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- Patrick T. O'Gara, MD, FACC, President, American College of Cardiology∗ (, )
- Chris Cooper, MD, FACC, American College of Cardiology Ohio Chapter Governor and
- Edward Fry, MD, FACC, American College of Cardiology Indiana Chapter Governor
- ↵∗Address correspondence to:
Patrick T. O'Gara, MD, FACC, American College of Cardiology, 2400 N Street NW, Washington, DC 20037
It is quite sobering to consider how rapidly the landscape of cardiology practice has changed in less than a decade.
In September 2009, an American College of Cardiology (ACC) survey published in the Journal declared a cardiology workforce crisis. The survey reported a shortage of 1,685 general, 660 electrophysiology, 1,941 interventional, and 127 pediatric cardiologists, noting that only about 750 general cardiology fellows were completing training each year (1). These trends, coupled with predictions of a major increase in U.S. adults with cardiovascular disease, had the survey authors recommending an increase in supply of cardiovascular specialists—and quickly.
What has ensued is one of the most amazing examples of why it is so difficult to make predictions about the future. Just 1 year after the survey, the global economy took a significant turn for the worse, collapsing 401(k)s and resulting in a dramatic drop in employment overall—not to mention employment with health benefits. In addition, massive Medicare practice expense cuts for cardiovascular services sparked a surge in the number of physician practices integrating with hospitals or other large health systems.
More recently, passage of the Affordable Care Act and the ensuing debate and uncertainty over its implementation, as well as the continued transition from a healthcare system focused on volume to a system focused on value, have forced hospitals and practices to change tactics when it comes to workforce and day-to-day business. An increased focus on quality and cost savings, Medicare's efforts to bundle payments, and the reduction in services resulting from a high deductibles in tiered health plans have significantly impacted the workforce discussion. Simply put, a decline in cardiovascular testing and procedures means that fewer people are needed to perform these tasks. The expansion of Accountable Care Organizations and other risk-based payment models have further de-emphasized specialty referral in many cases.
The list of dynamic market force changes negatively affecting the cardiovascular specialist could be further expanded. Regardless, the result has been an unprecedented drop in demand for professional services and a relative oversupply of highly-compensated individuals, especially in prime geographic locations.
Speaking at the ACC's Cardiovascular Care Summit in Las Vegas earlier this year, Suzette Jaskie, MBA, President and Chief Executive Officer of MedAxiom Consulting, noted that, despite an aging population, hospitals have experienced a drop in volume from 123.2 to 111.8 inpatient stays per 1,000 population between 1991 and 2011 (2). This has led many hospitals to cut jobs to be more efficient and reduce costs. According to the American Hospital Association, an accumulated total of 278,000 lost jobs are projected by 2021 (3).
Similarly, in a recent paper in a special issue of CardioSource WorldNews for fellows in training and early career professionals, Cittur A. Sivaram, MBBS, Director of the Cardiovascular Diseases Fellowship Training Program at the University of Oklahoma and Chair of the ACC Cardiology Training and Workforce Committee, said that “one of the concerns out there is about a real decline in the number of open jobs in desirable locations” (4). He noted that job candidates must be willing to cast a wide net.
Jobs are even harder to come by for those trained in cardiovascular specialties. A recent survey of ACC members found that roughly 40% of job openings are in general cardiology. In contrast, about 24% of job openings are in interventional cardiology, 15% in electrophysiology, and only 8% in imaging (5).
In an interview as part of the CardioSource WorldNews paper (4), Zachary M. Gertz, MD, Director of Structural Heart Disease at Virginia Commonwealth University, noted that it is a very competitive market for incoming cardiovascular professionals interested in structural heart disease, valve disease, advanced electrophysiology, and other procedure intensive areas. “These are tougher jobs to get,” he said, but he also pointed out that general cardiology and heart failure opportunities are looking more plentiful (4). We have quickly moved from an era in which many openings went unfilled to an environment where jobs are tight, compensation is under pressure, and there is an oversupply of trainees. It is clear that we need better tools and modeling algorithms to help inform our appreciation of future workforce supply and demand. We should anticipate the downstream effects these trends may have on cardiovascular training programs.
These trends also underscore the need to build physician and care team leaders who can respond to and lead others through the turbulent times we face. We need leaders who can help manage trainee expectations regarding income. We need leaders with business acumen who can help practices survive and thrive in a time of steadily lowering reimbursement and increased reporting requirements. We need leaders who understand the hospital environment and who can explain the pros and cons of hospital employment. Finally, we need leaders and mentors who can help fellows adapt their portfolio to meet the demands of the new marketplace we occupy.
C. A. Sivaram said it best in the CardioSource WorldNews paper: “What is hot right now [for fellows] in cardiology may be nearly irrelevant later in their career. Any good cardiologist must be willing and able to do everything, from learning about safety and coordination of care to managing hypertension and diabetes, so that they can survive whatever shifts may occur in practice in the next five or 10 years” (4).
The ACC is the perfect training ground for these new leaders. By virtue of its inclusion of members across the entire cardiovascular team, the College is blessed with a deep well of talented and dedicated individuals from which it can draw. The growing number of training directors who are also ACC members is especially critical. Providing them with the tools and resources to help stay on top of environmental trends and ensure that they are graduating the right number of fellows, as well as the right complement of trainees, can go a long way toward helping respond to rapid and unexpected changes to the cardiovascular environment.
- American College of Cardiology Foundation
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- Conti J.B.,
- Feinstein J.A.,
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- ↵McGuire R. Road to recovery? Medicine moves from proficiency-based art to data-driven science. CardioSource WorldNews. Vol. 3, No. 2. February 2014. Available at: http://www.cardiosource.org/News-Media/Publications/CardioSource-World-News/2014/02/Road-to-Recovery-Medicine-Moves-from-Proficiency-Based-Art-to-Data-Driven-Science.aspx. Accessed April 4, 2014.
- ↵American Hospital Association. The negative employment impacts of the Medicare cuts in the Budget Control Act of 2011. September 2012. Available at: http://www.aha.org/content/12/12sep-bcaeconimpact.pdf. Accessed March 30, 2014.
- ↵Lawrence L. Workforce wake-up call: a physician shortage or a job shortage? CardioSource WorldNews: Focus on Fellows in Training and Early Career Cardiologists. Vol. 1, No. 4. Fall–Winter 2013. Available at: http://www.cardiosource.org/News-Media/Publications/CardioSource-WorldNews-Focus-on-FITs-and-Early-Career-Cardiologists/2013/Fall-Winter/Cover-Story.aspx. Accessed February 4, 2014.
- ↵Workforce Shortages in CV Practices. American College of Cardiology CardioSurve Newsletter. December 2013. Available at: http://www.cardiosource.org/news-media/publications/∼/media/5F1949B15F6348CE9A82EF91DBB4FA10.pdf. Accessed March 30, 2014.