One day last fall, Dr. Charles Ouimet walked into his neuroanatomy course and knew immediately something was up.

    The entire class was crowded into desks on the right side of the room. His male students' faces were clean shaven on one side, bearded on the other. Women students had exactly half their faces made up with brightly colored lipstick, while the other side was deliberately left bare. Each wore a single large earring--on the right side. Every student was shoeless on the left side.

    Ouimet collapsed in laughter. He had been lecturing his Program In Medical Sciences (PIMS) students about a medical condition that makes people ignore half of their bodies. The students were letting him know, in their own humorous way, that they grasped the concept.

    His PIMS students are unlike any other group that this FSU professor of neuroanatomy has taught. "It's not cut-throat like many people might expect of medical students," Ouimet says. "A very nice camaraderie develops. They help each other out."

    That's a strength of PIMS, he says. "You end up with this cohesiveness, unlike any I've experienced before."

    Established in 1971 through a five-year medical grant from the National Institute of Health, PIMS is a cooperative effort in medical education between Florida State and the University of Florida's College of Medicine in Gainesville. Each year, 30 students are selected by the program's admission committee to begin their medical education on the FSU campus through PIMS. Upon successful completion of the program's curriculum, they are guaranteed entry as second-year students at UF's College of Medicine.

    The program was started as a multi-faceted effort to expand the class size of first-year medical students at UF, without having to put a lot of money into facility expansion; to reach out to non-traditional medical students; and to increase the numbers of primary-care physicians.

    In April 1999, the program's 29th class will complete its first year of medical school at Florida State. Since its inception, the program has produced over 800 grads who are in medical practice, residency or still in med school. Statistics show the graduates are demographically diverse and have a strong propensity toward generalist medicine, says Dr. Myra Hurt (Ph.D. Tennessee), who became the program's third director in 1992.

    Fully half of PIMS graduates wind up choosing a generalist specialty--which includes family practice, internal medicine and pediatrics, says Hurt. Another 14 percent go into emergency medicine or obstetrics/gynecology, which means more than 60 percent choose primary-care medicine--about double the national average of those beginning their first year at a traditional medical school.

1998 Spotlight

    PIMS' success captured the attention of Florida lawmakers in the 1998 legislative session in a big way. Citing a need to expand medical training in primary care and cultivate physicians with a clinical orientation in geriatric medicine, legislators looked to PIMS as a way to make it happen.

    Legislators noted that nearly a quarter of Florida's 14 million residents is 60 years old or older--a major segment of Floridians on the verge of requiring special health-care needs. A medical program whose primary focus is recruiting and training medical professionals to serve the elderly might be just what the doctor ordered, backers of the legislation argued, and a second year for PIMS would represent a major step closer to making that happen.

    A topic of hot conversation during the '98 Legislature, at sine die lawmakers passed a bill calling for a one-year expansion of PIMS. Accompanying the bill was a $900,000 appropriation to add more faculty to the first-year program and to fund a Board of Regents (BOR) feasibility study on medical needs in the State of Florida. For the bill's primary authors, including Rep. Durell Peaden, Jr., M.D. (R-Crestview), the legislation laid the groundwork for a four-year med school down the road in Tallahassee.

    Though the legislation includes bold language, specifically calling for a PIMS second year, Hurt and her team are proceeding cautiously. The allocation accompanying the legislation covers only the feasibility study and costs associated with enhancing faculty for the first year, she said.

    "We have some money, yes, but (the second year) is not a done deal," she says.

    Hurt's caution is based on a big caveat lawmakers tacked onto the end of the bill. The provision for adding a second year can be repealed during the 1999 legislative session if the BOR study shows that the move would jeopardize the accreditation of the UF School of Medicine, or if the expansion of the PIMS would be cost-prohibitive.

    Results from the feasibility study are expected to be presented in January, in time for '99 lawmakers to decide on the second year's fate. If the reaction is positive and funding is secured, Hurt says, she'll start an aggressive effort to add the necessary faculty. Because a national search is required to recruit these faculty, the expanded program would be another two years in the making.

Partners in Medical Education

    As much as Hurt and others believe the second year at PIMS has been earned and is warranted by the needs of the state, she knows the issue is politically charged. However, through PIMS, Hurt says, UF and FSU have been partners in medical education for a long time. Since the program's birth, the two institutions have enjoyed an unusually smooth and positive working relationship, observers say.

    Hurt said the mandate of the accrediting organization, the American Association of Medical Colleges, is that PIMS, as a satellite campus of the College of Medicine, must provide a first-year curriculum that is equivalent in quality to the first year at UF's med school. To assure equivalence in basic science instruction, faculties from FSU and UF who are involved in teaching the first year curriculum meet yearly, alternatively in Gainesville or Tallahassee, said Hurt.

    Where PIMS is unique, she says, is in exposing students to the clinical setting--working with real patients throughout their first year of medical school. In recent years, UF has added three weeks of clinical training (on-site work with physicians) to their first semester curriculum, whereas the PIMS clinical curriculum is continuous throughout the PIMS year.

    Comparisons are moot, however, as long as both programs are doing a good job turning out well-prepared, first-year students, which officials at both institutions say they are.

    Dr. Robert Watson, senior associate dean for educational affairs at UF's College of Medicine, says that despite different approaches, PIMS has done a good job of preparing students, and they blend easily with the UF class their second year.

    "I think PIMS students are just terrific," he said. "They get over here and become so quickly assimilated. When they hit the wards, you never know (the difference except) some of them wear FSU logos. Other than that you would never know. It's been a really neat program."

    It's not unusual for a PIMS student to become chairman of the class, or even achieve the highest board scores, Watson said.

Rough Years

    The spotlight on PIMS this past year also has given players on both sides of the field a chance to reflect on PIMS' brush with disaster just a few years ago. None are anxious to re-live those memories. When a nationwide down-turn in med school applicants developed in the mid-1980s, FSU's program was hurt badly. With a limited applicant pool to begin with, when the national pool dipped, the number of qualified PIMS applicants sank like a stone.

    For several years following, PIMS students were testing much lower on the first part of the national board exams (the national licensure examination given to all students at the end of their second year of med school) than expected. While the national failure rate hovered at around 12 percent, nearly half of the PIMS students failed the first step of the national boards.

    In 1991, faculties from both FSU and UF came together to find answers. The panel laid out a course for better coordination between the UF College of Medicine curriculum committee and the PIMS planning committee; more space for PIMS offices and classrooms; adoption of some UF educational materials and evaluation tools; publication of new recruiting brochures; and stepped up involvement between PIMS students and their classmates at UF.

    Hurt, too, was part of the solution. She was hired in August 1992 and immediately revamped the curriculum and returned the PIMS focus to clinical training, including having students work with a family-practice physician for a semester at TMH and spending a semester with a primary-care physician. Hurt lobbied for and won approval to open up the PIMS applicant pool to the American Medical College Application Service so PIMS could then accept applications from any legal resident of the state of Florida. The number of applications went from less than 100 to over 900 in one year.

    Hurt's proposals soon won funding from the Florida Legislature for new faculty and staff. With a new team in place, she then coordinated building and equipping an entirely new facility centered around a student learning center, completed in 1993. The center houses top-drawer computer-aided learning stations, microscopes, human models and other study aids, and a small medical library. The administrative suite wraps around the learning center so that the medical students have easy and quick access to the staff and faculty.

    The changes worked better than many expected. UF's Watson said that within three years after the new direction was taken, PIMS scores and its students were indistinguishable from students completing the first year at the University of Florida.

TLC Trumps GPA

    From the outset, PIMS set out to distinguish itself from traditional, first-year med-school training in several ways. Today's program is holding the course, says Hurt, starting with the admissions process.

    The process is, by far, the jewel in the crown for PIMS, says Hurt, and faculty at both UF and FSU agree. Traditional medical schools turn out a high percentage of specialty physicians, what Hurt calls "well-trained physician-scientists." PIMS' goal, from the beginning, has been finding those students in the applicant pool with a tendency toward community-based primary care medicine.

    While acceptance to PIMS requires academic performance that predicts success in medical school, more emphasis is placed on personality and communication skills, she said. Many traditional medical schools pick candidates primarily on academic performance.

    "We're looking for more than that 4.0 GPA. We look for a lot of experience in patient-care settings. My theory is that the best thing we do is pick a very diverse class. They're sometimes older, maybe changing professions; they have different life experiences; they are very literally Florida ," Hurt said.

    Each student tapped for PIMS has been through a rigorous screening process that involves whittling down 1,200 applicants to 500, then more whittling to 100 individuals who must then endure two one-hour interviews for the chance to become one of the 30 students in the PIMS class.

    Experience working in patient-care settings and commitment to community volunteer activities such as with Alzheimer's patients and support groups goes a long way with the PIMS admission committee, Hurt said. And there's no faking it--part of the interviewing process involves talking about the prospective student's experiences in these settings.

    "Medicine is not for everyone," Hurt says, and that makes careful selection necessary. "Some people come in here with a glamorous and distorted idea about the life of a physician. We want them to get into the trenches. We don't want them to get into their third year of med school and have doubts, so we do the weeding on the front end."

    Charles Ouimet, who previously served on the PIMS selection committee, says the process results in a medical student population unlike anywhere else in the country. In traditional medical school admissions, he says, "personality characteristics" are often missing.

    "The ability to have empathy with the patient; to feel their pain," says Ouimet. "That's what makes a good doc--someone smart enough to figure out what's wrong with you and compassionate enough to have a good bedside manner. That counts in healing somebody."

    After all the careful screening and the patient contact, it's still a gamble on whether or not the student will choose family practice, but Hurt says their selection process increases the odds.

Medical Ed, FSU and Florida's Future

    Dr. Paul Elliott (Ph.D. Michigan), associate chair for undergraduate studies in FSU's Department of Biological Sciences, says the partnership between FSU and UF has served both schools and the needs of the state well. Elliott should know. In 1971, Elliott was dean of professional programs (College of Medicine and Dentistry) at UF when he was persuaded to come to FSU as PIMS' first director.

    "We were ahead of our time," Elliott recalls, noting the establishment of similar programs across the nation since PIMS' birth.

    Designed to satisfy several health-care needs for the state--most of all educating primary-care doctors who would practice in the state's less populated counties--the program was planted in the perfect setting, said Elliott. In 1971, more than 40 percent of FSU's student population came from rural backgrounds, making the campus a likely place to begin a project like PIMS.

    "You don't get Coral Gables kids wanting to practice medicine in Marianna," explained Elliott.

    The move to expand PIMS makes sense, he feels. Among other things, he said, it would improve the number of clinical training sites where students learn directly from practicing physicians. But ambitions to build a traditional medical school on the scale of UF is unlikely to accomplish the goal of more primary-care physicians, he says. Elliott instead favors a four-year, four-city consortium, while leaving UF in charge.

    "You could use the two years at FSU, plus Gainesville, plus the tremendous facilities in Jacksonville at the Mayo Clinic, and Pensacola. You could easily set up a system where people move place to place, depending on their interests."

    By concentrating their training all across North Florida, instead of at a traditional medical school, students would be encouraged to stick to primary care, he feels.

    Hurt began discussions about such a community-based, four-year medical program centered at FSU several years ago. The central concept of her proposal involves putting physicians-in-training in community-based settings (such as community physician clinics and offices) rather than in a tertiary care medical center as physicians are traditionally trained in the U.S.

    In her proposal, students would complete basic medical science training (two years) at FSU, building on the current first-year program already in place. Then, students would complete clinical training in the primary care specialties, such as family practice, in community-based settings in Tallahassee in cooperation with Leon's County's largest hospital, Tallahassee Memorial Healthcare (TMH).

    TMH has been a player since the program's beginning, she says, even though no money has changed hands. Under her proposal, medical students would go to other Florida cities such as Jacksonville and Gainesville for specialty training.

    Florida is unlike any other state, Hurt says, both in terms of the medical needs of its population and the fact that the state has relied on "the kindness of strangers," she says, for the education of its physicians. Three-quarters of the doctors licensed yearly in Florida are trained outside the state, she said. Florida's three allopathic (conventional) medical schools produce only 400 M.D.s a year, one of the lowest numbers in the U.S. when compared to population size, and of the nation's most populous states, the lowest number by far, says Hurt. Texas, with a population size similar to Florida's, has seven allopathic medical schools, and New York, with 25 percent more population, produces 300 percent more physicians, she said.

    With talk of oversupply of specialists and downsizing of residency training programs nationwide, why expand medical education in Florida now? Precisely because of downsizing elsewhere, Hurt says. Citing studies published in the last year in the Wall Street Journal and elsewhere, she says Florida will be particularly effected by losing the supply of physicians it has counted on from outside the state.

    UF's Watson, while having high praise for PIMS as it is, thinks an expansion and talk of an FSU med school are unwise. He also said that a two-year PIMS would mean that as the accrediting institution, UF would take the heat if the second year at FSU does not meet accreditation standards.

    If the BOR's feasibility study determines that the state needs to expand its medical education, why not let the states' three medical schools address the problem?, Hurt asks rhetorically.

    "Quite simple--let them keep doing what they do best," she said. "The high-tech medical centers are necessary to continue the fight against cancer, to push the boundaries of our understanding of the brain and how it functions, to continue to press all of the boundaries of knowledge of the human body, and to offer the best specialty training across the spectrum of clinical care.

    "But the time is right for FSU and PIMS to build on its unique mission in a community-based setting to meet the unique medical needs of the State of Florida."

Bringing it Home

    Whatever lawmakers decide next session, FSU's program has been strengthened, says one PIMS advocate.

    Dr. C. David Smith is a family physician in Jay, Florida--a Panhandle town with a population of 670--and is a PIMS grad, class of 1975. On the issue of PIMS expansion, Smith addressed the legislative committees during the legislative discussions last spring.

    Smith says there's an "incredible urge" to sub-specialize at traditional medical schools, primarily because these schools attract patients with complex illnesses, and the majority of physician role models the students see are sub-specialists themselves.

    As a young man, Smith had dreamed about practicing medicine in his home town. He learned about PIMS through a flier circulating in the Pensacola Junior College mail room where he worked part-time while attending school.

    To increase his odds of being accepted in the program, he transferred to Florida State where he completed his undergraduate degree, applied to PIMS and was accepted. He finished medical school at the University of Florida in 1979.

    During his residency at the University of Southern Alabama, Smith got a call from administrators at Jay Medical Center. They said the hospital was in financial straits and desperately needed him to come home. He left the residency program and opened up his primary care practice on Jay's main street in 1980.