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
The Issue This proceeding involves Certificate of Need (“CON”) application number 10449, submitted to the Agency by Munroe Regional, seeking to establish a 66-bed general acute care hospital in Marion County, Florida, District 3, Subdistrict 3-4. The nature of the controversy is whether, on balance, the CON application satisfies the applicable statutory and rule criteria and should be approved.
Findings Of Fact (The following findings of fact are derived from the stipulation of the parties, the admitted exhibits, and the oral testimony at final hearing in this matter.) Parties AHCA is the state agency responsible for, inter alia, the review and approval (or denial) of CON applications. As previously noted, AHCA made a preliminary decision to approve issuance of CON 10449 to Munroe Regional. Munroe Regional is a 421-bed tertiary care hospital located in Ocala, Marion County, Florida, that offers inpatient, outpatient, medical, surgical, and emergency care. Its license covers both the 421-bed facility and a freestanding emergency department (known as TimberRidge) in the western part of Marion County. Munroe Regional is accredited by the Joint Commission on Accreditation of Healthcare Organizations and features a certified Chest Pain Center with specific accreditations for atrial fibrillation and heart failure. It is a general medical- surgical facility, including trauma care, obstetrics, pediatric services, surgery, neurosurgery, etc. It does not include care for burn patients, do transplants, or provide psychiatric services. Munroe Regional was opened in 1898 as a county-owned, not-for-profit hospital. In 1901 the hospital moved to a three- story building located at the corner of Adams and Orange Street, now Northwest Second Street and First Avenue. The hospital was upgraded to a 73-bed facility in 1927, and that hospital space now serves as administrative offices. The expansion to 421 beds occurred in 2003, at which time Munroe Regional underwent a 200,000 square foot expansion. In 2013, Health Management Associates (“HMA”) took over operation of Munroe Regional by way of a long-term (40 year) lease. In 2014, HMA was acquired by Community Health Systems (“CHS”), a national for-profit healthcare provider. The acquisition by CHS was not well received by some hospital staff and there were many who decided not to work for the new owner, including a large number of nurses. Some of those nurses have since returned, but the exodus had some negative impact on Munroe Regional at the time. Meanwhile, in 2002 Munroe Regional had opened TimberRidge, the first freestanding emergency department (“ED”) in the State of Florida. TimberRidge is located at 9521 Southwest State Road 200, just west of the Ocala city limits. It has 12 examination rooms as well as four additional rooms utilized for treatment. TimberRidge is the second busiest ED in the state (second only to the facility located in Tallahassee). When CHS took over operations, the lease agreement with the hospital obligated CHS to spend $150 million on major capital improvements and another $75 million in needed infrastructure improvements. CHS initially planned to construct a new bed tower on the current site of Munroe Regional. That plan was later changed, resulting in the plan to build a new hospital at the TimberRidge ED site. CHS determined that alternative to be a better way to improve service in the area. TimberRidge is located in an area of Marion County generally referred to as the “200 Corridor,” an area identified by State Road 200 as it goes from northeast to southwest in Marion County, starting at Interstate Highway 75 (“I-75”). I-75 is a federal highway which runs north and south through the center of Marion County, effectively dividing the county in half, east and west. The 200 Corridor is a rapidly growing area of west Marion County and includes a number of adult (age 55- plus) communities such as Top of the World, which has been approved for up to 36,000 lots for development. Although those lots have been “entitled” for development since 1972, only about seven thousand have actually been built out. There are several other age-restricted communities in the area as well, including Oak Run, Pine Run, Palm Cay, and Cherrywood Estates, to name a few. It is clear that the 200 Corridor is populated largely by middle-aged to elderly adults. There was significant testimony at final hearing concerning recent population growth and expectations for the future. Although it is clear that Marion County is growing, the testimony was not persuasive as to whether that growth alone would not necessitate building another hospital in the county. In 2016, Munroe Regional filed CON application number 10449, seeking approval of a new 66-bed general acute care hospital in Marion County, Florida. The hospital would be located on the same site as TimberRidge. Its proposed primary service area would be zip codes 34481, 34476, 34473, 34432, and 34474 in District 3, Subdistrict 3-4. Its secondary service area would be zip codes 34442, 34431, 34482, and 34434.1/ The proposed hospital would be a non-specialty/non-tertiary care facility. It would not include care in the area of obstetrics, newborns, psychiatry, substance abuse, burns, trauma, transplants, neurosurgery, or comprehensive medical rehabilitation. Munroe Regional timely submitted a letter of intent, providing notice of its intent to file the aforementioned CON application number 10449. AHCA deemed the application to have satisfied, on balance, the statutory requirements for approval. Preliminary approval of the application was published in the Florida Administrative Register. Ocala Health Systems operates Ocala Regional, an existing 222-bed general acute care hospital located in Marion County. Ocala Regional is a Level II trauma center. Ocala Health Systems also operates West Marion, an existing 94-bed acute care hospital also located in Marion County, and operates a free-standing ED in the southern portion of Marion County. Ocala Health Systems is an affiliate of Hospital Corporation of America (“HCA”). As both Ocala Regional and West Marion are operated by the same parent, the hospitals are much like a single entity with two locations (exactly as Munroe Regional is proposing for TimberRidge). Citrus Memorial is an existing 204-bed general acute care hospital located in District 3, Subdistrict 3-5, comprised of Citrus County. After experiencing operational and ownership difficulties beginning around 2008, Citrus Memorial began to decline. In 2014, HCA assumed operations of the hospital and began to make improvements. Citrus Memorial was experiencing very low utilization (around 50 percent) and its reputation in the community was poor. HCA has made strides in changing the community perception. Each of the Petitioners, as existing providers in the same District, could be substantially affected by the approval of the Munroe Regional CON application. Each of the Petitioners has standing to challenge the preliminary approval of the CON to Munroe Regional. Statutory Rule Criteria Subsection 408.035(1)(a), Florida Statutes: The need for the health care facilities and health services being proposed Munroe Regional raised several categories of facts that it suggests support the need for the proposed new hospital on the 200 Corridor. Those categories are, generally: 1) A large number of elderly persons living within close proximity to the proposed hospital; 2) Recent high occupancy rates at existing hospitals in Marion County; 3) The potentially positive impact on EMS transports if another hospital existed in the county; and 4) The possible reduction of “wall times” and other delays in emergency rooms if the hospital is approved.2/ Each of those areas will be discussed more fully below. Elderly Population in the Service Area The service area proposed by Munroe Regional for the new hospital would be primarily within the 200 Corridor, mostly in the age-restricted communities. However, the facility would be available to all residents of Marion County and surrounding areas. There are approximately 146,000 residents living within the area designated by Munroe Regional as its anticipated primary service area. Of those, some 123,000 are adults, with more than 70,000 of those being elderly, i.e., over 65 years of age. It is axiomatic that elderly adults utilize hospital services more than others. That fact may also explain why there are so many medical and doctors’ offices in the TimberRidge area. There are also other healthcare facilities in the service area, including a nursing home and a hospice. Several community representatives testified as to their desire to see a new hospital built on the 200 Corridor, but their testimony was not persuasive as to the “need” (versus the “want”) for a new hospital. The witnesses described the location of the new hospital as a convenience for local residents rather than addressing actual need. For example, Mrs. Gabriel frankly asserted that, “We would rather have [a hospital] right here in our own back yard.” Transcript, Vol. 2, page 296. Munroe Regional’s witness, Mr. Ott, spoke of his company’s involvement in building healthcare communities (assisted living facilities, nursing homes, etc.) in the rapidly growing area near TimberRidge. He noted, however, that such facilities had a singular goal of keeping people out of the hospital as much as possible. This militates against the addition of new hospital beds in Marion County. There was no persuasive testimony that the mere existence of a large elderly population near the 200 Corridor warranted construction of a new hospital in that area. Occupancy Rates at Existing Hospitals Munroe Regional has experienced low occupancy rates during the last few years and it continues to decline. Prior to its acquisition by CHS in early 2014, the hospital’s occupancy was around 67 percent. From April 2014 until December 2014, the occupancy averaged 63 percent. From January 2015 to December 2015, it was at 61 percent. And for calendar year 2016, the occupancy rate was at 56 percent. However, Munroe Regional asserts that calculation of occupancy is not a static event; there are many other factors that could be considered, e.g., semi-private rooms may be utilized by a person with an infection, thereby making the other bed in the room inaccessible to another patient; rooms or entire units may be taken out of use during renovations (and Munroe Regional is in the midst of renovating its entire hospital, unit by unit); certain units may not be full, such as OB-GYN, but the beds within that unit are not available for other types of patients, etc. Although AHCA data show Munroe Regional’s most recent occupancy rate to be around 56 percent, Munroe Regional calculates its “practical occupancy” to be in the range of 70 percent. And, if certain specialty units were omitted from consideration, Munroe Regional would say that its occupancy is close to capacity. By comparison, the occupancy rates at Ocala Regional and West Marion were very high during the past three years. Though the testimony and evidence was contradictory in many regards, depending on which beds or patients were actually included, it is clear from the totality of the evidence that both hospitals operated at or near capacity for much of the time. There were periods during which West Marion operated at over one hundred percent of its capacity, indicating the rapid transition of patients on a given day. The high occupancy at West Marion is being actively addressed by the hospital. West Marion first added 25 new beds, which went on-line in April 2015. There are 44 additional beds which have been approved and will be available early in 2018. West Marion has also built an additional floor of “shelled in” space, which could house up to 48 additional medical surgical beds. That shelled-in space, however, has also been offered as space to house new comprehensive medical rehabilitation (“CMR”) beds for which West Marion has applied, but the CON for those beds has not been approved by AHCA at this time. If approved, West Marion will look elsewhere for space to add additional medical surgical beds. Ocala Regional begins to look at expansion when its inpatient occupancy reaches about 80 percent, exclusive of observation patients.3/ 80 percent is a recognized level of “functional capacity” for a hospital in Marion County. In recognition of that loose standard and its present state of affairs, Ocala Regional will have a new 34-bed addition coming on line in late 2018. That addition will also contain 12 new beds in its ED and two new operating rooms. Though disputed by Munroe Regional, it seems logical the addition of those beds will reduce occupancy levels at Ocala Regional. The data presented by Munroe Regional as to the two competing hospitals was not entirely persuasive as to whether the high occupancy rates at the other hospitals constituted need for another hospital. In total, the evidence supports the contention that occupancy rates were high, but nothing more. Although Munroe Regional does not acknowledge the potential impact of its proposed new hospital on Citrus Memorial, it is clear from the evidence that Citrus Memorial has grave concerns about the proposed project. It is already difficult for Citrus Memorial to hire and retain professional staff; a new hospital in the area would further exacerbate that problem. The same is true concerning Citrus Memorial’s patient census. Already suffering from low utilization, another hospital just 25 to 30 miles northwest of Citrus Memorial (and only a short drive from many residents of Citrus County) could have significant negative impact on the hospital. Occupancy rates at Citrus Memorial of around 60 percent over the past three years cannot be ignored. Its CEO noted that there is very little in-migration from other counties by persons seeking healthcare in Citrus County. However, many Citrus County residents out-migrate for healthcare services to surrounding counties. In contrast to Munroe Regional’s position, Citrus Memorial sees its low occupancy as “room for growth” rather than “functional occupancy.” All in all, Munroe Regional’s dismissal of the potential negative impact on Citrus Memorial is not well taken. Furthermore, the occupancy rate at Munroe Regional over the past three years effectively defuses its claim of need for a new hospital, especially one operated by the same organization. As noted above, the evidence shows that a number of beds, even entire units, at Munroe Regional have been closed and out of use in the recent past. There is enormous capacity for additional patients at Munroe Regional, militating against approval of a new hospital in the subdistrict. Though not a hospital, TimberRidge is also a very busy provider of healthcare services. Annually, TimberRidge cares for over 32,000 emergency patients, a number greater than half of the hospital-based EDs around the state. TimberRidge transfers about 2,500 patients per year to hospitals for in- patient care, around 8 to 10 patients a day. Most of those patients go to Munroe Regional. And, although Munroe Regional operates at a fairly low occupancy, TimberRidge reports that patients sometimes have to wait 8 to 10 hours for a bed to become available. If the CON is approved, TimberRidge will add 14 more emergency treatment rooms, presumably handling even more emergency patients. Impact on EMS Transport Emergency transport to hospitals in Marion County is provided by a single entity, the Marion County Fire-Rescue service. This service consists of three different departments: Dunnellon Fire-Rescue, a non-transport, basic life support (“BLS”) service; Ocala Fire-Rescue, a non-transport advanced life support (“ALS”) service; and Marion County Fire-Rescue, an ALS entity that is both a non-transport unit and is the primary transportation provider for “scene calls,” i.e., to pick up patients at the scene of an accident or event. There is another BLS transport provider in Marion County which is allowed to do minimal inter-facility transfers, but it is not authorized to transport from scenes or to emergency rooms. About 450 to 475 emergency medical technicians (“EMTs”) and paramedics work within the system. It operates about 32 vehicles a day, seven days a week, on a regular basis, with some increase during peak season.4/ The annual call volume for Marion County Fire-Rescue is about 70,000 to 75,000 calls; of that number about 45,000 to 47,000 result in persons being transported to a hospital. The medical director for Marion County Fire-Rescue is Frank Fraunfelter, who, coincidentally, also works with the Munroe Regional ED. When a person is placed in an ambulance, he or she has the right to be transported to the hospital of their choice. If they do not have a preference or cannot make the decision, the transport will go to the nearest available hospital or ED. (Besides the freestanding TimberRidge ED, the Ocala Health System also operates a freestanding ED in the southeast quadrant of Marion County.) The patient’s condition or malady may dictate where they are taken, regardless of their preference. For example, heart attack victims or stroke alert patients usually require transport to the closest of either Munroe Regional, Ocala Regional, or West Marion. Trauma alert patients may only go to Ocala Regional. Pediatric trauma patients are sped to Shands, in Gainesville. When responding to calls on the west side of I-75, EMT drivers say many patients do not want to go all the way “into town” for care. That leaves West Marion and TimberRidge as the available sites for delivery of the patient. Though there was some evidence to suggest that individuals prefer not to go all the way into town, i.e., to Munroe Regional or Ocala Regional, the evidence was not sufficient to establish that preference as an absolute fact. Due to the layout of Marion County, it often takes EMS longer to transport patients from the western areas of the county to the two downtown hospitals. Another hospital located on the 200 Corridor would obviously cut down on their drive time for some patients (if the patient chose to go to that hosptial). The number of facility-to-facility transfers could also be reduced if patients at TimberRidge ED had the option to remain at the new hospital rather than being transferred to Munroe Regional. The EMS drivers noted that it sometimes takes 20 to 30 minutes to reach the downtown hospitals (Munroe Regional and Ocala Regional), followed by 20 to 30 minutes waiting at the hospital ED, plus 20 to 30 minutes to drive back to the station. The time spent at the hospital involves getting the hospital room assignment from the charge nurse, discussing the patient’s status with the RN who will be taking over care of the patient, and getting the patient transferred to a hospital bed or gurney. The division chief of Marion County Fire-Rescue supports the addition of the hospital at TimberRidge, but it seems to be because it would be more advantageous to his business, i.e., not because there is a “need” for the hospital. He said, “I’d love to see a hundred more beds at each of the hospitals. More beds means they are off my stretcher; gets my truck back in service.” Transcript, Vol. 3, page 392. His stated “preference” does not support need for a new hospital in the area. While wall times and diversions have been a problem in Marion County for some time, the evidence suggests that the problem is less acute in recent months. Everyone involved seems to be working to eliminate delays. The EMS division chief noted, for example, that the addition of beds at West Marion has had a positive effect on transportation times. The additional beds coming on line at that hospital should further impact this improvement. So should the renovations of the EDs at Munroe Regional and Ocala Regional. There was extensive testimony at final hearing concerning drive times and how long it took EMS to reach this hospital or that. The testimony was not persuasive, as witnesses seemed to presuppose that all patients would be picked up at a location furthest from the hospital being discussed. For example, EMTs testified that it takes up to 30 minutes to get from the 200 Corridor to Ocala Regional or Munroe Regional. But the 200 Corridor is a fairly long stretch of road. It cannot possibly take “up to 30 minutes” for every patient, no matter where on the Corridor they were picked up. And, obviously, traffic patterns change; sometimes it is heavier than others. The drive time testimony seemed very speculative and unreliable. One important issue became clear through testimony in this proceeding: As the single provider of transportation in the county, Marion County Fire-Rescue could relieve its busy schedule by allowing ALS facility-to-facility transfers to be done by a private entity. There does not seem to be an absolute need for Marion County Fire-Rescue ambulances (which are needed for emergency situations) to be utilized for such transfers. One reason is that EMS drivers consider facility-to-facility transfers to be rather mundane; they would prefer to transfer patients directly from the scene of an accident or event. (This was described as a “morale” issue for the drivers.) The issue has been addressed with Marion County Fire-Rescue by the county hospitals, but it seems they are getting push-back from the EMS provider for some reason. It also seems that having EMS testify concerning the need for a new hospital is, as one witness suggested, like the tail wagging the dog. Perhaps it should be Marion County Fire- Rescue adding additional stations or vehicles rather than building a new hospital costing up to $100 million dollars. Reduction of Wall Times Marion County, like many other areas within Florida and nationwide, has historically experienced chronic difficulties by EMS transporters (ambulances) in discharging of patients at hospitals in a timely fashion. Often, the driver of an ambulance must wait extended periods of time for a hospital to admit the patient or accept the patient into the hospital’s care. This so-called “wall time” results in the EMT not being available to respond to other calls in the community. Wall times may exist for a number of reasons, including but not limited to: a major accident within the vicinity might require simultaneous treatment for numerous victims; an unforeseen spike in the number of persons needing treatment at one time; a natural calamity resulting in injuries; other hospital EDs being full, etc. A major factor faced by many hospitals is that there simply are not enough beds available within the hospital at certain times to which the ED patients could be admitted. The patient, therefore, must occupy an ED bed, denying the use of the ED beds to later-arriving patients. This problematic situation is exacerbated by the common practice of uninsured people utilizing the ED as their private doctor’s office. When those persons show up at an ED with a non-emergency complaint, they occupy space which would otherwise be available to treat patients brought in by EMS from accident sites or the like. One method utilized by individual hospital EDs to reduce wall times is a process called “diversion.” This simply means the hospital will contact the EMS provider and ask that all emergency patients be diverted to another hospital for a prescribed period of time, usually about an hour or two. The diversion allows the hospital to catch up on its existing patients before others are brought into the ED. Diversion is a commonly accepted means of dealing with ED overcrowding. There are some exceptions to a hospital’s request for diversion. For example, patients suffering a heart attack or other similar problem will be sent to the nearest appropriate hospital, whether it is on diversion or not. And if two hospitals ask for diversion at the same time, then all hospitals are denied diversion. Diversion, however, is only applicable to patients who arrive at an ED by way of emergency transport, which is about 15 percent of the total ED patients. The great majority of patients, who arrive via other means (personal car, family, friends, taxi, etc.) are accepted by the ED even if it is on diversion. Munroe Regional is restructuring its ED, adding four additional beds (or bays) and reconfiguring the ED so that EMTs have better access to the area. The changes will also make it easier for nurses to maintain visual contact with the patients. The changes will make the process of safeguarding bays for psychiatric patients much faster and easier. These changes will have a positive impact on the ED and contribute to less wall time for EMTs. After having the largest amount of time on diversion from July 2015 to June 2016, Munroe Regional has not gone on diversion for over one full calendar year. It has taken steps to improve its ED wall times. The low occupancy at Munroe Regional would seem to suggest that it would not have a problem finding ED patients a bed within the hospital, thus alleviating at least that one reason for going on diversion. But even though Munroe Regional has more vacant beds than other hospitals in the subdistrict, that fact does not automatically mean that it has more beds to which patients may be admitted. If the available beds are in an area of the hospital that is not appropriate for admission of an ED patient, the patient must still wait for an appropriate bed. Still, one must wonder why a hospital operating at less than 60 percent occupancy would have trouble finding a bed for patients who are waiting in the ED. Munroe Regional provided no empirical data at final hearing as to the needs of its ED patients versus the kinds of open beds at the hospital, so a conclusion cannot be reached in that regard. By comparison, West Marion had the shortest wall times despite having the highest occupancy rate of the county hospitals. The correlation between census and delays is nebulous at best. Munroe Regional’s EMS coordinator confirmed the regular phenomenon of beds not being available for patients coming in through the emergency rooms, but acknowledged that the current closure of many units contributes to that problem. Also, Munroe Regional is in the process of renovating its emergency department, which should help alleviate some of the wall time problems. Ocala Regional has shown the longest wall times of all hospitals in the county. Its high occupancy and downtown location contribute to that fact. The hospital has taken steps to reduce wall times and has made some progress. As the wall time issue continues to improve county-wide, Ocala Regional’s wall times have decreased around 50 percent as well. Subsection 408.035(1)(b): The availability, accessibility, and extent of utilization of existing health care facilities and health services in the service district of the applicant All citizens have access to the existing hospitals and EDs in Marion County, as well as two facilities in surrounding counties. In the service area identified by Munroe County for its new hospital, the closest hospitals are, in geographic order, Marion West, Munroe Regional, Ocala Regional, and Citrus Memorial. The occupancy rates at the existing hospitals are discussed above and need not be repeated here. Suffice to say that Munroe Regional is arguably not being utilized to the same extent of the other Marion County hospitals. Reasons for the lower utilization include the fact that Munroe Regional has several diverse medical units. Some beds in the open heart or neurosurgery units might be empty, while OB-GYN beds are needed. It is not possible to utilize beds in the former units to treat the latter patients. Thus, beds remain empty even as beds are needed. It is a difficult problem for any hospital to manage. It should be noted, however, that there are no established desired occupancy rates for hospitals. That is, AHCA does not penalize a hospital for having a high or low occupancy. Subsection 408.035(1)(e): The extent to which the proposed services will enhance access to health care for residents of the service district Clearly, having another hospital on the 200 Corridor would be more convenient for persons living in that area of town. The new hospital would, therefore, enhance access – at least to the extent access is equated to less travel time for some residents. The new hospital would not offer any services which are not already available at area hospitals. The most persuasive evidence is that the approval of the TimberRidge hospital would not significantly improve drive time for persons living in the areas that hospital would serve. Of the 27 zip codes which are in or near the TimberRidge proposed service area, only six would have reduced drive times to a hospital. (One of those zip codes would be affected by about three minutes.) The large age-limited communities addressed by TimberRidge are all within 20 minutes’ drive time to West Marion – the existing hospital in western Marion County. If the new hospital is not approved, 98 percent of the population of Marion County would still be within 30 minutes’ drive time of an existing hospital. Stated differently, only about 5,500 people in the population of 266,000 would realize a significantly positive impact on their drive time to a hospital, if the TimberRidge hospital is approved. (Note: Testimony and evidence to the contrary at final hearing was not persuasive.) From a purely transportation perspective, the existing TimberRidge ED is moving most of its patients needing acute care to Munroe Regional, i.e., its sister facility. Munroe Regional presumes those same patients would prefer to remain at TimberRidge if a hospital was available on-site, but of course that is speculative. If all patients arriving at the TimberRidge ED chose to stay at TimberRidge Hospital, then access for those patients would be greatly enhanced (as long as there were beds available). The same cannot be said for the remainder of the populace. Subsection 408.035(1)g): The extent to which the proposal will foster competition that promotes quality and cost-effectiveness The new hospital would necessarily compete with West Marion, its closest unaffiliated facility. Because it would be located within Marion County, it would also compete somewhat with Ocala Regional. It would also compete to a much lesser degree with Citrus Memorial. It seems reasonable that the new hospital would also “compete” with Munroe Regional, i.e., it would retain patients from the TimberRidge ED who might otherwise be transferred to Munroe Regional. Such competition could have a negative impact on Munroe Regional’s ability to improve its already-flagging census. It would appear that a satellite hospital for Munroe Regional would increase cost-effectiveness for CHS, which would then be operating two hospitals within the county. The question is whether the competition would promote quality and cost-effectiveness overall. The most persuasive evidence suggests that it would not. The primary problem espoused by the Ocala Health System witnesses about the proposed new hospital had to do with staffing. There is a shortage of nurses in Marion County, similar to the shortage across the state and the country. There are, e.g., some 67,000 nursing vacancies in Florida at this time. Munroe Regional normally has 50 to 60 vacancies on its nursing staff at any given time. Right after CHS took over, Munroe Regional was down about 240 nurses; just prior to the final hearing, that number was at around 100 vacancies. However, there are currently 80 nurses in orientation at Munroe Regional who will be coming on board soon. No evidence was presented as to whether these would be experienced nurses, recent nursing school graduates, LPNs or RNs. Munroe Regional generally has a turnover rate for nurses of about 24 percent, which is very high. That means about one in four positions are vacant at any given time. This rate is comparable to Citrus Memorial, which currently has 15 to 20 percent of its nursing positions vacant. Many of the area hospitals are operating with less than a full nursing staff. Many nurse positions have to be filled by “travelers,” i.e., nurses who go from community to community for interim work positions. The travelers demand higher salaries than local, permanent nurses. They are, however, simply needed at certain times to meet a hospital’s needs. The same is true for physicians needed to staff the area hospitals; they are hard to recruit and difficult to retain. This is especially true for Citrus Memorial, located in an area that does not provide the cultural amenities desired by families of many physicians. Citrus Memorial often has to rely on temporary doctors, locum tenens, to fill needed positions when no permanent doctors are available. The competition for nurses and physicians would not promote quality and cost-effectiveness. To the contrary, such competition could have significantly negative consequences for all hospitals in the area. Subsection 408.035(1)(i): The applicant’s past and proposed provision of health care services to Medicaid patients and the medically indigent Munroe Regional’s payor mix includes about 24 percent Medicaid and indigent care; its emergency department’s Medicaid average is around 39 percent; and TimberRidge’s is at about 37 percent. In the CON application, Munroe Regional agreed to a condition equal to the current community average for Medicaid and charity care, i.e., 13 percent.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency for Health Care Administration issue an order denying CON 10449 to Munroe Regional. DONE AND ENTERED this 15th day of November, 2017, in Tallahassee, Leon County, Florida. S R. BRUCE MCKIBBEN Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 15th day of November, 2017.
Findings Of Fact Jack I. Newcomer, a foreign medical school graduate, applied for licensure by endorsement and the Board of Medical Examiners considered his application on April 12, 1985. Newcomer's application was denied by Order of the Board dated May 9, 1985, on the following ground: The applicant's supervised clinical training was not obtained in either a hospital affiliated with a medical school approved by the Council on Medical Education of the American Medical Association or in a residency program approved by the Accreditation Council for Graduate Medical Education as required by Florida Administrative Code Rule 21M21.18[sic]. Pierre Andre, M.D., a foreign medical-school graduate certified by the Educational Commission for Foreign Medical Graduates (ECFMG) applied for licensure by endorsement. Andre had passed the ECFMG examination and also the Foreign Licensure Examination (FLEX). The Board considered his application, and denied said application on the ground that his supervised training was not obtained in either a hospital affiliated with a medical school accredited by the Liaison Committee on Medical Education or in a residency program accredited by the Accreditation Council for Graduate Medical Education in the specialty area in which his clinical training was obtained as required by Rule 21M-22.18, Florida Administrative Code. The Board adopted Rule 21M-22.18, which took effect on November 28, 1984, and it provided: Foreign Medical Graduates: Qualification Requirements. Before any foreign medical school graduate, except a graduate of an approved school in Canada is admitted to take the written licensure examination or be licensed by endorsements[sic], he or she must demonstrate (in addition to other requirements set forth in Chapter 458, F.S.) that the supervised clinical training received in the United States as part of the curriculum of the foreign medical school was obtained either in a hospital affiliated with a medical school approved by the Council on Medical Education of the American Medical Association or in a residency program approved by the Accreditation Council for Graduate Medical Education. The Board subsequently amended Rule 21M-22.18, and the amendment took effect March 13, 1985, to provide: Foreign Medical Graduates: Qualification Requirements. Before any graduate of a medical school not accredited by the Liaison Committee on Medical Education, except a graduate of an accredited school in Canada, is admitted to take the written licensure examination or be licensed by endorsement; he or she must demonstrate (in addition to other requirements set forth in Chapter 458, F.S.) that the supervised clinical training received in the United States as part of the curriculum of the medical school was obtained either in a hospital affiliated with a medical school accredited by the Liaison Committee on Medical Education or in a residency program accredited by the Accreditation Council for Graduate Medical Education in the specialty area in which the clinical training is being obtained. This rule, as well as its amendment, were adopted to implement Sections 458.311 and 458.313(4), Florida Statutes. The parties stipulated at the hearing that only Rule 21M-22.18 as originally enacted was applied to Petitioners and not the amendment which took effect March 13, 1985. According to Charles P. Gibbs, M.D., Assistant Dean for Curriculum at Shands Teaching Hospital and former chairman of the clerkship committee at Shands, clerkships are an essential part of a medical education because they are the first time the student is introduced to the real practice of medicine and contact with patients. Clerkships occur in the third and fourth years of a medical education, after the student has had courses in the basic sciences, pathology, pharmacology and an introduction to clinical medicine. During a clerkship, the student participates as part of a team and does patient histories, physicals, participates in discussions about patient care, observes operations and attends lectures. Dr. Gibbs testified that written exams, such as FLEX or the National Board, are important in measuring a student's cognitive knowledge and determining minimum qualifications, but cannot measure clinical qualities of a doctor such as how he relates to patients and reacts in stress situations, how he works with colleagues, and how he communicates. Clerkships are important in determining a student's performance level in these clinical qualities. The Liaison Committee on Medical Education has adopted standards for the accreditation of medical education programs which were ratified by the Council on Medical Education of the American Medical Association on March 1, 1985, and the Executive Council of the Association of American Medical Colleges on April 4, 1985, and which state in part: The traditional required clinical subjects, which should be offered in the form of required experiences in patient care (customarily called clerkships), are internal medicine, obstetrics and gynecology, pediatrics, psychiatry and surgery. Additionally, many schools require a clerkship in family medicine . . . . The curriculum must provide grounding in the body of knowledge represented in the disciplines that support the fundamental clinical subjects, for example, diagnostic imaging and clinical pathology. Students must have opportunities to gain knowledge in those content areas that incorporate several disciplines in providing medical care, for example, emergency medicine and the care of the elderly and disabled. In addition, students should have the opportunity to participate in research and other scholarly activities of the faculty. Robert B. Katims, M.D., testified as a member of the Board and Chairman of the Foreign Medical Graduates Committee of the Board. As Committee Chairman he had noted problems with the clinical experience being received by graduates of certain foreign medical schools that are not accredited and that are relatively new schools whose primary purpose is to train United States students rather than their own nationals. Dr. Katims observed that problems with the clinical experience offered at these schools arise because there are not enough teaching hospitals in some foreign countries, and therefore students cannot receive clinical training in those countries through a clerkship. Instead, they must arrange their own clinical experience, usually a preceptorship, in the United States. A preceptorship differs substantially from a clerkship in that it is usually either a one on one affiliation with a practicing physician with very little structured training, or occurs at an outpatient prepaid health plan facility. Dr. Katims testified that preceptorships do not meet the clinical training standards of the Liaison Committee on Medical Education, and do not represent supervised clinical training.
Findings Of Fact The Petitioner was born on December 22, 1941, in Ciego De Avila, Cuba. After graduating from high school, the Petitioner obtained a bachelor of arts degree in 1963, and a bachelor of science degree in 1966 from the pre-university Institute of Ciego De Avila. The Petitioner then enrolled in a one-year pre- medical school training program at the University of Havana, successfully completed that program, and then became a student at the University of Camaguay Medical School. The University of Camaguay was originally a campus of the University of Havana. During the first two years of medical school, the Petitioner attended some lectures in the City of Havana and some lectures in the City of Camaguay. The Petitioner successfully completed the University of Camaguay Medical School curriculum which included the courses in the basic sciences such as anatomy, embryology, histology, biochemistry, physiology, medical statistics, neuroanatomy, plus philosophy and the history of medicine. The Petitioner completed a medical rotation with training which included internal medicine, pathological anatomy, radiology, clinical laboratory, microbiology, and parasitology. In the fourth and fifth years, the rotations included pediatrics, surgery, psychiatry, pharmacology, obstetrics/gynecology, ophthalmology, otolaryngology, dermatology, and orthopaedics. The Petitioner's sworn testimony at the hearing pertaining to these matters was confirmed by a certified copy of his transcript from the University of Camaguay. The Petitioner's testimony concerning his attendance and successful completion of the curriculum at the University of Camaguay was confirmed by two former professors of the University of Camaguay. Dr. Jorge Dieppa was a professor of internal medicine at the University of Camaguay Medical School commencing in 1968. Dr. Dieppa testified that Dr. Mata was his student of internal medicine at the University of Camaguay, and testified that Dr. Mata attended the University from the end of the `60's through the beginning of the `70's. Likewise, Dr. Amelio Hernandez was a professor of psychiatry at the University of Camaguay. He testified that he began teaching students at the University of Camaguay sometime before 1970. Although Dr. Hernandez is not sure of the exact date when Dr. Mata graduated from the University of Camaguay, he did know Dr. Mata to be a graduate of the University, and knew that Dr. Mata, after his graduation, performed reconstructive surgery on burn patients at the local hospital. Dr. Mata graduated from the University of Camaguay on December 22, 1972. At the time he completed his curriculum, he was issued an official government identification card certifying that he had successfully completed his curriculum as a medical doctor. A renewed official card was issued each year thereafter. A copy of his official identification card was admitted in evidence. Although Dr. Mata completed his curriculum in 1972, for administrative reasons, an official University diploma was not issued until 1976. The delay in the issuance of the diploma was not personal to Dr. Mata. Rather, this was true as to numerous other graduates of the medical school. A copy of Dr. Mata's official diploma issuing him the degree of Doctor of Medicine from the University of Camaguay, along with a certified translation of the diploma, is part of this record. The University of Camaguay Faculty of Medicine is also known as the "Superior Institute of Medical Sciences (Carlos J. Finlay)." (Instituto Superior de Ciencias Medicas "Carlos J. Finlay.") This is confirmed in an official letter containing the seal of the Consul General of Cuba dated February 9, 1984. The Instituto Superior de Ciencias Medicas "Carlos J. Finlay" at the University of Camaguay is a medical school recognized by the World Health Organization of the United Nations as a medical school which began instruction in 1968. The Petitioner moved into evidence a portion of the Sixth Edition of the World Directory of Medical Schools published by the World Health Organization in 1988. This medical school directory confirms that the medical school began instruction in Camaguay in 1968. This is consistent with the testimony of Petitioner and is also consistent with the testimony of the two former professors of the University of Camaguay who testified on behalf of the Petitioner. There is no indication in the World Health Organization directory or any place else in this record that more than one medical school existed in the City of Camaguay. Apparently, the Respondent Board of Medical Examiners (now known as the Board of Medicine) previously believed that the University of Camaguay was not in existence during the years that Dr. Mata stated he was a student (1968-1972). This was due to an error contained in the Fifth Edition of the World Directory of Medical Schools published by the world Health Organization in 1979. The Petitioner moved into evidence this Fifth Edition to demonstrate how this error occurred. For some unknown reason, the Fifth Edition of the World Directory of Medical Schools published by the world Health Organization indicated that the University of Camaguay was not opened until 1976. Obviously, this mistake was recognized by the World Health Organization because the Sixth Edition of its publication shows that the University was actually opened in 1968. These publications explain the reason that the Board incorrectly concluded that the University of Camaguay was non-existent prior to 1976, and also confirm the Petitioner's evidence that he did graduate from a medical school recognized by the World Health Organization. The Petitioner has fulfilled the medical education requirements for the issuance of a license as a physician by endorsement. Subsequent to his graduation, Dr. Mata continued his medical studies and became a specialist in reconstructive surgery. He obtained a diploma as a Specialist of the First Degree in Corrective Surgery. He published a thesis based on his work with patients at the burn unit of the General Hospital. As a result of Dr. Mata's interest and expertise specializing in reconstructive surgery to burn patients, he presented numerous papers, served as an instructor at the University of Camaguay, and participated in numerous "journeys" where he met with other surgeons for the purpose of presenting cases and scientific works. Dr. Mata presented evidence to establish that he was a highly respected plastic and reconstructive surgeon in Cuba prior to his defection in 1981. He had occasion to present numerous scientific works pertaining to his specialized interest in the treatment of burn patients. These works included: "Care of Burned Patients in the Province of Camaguay: Historical Survey"; "Morbi-Mortality in burns: A study of a Semester"; "Clotting Alterations in Burned Children"; "Distribution of Burned Patients in Our Province"; "Importance of Emotional Support in Highly Burned Children"; Importance of Emotional Support in Adult Burn Patients"; "Treatment of Burn Patients During Civil Catastrophes: Our Experience"; and "Hydration with Electrolytical Solutions to Burn Patients During the First 24 Hours." Solely due to his standing in the medical community, Dr. Mata was permitted by the Cuban authorities to travel to several communist block countries, including the U.S.S.R., Czechoslovakia, Germany, Hungary, and Rumania, with the permission of the Cuban Ministry of Public Health to visit burn clinics and cosmetic surgery units. Dr. Mata assisted the Catholic church in Cuba by providing charitable medical services to members of the church. Dr. Mata developed a personal relationship with the Bishop of Camaguay while providing medical services to parishioners. This close relationship with the church was frowned upon by Cuban authorities and was one of the reasons Dr. Mata defected from Cuba. In 1981, Dr. Mata defected from Cuba by leaving an airplane in Gander, Canada, seeking political asylum. At that time, he was returning to Cuba after working in the plastic surgery service in Moscow and the reconstructive surgery service in Germany. After staying in Canada for 1 1/2 years, Dr. Mata moved to Florida in 1983 and applied to be a licensed physician. The Respondent has stipulated that the Petitioner holds an active and valid certificate issued by the Educational Commission on Foreign Medical Graduates (ECFMG). The ECFMG certificate was issued on August 16, 1984. Dr. Mata successfully passed the FLEX examination. The Petitioner first applied for a Florida medical license on October 26, 1983. However, this license application was denied by the Board of Medicine for two reasons: The Board took the position that the University of Camaguay did not exist in 1972, when the Petitioner stated he had graduated. Also, the Board denied the license based on the Petitioner's failure to have an ECFMG certificate. On August 29, 1984, a formal administrative hearing occurred before then DOAH Hearing Officer, R.T. Carpenter, DOAH Case No. 84-2648. After hearing the evidence presented by both sides, Hearing Officer Carpenter rendered a Recommended Order on October 3, 1984, finding that the Petitioner established that he met the requirements for licensure as a physician by endorsement, pursuant to Section 458.331, Florida Statutes (1983). The Hearing Officer specifically determined that the Petitioner did, in fact, hold a medical degree from an institution recognized by the World Health Organization and that the Petitioner was certified by the ECFMG. The Petitioner has admitted that he engaged in the practice of medicine prior to the Board of Medicine granting him a license. This caused the Petitioner on February 3, 1985, to withdraw his first application for licensure. The Petitioner explained the circumstances which caused him unlawfully to practice medicine when he testified in this cause on January 5, 1989. The Petitioner did not knowingly break the law at the time he practiced medicine without a license. While the Petitioner was awaiting the approval of his license application, he was self-employed as a gardener and a handyman. One day while Petitioner was employed painting a house, an anesthesiologist he knew suggested that Petitioner apply for a job at a clinic in Southwest Miami. Dr. Mata went to the clinic and was interviewed by an obstetrician/gynecologist, Dr. Nabil Ghali. Dr. Mata explained to Dr. Ghali his educational background and explained that he had passed the FLEX and ECFMG and was waiting for his license from the Florida Board of Medicine. Dr. Ghali, as had the anesthesiologist, told Dr. Mata that he could practice at the clinic in a clinic environment without a license, since Dr. Ghali would be supervising his practice. Dr. Mata did not know that this was illegal and was under the mistaken impression that he could work in this clinic environment prior to the issuance of his license because the clinic was being supervised by Dr. Ghali. It is clear from Dr. Mata's testimony that he later recognized that his employment at the clinic was against the law. Dr. Mata's demeanor at the formal hearing indicated that he was truly remorseful pertaining to his conduct, and he realized that it was improper for him to accept employment at Dr. Ghali's clinic. While Dr. Mata was working at the clinic during July, 1984, a patient had a cardiac arrest during the induction of anesthesia. Dr. Mata applied CPR and then called fire rescue. The patient was transported to Palmetto Hospital in Miami. The patient recovered fully without any sequela. There is no evidence that Dr. Mata caused this complication to the patient. A subsequent police investigation revealed that Dr. Mata was not licensed, and he was arrested for the unlawful practice of medicine, relating to that one patient. Dr. Mata admitted that he had seen other patients while Dr. Ghali was present, but no charges were brought pertaining to these patients. Dr. Mata cooperated with the police, plead no contest to the charges, and was sentenced to three years probation with the requirement that he provide 200 hours of community service and relinquish his right to be licensed as a doctor during the term of his probation. The Petitioner provided 200 hours of community service as a volunteer at the Emergency Department of Jackson Memorial Hospital in Miami, working as a janitor, as a translator, and performing any task given him. The Petitioner presented a letter from Jackson Memorial Hospital commending his service and recommending him highly. The Petitioner successfully completed his probation and was terminated from probation early because of his favorable attitude and his good performance. A letter from the Petitioner's probation officer states that although Petitioner did break the law, "he has paid his debt in full for that mistake." The Petitioner's criminal record pertaining to this matter was sealed and expunged by the presiding judge, pursuant to Section 943.058, Florida Statutes. The judge found that the Petitioner had never previously been adjudicated guilty of a criminal offense or a comparable ordinance violation and was not adjudicated guilty of charges stemming from his arrest. From July 1, 1985 until June 30, 1986, the Petitioner served as a resident in pediatrics at the Newark Beth-Israel Medical Center/St. Michael's Medical Center in Newark, New Jersey. Frank Esposito, M.D., testified in this matter by deposition. Dr. Esposito was the Acting Director of the Department of Pediatrics at the St. Michael's Center. He was responsible for coordinating the educational activity of the pediatric residency program attended by Dr. Mata. Dr. Esposito testified pertaining to Dr. Mata's skill and safety as a physician without contradiction as follows: Question: Did you form an impression as to Dr. Mata's abilities to practice medicine from the standpoint of his skill and safety as a physician? Answer: Yes, I did. I would give him my unqualified recommendation for such. Question: Why would you give him your unqualified recommendation? Answer: I think during my experience with him, he demonstrated or he certainly had good medical background. He has good clinical judgment. His ability to deal with children and families is outstanding. He is a caring, dedicated physician and I was very pleased with his performance. Dr. Esposito had an opportunity to evaluate Dr. Mata's personal character during the course of the residency. He described Dr. Mata as an ethical person and his character to be "of the highest order." Similarly, the Director of Residency Education at Newark Beth Israel, Barry J. Evans, M.D., sent a letter contained within the file of the Board of Medicine recommending Dr. Mata for licensure "with no reservations," stating that Dr. Mata's "moral and ethical conduct is without blemish, his clinical acumen is superior." Although Dr. Frederic Justiniani, Director of Medical Education at Mt. Sinai Hospital in Miami Beach, could not provide any recommendation for or against Dr. Mata in his letter to the Board, this is understandable since Dr. Justiniani's only exposure to the Petitioner was during a three week period. A strong recommendation in support of licensure was also received from the Chief Resident of the New Jersey program, Clara Machado, M.D., who closely observed Dr. Mata's medical skills for an entire year. In the two years that have elapsed since his New Jersey residency, Dr. Mata has taken numerous continuing medical education courses, has remained active in physician organizations, and has attempted to remain current in his medical knowledge even though he is not in a position to practice medicine in the State of Florida unless the Respondent approves his license application. The Petitioner has completed the Mini-Residency program at Mt. Sinai Hospital in Miami Beach. Likewise, the Petitioner has remained an active member of the American Medical Association since 1984, is certified by the Inter-American College of Physicians and Surgeons, and has been accepted into the International Academy of Cosmetic Surgery. The Petitioner has established based on recommendations and documents in this record that he can practice medicine with reasonable skill and safety. During cross-examination at the final hearing, the attorney for the Respondent attempted to impeach the credibility of the Petitioner. The Petitioner is very credible. Although the written record discloses some inconsistencies between the oral testimony and the documentary evidence, these inconsistencies are the result of confusion on the part of the Petitioner and not as the result of any intent to present false testimony. For example, the Petitioner introduced into evidence numerous certificates acknowledging his presentation of various scientific papers. The Petitioner's testimony that he prepared and presented each of these scientific works was credible, and Respondent offered no evidence that he did not. Each of the certificates of recognition indicated they were presented to the Petitioner on various dates, and these dates were consistent with all evidence in the record. Various certificates issued on different dates contain the official seals of different organizations and the signatures of different individuals. A review of these documents, the demeanor of the Petitioner while testifying, and the substance of the Petitioner's testimony belie any suggestion that the Petitioner concocted a scheme to counterfeit these documents as part of a plan to obtain his medical license. Furthermore, none of these documents are the type of diplomas or certificates needed for licensure. Any thought that the Petitioner would go to such lengths to create various certificates of appreciation that are not even a prerequisite for licensure is totally illogical. While the Respondent's cross-examination of the Petitioner indicated that the originals of some documents were in Cuba subsequent to the date that the translations were certified in Miami during 1983, the Petitioner was uncertain and/or mistaken about the dates on which the documents were brought out of Cuba. Several diplomas and related documents were brought from Cuba to the United States and to Canada on various dates. For example, the Petitioner testified that a Canadian friend brought the Petitioner's University of Camaguay diploma to Canada in 1981 or 1982, and that his Bachelor of Science and Bachelor of Arts diplomas were brought to the United States by his parents either 3, 4, or 5 years before the January, 1989 hearing. Further, Petitioner stated that Exhibits 12 through 15 were removed from Cuba last year. It is found that the Petitioner confused these dates when asked questions about various "exhibit numbers" during his testimony, and that the documents translated in Miami in 1983 were brought to the United States by the Petitioner's parents in 1983. Petitioner became licensed in Montana. The date that his license was issued does not appear in this record. Therefore, no evidence exists as to whether the license was issued before or after the Petitioner's application for Florida licensure on January 21, 1987. Observation of Dr. Mata during the course of the final hearing indicates that he testified truthfully. He is a sensitive and concerned individual, qualified to be a Florida physician. It is clear that he is truly remorseful pertaining to the events which resulted in his arrest while working at the clinic in Miami prior to the issuance of his Florida medical license.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a Final Order be entered granting Petitioner's application for licensure as a Florida physician. DONE and ENTERED this 30th day of March, 1989, in Tallahassee, Leon County, Florida. LINDA M. RIGOT Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904)488-9675 Filed with the Clerk of the Division of Administrative Hearings this 30th day of March, 1989. APPENDIX TO RECOMMENDED ORDER DOAH CASE NO. 88-0270 Petitioner's proposed findings of fact numbered l- 39 have been adopted either verbatim or in substance in this Recommended Order. Respondent's proposed findings of fact numbered L.- 4, 6, and 9 have been adopted either verbatim or in substance in this Recommended Order. Respondent's proposed finding of fact numbered 5 has been rejected as being irrelevant to any issues under consideration in this cause. Respondent's proposed finding of fact numbered 7 has been rejected as being contrary to the weight of the evidence in this cause. Respondent's proposed findings of fact numbered 8 and 10-17 have been rejected as not being supported by the totality of the evidence in this cause. COPIES FURNISHED: Mark A. Dresnick, Esquire Dunn, Dresnick, Lodish & Miller One Biscayne Tower, Suite 2400 Two South Biscayne Boulevard Miami, Florida 33131 Ann Cocheu, Esquire Assistant Attorney General Department of Legal Affairs Suite 1603, The Capitol Tallahassee, Florida 32399-1050 Dorothy Faircloth, Executive Director Florida Board of Medicine 130 North Monroe Street Tallahassee, Florida 32399-0750 Kenneth D. Easley, Esquire General Counsel Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750
The Issue The issue in this case is whether the Petitioner, Rene Delgado Leon, M.D., is eligible for examination for licensure to practice medicine in the state of Florida. The Petitioner, of course, contends that he is eligible. The Respondent, Board of Medical Examiners, contends that the Petitioner has failed to demonstrate eligibility, having previously advised him, inter alia: Your application and supporting documentation contained substantial omissions of material information relative to your medical education. Additionally, your application and supporting documentation does not provide sufficient information to demonstrate that you can practice medicine with reasonable skill and safety. See Section 458.301, Florida Statutes.
Findings Of Fact Based on the stipulations of the parties, on the exhibits received in evidence, and on the testimony of the witnesses at the hearing, I make the following findings of fact. The Petitioner, Dr. Rene Pedizo Delgado Leon, was born on November 26, 1936, in Cuba. All of his formal education prior to medical school was obtained in Cuba. He attended medical schools, off and on, at various times and places between 1955 and June of 1980. His medical education commenced in 1955 at the Medical School of the University of Havana and ended when he-was awarded his medical degree from the University of Dominica in June of 1980. The Petitioner's first language was Spanish and he is not completely fluent in the English language. When communicating in English he appears to have a tendency to interpret statements and questions in a very literal manner. The Petitioner does not appear to have intended to deceive the Board of Medical Examiners or to misrepresent information about his education and experience. Nevertheless, he has not been very clear about a number of details. Since receiving his degree from the University of Dominica in 1980, the Petitioner has completed a residency in pathology, has passed the FLEX exam in conjunction with his application for licensure in the state of Georgia, and has been licensed to practice medicine in the state of Georgia. There were several discrepancies between information given by the Petitioner to the Board of Medical Examiners and to the Hearing Officer concerning various aspects of his background, particularly concerning his medical education. With regard to his medical education, Petitioner listed on his first application that he attended medical school in Havana, Cuba, from April 1954 until December 1962. On his second application he stated that he attended medical school in Havana, Cuba, from September 1955 until September 1960. He testified before the Foreign Medical Graduate Committee that he attended medical school at the University of Havana from 1955 until 1962. At the final hearing he testified that he attended the University of Havana from 1955 until 1962. On his first application, in response to the direction that he list all universities or colleges where he attended classes and received training as a medical student, he stated only that he attended the University of Dominica from June of 1977 until June of 1980. He subsequently filed a form, received by the Board on October 26, 1983, stating that he had attended the University of Zaragoza, Zaragoza, Spain, and received training as a medical student from November of 1974 until April of 1975. On his second application, he stated that he had attended the University of Zaragoza as a medical student from November of 1974 until April of 1975. At the final hearing he testified that in 1973 while he was in Zaragoza he applied to revalidate old courses taken in Havana and that thereafter he took all examinations up to the third year. He stated that he took other courses in Zaragoza, but that he did not take the examinations for any of the medical courses taken in Zaragoza. He also testified that he was given credit for courses at Zaragoza even though he did not take the examinations. The next segment of his medical education was consistently testified to as having been had at the Universidad Central del Este in the Dominican Republic. He attended the Universidad Central del Este for only one semester, during which he took six or seven subjects. He testified that Universidad Central del Este did give him some credit for the third year of medical school; in spite of the fact that he did not take examinations in any of the third-year courses he took in Zaragoza. In January of 1979 he transferred to Universidad Nordestana and spent approximately one year there. Univeraidad Nordestana gave him two and one half to three years of credit. Although his initial application showed that he had attended the University of Dominica in the West Indies from June of 1977 until June of 1980, his subsequent written and oral testimony was that he was enrolled at the University of Dominica only from January of 1980 until June of 1980. He testified before the Foreign Medical Graduate Committee that at the time he transferred from Nordestana, he was basically finished with his medical education and he said he transferred to Dominica because they did not talk in English in Santo Domingo. He also testified that he transferred to Dominica so that he could get some exposure to how medicine was practiced in the United States. Petitioner testified that although he transferred to the University of Dominica and he received his degree from the University of Dominica six months after he transferred there, he did not pay any monies to the University of Dominica. His explanation of why he did not pay money to the University of Dominica is that he wrote things for them, like a pathology booklet. The application form which Petitioner completed requested that he specify all places of residence since beginning medical training. On his first application he showed that he resided in Dominica, West Indies, from January of 1980 until June of 1980. On his second application he listed as residences since initiation of medical training only the University of Miami, Jackson Memorial, VA Hospital, and the University of South Florida, Tampa. In August of 1983 he followed up the second application with a letter to Mrs. Faircloth which stated that his place of residence while attending medical school was the "students quarters and dormitories" at Portsmouth, University of Dominica, West Indies. However, at the hearing before the Foreign Medical Graduate Committee and at the final hearing, Petitioner admitted that he was, in fact, on the campus of the University of Dominica only one day, and that was on graduation day. In fact, when he testified before the Foreign Medical Graduate Committee, he was specifically asked, "When you left Nordestana, where did you go?" To that question he replied, "Oh, to Dominica." However, he later admitted that when he left Nordestana, he went to Miami and he did not go to Dominica until he went six months later in order to graduate. On both of his written applications, Petitioner was asked to list the degrees earned other than M.D. On neither application did he list a bachelor's degree. Yet, in testimony before the Committee and at the final hearing, he testified that he had earned the equivalent of a B.S. in chemistry at the University of Havana. He testified that the reason that he omitted it was that he thought the question referred to medical education. However; in response to the same question, he listed that he had obtained a Licensee in Science and a Doctor in Science from the University of Zaragoza. With regard to the matter of what clerkships, if any, Petitioner performed as part of his medical education, the record shows that he was enrolled at the University of Dominica, the school from which he received a medical degree, from January or February of 1980 until June of 1980. The record also shows that during that five- or six-month period he performed what purported to be clerkships at the VA Hospital and at Coral Gables Hospital, in Miami, and at the same time was an employee of the VA Hospital. He testified that his clerkship at the VA Hospital was in pathology and that he was employed full time in the same area as he was receiving clerkship credit. He arranged the clerkships himself and informed the university of the clerkships. He testified that he did the same activities as the other clerks did, but he worked approximately forty hours and they worked thirty to forty hours. He effected his transfer to the University of Dominica by writing to the New York office and by taking some "required" examinations in basic sciences and clinical studies. He took the examinations in Miami and passed everything but gynecology. He eventually passed gynecology, but not until May of 1980 after he had almost completed clerkships. He testified that when he did his "rotation" at the VA Hospital, he was told that he could "moonlight." He testified that he did all of the autopsies while the other medical students watched. He testified that he went in to work at about 7:00 a.m. and left around 4:00 p.m. and that the other residents did not arrive until about 8:00 a.m. However, he did testify that the clerks arrived at 6:00 a.m. Petitioner testified that he was doing a clerkship at the time, not a residency, and that it was the extra time that he put in that justified his being both paid and given credit for an educational experience. Dr. Robert M. Clark was Petitioner's supervisor during the period of approximately January of 1980 until June of 1980. Petitioner worked in the morgue as a Physician's Assistant and also did "resident physician work." Petitioner was paid at the same time as he was doing a rotation because there was a shortage of residents. Petitioner had the same exposure to pathology as the other residents, all of whom were from the University of Miami. None of the other students were paid employees. A Physician's Assistant requires two years of medical school. Dr. Clark was introduced to Petitioner by Dr. Kuhnhardt. Dr. Kuhnhardt was not connected in any way with the medical school at the University of Dominica. The only other purported clerkship about which there was testimony at the hearing related to a clerkship at Coral Gables Hospital. That clerkship was under Dr. Hurst. That clerkship was done from January of 1980 until June of 1980, the same period during which the clerkship at the VA Hospital was done. Petitioner testified that he went to Coral Gables Hospital after he left the VA Hospital, usually after 4:00 p.m., and stayed however long was necessary, possibly as late as 8:00 or midnight. Dr. Hurst only let the students observe medical procedures. That clerkship was conducted in a community hospital. As for the supervision by the school, the testimony was that the school played no role in arranging the clerkships. Petitioner testified that people from the school came for general meetings every once in a while during the clerkships. As for evaluation, Petitioner testified that the school sent evaluation forms to him and he distributed the forms to whoever was supervising him.
Recommendation Based upon all of the foregoing it is my recommendation, because of the contradictions and uncertainties on the record in this case regarding the nature of the Petitioner's medical education, that the Board of Medical Examiner issue a final order denying the Petitioner's application for licensure by examination without prejudice to the filing of any future application for licensure by examination or endorsement, unless; for reasons analogous to those set forth in the Lopez decision, supra, the Board is persuaded that the shortcomings in the application and its supporting evidence may be overlooked in light of the Petitioner's achievements since 1980. DONE AND ORDERED this 3rd day of January, 1986, at Tallahassee, Florida. MICHAEL M. PARRISH, Hearing Officer 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 3rd day of January, 1986. COPIES FURNISHED: M. Catherine Lannon, Esquire Assistant Attorney General Department of Legal Affairs Room LL-04, The Capitol Tallahassee, Florida 32301 Jorge A. Sibila, Esquire 2751 Coral Way Miami, Florida 33145 Dorothy Faircloth; Executive Director Board of Medical Examiners Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Fred Roche; Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Salvatore A. Carpino, Esquire General Counsel Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 APPENDIX The following are my specific rulings on each of the proposed findings of fact submitted by each of the parties. Rulings on Petitioner's proposed findings: The Petitioner's proposed findings of fact consist of a two- line introductory clause and six unnumbered indented paragraphs. The six unnumbered indented paragraphs are addressed below in the order in which they appear in the Petitioner's proposed findings of fact. First Paragraph: Rejected. This paragraph is merely a commentary on the state of the record and does not contain any proposed finding of fact. Second Paragraph: Rejected for the same reason as the first paragraph. Third Paragraph: Rejected in part and accepted in part. Rejected portions are rejected for the most part for the same reason as the rejection of the first two paragraphs. The "fully explained" portion of this paragraph is rejected as not supported by the greater weight of the evidence. Findings have been made consistent with the portions of this paragraph relating to when Petitioner's medical education began and ended, his completion of a residency in pathology, and his passing of the FLEX examination. Fourth Paragraph: The first sentence of this paragraph is rejected in part because it is merely a commentary on the state of the record and in part because it is inconsistent with the evidence of record. Dr. Clark did not explain the Petitioner's work in detail: to the contrary, his testimony was rather vague about a number of the details and he failed to recall a number of specific details. The last sentence of this paragraph is rejected because it is not supported by competent substantial evidence. Fifth Paragraph: Rejected for the same reason as the first paragraph. Sixth paragraph: The first sentence of this paragraph is rejected because the Petitioner's explanations were incomplete. With regard to the second sentence of this paragraph, it is accepted that the Petitioner is "not fluent/native in the English language or in legal terminology," and that the Petitioner did not intend to deceive the Board or misrepresent information to the Board. m e remainder of the second sentence is rejected on the grounds that it is in part irrelevant and immaterial as well as on the grounds that the ultimate factual conclusion urged in the second sentence is not warranted by the evidence in the record. Rulings on Respondent's proposed findings: The Respondent's proposed findings of fact consist of seventeen separately numbered paragraphs. The paragraph numbers which follow correspond to the numbers of the paragraphs of the Respondent's proposed findings. Accepted in substance with certain gratuitous editorial material deleted. Accepted in substance. Accepted in substance with the exception of the sentence reading: "In contradiction, he testified at the final hearing, on both direct and cross-examination, that he furthered his medical education in Spain in 1970." The quoted sentence is rejected because it does not accurately reflect the totality of the Petitioner's testimony on this subject. Some other redundant material in this paragraph is also rejected. Rejected on the grounds that it consists of irrelevant and cumulative details which are not necessary to the disposition of this case. Accepted in substance with certain gratuitous editorial material deleted. The first sentence of this paragraph is accepted. The second sentence is accepted with the exception of the words ". . . at which time he needed three years." The quoted language is rejected as not being supported by persuasive competent substantial evidence. Accepted. The first two sentences of this paragraph are accepted in substance. The last sentence is rejected as irrelevant in part, cumulative in part, and not supported by competent substantial evidence in part. Accepted in substance with certain gratuitous editorial material deleted. Accepted. Accepted in part and rejected in part. Reasons for rejection include the feet that although most of this paragraph is an accurate summary of portions of the Petitioner's testimony; some of the testimony on this subject was not persuasive and has not been used as the basis for findings of fact. The parenthetical mention of the pathology booklet is rejected because there is no competent substantial evidence as to when Petitioner wrote any pathology books Accepted in substance. Accepted in part and rejected in part. Reasons for rejection include the fact that although much of this paragraph is an accurate summary of portions of Dr. Clark's testimony, much of the testimony on this subject was not persuasive and has not been used as the basis for findings of fact. Portions of this paragraph have also been rejected on the grounds that they constitute commentary on the quality of the testimony or argument and are not proposed findings of fact. Accepted in part and rejected in part. Reasons for rejection include the fact that although most of this paragraph is an accurate summery of portions of the Petitioner's testimony, much of the testimony on this subject was not persuasive and has not been used as the basis for findings of fact. Accepted. Rejected as findings of fact because it constitutes argument rather than proposed findings of fact. [Much of the argument is well taken, but it is argument nevertheless and not appropriately part of the findings of fact.] Rejected for the same reason as Paragraph 16.
The Issue The central issue in this case is whether Petitioner is entitled to licensure by endorsement.
Findings Of Fact Based upon the testimony of the witnesses and the documentary evidence received at the hearing, I make the following findings of fact: The Petitioner, Gerardo Hevilla, completed the application for licensure by endorsement and submitted all degrees, test results, certificates, recommendations, and other documents required by law to be considered for licensure by endorsement as a medical doctor in Florida. The degrees, test results, recommendations and other documents submitted by Petitioner are authentic. Petitioner obtained a doctor of medicine degree from the Universidad Nacional De Rosario in Argentina on July 1, 1980. Universidad Nacional De Rosario Medical School (School) is a medical school duly listed by the World Heath Organization. Graduates of the School are eligible to seek medical licensure in Florida by endorsement pursuant to the provisions found in Section 458.313, Florida Statutes, and the rules and regulations promulgated by the Board of Medicine (Board). On November 20, 1985, Petitioner satisfied the requirements of the Educational Council on Foreign Medical Graduates (ECFMG) and was issued ECFMG certificate no. 339-394-9. Petitioner obtained a passing score on the Federated Licensing Examination (FLEX) within 10 years immediately preceding his application for licensure by endorsement in Florida. Petitioner successfully completed one year of post- graduate training at Lincoln Medical and Mental Health Center as a resident in general surgery. Petitioner has satisfied all preliminary requirements of the Board to be considered for licensure by endorsement. Petitioner came to Florida in April, 1981. At that time he did not speak English and, therefore, was not able to pass the English portion of the ECFMG examination. In order to learn English, he enrolled at Miami High School. While enrolled at the high school, Petitioner volunteered his services to a clinic located approximately two blocks from the school. Petitioner worked at this clinic, LeGran Familia Clinic (Clinic), from 1982 until 1984, while he attempted to learn English. Since many of the doctors and patients at the Clinic spoke Spanish, Petitioner did not have difficulty. The Clinic had 20-22 licensed physicians on staff during the time Petitioner worked there. During the time Petitioner worked at the Clinic, he was primarily under the supervision of Dr. Mirabal. According to Dr. Mirabal, Petitioner was a brilliant, though ambiguous, physician. Petitioner did not represent himself to patients as a physician but was responsible for taking vital statistics, patient histories, and transcribing Dr. Mirabal's dictation. A licensed physician was present at the clinic at all times during which Petitioner performed these services. Subsequently, the Clinic came under investigation for Medicaid fraud. Petitioner was named as one of several defendants in the criminal prosecution. This charge was later dismissed by the prosecuting State Attorney and is not claimed as a basis for the denial of Petitioner's application for licensure. A second charge, the unauthorized practice of medicine, was alleged against Petitioner in State of Florida v. Gerardo Hevilla, Dade County Circuit Court, Criminal Division, case no. 84-8608. Initially, Petitioner pled not guilty to this charge. On May 3, 1985, Petitioner changed his plea to nolo contendere based upon a representation by the State Attorney to the trial judge that the Department of Professional Regulation had been contacted and had agreed that such plea would not be used against Petitioner in his future licensing efforts. This representation was made on the record and is a part of the plea colloquy. Prior to this presentation, Petitioner had refused, and intended to continue to refuse, to change his plea because of his concern that such a plea would adversely affect his ability to become licensed. The estimated cost to defend the criminal case exceeded $25,000. Petitioner accepted the negotiated plea as a financial concession only after the assurances were given that it would not affect his ability to become licensed. In January or February, 1984, Petitioner became employed at the South Florida Medical and Surgical Center (Center). He remained associated with the Center until June, 1986. While at the Center, Petitioner worked as a surgical assistant and helped the licensed surgeons as they directed. Petitioner did not treat patients independently of the licensed doctors and did not hold himself out as a licensed physician. He told one patient, Zoraida Wong, that he was a student. Petitioner assisted Dr. DeGeronimo and Dr. Alexander at the Center. These doctors found Petitioner to be competent, skilled, and a good worker. In fact, Dr. DeGeronimo was so pleased with Petitioner's work that he employed him at his private office until June, 1986. The work performed by Petitioner at the Center and with Dr. DeGeronimo consisted of setting up the operating area, ordering supplies, assisting in surgery by wiping blood, holding retractors, or cutting stitches, and bandaging wounds. All work was done under a licensed physician's supervision. From June, 1986 until July, 1987, Petitioner performed a one year residency at the Lincoln Medical Hospital. During this period, Petitioner was supervised by Drs. Stahl, the program director, and Kazigo, an associate professor. According to these physicians, Petitioner is qualified for licensure, possesses the requisite knowledge and skill, and successfully completely the residency program. Following the completion of his residency, Petitioner returned to Miami and is employed again as an assistant to Dr. DeGeronimo in his plastic surgery practice. Petitioner did not perform facial plastic surgery on the patient, Zoraida Wong. Petitioner did not withhold facts regarding his criminal plea from the Board.
Recommendation Based on the foregoing, it is RECOMMENDED: That The Board of Medicine enter a final order approving Petitioner's application for licensure by endorsement. DONE and RECOMMENDED this 30th day of December, 1988, in Tallahassee, Leon County, Florida. JOYOUS D. PARRISH Hearing Officer 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 30th day of December, 1987. APPENDIX TO RECOMMENDED ORDER RULINGS ON PETITIONER'S PROPOSED FINDINGS OF FACT: The first sentence in Paragraph 1 is accepted. With regard to the sentence, that portion which alleges Petitioner took courses at the University of Miami is accepted the rest is rejected as beyond the scope of evidence presented or irrelevant to these proceedings. Paragraph 2 is accepted as to all parts. With regard to paragraph 3A. with the exception of the reference to full-time study of English it is accepted. The record does not conclude whether or not Petitioner was in school full-time, he did enroll at Miami High School to learn English so to that extext it is accepted, otherwise rejected as not supported by the record. Paragraphs 3B-D are accepted. Paragraph 4 is accepted. Paragraph 5A. is accepted. The first sentence and last sentence of the first paragraph of paragraph 5B are accepted; the remainder of the first paragraph is rejected as irrelevant, immaterial, not supported by the record or speculation. The second, third and fourth paragraphs of Paragraph 5B are accepted. The first paragraph of SC is accepted. The second paragraph of SC is rejected as irrelevant; the Board has not claimed the allegations relating to the alleged Medicaid fraud were a basis for denial of Petitioner's license. The first three sentences of the first paragraph of Paragraph 6 are accepted. The remainder of the first paragraph is rejected as a recitation of testimony, irrelevant, or unsupported by the record. The second paragraph of Paragraph 6 is rejected as a recitation of testimony, irrelevant, or argument. The third paragraph of Paragraph 6 is rejected as a recitation of testimony, irrelevant, or argument. The fourth paragraph of Paragraph 6 is rejected as a recitation of testimony, irrelevant, or argument. With regard to these paragraphs, see finding of fact which concludes Petitioner did not operate on the patient Wong. Petitioner's testimony, Dr. DeGeronimo's, and Urquiza's testimony were deemed credible. Dr. Garcia-Lavin and Wong were not. The fifth paragraph of Paragraph 6 is rejected as argument, but as to facts therein see explanation in p. 13 above. RULINGS ON RESPONDENT'S PROPOSED FINDINGS OF FACT: Paragraphs 1-11c are accepted. The first sentence of paragraph 12 is accepted. The remainder of paragraph 12 is rejected as contrary to the weight of credible evidence. Petitioner was not eligible to take the residency until he had mastered English to a sufficient level to pass required examinations. Petitioner's explanation for the period was acceptable. Paragraph 13 is accepted. Paragraph 14 is rejected as contrary to the credible evidence, argument or irrelevant. Petitioner is found to be credible. Paragraph 15 is rejected as contrary to the evidence, argument or irrelevant. Paragraph 16 is rejected as irrelevant, unsupported by the credible evidence or argument. Paragraph 17 is rejected as irrelevant or argument. That the Department did not actually pledge to hold Petitioner harmless by reason of the plea is not a disputed issue Petitioner had a reasonable basis for believing that to be the case; however, and was induced to change his plea on that basis. Paragraph 18 is accepted but is irrelevant; see p. 7 above. The first three sentences of paragraph 19 are accepted. The record does not disclose how many licensed physicians may performed surgery at the Center; therefore the fourth sentence is rejected. The record does support a finding that Drs. Alexander, DeGeronimo, and Garcia-Lavin worked there and that the facility only used one surgical room. Paragraph 20 is rejected as irrelevant to the issues of this case. Paragraph 21 is rejected as irrelevant, immaterial or unnecessary to the resolution of the issues of this case. Paragraph 22 is rejected as irrelevant, immaterial, contrary to the evidence or unnecessary to the resolution of the issues of this case. The first two sentences of paragraph 23 are accepted, the remainder is rejected as contrary to the credible evidence, irrelevant, or immaterial to the resolution of the issues of this case. Paragraphs 24-26 are rejected as contrary to the weight of the evidence, irrelevant or immaterial to the resolution of the issues of this case. It is possible that Petitioner remained associated with the Center and also worked for Dr. DeGeronimo. The testimony of the three (Petitioner, Alexander, and DeGeronimo) does not conflict. COPIES FURNISHED: Rodney W. Bryson Bryson & Berman, P.A. Suite 219 8525 N.W. 53rd Terrace Miami, Florida 33166 Ann Cocheu Assistant Attorney General Department of Legal Affairs Suite 1603, The Capitol Tallahassee, Florida 32399-1050 Dorothy Faircloth Executive Director Board of Medicine Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Bruce D. Lamb General Counsel Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750
The Issue Whether a license as a technologist should be granted the Petitioner.
Findings Of Fact The Petitioner, Amita A. Patil, an applicant for licensure as a technologist in the State of Florida, sought an administrative hearing prior to this hearing, which was held on October 26, 1977. The Recommended Order from this prior hearing was entered February 7, 1978, and the Final Order of the agency was entered April 25, 1978. These Orders are attached hereto and made a part hereof. Thereafter, a request was made for a second or further hearing, which was granted by the Respondent, Department of Health and Rehabilitative Services. Petitioner submitted as her "Exhibit 1" a letter from Florida International University dated December 18, 1978, which notified Petitioner that she had been provisionally admitted to the School of Technology at Florida International University. This was the only new evidence submitted by the Petitioner pertinent to her application for licensure, and the provisional admission to the School of Technology at Florida International University has no bearing on her qualifications for licensure as a medical technologist.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, the Hearing Officer recommends that the Respondent Department deny the application of Petitioner Patil for licensure as a medical technologist. DONE and ORDERED this 22nd day of June, 1979, in Tallahassee, Leon County, Florida. DELPHENE C. STRICKLAND Hearing Officer Division of Administrative Hearings Room 101, Collins Building Tallahassee, Florida 32301 (904) 488-9675 COPIES FURNISHED: Leonard Helfand, Esquire Department of HRS Room 1040, Ruth Rhodes Building 401 NW 2nd Avenue Miami, Florida 33128 Amita A. Patil 4371 SW 137th Court Miami, Florida 33175
Findings Of Fact Petitioner, Omar J. Adams, was born in Pahokee, Florida, on July 18, 1950. He attended the University of Florida from 1968 to 1973 and was awarded the degree of Bachelor of Science in chemistry upon graduation. Immediately upon graduation, he spent one year teaching special high school students and in 1974 applied for admission to the medical school of the University of Florida but was not accepted. He also applied to other medical schools and, likewise, was not accepted. He thereafter applied for admission to the Program in Medical Sciences (PIMS) conducted jointly by Florida State University (FSU), Florida A & M University (FAMU) and the University of Florida College of Medicine (UF Med) and was accepted. This program is designed to provide to individuals not accepted to medical school a two-year course of study parallel to that given to first- and second-year medical students enrolled at UF Med, so that if a vacancy occurred in UF Med at the completion of the first two years of academics the PIMS student could step into that vacancy for the third and fourth years of clinical training. After two years in PIMS at FSU and FAMU in Tallahassee, Petitioner transferred to the University of Florida for two more semesters of science courses. UF MED was aware of his efforts to he admitted. In fact, his studies at the University of Florida after the PIMS years were courses taken at UF Med, and UF MED sponsored him for admission to a course in gross anatomy at McHarry College in Tennessee, although he was not enrolled in the medical school as a medical student. Petitioner's grade point average for the PIMS years and the additional studies at the University of Florida was 3.8 out of a possible 4. Petitioner fully expected to be admitted to UF Med in 1977 and was sponsored by that institution to take Part I of the examination of the National Board of Medical Examiners (National Boards), which he took both in June 1977 and June 1979, achieving a passing score each time. However, because an act passed by the United States Congress in 1977 gave preference for funds for admission to U.S. medical schools to U.S. students in foreign medical schools, he again was not admitted to UF MED or to any other medical school in the United States to which he had applied. In the fall of 1977, he heard that some foreign medical schools would permit their students to do their clinical training in the United States. After several months in both the Dominican Republic and Mexico studying Spanish and attempting to gain admission to medical school, he applied to medical school in the Dominican Republic and was provisionally accepted. He chose not to go there, because they would not give him transfer credit for his PIMS work and would have required him to take his third and fourth years of medical school in that country. When Petitioner left the Dominican Republic, he went to Mexico where, in early 1978, he applied for admission to and was accepted at the school of medicine of the Centro de Estudios Universitarios "Xochicalco," A.C. (CEUX), which was incorporated into the Universidad Autonoma de Guerrero (UAG). This school is approved by the World Health Organization. CEUX gave him full credit for the PIMS courses he took in 1976 and 1977 even though he did not take even one day of classes at that institution, which, coincidentally, was not established until December 18, 1977; nor did he ever see any of the institution's classrooms or laboratories. He paid a fee of approximately $5,000 per year for each of the two years work for which he was given credit and was admitted to the school's clinical program conducted out of a sparsely manned office in New York City. Under this program, Petitioner was responsible for arranging his own clinical training, which he did at teaching hospitals in the New York City area during 1978, 1979 and 1980. These hospitals and the medical schools with which they were affiliated, at which Petitioner took his externships, were: Medical, OB/GYN: New York Infirmary (NYU School of Medicine) Neurology, Pediatrics: Elmhurst City Hospital Center (Mount Sinai School of Medicine) Surgery: Beeckman Downtown Hospital (Cornell University Medical College) Cardiology: Downstate Medical Center (SUNY College of Medicine) Radiology, Pneumology: Mount Sinia Medical Center (Mount Sinai School of Medicine) Basic Medical Science Review: College of Physicians and Surgeons (Columbia University School of Medicine) Urology, Psychiatry: Beth Israel Medical Center (Mount Sinai School of Medicine) Otorhinolaryngology, Ophthalmology: Manhattan EET Hospital (Cornell University Medical College) Nephrology: VA Hospital (Bronx) (Mount Sinai School of Medicine) Forensic Medicine: Chief Medical Examiner' s Office (NYU School of Medicine) Family Practice: Brookdale Hospital (SUNY College of Medicine) Family Practice: Lutheran Medical Center (SUNY College of Medicine) Medicine, Dermatology: VA Hospital (Brooklyn)(SUNY College of Medicine) Family Practice: Halifax Hospital (Daytona Beach)(UP School of Medicine) Upon completion of these externships, Petitioner was awarded a Certificate of Completion on June 23, 1980, by the Dean of the School of Medicine at UAG. He was not awarded a diploma because, under the Mexican requirements, he would have had to complete a year of community service in Mexico as a condition precedent to the award of a diploma. He did not desire to do this and instead enrolled in the Fifth Pathway Program conducted-by the Mount Sinai Medical Center (Mount Sinai) in New York. This program, otherwise known as a supervised clinical clerkship, was established at that school in 1975 in accordance with guidelines proposed by the Council on Medical Education of the American Medical Association (AMA) to provide a year of supervised clinical training for students who completed their premedical requirements in the United States, were qualified but where unable to gain admission to a United States-medical school, and had completed the formal requirements of a foreign medical school except for internship and/or social service. The primary aim of the program is to provide an opportunity for superior students from foreign medical schools to benefit from a formal, supervised clinical training experience in an American medical school and to develop and refine their clinical abilities in preparation for obtaining the maximum benefits from internship and residency in the United States. Following completion of the program, the student is awarded a Certificate and is eligible to enter the first year of an AMA-approved graduate training program (internship and residency). Students are also eligible for licensure in those states in which the program is acceptable. Petitioner successfully completed the program in June 1981. Florida accepts this program when accompanied with passage of the ECFMG examination and completion of one year of internship or residency. Over a year prior to entering the Fifth Pathway Program in January 1979, Petitioner took and passed the written examination of the Educational Commission for Foreign Medical Graduates (ECFMG) and, in June 1981, passed the FLEX examination for certification for medical licensure in New York State. As a result, on October 13, 1981, Petitioner was issued license number 148022 to practice medicine and surgery by the State of New York. After getting his New York license, Petitioner decided he wanted a specialty in Family Practice, which requires a three-year residency. He applied to and was accepted in August 1981 into the program at Halifax Hospital in Daytona Beach, Florida, where he is currently enrolled under the supervision of Dr. Bernard Breiter, Director of the Family Practice Residency Program. In this program, Petitioner is subjected to an ongoing system of evaluation by all physicians with whom he works in the residency. Based on input from these evaluating physicians and his own observations of Petitioner, Dr. Breiter has very positive feelings about him and considers him well above average. Petitioner is comparable with all other residents at his same level of experience, all of whom are graduates of American medical schools. In May 1982, Petitioner applied to the State Board of Medical Examiners of Florida (Respondent) for licensure to practice medicine and surgery in Florida by endorsement. On the application, he listed his basis for the application as Federation Licensure Examination (FLEX). He also reflected he had attended the University of Florida from September 1968 to August 1973, which was true, and FSU from September 1975 to June 1976, which was also true. He neglected to reflect his schooling at FSU-FAMU during the 1974-1975 school year by oversight. The grades earned during that period, all As, certainly give no reason for intentional concealment. He also indicated on the application that he attended UAG from January 1976 to June 1980, and that he obtained the degree of Doctor of Medicine from that same university. Both entries are technically incorrect. Petitioner was not enrolled in UAG until 1978, at which time he was given credit for courses as if he had taken them in 1976 and 1977. A Certificate of studies issued by UAG medical school in March 1978 so indicates and was admitted into evidence as Petitioner's Exhibit 4. In addition, Petitioner was not awarded the degree of Doctor of Medicine, or its Mexican equivalent "Titulo," because he failed to perform the one-year community service requirement of the school. That this is a common situation for American graduates of foreign medical schools is recognized in the literature of the Fifth Pathway Program, introduced as Petitioner's Exhibit 10. The application form utilized by the Florida Board of Medical Examiners does not provide answer blocks appropriate to Petitioner's situation. He should have answered accurately and attached a certificate of explanation. He did not do so, however, though his entries, while technically false, are not fraudulent. Though Petitioner did not attend classes at a medical school as a full-time registered medical student, during 1978, 1979 and 1980, he was a full- time registered medical student when he attended his clinical training as outlined in paragraph 7, supra. The parties have stipulated Petitioner is of good moral character and there is no evidence to suggest he is not capable of safely engaging in the practice of medicine.
Recommendation Based on the foregoing, it is RECOMMENDED: That the Florida Board of Medical Examiners issue Petitioner a license to practice medicine in Florida by endorsement. RECOMMENDED this 22nd day of September, 1983, in Tallahassee, Florida. ARNOLD H. POLLOCK, Hearing Officer 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 22nd day of September, 1983. COPIES FURNISHED: Edward F. Simpson, Jr., Esquire Post Office Box 305 Ormond Beach, Florida 32075 John E. Griffin, Esquire Assistant Attorney General Department of Legal Affairs The Capitol Tallahassee, Florida 32301 Ms. Dorothy Faircloth Executive Director Board of Medical Examiners Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Mr. Fred Roche, Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301
The Issue The issues to be determined are whether Petitioner meets the requirements for licensure by endorsement pursuant to section 458.313, Florida Statutes (2013), and whether the Board’s interpretation of section 458.311(3), Florida Statutes, is an unadopted rule in violation of section 120.54(1), Florida Statutes (2013).
Findings Of Fact Based upon the stipulations of the parties and the documentary evidence presented, the following facts are found: Petitioner, Leon Rawner, M.D., is a licensed medical doctor in the state of Wisconsin and an applicant for licensure as a medical doctor by endorsement in Florida. The Florida Board of Medicine is the agency charged with the licensing and regulation of allopathic medical doctors pursuant to section 20.43 and chapters 456 and 458, Florida Statutes. Applicants for licensure by endorsement must meet the requirements specified in section 458.313. Those requirements include meeting the qualifications identified in section 458.311(1)(b)-(g) (alternative one) or section 458.311(1)(b)-(e), (g), and (3) (alternative two). Petitioner is over 21 years of age, and has submitted a set of fingerprints on a form and under procedures specified by the Department of Health, along with a payment in an amount equal to the costs incurred by the Department of Health. Petitioner has successfully passed the required criminal background screening. Petitioner’s application for licensure by endorsement demonstrates that he is licensed to practice medicine in another jurisdiction, the state of Wisconsin, and that he has been active in the practice of medicine for at least two of the four years immediately preceding the application. Petitioner has a clean record in his current medical practice in Wisconsin and is not under any investigation in any jurisdiction for an act or offense which would constitute a violation under section 458.331, and has not committed any act or offense in any jurisdiction which would constitute the basis for disciplining a physician pursuant to section 458.331. Petitioner has completed the equivalent of two academic years of pre-professional, postsecondary education, as determined by rule of the Board, which included, at a minimum, courses in anatomy, biology, and chemistry prior to entering medical school. Petitioner received a bachelor’s degree from Brandeis University, an accredited United States university. Petitioner has passed the appropriate medical licensure examinations, the United States Medical Licensing Examination, Step-1, Step-2, and Step-3. Petitioner holds an active, valid certificate issued by the Educational Commission for Foreign Medical Graduates (ECFMG) and has passed the examination used by the Commission. In 2006, Petitioner graduated with a degree of Doctor of Medicine from American University of the Caribbean School of Medicine. Petitioner graduated from an allopathic foreign medical school (American University of the Caribbean School of Medicine) which is recognized by the World Health Organization. Petitioner completed all of the formal requirements for graduation from American University of the Caribbean School of Medicine. Petitioner’s application for licensure demonstrates that he has completed the academic year of supervised medical training prior to graduation as required under section 458.311(3)(d). Petitioner did not graduate from an allopathic medical school or allopathic college recognized and approved by an accrediting agency recognized by the United States Office of Education. Petitioner did not graduate from an allopathic medical school or allopathic college within a territorial jurisdiction of the United States recognized by the accrediting agency of the governmental body of that jurisdiction. Petitioner is not a graduate of an allopathic foreign medical school registered with the World Health Organization and certified pursuant to section 458.314, Florida Statutes, as having met the standards required to accredit medical schools in the United States or reasonably comparable standards. Petitioner has not completed an approved residency or fellowship of at least two years in one specialty area. Petitioner’s application for licensure demonstrates that he does not meet the postgraduate training requirements under section 458.311(1)(f)3. Petitioner completed one year of residency training in the Internal Medicine Program at Mt. Sinai-Elmhurst Hospital Center, Queens, New York. Besides the residency training program at Mt. Sinai– Elmhurst Hospital Center, Queens, New York, Petitioner has not completed any other residency or fellowship training. Petitioner does not have two years of any residency or fellowship training which can be counted toward regular or subspecialty certification by a board recognized and certified by the American Board of Medical Specialties. Since January 24, 2011, Dr. Rawner has been practicing medicine in Wausau, Wisconsin, as a staff physician with Knee Pain Solutions Center. Accordingly, he has been in the active practice of medicine for the two years preceding his Florida application. Dr. Rawner submitted his application for licensure by endorsement on March 13, 2013. Supplemental documentation was filed with the Board by letter dated March 18, 2013. In that letter, Dr. Rawner expressly stated that he was relying on the second alternative for establishing licensure by endorsement, which does not include the requirements identified in subsection 458.311(1)(f). On April 3, 2013, the Board requested additional information, and in response, Dr. Rawner provided a copy of his undergraduate degree and information related to his one year of supervised medical training. Other information requested in the April 3, 2013, letter was sent directly to the Board office by the appropriate agencies, including an official United States medical examination transcript, indicating that Dr. Rawner passed USMLE Steps I, II, and III; a letter from the residency program director, indicating that Dr. Rawner completed one year of residency training; confirmation from the Wisconsin Medical Board confirming his current, valid medical license in the state of Wisconsin; an American Medical Association (AMA) profile letter; and Dr. Rawner’s fingerprints and clear background check. Program Operations Administrator Chandra Prine notified Dr. Rawner by letter dated June 26, 2013, that he was required to appear before the Credentials Committee of the Board. The purpose of the appearance was to discuss: Failure to meet the training requirement pursuant to section 458.313(1)(a), 458.311(1)(f)3.c., Florida Statutes. Failure to complete an academic year of supervised clinical training pursuant to section 458.311(3)(d), Florida Statutes. Dr. Rawner appeared before the credentials committee of the Board of Medicine on August 1, 2013. The committee recommended that his license be denied. On August 22, 2013, the Board of Medicine issued a Notice of Intent to Deny Licensure, stating that it intended to deny Dr. Rawner’s application because Dr. Rawner did not meet the requirements of section 458.313(1), which requires an applicant to meet the qualifications outlined in either section 458.311(1)(b)-(g) (alternative one), or in section 458.311(1)(b)- (e), (g) and (3) (alternative two). The notice stated that with respect to alternative one, Dr. Rawner did not meet the requirements of section 458.311(1)(f)3., because he had not completed an approved residency or fellowship of at least two years in one specialty area. With respect to alternative two, the Board determined that Dr. Rawner did not meet the requirements of section 458.311(3)(c) because, in the Board’s view, the section was inapplicable to Dr. Rawner because he had completed all requirements of the foreign medical school, with none outstanding, and did not meet the requirement of (3)(d) because he had not completed an academic year of supervised clinical training in a hospital affiliated with a medical school approved by the Council on Medical Education of the American Medical Association. Dr. Rawner filed a Petition for Administrative Hearing with respect to the Notice of Intent to Deny, and the matter was reconsidered at the credentials committee’s meeting on October 3, 2013. The credentials committee voted to reconsider the application based on the issues presented in the Petition. On October 22, 2013, the Board issued an Amended Notice of Intent to Deny Licensure. With respect to alternative two, in the Amended Notice, the Board stated: [t]he application file reveals that Dr. Rawner fails to meet subsection (3) for the reasons set forth below. Subsection (3) provides: Notwithstanding the provisions of subparagraph (1)(f)3., a graduate of a foreign medical school need not present the certificate issued by the Educational Commission for Foreign Medical Graduates or pass the examination utilized by that commission if the graduate: Has received a bachelor’s degree from an accredited United States college or university. Has studied at a medical school which is recognized by the World Health Organization. Has completed all of the formal requirements of the foreign medical school, except the internship or social science requirements, and has passed part I of the National Board of Medical Examiners examination or the Educations Commission for Foreign Medical Graduates examination equivalent. Has completed an academic year of supervised clinical training in a hospital affiliated with a medical school approved by the Council on Medical Education of the American Medical Association and upon completion has passed part II of the National Board of Medical Examiners examination or the Educational Commission for Foreign Medical Graduates examination equivalent. Subpart (3)(c) provides in relevant part all of the formal requirements of the foreign medical school, except the internship or social service requirements, and has passed certain examinations. A plain reading of this subpart is that the foreign medical school has an internship or social service requirement and that the internship or social service requirement has not been completed. The application file demonstrates that Dr. Rawner graduated in June, 2006, with a degree of Doctor of Medicine from the American University of the Caribbean School of Medicine. Thus, subpart (3)(c) is inapplicable to Dr. Rawner, because the application file reveals that he completed all of the formal requirements of the foreign medical school and there are no outstanding or pending internship or social service requirements. Based on the foregoing, the Board finds that the Applicant has not demonstrated that he meets the requirements for licensure by endorsement set forth in Section 458.313(1)(a), Florida Statutes. The Amended Notice no longer listed failure to complete an academic year of supervised clinical training as a basis for the denial of Dr. Rawner’s application. There is no persuasive evidence presented that Respondent’s interpretation of the requirements of section 458.311, Florida Statutes, as it applies to this case, is a statement of general applicability.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Florida Board of Medicine enter a Final Order approving Leon Rawner, M.D.’s application for licensure by endorsement. DONE AND ENTERED this 28th day of April, 2014, in Tallahassee, Leon County, Florida. S LISA SHEARER NELSON Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 28th day of April, 2014. COPIES FURNISHED: Donna C. McNulty, Esquire Office of the Attorney General The Capitol, Plaza Level 01 Tallahassee, Florida 32399 Amy W. Schrader, Esquire GrayRobinson, P.A. 301 South Bronough Street, Suite 600 Post Office Box 11189 Tallahassee, Florida 32302 Allison M. Dudley, Executive Director Board of Medicine Department of Health Division of Medical Quality Assurance Boards/Councils/Commissions 4052 Bald Cypress Way Tallahassee, Florida 32399 Jennifer A. Tschetter, General Counsel Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399 Edward A. Tellechea, Esquire Office of the Attorney General The Capitol, Plaza Level 01 Tallahassee, Florida 32399
