Author + information
- ↵*Send correspondence to:
Carl J. Pepine, MD, MACC, Professor and Chief, Division of Cardiovascular Medicine, University of Florida College of Medicine, Box 100277, 1600 Archer Road, Gainsville, Florida 32610-0277, USA.
Several of my predecessors (1–3)have written about the developing shortage of cardiovascular specialists, and I am compelled to join them. Each year, it becomes more apparent that this is an extremely important issue not only for our profession but also for our patients. Based on the questions I receive, it seems that most members do not fully understand this issue and its implications. Therefore, I will try to shed some light on the subject.
Statistical data released in the early 1990s, however flawed, suggested that the cardiovascular workforce was ∼100% larger than necessary for the new millennium. In response, a joint recommendation to reduce the number of trainees by 20% was made by the American Medical Association and the Association of American Medical Colleges. In 1994, the American College of Cardiology (ACC) adopted a workforce statement supporting a reduction in the total number of adult cardiology fellowship positions and acknowledging an oversupply of practitioners in invasive cardiology. The College also advocated a reduction in the number of interventionalists to be trained.
Why we need to be concerned
Ironically, the challenge of ramping up the number of cardiology fellowships appears much more daunting than it was to shrink those opportunities years ago. We need to understand why it is important to do so and what happens when there aren't enough cardiovascular specialists to accommodate the demand for services. In fact, several undesirable things do occur: cardiovascular care is given by physicians who are not trained in cardiology or other cardiovascular subspecialties, there is limited access to a specialist's care, and there is an overworked cardiovascular workforce.
These undesirable circumstances are already taking shape today: nonspecialized physicians who have time available have started seeing more patients with cardiovascular disease. Although it initially addresses some of the demand, this practice can chip away at the quality of specialized care. In some large HMOs and group practices, the generalist who sees the most patients with cardiovascular disease is designated the “cardiovascular person,” seeing consults and maybe even reading electrocardiograms and echocardiograms. This practice threatens our profession's integrity and future excellence.
My immediate predecessor, W. Bruce Fye, MD (3), established a Task Force to Develop a Consensus Conference on Workforce, which believes that it could take as long as 10 years to expand the cardiology workforce to proportions that could meet expected demand. That expansion assumes many changes, however, including the uncapping of Medicare expenditures that subsidize cardiology training programs.
As chair of one of 10 work groups under the Task Force that is studying short-term solutions leading to faster (<5 years) expansion of the ranks prior to the implementation of definitive plans, I have learned that it would likely take six to seven years to bring more cardiologists into the field. First, we would need to obtain more fellowship funding, then apply for local Graduate Education Committee approval to increase the number of cardiology fellowships, then apply for Residency Review Committee/Accreditation Council for Graduate Medical Education (RRC/ACGME) accreditation for those approved training positions, and then recruit and match new candidates for them. This multi-year projection presumes a process that is initiated now and proceeds smoothly—an unlikely scenario.
Analyzing the challenge
The shortage of cardiologists is further complicated by the number of cardiologists retiring. Last but not least, the rate at which patients with cardiovascular disease is increasing stands at roughly 1% to 2% per year, according to the American Heart Association (AHA). The situation is even more critical in clinical electrophysiology and interventional cardiology due to the limited availability of RRC/ACGME-accredited training programs/positions and longer training periods.
Medicare funds—specifically for postgraduate physician training—were capped by the Balanced Budget Act of 1997, which froze the number of cardiology fellowships in relation to the number of residents in training on or before December 31, 1996. Many other medical specialty training programs were also capped and reimbursed at some fraction of the primary-care level.
Uncapping Medicare at the local institutional level, where training occurs, is a zero-sum game that must come either at the cost of another specialty's training program or with the addition of new money to the system. Both are unlikely at a time when a bill currently making its way through the legislative process will continue to freeze funding for graduate medical education (GME) for the next seven years to offset the cost of pharmaceutical prescriptions. But Medicare shouldn't be the only program shouldering the burden of providing funding for training the next generation of physicians—reasonably, other stakeholders would contribute their fair share, too.
A patient-driven dilemma lies at the core of the cardiologist shortage, too. Traditionally, when coronary patients left the hospital after an acute illness, we cardiologists reflexively sent them back to their referring physicians. But more and more patients don't want to go; they want to continue their recovery under a specialist's care. Virtually every study reported shows that a patient with a cardiovascular disease, particularly an acute one (myocardial infarction, unstable angina), does better when taken care of by a cardiologist than when taken care of by a generalist. Patients are aware their outcomes are likely to be better when they are cared for by a specialist, and they will do everything—either overtly or covertly—to stay in your practice.
Short-term recommendations to help us manage patient care while demand is high and physician supply is low include increased utilization of the cardiovascular care team, headed by a cardiologist. This approach, emphasized at the ACC 2003 Annual Scientific Session, provides a solution for time-pressed specialists deluged by patients even after an acute condition has been resolved. Cardiac-care team workers can include internists and physician extenders to do basic clinical work and also nurses, exercise scientists, and pharmacists to do more focused work, such as stress testing, blood pressure, and lipid or anticoagulation management. The further patients move away from an acute event, the more value the cardiac-care team can bring to your practice. Should patients become acutely ill again, they move up the queue into more direct care with the cardiovascular specialist.
Putting the cardiac-care team into practice can increase the number of cases seen by most cardiovascular specialists without sacrificing quality of care. Moreover, Dr. J. Willis Hurst's comments (4), expressed in an editorial in the May 21, 2003, issue of the Journal of the American College of Cardiology, are on target. He writes, “We may need to train a few more physicians who subspecialize in cardiology to meet the needs of the future, but that need is not as clearly evident as the demand for more general cardiologists.” [Editor's Note:A future President's Page will probe how the subspecialization of cardiovascular medicine contributes to the general cardiologist shortage.]
We also can develop “retraining programs” for specialists with clinical experience in related disciplines (primarily internists and, possibly, critical-care specialists and selected family physicians) who desire to change careers. Such programs could include on-the-job training (working with a cardiologist several hours per day for several years), focused programs on weekends (three weekends/month, including Friday, for two years), or other accelerated programs. Models for new programs can be found in new technology training programs, at-home learning programs (to avoid travel), wireless contact, and telemedicine.
Retraining programs that encourage retired cardiologists to return to the workforce might include an emphasis on the advantages of selected practice settings—those that offer no or lower malpractice insurance expense, lower fringe-benefit costs, part-time work, and no night call. Returning cardiologists could also be valuable to the ACC, AHA, and other cardiology-related institutions for volunteer work or advisory services.
How do we train a larger number?
This very complex issue deals with the volume of trainee applicants, funding for trainees, length of training, number of trainers, and other considerations. Most specialists in the field would agree that, currently, there is no problem with the volume of high quality applicants for training programs. At the University of Florida, for example, every training slot attracts about 100 applicants. After thorough screening, interviewing, and selecting those to list for the match, approximately 20 highly qualified applicants remain viable candidates for each position. Despite the fact that applicants file multiple applications, this plentiful scenario is probably mimicked around the country.
The fact remains, however, that to expand the number of cardiovascular fellowships, we need to increase available funding—unless we revert to a system where we don't pay fellows in training a full salary. Such a system, however, is likely to weaken the attraction our training holds for young people seeking to learn a new specialty. Sometimes moonlighting opportunities (in emergency rooms or in medical practices as internists) can provide supplemental income for trainees until they complete their fellowships, but the RRC and ACGME have mandated an 80-h work week. That mandate makes it unlikely that candidates would complete cardiovascular specialty training in three years, if moonlighting is necessary to support themselves and their families.
At the other end of the spectrum, there is a proposal to charge tuition to fellows in training. Radical? Perhaps, but there are plenty of applicants who wish to enter cardiovascular medicine. At the University of Florida, stipends for postgraduate trainees are fixed by the state, based on rates set by the National Institutes of Health, according to medical specialty. This system, unfortunately, creates another obstacle for new funding possibilities. For example, if a candidate agreed to waive half of his or her stipend, thereby making way for another cardiovascular candidate, would the state agree to the arrangement?
Many areas of self-interest could derail the expansion of cardiology training; the status quo is valued by many of the institutions involved (i.e., the RRC/ACGME). At universities, favoring the growth of one medical specialty has the potential to upset the balance strived for by a local GME office. National accrediting bodies have their own agendas, too, and upsetting apple carts at teaching hospitals around the country certainly would not take priority.
It sounds so simple: create more training opportunities for cardiologists, but it's extraordinarily complex, loaded with political and economic landmines.
A longer-term possibility that might remedy the shortfall of cardiologists is a shorter training period. We probably over-train in the preliminaries required prior to getting into cardiovascular disease training. We could trim at least one year of the internal medicine training program and maybe up to a year of the latter part of medical school. Taking even one year out of the training period would make a significant difference in bringing more cardiologists into the professional practice environment sooner. Establishing a “short track” training path, not only in internal medicine but also in cardiology, could reduce total training time by two years. Developing subspecialty one- or two-year training programs to provide limited certification is another possibility. This would require approval by the RRC/ACGME, subspecialty groups, and the American Board of Internal Medicine (ABIM).
Creating a shorter training path has pitfalls, too. In all likelihood, it would create a chasm between our parent certifying board, the ABIM, which may perceive such an initiative as eroding the internal medicine program, and the internist's path to specialized medicine.
Other specialties, such as dermatology and neurology, have established precedents for proactively setting their sights on growth. Each has created its own certification board on the route to medical specialization. This model provides a pathway we need to consider.
Finally, in determining how we can increase the number of cardiologists, we must consider our patients. With health care being doled out to “haves” and “have-nots” around the country, we must reckon with the fact that a health care sector with a dearth of cardiovascular specialists presents the distinct possibility that only the fortunate (i.e., those with better-paying insurance) will be able to avail themselves of our care. This trend may have begun already. In Texas, dozens of cardiology practices have terminated their relationships with payers like Aetna, Blue Cross and Blue Shield (BC/BS), and Cigna due to reimbursement and other issues. At the University of Florida, we have dropped BC/BS HMO, yet our patient load does not decline. So many patients demand our services, that those slots don't remain empty; they are filled by patients with more favorable insurance plans. You can see the trend: as specialists in demand limit the lowest payers, appointment times are filled by patients represented by better payers, and access to specialized care becomes limited.
↵1 President, American College of Cardiology
- American College of Cardiology Foundation
- Beller G.A.,
- Alexander J.,
- Baughman K.L.,
- Gardin M.J.,
- Limacher M.C.,
- Moddie D.S.
- Beller G.A.
- Fye W.B.
- Hurst J.W.