establishing a base for development of graduate medical education (GME) programs. Building the community physician work force. Supporting stronger communications and partnerships within the health-care community. Enhancing the quality of care.
Community board members were uniformly proud that their community was selected to serve as one of the clinical training sites for the College of Medicine. While some of the sentiment was understandable community pride, the impact also included tangible economic benefits. The board members observed: • • • • • • • • •
The regional medical campus is a tremendous asset for our community (Daytona Beach). Having a medical school campus helps build the national reputation of our community (Pensacola). The FSU College of Medicine is a big factor in our community’s efforts to reverse its brain drain (Pensacola). It is prestigious for our community to be a site for a medical school (Tallahassee). College of Medicine students are very involved and visible in the community (Daytona Beach). The Torrey Pines Institute for Molecular Studies knew an FSU College of Medicine campus was coming to town when they made a decision to come to the region (Fort Pierce). We always mention the FSU College of Medicine when working with industrial recruitment teams (Fort Pierce). Clinical partners all value their affiliation with medical education (Orlando). The College of Medicine is a big asset to our hospital (Sarasota).
The original Adequacy and Capacity study, the implementation plan and House Bill 1121, along with numerous reports over the past decade, all stressed the need for Florida to build its capacity for graduate medical education. From our interviews with community board members, MGT found that the College of Medicine and its distributed education model are providing the impetus for long-overdue expansion of GME: • • • • •
Indian River Medical Center has a strong interest in establishing residency programs, and is considering affiliation with FSU among others. The hospital CEOs in Tallahassee are now talking about cooperative development of new GME programs. Involvement with FSU has stimulated interest in GME in Daytona Beach. Without first having positive experience with FSU, it would have been much more challenging to start a residency program in Daytona Beach. Our hospitals around Fort Pierce are now talking about starting residency programs; the College of Medicine expanded their vision about the value of hospitals in medical education. The College of Medicine will facilitate the development of residency programs in Sarasota. When we considered a residency in the past, our doctors in Fort Pierce worried it would not be a high-quality program; now a possible College of Medicine affiliation is seen as a viable solution. The College of Medicine was the catalyst for Florida Hospital Orlando to expand from three to seven residency programs. We see a role for GME in the future of Sarasota Memorial.
The College of Medicine’s impact on the local physician work force surfaced in interviews with community faculty members, but was even more pronounced in conversations with community board members and, especially, hospital executives. These individuals noted: • • • • • • • • • • • • • •
The College of Medicine has a higher percentage of graduates matching in primary care than other schools, and that is what we need here. Two College of Medicine graduates are already practicing in our region. We expect to hire many College of Medicine graduates in the future. At least five College of Medicine graduates are now practicing in our community. Three College of Medicine graduates are training in our local residency program. Two College of Medicine graduates are now training in our Family Medicine Residency Program. Many recent College of Medicine graduates have standing job offers to return to our community to practice when they complete residency training. Hospitals find it easier to recruit new physicians because of the College of Medicine presence. When new physicians come to town, they immediately inquire about and make known their interest in academic appointments. A high proportion of residents now at Orlando Health are recent graduates from the FSU College of Medicine program. The presence of the College of Medicine helps our residency programs recruit recent graduates from across the country. The College of Medicine is an important part of our strategy to recruit doctors to our hospital. Florida Hospital will be able to retain physicians who train at the FSU regional campus and then at one of the local residency programs. Sacred Heart promotes affiliation with FSU when recruiting physicians.
Increased communication among physicians and health-care providers is regarded as a major product of a regional medical campus presence. Board members volunteered: • • • • • •
A major long-term problem in health care is lack of communication, and the College of Medicine is bringing people together. The regional campus-sponsored events promote physician interaction across the region in a comfortable setting. The College of Medicine has been key to bridging the separate medical communities in our three-county region. The College of Medicine is opening communication across departments of our hospital. The College of Medicine was able to get the two big hospitals in town to work together for the good of the community. The College of Medicine provides an important common ground for the two hospitals to work for the common good of health care in our community.
“ The presence of students raises the level of knowledge of ever yone in the hospital.” --Steve Miles, M.D., Halifax Health, board member of Daytona Beach regional campus
Conversations with community board members about the quality of medical care often started with, “I don’t know how to define quality, but I know it when I see it.” With that disclaimer, board members went on to express their strong belief that the College of Medicine’s presence in their area was having a positive impact on the quality of care. • • • • • • • • • • • • • • •
We looked forward to its arrival, but our relationship with the College of Medicine has exceeded all expectations. I am absolutely convinced that quality of care has increased in our community since the FSU regional medical campus was established. The quality of medical care in the community has improved, since students bring accountability. Quality of care is hard to measure, but clearly the College of Medicine’s impact is positive. The new doctors being attracted to our community due to the FSU campus are of the highest caliber – this is more than a work force issue, it is being able to recruit the best of the best. We have been able to attract the top candidate to join our staff due to the potential of an FSU College of Medicine faculty appointment. The quality of care in our hospital went way up after the College of Medicine came; it was similar to what happened in one of our departments when it opened a residency program. Serving on the College of Medicine faculty keeps our physicians sharp – it provides another set of eyes, ears, and theories on how to care for the patient. College of Medicine students have stimulated and improved the medical staff. Affiliation with FSU is becoming a big factor in physician recruiting; e.g., we just signed a kidney transplant surgeon from USC. The College of Medicine’s presence energizes the doctors and the staff to become cutting-edge. Students bring a fresh eye into the clinic and propose valuable changes. FSU affiliation has brought very positive change to Sarasota Memorial Hospital, including more pride in being chosen to train new physicians. The presence of students raises the level of knowledge of everyone in the hospital. The College of Medicine has elevated the level of care in our hospital.
Impacts on Other Florida State University Programs The College of Medicine has become an integral part of The Florida State University. Although it receives a separate state appropriation from the rest of the university and operates more independently than most colleges, its presence has positively impacted the quality of the undergraduate student body, the universityâ€™s expanding research reputation, and the linkages that FSU has across the state. Over the past several decades, FSU has increasingly become a â€œuniversity of choiceâ€? for freshman applicants. Traditional measures of the quality of the incoming class, such as high grade point averages in high school and strong scores on college entrance exams (SAT and ACT), have seen increases over the period. While many factors have a role in these increases (e.g., growth in the state population, enrollment limitations, academic reputation of individual programs, and student life offerings), the medical school has had a major impact.
Medical schools are recognized for having rigorous academic admission standards, and high school seniors interested in medical careers are already thinking about how to gain a competitive edge in the medical school application process when they select their undergraduate institution. One factor they consider is whether their potential undergraduate universities also offer medical education, in hopes that they can establish valuable contacts through faculty references and undergraduate research opportunities that will help in medical school admission. This factor can be seen in the quality of the FSU freshman class since the establishment of the College of Medicine. As seen in Exhibit 27, the long-term upward trend began to increase even more rapidly after the announcement of the College of Medicine and, especially, once the new on-campus facilities were occupied several years later. EXHIBIT 27 TRENDS IN QUALITY OF INCOMING FRESHMAN CLASS FLORIDA STATE UNIVERSITY, 1990-2010
At the same time that the quality of the incoming freshman class was increasing, the proportion of students declaring a major in programs generally considered to be pre-med also increased. As seen in Exhibit 28, the programs in the life and natural sciences attracted approximately 10 percent of freshman majors in 2000 and nearly 16 percent in 2010. Interestingly, the number of majors in all other disciplines was almost the same in fall 2009 as in fall 2000, meaning that the pre-med majors absorbed all the growth in first-time freshmen at FSU. EXHIBIT 28 TRENDS IN SELECTION OF STUDENT MAJORS AMONG FRESHMAN STUDENTS AT FLORIDA STATE UNIVERSITY
FSU is a major research university, and it strives to become even more nationally prominent in its research endeavors. A high proportion of the top-ranked research universities rely heavily on the research productivity of medical faculty members to maintain and build their reputations. Medical research attracts both federal (primarily National Institutes of Health) and corporate sponsors.
EXHIBIT 29 TRENDS IN SPONSORED RESEARCH AWARDS FLORIDA STATE UNIVERSITY AND FSU COLLEGE OF MEDICINE FISCAL YEARS 2004 – 2009
The College of Medicine’s impact on university-wide research performance has been significant with the arrival of full-time faculty members at the medical school, particularly in the past five years. Total sponsored research funding for College of Medicine faculty members has grown from $3.7 million in FY 2004 to $10.6 million in FY 2009, as seen in Exhibit 29. On the basis of research funding per full-time faculty member, the College of Medicine’s performance is especially impressive. Compared with other schools and colleges at FSU, the research funding per faculty member for the College of Medicine ranks second highest. Of particular note, approximately 30 percent of the increase in overall research funding at FSU over the past five years is attributed to the College of Medicine.
As state appropriations have dwindled and limits on student tuition increases are encountered, private giving is becoming much more important to the success of FSU and other state universities in Florida. FSU has announced its intent to launch a major capital campaign in the near future, and its fundraising programs have undergone review and renewal. The dollar amounts from private giving through the FSU Foundation have fluctuated over the past decade because of changes in leadership and pressures on the national economy. One strong performer over this period, however, has been the communities where regional medical campus programs are offered â€“ likely because of the increased visibility of FSU in those locations. Analysis of cause and effect in private giving performance is beyond the scope of this analysis, but an interesting observation is that the five counties where the College of Medicine has regional medical campuses and the 12 counties where affiliation agreements exist with major hospitals have shown increased giving. (Note: Leon County is excluded from these calculations since it was already the home of FSU.) These counties represented approximately 18-19 percent of gifts to the foundation in the 2000 fiscal year and 31-33 percent in 2009. As seen in Exhibit 30, the pattern generally tracks with the announcement and establishment of five regional campuses in 2003-2007. EXHIBIT 30 TRENDS IN GIFTS TO FSU FOUNDATION BY COUNTY FISCAL YEARS 2000 - 2009
During site visit interviews, MGT heard about the excitement being generated in local communities by the presence of FSU through a regional medical campus, including observations such as: • • • •
The campus has raised the visibility of FSU beyond Tallahassee. It serves as a conduit to local alumni and civic groups for information about the overall university. The regional medical campus has raised the visibility of FSU in the region. More Daytona Beach high school students apply to FSU than before. The FSU College of Medicine campus has energized local alumni.
Impacts on State and National Medical Education Policy and Practice When legislative and university leaders began discussing their vision for a new medical school at FSU in the late 1990s, the initial reaction of many higher education and medical education leaders across the state and nation was one of disbelief. Quite simply, most were operating under the unfounded belief that there was a national surplus of physicians that would continue indefinitely. Now after 10 years, it is clear that creation and development of the FSU College of Medicine has enlightened public policy on the need for physicians. At the same time, the college has raised the bar for how medical education should be delivered. The documentation of an impending physician shortage in the early College of Medicine planning documents provided a breakthrough in the recognition of the national physician shortage. Despite the initial skepticism of the projections in the Assessment of Adequacy and Capacity report, virtually every major national medical organization has now adopted position statements expressing concern about the physician shortage. For instance, two leading groups in medical education have offered the following: •
American Medical Association - The United States faces a shortage of between 124,000 and 159,000 physicians by 2025. Already, at least 22 states and 15 medical specialties have reported physician work force shortages, including in medically underserved regions and front-line specialties including primary care and general surgery. Association of American Medical Colleges - Concerned that future demand for physicians will outstrip supply, the AAMC supports a 30-percent increase in U.S. medical school enrollment by 2015.
The increased awareness of a physician shortage has been especially profound in Florida. The established medical schools have expanded the sizes of their entering classes, and two new allopathic campuses and one new osteopathic campus have been established. Further, two other institutions are now listed as “applicant schools” with the LCME and are in the early stages of establishing new allopathic programs. Overall, the number of medical school slots per year in Florida has grown from approximately 500 in 1998 to 1,856 in 2010 and will grow to at least 3,136 over the next few years.
When the College of Medicine earned full accreditation in 2005, it was the first new school in the nation in more than 20 years. Over the past six years, however, seven new schools in six states have received preliminary accreditation and have enrolled their charter classes, and seven additional proposed schools have attained applicant status. While the same physician work force issues that contributed to the establishment of a new medical school at FSU in 2000 clearly had a major role in creation of the other new schools, a potentially greater contribution of the College of Medicine to this new wave of medical schools is its innovative instructional delivery model. The college has served as a role model and convener for the New and Developing Medical School Consortium that is funded by the Josiah Macy Foundation through AAMC. Longtime leaders in medical education are taking note of the FSU approach. For instance, Michael Whitcomb, the former editor of Academic Medicine and Senior Vice President for Medical Education at AAMC, recently wrote:
“The current period of medical school expansion has witnessed the emergence of a fundamental restructuring of the traditional departmental arrangements that have existed for decades in the overwhelming majority of medical schools. The development of the Florida State University College of Medicine set an example for other new schools by establishing only five departments — Biomedical Sciences, Clinical Sciences, Family Medicine and Rural Health, Geriatrics, and Medical Humanities and Social Sciences.” Whitcomb also observed that the structure for clinical faculty is changing along the lines of the FSU model. He noted that:
“Most of the new schools will depend on existing university faculty and the hospitals’ medical staffs to provide leadership for the development and implementation of the schools’ educational programs.”
During the past six months, we have examined the impacts that the relatively young Florida State University College of Medicine is having on various stakeholders across the state and nation. We have reviewed numerous reports and documents; interviewed students, faculty and health-care leaders; and analyzed quantitative and qualitative information to assess the College of Medicine’s impact from various perspectives. These activities enable us to offer summary observations and share our thoughts on the college’s future development.
Summary of Impacts The College of Medicine was envisioned from the outset as a special place. Not only was it expected to offer high-quality instructional programs for its students, but it was intended to become a socially responsive medical school. In particular, the school’s founding mission identified Florida’s need for primary care physicians, particularly for its rural, elderly and other underserved populations. On all these counts, the College of Medicine clearly has been successful.
Quality of Instruction Our analyses of both quantitative and qualitative information all lead to the same conclusion: The College of Medicine is providing a high-quality instructional program to its students. Of particular note: •
College of Medicine students’ performance on national licensure examinations is near or above the national average and greatly surpasses the outcomes of similarly qualified students who attend other medical schools. Graduating College of Medicine students report significantly higher levels of satisfaction than their counterparts elsewhere on virtually every measure related to instructional quality and professional development in a national survey of all medical school graduates. College of Medicine graduates are being selected by highly competitive residency programs and are attaining the prestigious “chief resident” designation at well above average rates. Leading physicians across the state who serve as community faculty members for the College of Medicine concur that “this is the way that medical school should be.”
Physician Work Force To date, the College of Medicine has had six graduating classes. Because of the phased enrollment build-up over the first decade, only 336 students have completed the M.D. degree there, and only 51 of these have completed residency training and entered practice. Based on the experience of the limited number of graduates to date and the continuing growth of the college, its impact on Florida’s physician work force is likely to be even greater in the near future: •
Approximately two-thirds (64 percent) of College of Medicine graduates who are now in practice have elected to stay in Florida – a retention rate that is highest among the state’s medical schools and 1.6 times the national average. Nearly half of all College of Medicine graduates (44 percent) have pursued residency training in Florida programs, despite the relatively small number of residency slots in the state. The current class of fourth-year students (the Class of 2011) was the first cohort to reach the full planned enrollment capacity, and the College of Medicine will now produce approximately 120 graduates per year.
Importance of Primary Care The legislation that established the FSU College of Medicine (House Bill 1121) emphasized that it “shall be dedicated to . . . preparing physicians to practice primary care.” While the college provides opportunities for its students to explore and succeed in any medical specialty of their choice, its success in promoting primary care is noteworthy: • •
On national surveys of matriculating students, College of Medicine entrants indicate they are much more likely than their peers nationally to become primary care physicians. The College of Medicine curriculum provides students with significant exposure to successful primary care physicians, and enables the students to recognize the importance of primary care in the nation’s health-care system. More than half (56 percent) of College of Medicine graduates in 2010 pursued residency training in primary care, compared with just 43 percent nationally and 42 percent for other Florida medical schools.
Understanding of Special Needs of the Elderly Based on early plans and its enabling legislation, the College of Medicine became one of the few medical schools in the nation with a separate Department of Geriatrics. Although it promotes careers in geriatrics, the express purpose of the department is to ensure that all College of Medicine graduates – regardless of intended medical specialty – have a strong grounding in the care and treatment of elders. •
The College of Medicine curriculum provides 325 contact hours per student in the diagnosis and treatment of elders – a level of contact significantly greater than other medical schools. Graduating students from FSU, as compared with their peers from other medical schools in a national survey, expressed significantly greater confidence in their ability to provide appropriate diagnoses and care for elder patients.
Emphasis on Rural Medicine Part of the rationale behind House Bill 1121 and its establishment of a new medical school at FSU was the proximity of the university to rural, medically underserved areas across North Florida. The College of Medicine has developed targeted strategies for student admissions and special training opportunities to successfully address rural healthcare needs in the state: • • •
While only 5.4 percent of its applicants have come from statutorily designated rural counties, these counties have contributed 6.9 percent of College of Medicine matriculants. In addition to its six regional campuses, the College of Medicine provides additional clerkship training opportunities in three rural and small-town locations. 20 percent of College of Medicine graduates practicing are in rural areas, although rural counties in Florida constitute only 6 percent of the state’s population.
Underserved Populations House Bill 1121 directed the College of Medicine to “provide access to medical education for groups which are underrepresented in the medical profession.” A major factor in the legislative intent was to address the needs of medically underserved populations. The College of Medicine has implemented various strategies to develop a more diverse physician work force and provide for the needs of the medically underserved: • • •
Approximately one-fourth (24 percent) of FSU medical students are either African-American or Hispanic, compared with just 10 percent of the Florida M.D. work force. The College of Medicine has been ranked by a national publication as among the best in the nation for serving Hispanic students. Care for the underserved is a major theme across all four years of the curriculum, and a special clerkship site provides opportunities to care for migrant workers and their families.
Impact on University Development Although not explicitly stated as a goal in House Bill 1121, the College of Medicine’s establishment has had favorable impacts on FSU itself. During the late 1990s, the Commission on the Future of Florida State University formulated a strategic plan that was intended to move the institution into “the top tier of America’s public universities.” Several elements of that plan addressed possible expansion of the university’s role in medical education and contributed to the legislative support for establishing the medical school. During the College of Medicine’s first decade, FSU experienced: • •
Significant increases in sponsored research awards, with nearly one-third of the overall increase being generated by College of Medicine faculty. Continuation of increases in average scores of entering students on the SAT and ACT admissions tests, with the rate of increase improving at an even faster pace since the College of Medicine’s establishment. A significantly greater concentration of entering students indicating an interest in majors in the biological sciences and other fields considered as pre-medicine. Increased private giving in the counties surrounding the regional campuses.
When Gov. Jeb Bush signed House Bill 1121 in the presence of university and legislative leaders, great expectations were expressed for what the College of Medicine could become and would contribute to the quality of life in Florida. While new challenges continue to emerge, all in attendance that day are likely to agree that their founding expectations have been realized.
Challenges and Opportunities Ahead Given the College of Medicine’s impressive accomplishments over its first 10 years of existence, a major challenge in the decade ahead will be to continue to meet the myriad expectations of the various stakeholders. In addition to sustaining progress to date, the college faces opportunities for expanded development and service to the people of Florida.
Strategic Plan The College of Medicine has recently invested much time and attention in strategic planning, and one tangible result is the delineation of four areas of excellence: • • • •
Teaching. Research. Service and clinical care. Community partnership.
Under these four focus areas, the College of Medicine has adopted 25 goals that, when attained, will further enhance the college’s ability to address Florida’s physician work force needs while providing a high-quality education for its students and contributing to scientific breakthroughs.
External Communications One goal of the community partnership focus calls for the College of Medicine to actively communicate its mission and successes. The interviews we conducted with community stakeholders revealed the perception that the college is not as well-known as desired in the six communities that serve as hosts to the regional medical campuses. Community board members and community faculty offered such observations as: • • •
We have success to talk about and we don’t do it. The local community has low awareness of the presence of the College of Medicine and its contributions to our healthcare system. We need to lift the basket off the candle.
The need for greater visibility within the regional campus host communities is taking on increased priority since the campus deans report that they are now expected to become fundraisers for the college. The concerns that were expressed about external communications were not intended as criticism of the quality of existing efforts, but rather the magnitude of investment in marketing and communications. Fortunately, the College of Medicine does have additional talent on its community boards and regional campus staff to contribute to a stronger effort. Opportunities to enhance external communications that were suggested for consideration during our site visits included: • • • • •
Work more closely with local FSU alumni chapters. Encourage hospitals to promote their affiliation with FSU more overtly. Sponsor and promote faculty lectures on topics of community interest. Expand efforts to share local success stories. Enhance contacts with and tracking of College of Medicine alumni.
Although most of the expressed concern for an expanded external communications program focused on the need to inform state and local stakeholders, the College of Medicine faces similar challenges at the national level. In part because of its youth and the obstacles faced in gaining initial accreditation, many medical educators do not yet regard it as the high-performing medical school that it has become. An enhanced external communications program should lead to more success in competition for grants and top students, and enable others across the nation to benefit from the innovative approach to medical education that has been implemented at FSU.
Graduate Medical Education One goal under the focus on excellence in service and clinical care calls for the College of Medicine to “identify partners to develop Graduate Medical Education programs.” State health leaders have recognized the need for expanded GME opportunities for well over a decade, but progress has been slow. Now that the College of Medicine is producing sizable numbers of graduates each year and other new medical schools will soon begin to do so, the need for more residency slots in Florida is becoming more acute. Many of the students we interviewed stated that gaining a residency slot in Florida is a high personal priority, but they expressed a desire to return to the state to practice, even if outof-state graduate medical education became necessary. One student, however, probably spoke for many when she said she fears she will not return to Florida if forced to leave for residency training, since she had grown tired of moving every few years and wants to establish roots. In each of the regional campus communities, we learned of growing support for establishing residency programs. While some community hospitals are at the advanced stages of program planning, others are just beginning to consider which programs are needed and can be supported. While this progress is encouraging, it is important to realize that the need will not be satisfied by the limited efforts currently under way. Just as it found ways to develop an innovative and highly effective medical school curriculum, the College of Medicine can play a vital and creative role in expanding the state’s system of graduate medical education.
Core Values Perhaps the greatest challenge facing the FSU College of Medicine over the next decade will be retaining its focus on the core values that have guided its development since its founding. Educational historians have noted that, while many colleges and universities have been founded with distinctive missions that address specific needs, these entities often suffer from mission drift over time as initial successes become taken for granted. Mission drift becomes more likely as the members of the founding leadership team leave their posts and the importance of the original mission is not a key factor in selection of new leaders. The founding mission of the College of Medicine has served the college well over its first decade because the mission addresses significant needs in the state and national health-care system. These social needs are at least as important today as they were 10 years ago when the College of Medicine was founded, ensuring that the college’s mission and core values will remain relevant for years to come.