The Issue Whether the Petitioner has met the requirements for licensure as a medical doctor in the State of Florida set forth in Section 458.311(1)(f), Florida Statutes (1986 Supp.), as required by Section 458.313(1), Florida Statutes (1986 Supp.)?
Findings Of Fact The Petitioner applied for licensure by endorsement as a medical doctor in Florida in September of 1986. Following notification by the Respondent that additional materials were required to complete the Petitioner's application, the Petitioner timely submitted the materials. In March of 1987, the Petitioner appeared before the Foreign Medical Graduate Committee of the Respondent. On April 5, 1987, the Respondent entered an Order titled Notice of Intent to Deny the Application for Licensure by Endorsement of Hien B. Nguyen. The stated basis for the denial of the Petitioner's application was that the Petitioner had failed to demonstrate that he graduated from a medical school. The Petitioner began medical school in 1967 at the University of Saigon, Faculty of Medicine, in Saigon, Republic of Vietnam. The Petitioner Successfully completed the six years required course work in medicine at the University of Saigon, Faculty of Medicine, in 1974. Following the completion of the course work required to earn a medical degree at the University of Saigon, Faculty of Medicine, the Petitioner was drafted into the Republic of Vietnam's military. He attended training for approximately six months immediately following the completion of his medical degree course work. The Petitioner was required to complete a thesis before being eligible for a medical degree from the University of Saigon, Faculty of Medicine. Upon completion of military training, the Petitioner commenced and completed work on his thesis. The Petitioner's thesis consisted of a translation of "Central Nervous Disease in Children," of Nelson's Pediatric Textbook, from English into Vietnamese. The Petitioner presented his thesis on April 14, 1975. Thuc R. Bach, M.D. attended the presentation of his wife's thesis on April 14, 1975, and witnessed the Petitioner's thesis presentation. The Petitioner was awarded a Certificate from the University of Saigon, Faculty of Medicine, on April 14, 1975, which indicated that the Petitioner had completed work necessary to be awarded a medical degree. The Certificate was issued temporarily. After approximately five years the Petitioner was required to return the Certificate at which time he could be issued an official diploma. On approximately April 30, 1975, the government of the Republic of Vietnam fell to the army of North Vietnam. Following the fall of the Republic of Vietnam, the Petitioner was confined to a concentration camp where the Petitioner acted as camp doctor. Following the Petitioner's release from confinement in 1976, the Petitioner worked as a physician at Saint Paul Clinic in Saigon until 1979. From 1977 until 1980 the Petitioner also attended and taught at a medical training center in Saigon. In October, 1980, the Petitioner escaped from Vietnam. He resided in Galang, Indonesia until March, 1981, when he moved to the United States. The Petitioner has completed the following since his arrival in the United States: December, 1981: Sat for the Federation Licensing Examination and was subsequently certified by the Federation of State Medical Boards; January 24, 1983: Certified by the Educational Commission for Foreign Medical Graduates; July, 1984 - June, 1985: Interned at the Cook County Hospital, Chicago, Illinois; July, 1985 - June, 1987: Residency program at Cook County Hospital, and February 19, 1986: Licensed as a physician by the State of Illinois (the license is currently active and unrestricted). The Petitioner was presented with a certificate from the Faculty- Council-in-Exile of the Faculty of Medicine of the University of Saigon dated April 20, 1981. The certificate affirms that the Petitioner "Successfully completed the course of study leading to the degree of Doctor of Medicine..." The certificate is signed by the Dean Emeritus of the University and Dao Huu Anh, M.D., Associate Dean of the University. Prior to the fall of the government of the Republic of Vietnam, graduates of the University of Saigon, Faculty of Medicine, were presented with a certificate authorizing them to practice as a physician without restriction upon completion of the required courses of study and a thesis. Graduates were not issued an Official Diploma until five years had passed since the issuance of their certificate. Although the Petitioner completed the required courses of study, presented his thesis and received a certificate authorizing him to practice as a physician, the Petitioner was not able to obtain an Official Diploma five years later because of the fall of the government of the Republic of Vietnam. In light of the fall of the government of the Republic of Vietnam, it is doubtful that the records of the University of Saigon, Faculty of Medicine are available or that the Petitioner could obtain an Official Diploma. The Petitioner is a graduate of the University of Saigon, Faculty of Medicine, a medical school.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a final order be issued GRANTING the Petitioner's application for licensure by endorsement as a medical doctor in the State of Florida. DONE AND ORDERED this 25th day of January, 1988, in Tallahassee, Florida. LARRY J. SARTIN Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 28th day of January, 1988. APPENDIX TO RECOMMENDED ORDER, CASE NO. 87-2969 The parties have submitted proposed findings of fact. It has been noted below which proposed findings of fact have been generally accepted and the paragraph number(s) in the Recommended Order where they have been accepted, if any. Those proposed findings of fact which have been rejected and the reason for their rejection have also been noted. The Petitioner's Proposed Findings of Fact Proposed Finding Paragraph Number in Recommended Order of Fact Number of Acceptance or Reason for Rejection 1 1. 2 2. 3 3. 4 4 and 5. 5 6. 6 7-10. 7 11-12. 13. The Petitioner worked at the training center from 1977 through 1980. 15. The Petitioner went from Vietnam to Indonesia in October of 1980. He did not travel to the United States until March of 1981. 10-12 Cummulative, summary of the evidence and unnecessary. Dr. Nghia Van Tran's letter was not accepted into evidence. 13 16. The last sentence is cummulative, a summary of evidence and unnecessary. The footnote is irrelevant. The burden of proof in this proceeding was on the Petitioner. The Respondent is not required to verify the signature of Dr. Dao. 14 10 and 17. 15 17-18. 16-18 Cummulative, summary of the evidence and unnecessary. The Respondent's Proposed Findings of Fact 1 1 and 3. 2-5 The Respondent's remaining proposed findings of fact are essentially summaries of the Respondent's inter- pretation of the evidence and argument concerning the evidence. The Respondent's interpretation of the evidence is rejected. The following is a brief discussion of why the Respondent's arguments have been rejected. The first two sentences are true and support the finding of fact that the Petitioner began medical school in 1967, completed his course work in 1974 and presented his thesis in April of 1975. See findings of fact 4-5 and 9. The third and fourth sentences are true but the Respondent has overlooked the fact that the Petitioner presented other evidence which supports his position. Therefore, even if the fifth sentence were correct, there is other evidence which supports findings of fact 4-5 and 9. The sixth sentence is irrelevant. Although the Board may have raised a question, the correct answer to that question is a matter of proof. The seventh sentence is true but irrelevant. The eighth sentence is not supported by the weight of the evidence. There was no testimony sufficient to support any finding of fact concerning Dr. Dao's signature on any document. Although the ninth sentence is correct, the weight of the evidence does not support the alleged fact set out in the tenth sentence. The eleventh sentence was taken into account in the weight given to Dr. Dao's statement. Although the twelfth sentence is correct the thirteenth and fourteenth sentences are not supported by the weight of the evidence. While it is true that the Petitioner's testimony with regard to when he completed his course work at the University of Saigon was not totally consistent, the weight of the evidence supports a conclusion that the Petitioner finished his course work in June of 1974. The Petitioner's explanation concerning the inconsistency in his testimony was credible. The first and second sentences are true. The third sentence is true but overlooks the fact that it corroborates non-hearsay evidence. The fourth sentence is law. The fifth sentence is true. The sixth and seventh sentences are true. The eight sentence is not supported by the weight of the evidence. The ninth and tenth sentences are true but they do not support the ultimate conclusion the Respondent suggests. It is possible that the Certificate in question could have been based upon other credible evidence. The first sentence is true. The second sentence is not supported by the weight of the evidence. The Petitioner testified that he completed his course work in 1974. The third sentence is true. The fourth and fifth sentences are not supported by the weight of the evidence. COPIES FURNISHED: Carolyn S. Raepple, Esquire Cheryl G. Stuart, Esquire Hopping, Boyd, Green & Sams 420 First Florida Bank Building Post Office Box 6526 Tallahassee, Florida 32314 M. Catherine Lannon, Esquire Assistant Attorney General Administrative Law Section Department of Legal Affairs Room 1601, The Capitol Tallahassee, Florida 32399-1050 Ms. Dorothy Faircloth Executive Director Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Tom Gallagher, Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 William O'Neil Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750
Findings Of Fact The Petitioner, James K. Hester, applied for licensure as a medical doctor in Florida. The Respondent is an agency of the State of Florida charged with administering and enforcing the statutory and regulatory standards by which physicians enter the practice of medicine in Florida as well as by which the practice of medicine by licensed physicians in Florida is regulated and enforced. The Petitioner's application was for licensure by endorsement. That application was denied on the basis that the Petitioner's supervised clinical training was not obtained in either a hospital affiliated with a medical school accredited by the LCME or in a residency program accredited by the ACGME in a specialty area in which the Petitioner's clinical training was done. This requirement is set forth in Rule 21M-22.018 (a substantial reenactment of former Rule 21M-22.18), Florida Administrative Code, the so-called "clerkship rule." The Petitioner's supervised clinical training at issue in this proceeding involved clerkships in internal medicine, surgery, obstetrics and gynecology, and pediatrics. The Petitioner performed the clerkships in 1983 and 1984. The parties have stipulated that the clinical clerkship performed by the Petitioner at Englewood Hospital in New Jersey in the area of internal medicine was an approved clerkship under the requirements of the above Rule. Therefore, the only clerkships at issue concern those in surgery, obstetrics and gynecology, and pediatrics, which were performed at Englewood Hospital by the Petitioner. In determining which clerkships comply with the Rule, and thus which hospitals are affiliated with accredited medical schools in certain specialty areas and in determining which residency programs are accredited by the ACGME in specified specialty areas, the board commonly and customarily relies on a directory or compilation of accredited programs which depicts medical training programs on a nationwide basis which are accredited by the ACGME. This compilation is generally relied upon by professionals in the medical education field as well as by medical licensing regulatory agencies nationwide. Its compilations of accredited medical schools and affiliated hospitals and accredited residency programs are compiled by the ACGME which organization in turn is accepted as authoritative in determining such matters, as is depicted on the face of the above-cited Rule. 1/ Englewood Hospital is not affiliated with a medical school which is accredited by the liaison committee on medical education in the specialty areas in which the Petitioner's disputed clinical training was performed. The hospital does not have a residency program accredited by the ACGME in the specialty areas in which the Petitioner's clinical training was performed. Although residents training in a residency program of other hospitals in the area accredited by the ACGME rotated through Englewood Hospital and took training in the relevant specialty areas in which the Petitioner participated, the Petitioner was not a participant or enrolled member in those residency programs of the other hospitals whose residents trained in part at Englewood Hospital. Although the Petitioner participated in some of the clinical training programs which residents affiliated with training programs at other hospitals participated in at Englewood, in addition to not being enrolled in residency training with those other hospitals and accredited programs, it was not shown he participated in all of the required "rotations" of those accredited training programs which full complement of rotations was the essential basis for the accreditation of those residency programs. Although Englewood Hospital had a relationship with the unaccredited medical school from which Petitioner graduated and certified the completion of his clerkships at Englewood, the Petitioner's training was not certified by an accredited residency program or hospital, because the Petitioner and his medical school had no affiliation with those accredited hospitals and residency programs who happened to have participants training at Englewood. Thus the Petitioner's clerkships in the disputed specialty areas were not verified as to their completion by any hospital affiliated with an accredited medical school or whose residency program was accredited by the above organization. Englewood Hospital was not approved or accredited for training in surgery, obstetrics and gynecology, or pediatrics for the years 1983-1984 at issue, as clearly shown by Respondent's Exhibit 1 in evidence.
Recommendation Having considered the foregoing Findings of Fact, Conclusions of Law, the evidence of record, and the candor and demeanor of the witnesses, it is, therefore RECOMMENDED that a Final Order be entered by the Board of Medical Examiners denying the application of James K. Hester for licensure as a medical doctor in the State of Florida. DONE and ORDERED this 28th day of October, 1986 in Tallahassee, Florida. P. MICHAEL RUFF Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399-1550 (904)488-9675 Filed with the Clerk of the Division of Administrative Hearings this 28th day of October, 1986.
Findings Of Fact Petitioner, David U. Ewing-Chow, filed an application for licensure by examination as a medical doctor with respondent, Department of Professional Regulation, Board of Medical Examiners, on February 24, 1984. The application was reviewed and considered by respondent at a meeting on December 2, 1984, and proposed agency action denying the application was issued on January 9, 1985. As grounds for denying the application, the agency stated that: . . . the applicant has not demonstrated to the Board that he is capable of safely engaging in the practice of medicine with reasonable skill and safety. See Section 458.311 (3), F.S. Further, the applicant has not graduated from medical school or college as required by Section 458.311(1)(b), F.S. The proposed agency action prompted this proceeding. In his request for a hearing, petitioner challenged the agency's signs, and contended he satisfied both objections raised by the agency. Petitioner first enrolled as a regular medical student in October, 1969 at the University of the West Indies in Kingston, Jamaica. He remained in the school's medical program until he failed the preclinical examination a second time in 1972. Because successful completion of that examination was required to remain in medical school, he withdrew from school and moved to England. There he successfully completed the conjoint preclinical examination administered by the Conjoint Society of Apothecaries Preclinicals in London, England. Having passed that examination, Ewing-Chow was readmitted in October, 1972 to the University of the West Indies as a non-degree seeking student to pursue clinical medical courses to qualify him to take the licensure examination in England. Although he was a special student, Ewing-Chow's curriculum was identical to the coursework required of medical degree seeking students. He completed the program in 1975, but did not receive a medical degree from the university. After completing his medical coursework, EwingChow returned to England where, based upon his medical education, he qualified to take the examination for a License in Medicine and Surgery administered by the Society of Apothecaries of London (Society). To qualify for this examination, one need not graduated from a medical school. The Society is not a school or university, and offers no instruction. Rather, it conducts examinations for a License in Medicine and Surgery, and is described in The World Directory of Medical Schools as a "nonuniversity licensing bod(y)." After passing the examination EwingChow received a "Diploma of Licentiate in Medicine and Surgery" from the Society. The Diploma of Licentiate is not a degree in medicine, but is a title or qualification which allows the individual to "temporarily" register for an internship. A one-year internship is required before one can be issued a certificate of registration by the General Medical Council (Council), a statutory body responsible for registering all medical practitioners in Great Britain. Like the Society, the Council grants no degrees, but merely issues a certificate of registration to qualified physicians. In the case at bar, Ewing-Chow completed a one-year internship program in both Trinidad and the University of West Indies. Thereafter, he was certified in full registration by the Council and was accordingly authorized to practice medicine in the United Kingdom. Full registration is the British equivalent to a license to practice medicine in the United States. He also received a license to practice in the European Economic Community. In addition, he is licensed to practice in Trinidad, Jamaica and Tobago. After spending some thirty months in Trinidad as a government physician, Ewing-Chow moved to Miami, Florida in September, 1980, and enrolled in the three-year residency program in the Department of Family Medicine at Jackson Memorial Hospital. He successfully completed this program in June. 1985 and is now chief resident in the family practice residency program. As such, he is in charge of supervising thirty-six other residents in the program. He is eligible to take the examination for board certification in the family practice specialty, but must first be licensed by the State of Florida in order to take the examination. Ewing-Chow has also submitted his credentials to the Educational Commission for Foreign Medical Graduates (ECFMG), and has passed the examination administered by that body. The evidence clearly demonstrates that Ewing-Chow is capable of safely engaging in the practice of medicine with reasonable skill and safety. This was attested to by the chief of family practice at the University of Miami School of Medicine at Jackson Memorial Hospital and is evident from Ewing-Chow's present responsibilities as chief resident in that program.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that the application of David U. Ewing-Chow for licensure as a medical doctor by examination be DENIED. DONE and ORDERED this 26th day of March, 1986, in Tallahassee, Florida. DONALD R. ALEXANDER, Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 Filed with the Clerk of the Division of Administrative Hearings this 26th day of March, 1986.
The Issue Whether Lazaro Saavedra is eligible for licensure by endorsement as a registered nurse in Florida, as provided in Chapter 464, Florida Statutes, and Chapter 210, Florida Administrative Code?
Findings Of Fact Petitioner, Lazaro Saavedra, received his education in Cuba (Tr. 109). There is evidence that he attended medical school for a period of four to five years beginning in 1960 (Tr. 109, 110, 119; JX-4), but he did not complete his medical education (Tr. 109). Petitioner asserts that he attended nursing school in Cuba from 1959 to 1962 (Tr. 108), and was licensed to practice nursing in Cuba (Tr. 118-119, 125). The record in this cause is devoid of any documentation of Petitioner's nursing education. While a witness apparently had a paper that may have been some sort of copy of Petitioner's nursing degree, it was neither identified for the record or offered into evidence (Tr. 85, ln. 11-15; 86, ln. 2-6). Petitioner attempted to prove his nursing education by his own testimony, but he was unable to describe well the content of his nursing program (Tr. 124, ln. 24-25, 125). He was unclear and imprecise regarding the dates of his nursing education and its overlap with his medical education (Tr. 109, 110, 124). The only testimony Petitioner offered to prove his attendance in nursing school, other than his own, was that of Bruno Barreiro. Mr. Barreiro knew Petitioner to be a nursing student (Tr. 91). He later saw Petitioner on "rounds" at a hospital (Tr. 92), but stated that medical students and nursing students took rounds together (Tr. 99). The witness expressed no knowledge of Petitioner as a graduate or as a practicing licensed nurse (Tr. 91, 98). Petitioner attempted to prove his nursing education and licensure in Cuba by the testimony of witnesses who "knew him as a nurse" in Cuba. Alicia de la Rua is a Florida licensed nurse who worked in the same hospital as Petitioner in Cuba for three months in 1964 (Tr. 55, 56, 59). They did not work together (Tr. 59), but were on the same ward in separate men's and women's sections (Tr. 61). Ms. de la Rua never saw Petitioner's nursing diploma or license (Tr. 60) and has no personal knowledge that he attended nursing school in Cuba (Tr. 61). She did see him dressed as a nurse and acting as a nurse in the principal hospital in Matanzas, Cuba (Tr. 55, 61-62). Francisca Garcia is licensed as a nurse in Florida. She met Petitioner in 1965 or 1966 in the clinic Petitioner's father and brother, who were medical doctors, operated in Havana (Tr. 69, 91, 118-119). Petitioner treated Ms. Garcia's nephew by giving him a vaccination (Tr. 70). In Cuba that treatment could have been performed by someone with a medical education or even a nurse's aide (Tr. 70). Although Ms. Garcia states that she saw Petitioner's diploma or license at the clinic (Tr. 65, ln. 9-15), no such document has been offered in this proceeding, and her testimony about the diploma is not persuasive due to Petitioner's failure to offer any copy of the degree for admission into evidence, although a copy was apparently available at the hearing. See Finding of Fact 2, above. Petitioner first sought licensure in Florida in 1977 (JX-4). The basis for that application was his incomplete medical education, and the application was denied (Tr. 111, 117). On that application, Petitioner did not indicate any nursing education, either under "Official Name of Nursing Program" (JX-4, ln. 8) or under a question regarding receipt of nursing education in another country (JX-4, ln. 10). The latter question was left blank; all other questions on the application were answered (JX- 4), including that Petitioner had not written a nursing licensing examination before. Petitioner again applied for licensure by examination in 1981 (JX-5). On the 1981 application, Petitioner did refer to his nursing education, but in vague terms, giving the Official Name of Nursing Program as "Registered Nurse" (JX-5, ln. 8). This application also contains the false statement that Petitioner had never before made application for licensure in Florida (JX-5, ln. 9), and the statement that he had not written a nursing licensing examination before. Petitioner applied for licensure a third time, this time by endorsement rather than by examination, in an application received by the Board on May 18, 1984 (JX-3). This application contains several false statements or omissions. Petitioner again failed to advise the Board of his previous applications (JX-I, section 4E). Petitioner stated that he had never held a license to practice nursing in another country (JX-3, section 4F). Petitioner again stated that he had never written a nursing licensure examination in Florida or any other state or country (JX-3, section 6A). Petitioner made a further false answer to the question "Have you ever been denied a license to practice nursing in Florida . . .?" (JX-3, section 6D). Truthful answers to these questions are necessary so that the Board and its staff may review sufficiently and evaluate an application, taking into consideration any previous Board actions (Tr. 146, 147). To prove eligibility for licensure by endorsement, an applicant who was educated and licensed in Cuba before a prescribed date must demonstrate that licensure by means of official documents (Tr. 140). If original documents are unavailable, as is often the case with Cuban nurses (Tr. 98), the Board requires some other competent, substantial proof, including affidavits of other nurses or doctors licensed both in Cuba and in Florida (Tr. 140, 149). Those affidavits must be consistent with other information received by the Board concerning the applicant's qualifications (Tr. 149). The Board amended its rules by emergency rule effective May 18, 1984 (RX-1), to provide that nurses licensed in Cuba prior to December 31, 1961, would be eligible for licensure by endorsement upon successful completion of a refresher course (Tr. 142, 143). Although Petitioner purportedly graduated from nursing school after that date, the Board reconsidered his application because he had been approved to begin and had completed the refresher course at Miami-Dade Community College before the effective date of the emergency rule (Tr. 144, 145). Petitioner completed the variable time nursing refresher program at Miami-Dade (Tr. 46; JX-2), which was a 16- week course designed for people who had never taken a licensing examination (Tr. 45, ln. 9-14). This program contained no clinical component or direct patient care (Tr. 46, 47). According to the dean of the Miami-Dade program, Dr. Jeanne Stark, who also developed the program (Tr. 46, 47), an individual with a medical background but who had not had a nursing education could successfully attend and complete the 16-week variable time refresher program (Tr. 47-50). Petitioner was approved to take the refresher course by the Board (Tr. 51), prior to his 1984 application, on the basis of affidavits provided by the Cuban Nurses in Exile Association that he was licensed in Cuba (Tr. 141, 142). Those affidavits are no longer relied on by the Board as proof of licensure because of inconsistencies and inaccuracies in them (Tr. 141, 144).
Recommendation Based on the foregoing, it is recommended that the Board of Nursing enter a final order DENYING the application of Lazaro Saavedra for licensure by endorsement. DONE AND ORDERED this 4th day of April 1986 in Tallahassee, Leon County, Florida. WILLIAM R. DORSEY, JR., Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 4th day of April 1986.
The Issue The issue in these two consolidated cases is whether disciplinary action should be taken against Luis J. Marti, M. D., hereinafter referred to as "Respondent Marti," and/or Jesus Escar, M.D., hereinafter referred to as "Respondent Escar," based upon the alleged violations of Chapter 458, Florida Statutes, contained in the separate Administrative Complaints filed against each of the Respondents.
Findings Of Fact Based on the stipulations of the parties; on the testimony of the witnesses, and on the exhibits received in evidence at the hearing; I make the following findings of fact. Respondent Escar is, and has been at all times material hereto, a licensed physician in the state of Florida, having been issued license number ME 0034247. Respondent Escar's last known address is 935 West 49th Street, Suite #107, Hialeah; Florida 33012. Respondent Marti is, and has been at all times material hereto, a licensed physician in the state of Florida, having been issued license number ME 0034842. Respondent Marti's last known address is 24355 West Flagler Street, Miami, Florida 33125. Respondent Marti went to medical school in Madrid, Spain. In approximately 1970, while Respondent Marti was in medical school in Madrid, Spain, Respondent Marti met Jose A. Tudela for the first time. At the time, Tudela had come to Madrid, Spain, for the purposes of starting medical school. In approximately 1975, while Respondent Marti was working as a resident at Cedars of Lebanon Hospital, Respondent Marti again saw Jose A. Tudela. At about the same time, Respondent Escar met Tudela for the first time. Tudela's father, Francisco Tudela, a physician, was an attending physician at Cedars of Lebanon Hospital. Respondents Marti and Escar saw Jose and Francisco Tudela in 1975 while on rounds at the hospital. In 1979, while Respondents Marti and Escar were working at Palm Springs General Hospital, Jose A. Tudela came to the hospital to apply for a position as a house physician and saw Respondents Escar and Marti. When Tudela applied for the position of house physician at Palm Springs General Hospital, Respondents Marti and Escar were both residents at the hospital. On the day that Jose A. Tudela came to apply for the position of house physician at Palm Springs General Hospital, Tudela came to the doctors' lounge at the hospital where he spoke with Respondents Escar and Marti. Tudela had with him a diploma which appeared to Respondents Escar and Marti to be authentic and which appeared to have been issued by the Universidad Central del Este. The diploma had on the back what appeared to be official stamps and seals and the signature of the Vice Consul of the United States. Additionally, a translation of the diploma was attached to the diploma. On the date that Tudela came to apply for the position of house physician at Palm Springs General Hospital, Tudela also showed Respondents Escar and Marti what appeared to be a transcript of his grades from the Universidad Central del Este and a letter purportedly from one Victoria Marcial de Gomez. The transcript and letter appeared to Respondents Escar and Marti to be original and authentic. The letter from Gomez, who purportedly was the medical director for the health center of Trujillo Alto Health Department, in the associated Free State of Puerto Rico, appeared to verify the fact that Dr. Jose A. Tudela had worked in the Health Center of Trujillo Alto for seven months. When Respondent Marti reviewed Tudela's documents, he knew it was important that foreign papers be certified because he had had the experience of having to leave Cuba and re-establish himself. Respondent Marti's own diplomas from Spain bear attestations of notarization of a foreign government. Respondent Escar believed that Tudela's documents were originals because of his experience in having seen similar original documents of other residents in the past. On or about August 1, 1979, Jose A. Tudela completed an application for employment as a house physician at Palm Springs General Hospital. The application contained basic personal information about Tudela and listed some of Tudela's education and work experience. According to the application, Tudela went to Belle Glade High School, in Belle Glade; Florida; Warwick High School, in Newport News, Virginia, where he graduated in 1965; and the University of Miami; in Coral Gables, Florida where he graduated in 1970. According to the application, Tudela worked in an unspecified capacity in the Centro de Salud, in Trujillo Alto, Puerto Rico, from 1978 to 1979. The application form does not contain any information about Tudela's medical education. Specifically, it does not contain any mention of University of Santo Domingo, Universidad Central del Este, or U.C.E. On or about August 8, 1979, Jose A. Tudela was employed by Palm Springs General Hospital as a house physician. Jose A. Tudela remained at Palm Springs General Hospital as a house physician until October 29, 1979. Tudela left Palm Springs General Hospital on that date to become a surgical assistant at Miami Children's Hospital. While employed a Miami Children's Hospital, Tudela received the highest score on every item on his employee evaluation form. That hospital never knew of any problem with Tudela's performance or credentials until this case occurred. Between approximately 1979 and 1983, Respondents Escar and Marti practiced medicine together as partners. In 1980, Jose A. Tudela approached Respondent Marti and asked Respondent Marti to sign an affidavit on behalf of Tudela. Therefore, on or about March 13, 1980, Respondent Marti signed a Form B-1 which was addressed to Rafael A. Penalver, M.D., Director, Office of International Medical Education, University of Miami School of Medicine; Miami; Florida. The form B-1 contained the following sworn statement: This is to certify that Jose A. Tudela born in Cuba and a graduate from the University Santo Domingo on 1978 was legally engaged in the practice of medicine from ---- to in Puerto Rico. I have known the applicant since 1975 and was acquainted with him/her during the time he practiced medicine. I was algo (sic) engaged in the practice of medicine in Miami U.S.A. during the years of 1975 and up. At some time after Respondent Marti signed the Form B-1, the abbreviation "(U.C.E.)" was added to the above-referenced sworn statement after the school name, "University Santo Domingo." Respondent Marti did not place the quoted abbreviation on the Form B-1. Prior to signing the subject Form B-1, Respondent Marti reviewed, for verification purposes, the employment application of Jose A. Tudela for Tudela's employment as a house physician at Palm Springs General Hospital. However, the employment application in question does not reflect any attendance by Tudela at any educational institution in the Dominican Republic or Santo Domingo. Furthermore, the employment application does not indicate the capacity in which Tudela worked in the Centro Salud in Trujillo Alto, Puerto Rico, and does not specifically indicate that Tudela practiced medicine in Puerto Rico. In 1980, Jose A. Tudela also approached Respondent Escar and asked Respondent Escar to sign an affidavit for him. Therefore, on or about March 13, 1980, Respondent Escar signed a Form B-1 which contained the following sworn statement: This is to certify that Jose A. Tudela born in Cuba and a graduate from the University of Santo Domingo on 1978 was legally engaged in the practice of medicine from ---- to in Puerto Rico. I have known the applicant since 1970 and was acquainted with him/her during the time he practiced medicine. I was algo (sic) engaged in the practice of medicine in Miami, Fla during the years of 1977 and up. The Form B-1 was addressed to Rafael A. Penalver, M.D., Director; Office of International Medical Education, University of Miami School of Medicine, Miami, Florida. At some time after Respondent Escar signed the Form B-1, the abbreviation "(U.C.E.)" was added to the above-referenced sworn statement after the school name, "University of Santo Domingo." Respondent Escar did not place the quoted abbreviation on the Form B-1. Respondent Escar relied upon Respondent Marti's verification of Tudela's background information in signing the Form B-1 described in the immediately preceding paragraph. Respondent Escar did not personally review Tudela's application for employment at Palm Springs General Hospital but discussed the information contained in the employment application with Respondent Marti. At the time Respondents Marti and Escar signed the Forms B-1, they did not know Tudela very well and did not know very much about his background. Although they both thought Tudela was probably a graduate of a medical school, they did not remember what school he had supposedly graduated from, as evidenced by the fact that they put the wrong school name on the Forms B- 1. Both Respondent Escar and Respondent Marti lacked personal knowledge of the information contained in the Forms B-1 which they signed for Jose A. Tudela. Neither of the Respondents saw or taught Tudela at medical school in the Dominican Republic. Furthermore, neither Respondent Escar nor Respondent Marti was in Puerto Rico at the time Jose A. Tudela allegedly practiced medicine at the Centro Salud in Trujillo Alto, Puerto Rico. Neither of the Respondents had any source of information about Tudela's alleged medical education in the Dominican Republic or his alleged practice of medicine in Puerto Rico other than statements Tudela may have made to them, statements Tudela wrote on the application form at Palm Springs General Hospital, and whatever information could be gleaned from a casual review of Tudela's forged credentials. Jose A. Tudela has never graduated from the Universidad Central del Este, which is located in the Dominican Republic, nor from any other medical school. Tudela enrolled in the Universidad Central del Este (U.C.E.) medical school in August, 1977. There is no evidence in the school records for U.C.E. that Tudela passed any of his courses. In May of 1978 Tudela was no longer at the university. Tudela was given a special concession at U.C.E. so that upon presentation of a pre-medical certificate which Tudela claimed to possess, Tudela could receive credit for the pre-medical program training. However, Tudela never presented the required proof of his pre-medical program. Tudela did not complete any of the twelve semesters at U.C.E. which make up the medical degree program including pre-medical training. Although Respondent Marti first met Tudela in 1970 and Respondent Escar met him in 1975, the Form B-1 signed by Respondent Marti states that he met Tudela in 1975, and the one signed by Respondent Escar states that he met Tudela in 1970. The reason for this error is that both of the forms were prepared by Respondent Marti and the forms were inadvertently switched at the time they were signed. The Forms B-1 signed by Respondents Marti and Escar were submitted to the Board of Medical Examiners by Jose A. Tudela as attachments to an Application for Continuing Medical Education Program, which was submitted as part of Tudela's application for licensure as a physician in Florida. Tudela applied for licensure in Florida under the provisions of a special law which provided that the Board of Medical Examiners would establish continuing education courses designed to qualify for licensure those individuals who were resident nationals of the Republic of Cuba and were residents of Florida on July 1, 1977. In order to qualify for the continuing education program set up by the Board of Medical Examiners for Cuban nationals, an applicant had to demonstrate that he was a graduate from a medical school with a medical degree and that he was a resident national of the Republic of Cuba and a resident of Florida on July 1, 1977. Upon approval of the applicant to participate in the continuing education program set up by the Board of Medical Examiners, the applicant would have to complete the continuing education program. Upon completion of the continuing education program, the applicant would be qualified to take the licensing examination. In or about March of 1980, Tudela submitted an Application for Examination, an Application for Florida State Board of Medical Examiners Continuing Education Program, and the necessary attachments, which included the Forms B-1 signed by Respondents Escar and Marti and copies of what purported to be his diploma and transcript of grades. After successfully completing the continuing medical education program and the licensure examination, Tudela became certified to practice medicine and surgery by the Board of Medical Examiners on August 23, 1982. At the time of Tudela's application for medical license, the staff of the Board of Medical Examiners conducted the initial review and made the initial determination as to whether an individual was qualified to take the continuing education course and to take the licensure examination for certification to practice medicine and surgery in Florida. In making such determinations, consideration is given to all of the information contained in an applicant's file, which includes such things as the applicant's degree or diploma, transcript of grades, and the Forms B-1. At the time Tudela applied for licensure, the staff of the Board of Medical Examiners did not verify the medical education of applicants and conducted no investigation into the school or the graduation of applicants for licensure. Prior to approving Tudela's application, neither the Board members nor the staff independently contacted the Universidad Central del Este to verify whether Tudela actually graduated from medical school. The Board members did not personally review Tudela's application. The staff reviewed the papers and presented the Board with a list of applicants who appeared to be eligible for the continuing education course and the licensure examination. The diploma and the transcript of grades which Tudela showed to the Respondents and filed with the Board of Medical Examiners are forgeries. They are very good forgeries and bear a remarkable resemblance to genuine diplomas and transcripts issued by the Universidad Central del Este. The false documents provided by Tudela to the Board as part of his application, along with the Forms B-1 signed by Respondents Marti and Escar, deceived the staff into recommending Tudela for the continuing education course, the licensure exam, and ultimately for certification to practice medicine. Tudela's application to the Board also contains several letters of recommendation from other physicians who were convinced of Tudela's competence. The Educational Commission for Foreign Medical Graduates granted Tudela a certificate despite his forged documents. In November 1984, an Administrative Complaint was filed against Jose A. Tudela which alleged that Tudela did not graduate from or obtain a degree of Doctor of Medicine from U.C.E., contrary to what Tudela had indicated in his application for licensure examination described above. In March 1985, the Board of Medical Examiners entered an order accepting the surrender for revocation of Jose A. Tudela's license to practice medicine in lieu of further prosecution of the charges contained in the Administrative Complaint which had been filed in November 1984. Tudela is not currently licensed as a physician in the state of Florida. No further action was taken against him for his having fraudulently obtained a medical license in Florida. Respondents Escar and Marti were both aware of the fact that the Forms B-1 which they signed were to be submitted as part of the application for the continuing medical education program which had been established by the Board of Medical Examiners for Cuban nationals as a prerequisite to take the licensure examination. In fact; Respondent Marti became eligible to take the medical licensure examination in Florida by completing the same continuing medical education program. When the Respondents Escar and Marti signed the subject Forms B-1, neither of them had any personal knowledge as to the truth or falsity of the statements therein regarding Tudela's medical education and experience; yet they deliberately certified, under oath, to the truthfulness of matters about which they were distinctly uninformed. When the Respondents Escar and Marti signed the subject Forms B-1, both of them knew the purpose of the forms and both knew that the Board of Medical Examiners would rely on the information in the forms.
The Issue Whether Petitioner's application for license to practice medicine by endorsement pursuant to Chapter 458, Florida Statutes, should be approved. Petitioner appeared at the hearing unaccompanied by legal counsel and was advised of her rights and applicable procedures in administrative proceedings under Chapter 120, Florida Statutes. She elected to represent herself in this matter. This case arises from the provisional denial of Petitioner's application for licensure by endorsement to practice medicine, pursuant to Chapter 458, Florida Statutes. By Respondent's Order, dated January 29, 1982, the application was denied pursuant to subsection 458.313(1)(d), Florida Statutes, on the ground that Petitioner had not been certified by licensure examination of the Federation of State Medical Boards of the United States, Inc., and is not certified by the National Board of Medical Examiners as having completed its examination within the ten years immediately preceding the filing of the application for licensure by endorsement. In its Order, Respondent advised Petitioner-of her right to petition for a hearing. Petitioner so requested a hearing under Section 120.57, Florida Statutes, by letter to Respondent, dated May 2, 1982.
Findings Of Fact On October 1, 1981, Petitioner Elda Giannantonio filed an endorsement application with Respondent on a standard form provided by the agency, together with supporting documents and the standard application fee. (Exhibit 1) By "Final Order" of the Board of Medical Examiners, dated January 29, 1982,which recited action taken by the Board on December 4, 1981, it was found that Petitioner had not been certified by licensure examination of the Federation of State Medical Boards of the United States, Inc., and is not certified by the National Board of Medical Examiners as having completed its examination within the ten years immediately preceding the filing of the application for licensure by endorsement. It was therefore concluded by the Board that Petitioner had not met the statutory requirements for licensure by endorsement pursuant to Section 458.313(d), Florida Statutes. In all other respects, Petitioner has met the necessary requirements for licensure by endorsement. (Testimony of Faircloth, Exhibit 1, Stipulation) Petitioner was born and educated in Italy where she received her Medical degree in 1953. To be licensed by endorsement in Florida, a foreign graduate must have received a standard certificate after passing an examination given by the Educational Commission for Foreign Medical Graduates. Petitioner received such a certificate on March 28, 1962. (Testimony of Faircloth, Petitioner, Exhibit 1) A statutory requirement of all applicants for licensure by endorsement is that the applicant must have been certified by licensure examination of the Federation of State Medical Boards of the United States, Inc. (FLEX) or certified by the National Board of Medical Examiners as having completed its examination; provided that said examination required shall have been so certified within the ten years immediately preceding the filing of the application for licensure. The National Board of Medical Examiners examination is administered only to students at Medical schools in the United States. Petitioner has not been certified by either licensure examination. All states, including Florida, recognize the FLEX examination as the standard test for licensure. (Testimony of Petitioner, Faircloth, Exhibit 1) Petitioner was of the mistaken opinion that the fact she had Practiced medicine in New York and had been certified by the Educational Commission for Foreign Medical Graduates was sufficient to qualify her for licensure by endorsement, without the need for either National Board or FLEX certification. However, the instructions provided applicants by Respondent clearly showed that both requirements must be met by foreign graduates. (Testimony of Petitioner, Faircloth, Exhibit 2)
Recommendation That the application of Petitioner Elda Giannantonio for licensure by endorsement pursuant to Section 458.313, Florida Statutes, be denied. DONE and ENTERED this 24th day of August, 1982, in Tallahassee, Florida. THOMAS C. OLDHAM Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 24th day of August, 1982. COPIES FURNISHED: Elda Giannantonio, M.D. 27 Kohr Road Kings Park, NY 11754 Chris D. Rolle, Esquire Department of Legal Affairs The Capitol Tallahassee, Florida 32301 Dorothy J. Faircloth Executive Director Board of Medical Examiners Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Samuel Shorstein Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301
The Issue The issues are as follows: (a) whether Petitioner attempted to obtain a license by misrepresenting or concealing material facts at any time during any phase of the licensing process in violation of Section 458.331(1)(gg), Florida Statutes; (b) whether Petitioner meets the training requirements pursuant to Section 458.331(1)(f), Florida Statutes; (c) whether Petitioner has had a license to practice medicine acted against by the licensing authority of another jurisdiction in violation of Section 458.331(1)(b), Florida Statues; and (d) whether Petitioner was convicted or found guilty or entered a plea of nolo contendere to, regardless of adjudication, a crime in any jurisdiction that directly relates to the practice of medicine in violation of Section 458.331(1)(c), Florida Statutes.
Findings Of Fact Petitioner is a medical doctor. He is currently licensed to practice medicine in Mississippi. Petitioner attended the University of Lagos, College of Medicine, in Lagos, Nigeria. While he was in medical school, Petitioner failed a pathology class. He did not have to repeat the entire class, but he was required to retake the examination in order to get credit for the course. In 1972, Petitioner graduated from the University of Lagos, College of Medicine, which is an allopathic foreign medical school. However, the medical school has not been recognized and approved by an accrediting agency recognized by the United States Office of Education (U.S.O.E.). Additionally, Petitioner's medical school is not located within a territorial jurisdiction of the United States. The U.S.O.E. has designated the Liaison Committee on Medical Education (LCME) as the approved accrediting organization. Pursuant to this designation, LCME only has authority to accredit medical schools in the United States and Canada. Foreign medical schools are not accredited by anyone in the United States. The U.S.O.E. has not designated an accrediting organization for foreign medical schools other than those located in Canada. Each foreign medical school (excluding Canada) is accredited by its own country. Therefore, Petitioner is not eligible for licensure pursuant to Section 458.311(f)1., Florida Statutes. The World Health Organization does not approve/accredit medical schools. Additionally, Respondent has never certified a foreign medical school pursuant to Section 458.314, Florida Statutes. Therefore, Petitioner is not eligible for licensure pursuant to Section 458.311(f)2., Florida Statutes. Graduates of foreign medical schools, which have not been certified pursuant to Section 458.314, Florida Statutes, must meet the requirements of Section 458.311(f)3., Florida Statutes. Petitioner meets these requirements in part because his medical credentials have been evaluated by the Educational Commission for Foreign Medical Graduates (ECFMG). He holds an active, valid certificate issued by ECFMG and has passed the examination utilized by that commission. Since October 1, 1992, graduates of foreign medical schools like Petitioner must complete an approved residency or fellowship of at least two years in one specialty area. The training must count toward regular or subspecialty certification by a board recognized and certified by the American Board of Medical Specialties. The Accreditation Council for Graduate Member Education (ACGME) is the body that certifies training programs in the United States. Petitioner has not completed an ACGME-approved residency or fellowship of at least two years in one specialty area. From October 1975 to September 1976, Petitioner completed one year of residency training in the Meharry Medical College Family Practice program at George W. Hubbard Hospital, in Nashville, Tennessee. He has not completed any other residency or fellowship training. Therefore, Petitioner is not eligible for licensure pursuant to Section 458.311(f)3., Florida Statutes. In late 1984 or early 1985, Petitioner had a private medical practice in Holly Springs, Mississippi. He lived across the state border in Tennessee where he maintained a business office. Petitioner also advertised his medical practice in a Tennessee newspaper. On or about September 3, 1985, Petitioner pled no contest to a criminal charge that he had met with and talked to four separate ladies about family planning in his Memphis, Tennessee, office. The Criminal Court of Shelby County, Tennessee, found Petitioner guilty of operating an ambulatory surgery treatment center without a license. Petitioner was required to pay a fine in the amount of $2,000.00. In August of 1989, the Mississippi Division of Medicaid initiated sanction proceedings against Petitioner for performing excessive routine laboratory tests in his private practice. In November 1990, the Medicaid and Medicare programs in Mississippi suspended Petitioner as a provider for three years. On or about July 26, 1991, the Mississippi State Board of Medical Licensure issued an order revoking Petitioner's Mississippi medical license. The order was affirmed on appeal. The Mississippi Board of Medical Licensure reinstated Petitioner's Mississippi medical license with conditions in August 1997. In September 1999, the Mississippi Board of Medical Licensure removed the restrictions/limitations from Petitioner's medical license. In February 2001, Petitioner had privileges at Hardy Wilson Memorial Hospital in Hazlehurst, Mississippi. Petitioner made the decision that he could no longer afford medical malpractice insurance. Because the hospital required physicians to have malpractice insurance, the hospital reduced Petitioner's clinical privileges. Although the timing of these events is not clear, Petitioner voluntarily resigned his privileges at the hospital. In April 2003, Petitioner signed an application form for medical licensure by endorsement in Florida. Petitioner filed the application with Respondent in June 2003. The April 2003 application contained the following affidavit, signed by Petitioner on April 6, 2003: I have carefully read the questions in the foregoing application and have answered them completely, without reservations of any kind, and I declare under penalty of perjury that my answers and all statements made by me herein are true and correct. Should I furnish any false information in this application, I hereby agree that such act shall constitute cause for denial, suspension or revocation of my license to practice Medicine in the State of Florida. Question 12b on the April 2003 application inquired whether Petitioner had been required to repeat any of his medical education. The question states that if the answer is "yes," the applicant should explain on a separate sheet providing accurate details. Petitioner answered Question 12b on the April 2003 application in the negative. His answer was misleading and inaccurate because it did not disclose that he had to retake an examination in order to pass a pathology course. Question 18 on the April 2003 application asked several questions, three of which are relevant here. First, the application inquired whether Petitioner currently held staff privileges in any hospital, health institution, clinic or medical facility. Petitioner answered "yes" to this question. Second, Question 18 instructed Petitioner to list any hospital/health institution/clinic or medical facility where he held staff privileges. Petitioner listed Jefferson County Hospital, Emergency Room Privileges. Third, Question 18 inquired whether Petitioner had ever had any staff privileges denied, suspended, revoked, modified, restricted, placed on probation, asked to resign or asked to take a temporary leave of absence or otherwise acted against by any facility. Petitioner answered this question negatively. Question 23 on the April 2003 application inquired whether Petitioner had ever been convicted or found guilty, regardless of adjudication, resolution, or expungement, or pled guilty or nolo contendere to a criminal misdemeanor or felony in any jurisdiction. Petitioner answered this question in the negative. Question 24 on the April 2003 application inquired whether, regardless of adjudication, Petitioner had ever been convicted of a violation of, or pled nolo contendere to, any federal, state, or local statute, regulation, or ordinance, or entered into any plea, negotiated plea, bargain, or settlement relating to a misdemeanor or felony, or ever had an adjudication, resolution or expungement. Petitioner answered this question in the negative. In a letter dated July 31, 2004, Respondent advised Petitioner that his application was incomplete. Among other things, Respondent stated that it was waiting for a response to an inquiry directed to Jefferson County Hospital, verifying Petitioner's staff privileges and good standing. Respondent also requested Petitioner to complete and file an current/updated application form. In August 2003, Petitioner filed the updated application with Respondent. In response to Question 16 on the updated application, Petitioner once again denied that he was required to repeat any of his medical education? In response to Questions 27 and 28 on the updated application, Petitioner continued to maintain that he currently held privileges at Jefferson County Hospital in Fayette, Mississippi. In response to Question 29 on the updated application, Petitioner, continued to assert that he had never had any facility staff privileges denied, suspended, revoked, modified, restricted, placed on probation, or asked to resign. Petitioner appeared before Respondent's Credentialing Committee in November 2003. The committee was obligated to review Petitioner's entire application file, including the April 2003 application and the August 2003 application. Petitioner failed to disclose his Tennessee criminal conviction on the April 2003 application. The conviction is related to practice of medicine because it involved Petitioner talking to patients from a Tennessee office. During the hearing, Petitioner identified the following two letters of recommendation: (a) Willie L. McArthur, M.D., on Jefferson County Family Medicine Center letterhead; and (b) Bernadette E. Sherman, M.D. on Jefferson Comprehensive Health Center, Inc. letterhead. Neither of the letters refers to Petitioner's privileges at Jefferson County Hospital. Petitioner testified that he answered Question 18 on the April 2003 application and Questions 27 and 28 on the updated application correctly, affirming that he held privileges at Jefferson County Hospital. There is no evidence to the contrary. The greater weight of the evidence indicates that Petitioner's reduction of clinical privileges at Hardy Wilson Memorial Hospital was due to his decisions not to secure malpractice insurance and to voluntarily resign his privileges. Therefore, he did not answer Question 18 on the April 2003 application and/or Question 29 on the updated application incorrectly.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED: That Respondent enter a final order denying Petitioner's application for a medical license by endorsement. DONE AND ENTERED this 5th day of January, 2005, in Tallahassee, Leon County, Florida. S SUZANNE F. HOOD Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 5th day of January, 2005. COPIES FURNISHED: Rosanna M. Catalano, Esquire Office of the Attorney General The Capitol, Plaza Level 01 Tallahassee, Florida 32399-1050 Olufemi Okunoren, M.D. Post Office Box 1992 Madison, Mississippi 39130 Larry McPherson, Executive Director Board of Medicine Department of Health 4052 Bald Cypress Way Tallahassee, Florida 32399-1701 R. S. Power, Agency Clerk Department of Health 4052 Bald Cypress Way Tallahassee, Florida 32399-1701
The Issue The issues for consideration in this case are those promoted by an administrative complaint in which the Petitioner has accused the Respondent of violating certain provisions within Chapters 455 and 458, Florida Statutes, pertaining to licensure. This relates to the contention by Petitioner that Respondent has obtained his license to practice medicine in Florida by fraudulent means. These allegations are more completely described in the conclusions of law.
Findings Of Fact Respondent is a licensed physician having been issued license number ME0043541. On or about September 9, 1983, Respondent submitted an application to the Board of Medical Examiners, now known as the Board of Medicine, seeking a license to practice medicine in Florida. This request was for licensure by endorsement. On the form application there is a section which refers to the applicant's medical education. It instructs the applicant to be specific and account for each year of the medical education calling upon the applicant to give the name of the medical school and the location. In response to this requirement, Respondent indicated that he attended the Universidad del Noreste in Tampico, Mexico, from July, 1977 to May, 1978; from July, 1978 to May, 1979 and from June, 1979 until May, 1980. He further stated that he attended Universidad Cetec, Santo Domingo, Dominican Republic, from June, 1980 until May, 1981 and received a degree of doctor of medicine from that university on June 8, 1981. In submitting the application for licensure by endorsement, he did so under oath and in the course of signing the application he acknowledged the following in his affidavit and oath: "I have carefully read the questions in the foregoing application and have answered them completely, without reservation of any kind, and I declare under penalty of perjury that my answers and all statements made by me herein are true and correct. Should I furnish any false information in this application, I hereby agree that such action shall constitute cause for the denial, suspension or revocation of my license to practice medicine and surgery in the State of Florida. As part of the application process, Dorothy J. Faircloth, Executive Director to the Board of Medical Examiners, sent a letter to Dr. Traynor on September 30, 1983, requesting additional information. The text of that letter was as follows: Dear Dr. Traynor: With further reference to your application for licensure in Florida by you are required to provide to this office, in the form of an affidavit, a narrative report on all your activities relating to your medical education beginning with date of enrollment in medical school. Such report should include, but not be limited to, all classes attended (dates and name and location of institution) which were not conducted at the main teaching hospital of the medical school from which you received a medical diploma. You are also required to complete the enclosed form, providing additional information regarding your medical education and places of residence while in medical training. Upon receipt of the above requested material, you may be required to make a personal appearance before the Board for consideration of your application. The form referred to in the second paragraph of the correspondence from Ms. Faircloth is the form entitled: Attachment for Application for Licensure. Within that form it asks that the applicant "list all places of residence during medical school." This is broken down into various lines on the form requiring the applicant to state the city, state or country and the various period in which he resided in those places. A copy of the executed form offered by the Respondent on October 7, 1983 may be found as a part of Petitioner's composite exhibit 5 admitted into evidence. In the course of describing his residence, he refers to Tampico, Mexico in the period August, 1977 through July, 1978; August, 1978 through July, 1979 and August, 1979 through July, 1980. He then describes his place of residence during medical school as being Santo Domingo, Dominican Republic, in the period July, 1980 through June, 1981. The attachment for application for licensure form then has a section which states "Medical Education: be specific. Account for each year. List all universities or colleges where you attended classes and received training as a medical student." In response to this request, the Respondent provided the same information which he had given in his initial endorsement application form described before. In swearing to the accuracy of those matters set forth in the Attachment for Application for Licensure offered on October 7, 1983, Respondent gave the same oath as related to the endorsement application form acknowledging the possibility of denial, suspension or revocation of any license which was received by the giving of false information. In reply to the first paragraph of the September 30, 1983 correspondence from Ms. Faircloth, Respondent offered a document entitled "Clinical Training." A copy of that document may be found as part of Petitioner's composite exhibit 5. That document states: CLINICAL TRAINING Kevin M. Traynor Aug. '77 - July '79: Basic science courses at Del Noreste; Tampico, Mexico August - Dec. '79: Del Noreste Hospital, Tampico, Mexico Pulmonary Ear, nose & throat Cardiology Ophthalmology Jan. - June '80: Del Noreste Hospital; Tampico, Mexico Traumatology (orthopedics) Forensic medicine Gastroenterology Dermatology July - Dec. '80: University Hospital; Cetec School of Medicine, Santo Domingo, Dominican Republic Neurology Infectious disease Endocrinology General surgery Jan. - June '81: University Hospital; Uni- versity Cetec School of Medicine, Santo Domingo, Dominican Republic Psychiatry Internal medicine OB-GYN Pediatrics By the representations set forth in the statement of clinical training which were made by the Respondent, the impression is given that all of his activities related to his medical education from the point of enrollment to the completion of his medical school training were conducted at the Universidad del Noreste and University Cetec and the hospitals affiliated with those institutions. Given that the Respondent is silent on other activities outside those settings, a reading of his explanation leads one to believe that he had no such activities. This is not a true depiction of his training in medical school. In this respect, the Respondent has misled the Florida Board of Medical Examiners in that the vast majority of clinical rotations which the Respondent participated in during his medical school education occurred during externships in the United States. In addition, Respondent, in his comments in the endorsement application form and in the Attachment for Application for Licensure form, has misled the Board of Medical Examiners by describing his residence in medical school as Santo Domingo, Dominican Republic, in the period July, 1980 through June, 1981. He was not residing in the Dominican Republic until January, 1981. Respondent's domicile or official residence was in Tampico, Mexico, until the end of 1980. Respondent did not receive medical education in the sense of attending classes and receiving training as a medical student in affiliation with the Universidad Cetec until January, 1981. This is contrary to his representations about residence and medical education in which he describes his association with Universidad Cetec dating from July, 1980. Respondent had made an inquiry about being admitted to Universidad Cetec in December, 1980, and was given the impression that that request would be approved. Respondent's official acceptance by Universidad Cetec occurred on January 8, 1981. In referring to the activities related to medical education spoken to in the September 30, 1983 correspondence from Ms. Faircloth, the records reveal that Respondent did externship at St. Francis Hospital in Miami Beach, Florida from July 9, 1975 through November 20, 1979. He further did externship at Kingsbrook Jewish Medical Center in Brooklyn, New York, from January, 1980 through May, 1980, rotations involving medicine, pediatrics and surgery. In that same institution from June 30, 1980 through July 13, 1980, Respondent did a rotation in neurology. In the period July, 1980 through December, 1980, Respondent performed unofficial and uncredited externship at Kingsbrook. All of these activities occurred under the aegis of his status as a medical student at Universidad del Noreste. In the period February, 1981 through May, 1981, while at Universidad Cetec, Respondent did an externship at Brookdale Hospital Medical Center in New York in hematology and renal and electrolytes. In April, 1981, as an extern at Nassau County Medical Center in East Meadow, New York, Respondent performed a clerkship in urology. Under the circumstances in examining the places of residence during medical school, while Respondent may have been in official residence in Mexico and the Dominican Republic, his actual residence was in various locations within the United States in the periods described in the preceding paragraphs. Following his graduation, Respondent also participated in training programs at Brookdale Hospital Medical Center related to an elective in emergency services from the period August 10, 1981 through September 4, 1981. He performed an elective in the period September, 1981 through October, 1981 in the Division of Pulmonary Medicine at the Down State Medical Center which is affiliated with the Department of Medicine, AIE University of New York. From 1981 through June, 1984, Respondent was involved in an internal medicine residency at Jersey Shore Medical Center/Fitken Hospital in Neptune, New Jersey. Beginning in 1984 through June, 1986, Respondent completed a cardiology fellowship program in Jacksonville, Florida, at the University Hospital which is part of JHEP, a training program associated with the University of Florida medical school. In explaining why he has reported his residence in his medical education as commencing in July, 1980 at Universidad Cetec, Respondent indicates that he had been told by the dean of the medical school at Cetec, upon his admission there, that his enrollment would be back-dated to the beginning of the fall semester, or June, 1980. To this end Respondent paid Universidad Cetec $2,500 which represented a tuition payment for the seventh semester running from approximately June, 1980 to December, 1980. This payment for back-dating and credit for the seventh semester was made on April 23, 1981. There is no indication that those records were back-dated to show acceptance of a seventh semester under association with Universidad Cetec. Respondent did not undertake any clinical training in that period which could be credited, with the exception of his urology clerkship at Kingsbrook Jewish Medical Center in the period June 30, 1980 through July 13, 1980. He did not stand examination in any of the subject areas pertaining to his medical education in that seventh semester running from June, 1980 to December, 1980, having foregone the examination sessions given by Universidad del Noreste at the conclusion of that seventh semester. In the final analysis, Respondent did not accomplish anything toward advancing his medical education in the seventh semester running from approximately June, 1980 through December, 1980 as recognized by either medical school which he attended. There is evidence that part of the unofficial work done by the Petitioner in the fall of 1980 at Kingsbrook Jewish Medical Center related to dermatology and E.R. Even accepting the concept explained by the Respondent to the effect that both of the medical schools he attended would allow a student to stand examination in medical subjects at times not correlated with the performance of clinical clerkships, to the extent that the seventh semester unofficial clinical clerkships being performed are germane, they have not been credited. Respondent claims that the period from the end of the fall of 1980 was not crucial in that he had fulfilled enough weeks in clinical rotation to allow his graduation. In any event, Respondent did graduate, was certified by the Educational Commission for Foreign Medical Graduates, passed the FLEX examination and has been licensed in the states of Georgia and New Jersey. In explaining his response to the requirements related to his application for licensure in Florida to practice medicine, Respondent indicates that he was of the persuasion that he need only provide information pertaining to his clinical training as credited by the two schools he attended. This is not a fair reading of the requirements expressed in the correspondence of September 30, 1983, in which all activities involving the medical education are sought. This contemplates that specific information as to the exact nature and location of the externship rotations performed in the United States should be explained. Respondent failed to do this and what he did offer by way of explanation is misleading in that clerkships are set forth pertaining to experience in the period July, 1980 through December, 1980 associated with the Universidad Cetec which did not occur at that time because the Respondent was not enrolled at Universidad Cetec during that period. In addition, the statement about clinical training given by the Respondent would have one believe that the training occurred in the affiliated hospitals associated with the two medical schools he attended which is erroneous. The clinical training statement by the Petitioner does not coincide with his actual clinical training, an example being that during the period January, 1980 through June, 1980 while affiliated with the Universidad del Noreste, he says that he received training in traumatology (orthopedics), forensic medicine, gastroenterology, and dermatology when in fact the training he was receiving at that time at Kingsbrook Jewish Medical Center was in the fields of medicine, pediatrics and surgery. It appears that Universidad del Noreste gave him credit for those subjects he relates, but this was not the clinical training he was undergoing in that time sequence. During the period July through December 1980 where he indicates that he received clinical training in neurology, infectious disease, endocrinology and general surgery, the only official training he received was in neurology. It is debatable whether the requirements for establishing residence as described in the endorsement application form and the Attachment for Application for Licensure form sought the official residence, that is, his residence in the country where he attended medical school or the actual residence where externships were being performed as well as when he was actually at the university. In any event, if it was seeking the official residence, his information is misleading in that he describes his official residence as Santo Domingo in the period July, 1980 through December, 1980, when in fact his official residence was Tampico, Mexico. Respondent was given his medical license by the State of Florida on December 5, 1983, based in part upon the information as set out in the endorsement application form, the Attachment for Application for Licensure form and the narrative on clinical training provided by the Respondent. Before the occasion of the present administrative complaint, there is no indication that the Respondent has been disciplined by the State of Florida. At present, Respondent is practicing medicine in Florida and is a resident of Stuart, Florida.
The Issue Whether the Petitioner correctly answered questions 37, 44, 49, 83, and 206 of the General Written Exam portion of the Physician Assistant Examination administered June 25 through June 29, 1998.
Findings Of Fact Based on the oral and documentary evidence presented at the final hearing and on the entire record of this proceeding, the following findings of fact are made: The Department of Health is the state agency responsible for licensing and regulating physician assistants. Sections 455.574 and 458.347(7), Florida Statutes (1997). Mr. Molina sat for the Physician Assistant Examination administered on June 25 though 29, 1998. At the hearing, he disputed the Department's determination that the answers he gave to questions 37, 44, 49, 83, and 206 are incorrect. The questions that comprise the General Written Exam portion of the June 1998 Physician Assistant Examination were objective, multiple-choice questions. The questions were drawn from a bank of questions written by licensed physician assistants trained by a psychometrician employed by the Department. Prior to being included in the question bank, these questions were reviewed and field-tested to ensure that they were good, fair questions that adequately and reliably tested the applicant's ability to practice as a physician assistant with reasonable skill and safety. After the test questions for the June 1998 examination were selected from the question bank, the questions were reviewed before the examination and after the examination. The candidates taking the examination in June 1998 were directed in the instructions to the examination to choose the best answer from among four possible answers. This instruction was included in the examination booklet provided to each candidate, and the Department's normal procedure was to read the instructions aloud prior to the examination. According to the Department, the correct answer to question 37 is "C"; Mr. Molina chose answer "B." Although question 37 is, on its face, clear and unambiguous, the reference book relied upon by the Department to support its answer, although an authoritative source for physician assistants, does not, in fact, unambiguously support the Department's answer. Question 37 refers to the "entire anterior chest," and the answer to the question can be derived from the "Rule of Nines." The "Rule of Nines" is a standard rule used in the practice of medicine and is illustrated in an authoritative text entitled Current Medical Diagnosis and Treatment, which contains a chart showing the outline of the human body divided into sections, each representing approximately nine percent of the body's surface area. The chart shows, in pertinent part, the trunk of the human body divided into the "posterior" upper trunk and the "posterior" lower trunk, with a line drawn somewhat above the umbilicus to illustrate the division of the trunk into the upper and lower portions. The Department's expert testified, without explanation, that the "entire anterior chest" is composed of both the upper and the lower trunk. This conclusion cannot be drawn from the chart contained in the reference book relied upon by the Department, and Mr. Molina's answer to question 37 is as reasonable as the answer the Department considers correct. Accordingly, Mr. Molina should receive credit for his answer to question 37. According to the Department, the correct answer to question 44 is "D"; Mr. Molina chose answer "B." Question 44 asks for the "MOST likely diagnosis" based on the facts contained in the question. Question 44 is clear and unambiguous, and the correct answer is included among the choices provided. The correct answer can be derived from information included in the reference book entitled Ophthamology for the Primary Care Physician, which is considered an authoritative text by physician assistants. Mr. Molina should not receive credit for his answer to question 44 because the answer he gave is not the correct answer. 3/ According to the Department, the correct answer to question 49 is "A"; Mr. Molina chose answer "C." Question 49 asks for the "MOST likely" diagnosis based on the facts contained in the question. Question 49 is clear and unambiguous, and the correct answer is included among the choices provided. The correct answer can be found in volume 1 of Harrison's Principles of Internal Medicine, a reference book included in the list of recommended books sent to the candidates for the Physician Assistant Examination and considered an authoritative text by physician assistants. Mr. Molina should not receive credit for his answer to question 49 because the answer he gave is not the correct answer. According to the Department, the correct answer to question 83 is "D"; Mr. Molina chose answer "C." Question 83 is clear and unambiguous, and the correct answer is included among the choices provided. The correct answer can be found in volume 1 of Harrison's Principles of Internal Medicine, a reference book included in the list of recommended books sent to the candidates for the Physician Assistant Examination and considered an authoritative text by physician assistants. Mr. Molina should not receive credit for his answer to question 83 because the answer he gave is not the correct answer. According to the Department, the correct answer to question 206 is "C"; Mr. Molina chose answer "A." Question 206 asks for the "MOST common" presentation of a precancerous lesion. Question 206 is clear and unambiguous, and the correct answer is included among the choices provided. The correct answer can be found in volume 2 of Harrison's Principles of Internal Medicine, a reference book included in the list of recommended books sent to the candidates for the Physician Assistant Examination and considered an authoritative text by physician assistants. Mr. Molina should not receive credit for his answer to question 206 because the answer he gave is not the correct answer.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Health enter a final order finding that Nigel Molina is entitled to credit for his answer to question 37 of the General Written Exam portion of the Physician Assistant Examination administered June 25 through June 29, 1998; finding that Mr. Molina is not entitled to credit for his answers to questions 44, 49, 83, and 206 of the General Written Exam portion of the Physician Assistant Examination administered June 25 through June 29, 1998; and recalculating Mr. Molina's score on the General Written Exam portion of the Physician Assistant Examination administered June 25 through June 29, 1998. DONE AND ENTERED this 8th day of February, 2000, in Tallahassee, Leon County, Florida. PATRICIA HART MALONO Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 8th day of February, 2000.
The Issue Whether Petitioner is qualified to be licensed as a medical doctor in Florida by endorsement.
Findings Of Fact Petitioner Jeffrey Jad Gaier applied for licensure by endorsement in Florida by filing a written application in November of 1983 with the Board of Medical Examiners, which is within the Department of Professional Regulation. He made a personal appearance before the Foreign Graduate Committee of the Board of Medical Examiners in April 1984. After Petitioner's appearance before the Foreign Graduate Committee, the Foreign Graduate Committee made a favorable recommendation regarding Petitioner's application for licensure to the Board of Medical Examiners. However, the full Board of Medical Examiners voted to deny Petitioner's application for licensure. On May 21, 1984, the Board of Medical Examiners rendered an Order denying Petitioner's application for licensure as a physician by endorsement, stating as the grounds: Your application and supporting documentation does not provide sufficient information to demonstrate that you can practice medicine with reasonable skill and safety. See Section 458.331(3), F.S. More specifically, the clinical training you received while attending the American University of the Caribbean as disclosed within your documentation was determined to be insufficient insofar as the clinical training was not received at a hospital affiliated with a medical school approved by the Counsel [sic] on Medical Education of the American Medical Association. The denial of Petitioner's application for licensure by endorsement was taken before the Board of Medical Examiners for reconsideration on February 3, 1985. Counsel for Petitioner was present at the hearing. At that hearing, the discussion by the Board of Medical Examiners of the request for reconsideration clarified the basis for the denial of the medical license as being the overall inadequacy of the clinical training and not specifically because the clinical training was not obtained at teaching hospitals. Except for the purposes of clarifying the issue(s) herein the collegial actions of the board are irrelevant to the instant de novo proceedings. Petitioner received a B.S. degree from Clark University, Massachusetts and a Masters degree in science education from Florida Institute of Technology, August 1978. Petitioner was granted a medical degree by the American University of the Caribbean after being enrolled at that school for less than three years. During that time, Petitioner was on the campus of the American University in Montserrat, British West Indies for only eight months. There the class used prepared slides instead of gross tissue samples. Before that, Petitioner studied at the campus in Cincinnati, Ohio, where the class used rubber cadavers instead of human cadavers. All of the clinical training received by Petitioner as part of the requirements for the completion of the medical degree consisted of preceptorships at hospitals in south Florida which included Florida Medical Center, Plantation General Hospital, University Community Hospital, and Bennett Community Hospital. Dr. Neil Katz, Petitioner's principal expert medical witness, supervised Petitioner for six weeks in a preceptorship in Family Practice. Dr. Katz is a board-certified Family Physician and a fellow of the American Academy of Family Practice. He has been Chairman of the Emergency Room Department, a member of the Credentials and Qualifications Committee, and a member of the Intensive Care Unit Committee at University Hospital, Tamarac, Florida. He has taught both foreign medical students in a clinical setting and has briefly qualified as a preceptor for the University of Florida College of Medicine. Dr. Katz actually supervised Petitioner only for the six-week period at the very beginning of Petitioner's rotations. After that six-week period of time, he only "touched base" with Petitioner, seeing him on an informal basis in the cafeteria or at meetings. During the six weeks formal observation period, Petitioner accompanied Dr. Katz in his work in his office, during hospital rounds, at the emergency room, and for most other activities that Dr. Katz participated in, including committee meetings at the hospital. Petitioner took histories and did physicals on patients under direct supervision. Petitioner displayed enthusiasm and energy in his association with Dr. Katz and the rest of the program. Dr. Katz found Petitioner "barely acceptable" in three of the nine categories for which he was to evaluate Petitioner during the preceptorship. These categories were diagnostic acumen, therapeutics and management, and medical knowledge. In explaining that evaluation, Dr. Katz testified that although Petitioner was able to take a history and a physical examination, he was not able to make a diagnosis. In fact, Dr. Katz testified that Petitioner did not have truly acceptable knowledge at the time as to the various therapeutic modalities available to a physician. He encouraged Petitioner to do more reading. During his preceptorship with the University of Florida Medical School students in their first clinical semester, Dr. Katz also saw problems similar to those exhibited by Petitioner, specifically that the University of Florida students were not "super ready," so to speak, on diagnosing and doing differential diagnoses and therapeutics at that particular stage in medical school because they were still learning. I accept Dr. Katz' opinion that Petitioner had adequate exposure to the major diseases and injuries which are common to Family Medicine, sufficient for Petitioner to go into an internship, but in light of his lack of involvement with Respondent's other preceptorships in several different hospitals after the first six weeks, and in light of his specific testimony that in his professional opinion, American-trained students were far superior to the Caribbean-trained students at the same level in terms of general knowledge (TR-65-66), Dr. Katz' opinion that Petitioner did "quite good" at the end of the year and a half period is without adequate predicate and is not persuasive. Dr. Isidoro Dunn was the primary force in the arrangements for preceptorships. Dr. Dunn talked with each preceptor to work out areas which should be covered in their respective rotations. Each preceptor had a "fair amount of latitude" in deciding how to supervise the students. Petitioner was assigned by his school to do his clinical rotations in Florida. He did 14 weeks in internal medicine, 14 weeks in surgery, 10 weeks in pediatrics, 10 weeks in obstetrics/gynecology, 4 weeks in psychiatry, and 10 weeks in electives. This totals 62 weeks, not even close to two years which is the norm in medical schools in the United States. Petitioner was required to follow patients from admission to discharge in each specialty within each of these clinical rotations. Petitioner had didactic teaching on a daily basis, weekdays. Petitioner represents that he had specific didactic courses in hematology, EKG readings, pathology, orthopedics, cardiology, radiology, and gastrointestinal invasive procedures. In each subspecialty, he had a written examination after completion of the rotation, didactic teachings in each rotation, and was required to read medical journals. On Saturdays, Petitioner was required to participate in case conferences, make case presentations, and complete assigned reading from current medical journals. The case presentations necessitated review of patient records, laboratory tests, x-rays, and pathology slides. On "patient management reviews," the Petitioner was "exposed to" or "spent time in" the dialysis unit, pathology laboratory, intensive care unit, emergency room, gastrointestinal unit, blood lab, catherization department, radiology department, EKG unit, and cardiac surgery unit. Petitioner testified, and Dr. Katz confirmed, that there was an entity called the "Doctors' Club," which had a considerable amount of audiovisual equipment available for use 7 days a week, 24 hours each day. Practicing physicians used this media to obtain continuing medical education approved for credit by the American Medical Association. Petitioner represented that "on several days" he signed out equipment or reading material. There is no precise language in his testimony that he used the equipment or that he read the reading material, but drawing any other inference is straining the clear meaning of Petitioner's unrebutted testimony. Petitioner and the other students were required to use various materials from this service, but there is no evidence that Petitioner or other students were objectively checked by Dr. Dunn or their preceptors to verify that they had actually read or viewed the material assigned. Petitioner specifically testified that there was not necessarily any follow-up by the preceptors. Dr. Katz did talk with Petitioner about the reading assignments he gave. Petitioner was required to pass a competency examination for each rotation. Petitioner's clinical studies evaluation forms in his school records indicate no overall evaluation grades below "Good." Petitioner was required to attend and pass both a written and practical examination for a two-day Advanced Cardiac Life Support Course. This course is required even of board certified emergency room (ER) physicians. In Petitioner's opinion, this course was imperative for medical doctors who might work in an emergency room because they need to be very familiar with how to handle a patient presenting with a cardiac arrest, including the administration of drugs, "cardioversion" and "intubation." To the best of Petitioner's knowledge, Dr. Dunn was to report the students' progress to the dean of the American University of the Caribbean. However, the predicate for that testimony is hearsay, uncorroborated by any direct, credible evidence. As for the relationship with the university, Dr. Katz had no knowledge as to any arrangement between Dr. Dunn and the American University of the Caribbean or any counterpart-sponsoring organization in the United States. He did not know if there was any arrangement whatsoever. Dr. Katims was accepted as an expert physician witness, as an expert teaching fellow witness, and as an expert witness in medical applications and licensure. He testified that in the normal course of medical education in the United States, part of a student's medical education is clinical training, and that experience consists of bedside outpatient treatment and supervised training under the supervision of a faculty selected particularly for their knowledge, background, and interest in education and teaching. Dr. Katz testified unequivocally that a preceptorship is very different from a clinical rotation or a clerkship. A clerkship takes place in a teaching hospital, which is a very structured environment, wherein students make rounds in a very large hospital and are given instruction in an approved clinical structure. In contrast, a preceptorship gives students more knowledge about what private practice is like and it gives students a view of direct patient care, but does not replace a formal teaching setting in clinical medicine. As recognized above, in Dr. Katz' opinion, American-trained students were far superior to the Caribbean-trained students at the same level in terms of general knowledge. In Dr. Katims' opinion, Petitioner's clinical studies consisting of only four semesters were not sufficient for him to practice medicine with reasonable skill and safety. Dr. Katims testified concerning the importance of clinical training in medical education, commenting that clinical training is the sine qua non of the practice of medicine. In the usual clinical rotation, medical students are assigned to a particular area of a hospital and perform under the full-time supervision of attending physicians. In teaching hospitals, faculties are selected for their ability, interest, and dedication to education, as well as to the practice of medicine. The attending staff at a teaching hospital include house physicians, interns, and residents. Dr. Katims himself has served as a preceptor and testified that a preceptorship is one method of obtaining a minor portion of clinical training, but is very unstructured and unsupervised. Dr. Katims testified that preceptorship training is an inferior method of training because the quality of training depends totally on the quality of the physician to whom the student is assigned and the program is unstructured. There was no testimony that any of the preceptors that supervised, or purportedly supervised, Petitioner were faculty members of any medical school, let alone the American University of the Caribbean. Upon the Requests for Admissions and the Joint Pre-Trial Stipulation of the parties, it is found that: the State of Florida Board of Medical Examiners has granted a medical license to a Dr. Flugsrud-Breckenridge and a Dr. Cobb, both having non-teaching clerkships. Three doctors, Adela Fernandez, Andrew Gonzalez, and Manuel E Garcia, did their clerkships principally at the International Hospital (Miami), a non-teaching/non-medical school-associated hospital, and obtained Florida medical licenses. At least 25 foreign graduates received Florida medical licenses within the years 1981-1984 and did their clerkships principally in non-teaching/non-medical school associated hospitals. No further information appears of record by which the undersigned may determine any other similarities or dissimilarities of these licensees to each other and/or to Petitioner. Nor does the record divulge what, if any, other facts may have been considered in these cases. Petitioner is licensed to practice medicine in Georgia and is a resident of Florida. Petitioner passed the first time his Educational Commission for Foreign Medical Graduates' (ECFMG) examination was given in June, 1981. The examination is a prerequisite to acceptance in a medical residency program. The Federation of State Medical Boards of the United States, Inc.'s (FLEX) examination is recognized by all 50 states, including Florida. Petitioner took this examination after completing his rotations in Florida. Petitioner passed the June 1982 FLEX examination with an 84 percentile ranking. Fifty percent of this test is on patient management. This clinical competence examination was taken before Petitioner started his first year of residency. Petitioner had passed the FLEX examination, completed one year of residency, and obtained a medical license in another state, Georgia, by the time of the April 1984 application hearing. In Dr. Katims' opinion, Petitioner's successful passage of the FLEX examination in the 84 percentile does not show Petitioner to have had good clinical rotations, even though the FLEX test consisted of 50 percent on patient management. Dr. Katims did not feel that by the time Petitioner was in his fourth year of residency, this would be curative of deficiencies in the clinical semesters at a non-teaching hospital, but expressed the opinion that if Petitioner passes his internal medicine board examination and becomes board certified, his clinical deficiencies would be cured and Petitioner should then be granted a Florida medical license by endorsement. Dr. Katz opined that Petitioner presently possesses the medical knowledge, judgment and competency to act with reasonable skill and safety in the practice of medicine in Florida. Affidavits of Ira Spiler, M.D. and John R. Middleton, M.D. support similar opinions of these New Jersey medical physicians. Petitioner has completed three years (July 1, 1982 to June 30, 1985) of Internal Medicine residency at Raritan Bay Medical Center, Perth Amboy General Hospital, New Jersey. Petitioner is presently enrolled in a Nephrology Fellowship program, Medical College of Georgia, a teaching hospital located at, and affiliated with, the University of Georgia Medical School. Petitioner is currently eligible for board certification in internal medicine and will be certified in the event he passes the board examination taken September 10-11, 1985. Petitioner has submitted letters of Ira Spiler, M.D. and Salvatore Chiaramida, M.D., both of New Jersey attesting to Petitioner's good moral character, and no contrary evidence was turned up by the Board's investigation. The parties have stipulated that Rule 21M-22.18, Florida Administrative Code, is not applicable to Petitioner's situation.
Recommendation That the Florida Board of Medical Examiners enter a final order denying Petitioner a medical license by endorsement. DONE and ORDERED this 16th day of January, 1986, in Tallahassee Florida. ELLA JANE P. DAVIS Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 16th day of January, 1986.
