The continuing saga of the CV workforce shortage

More cardiovascular training programs and positions are needed.

Little has changed since the Bethesda Conference report was issued last year on the looming workforce crisis in cardiovascular medicine. At recent count, more than 200 candidates ready to enter a fellowship in cardiology this year could not be placed because of the shortage of available first-year fellowship positions in this country.

Other specialties have the opposite problem: Fellowships in internal medicine and thoracic surgery remain empty because there are not enough suitable candidates to fill those slots. In CT surgery, there were about 40% more fellowship slots than applicants this year.

The shortage in fellowship slots in cardiology comes at a time when all forecasters say there will be at least 20 million more patients with heart disease in 2020 than there were in 2000. The number of patients with heart failure is expected to increase from 4.7 million symptomatic patients today to 10 million by 2037. This occurs while the number of trainees in CVD has remained about the same for almost a decade.

Chronic diseases increasing

Those numbers may be underestimated, however, given the dramatic increases we are seeing in obesity, diabetes and hypertension. Not only will there be more people with CVD, they will be living longer with chronic diseases and comorbidities, further straining a health care system that will not have enough cardiovascular specialists available to care for them.

Carl J. Pepine

One positive change would be a loosening of restrictions that prohibit retired cardiovascular specialists from practicing part-time in a state where they don’t hold a medical license. These physicians — including some who have retired early because of the rigors of a full-time practice — could help fill some of the voids in our academic centers. I have talked to several who are interested in coming to the University of Florida but cannot do so because they do not have a medical license in this state.

State medical boards and legislatures should be encouraged to enact reciprocity agreements.

Shorter-track training needed

A medical student interested in pursuing a career in electrophysiology or interventional cardiology must currently spend three years in a general internal medicine residency to qualify to take the ABIM general internal medicine examination, complete a three-year cardiology fellowship to qualify to take the ABIM cardiovascular examination, and then spend at least one year in an EP or interventional advanced fellowship to qualify to take the ABIM added-qualification examination in their respective area.

A shorter-track approach should be considered for cardiologists who want to pursue a specialty practice, one that would cut total training by at least one year. Many of us believe that it is inevitable that cardiology trainees in the future will not be required to complete a three-year general internal medicine residency before they begin a general cardiology fellowship, that is then often followed by a cardiology subspecialty fellowship.

But who will be bold enough with enough influence to reinvent training based on the real world of medicine in the early 21st century remains a question. According to Bruce Fye, MD, chairman of the Bethesda Conference, “the rules, regulations and documentation requirements have settled like silt on a river bottom over the past six decades.”

Changes to ABIM requirements

Fye has reported that efforts to get the ABIM to invite about 10 medicine department and CV division leaders to participate in a pilot shorter-track program for general clinical cardiologists have been held up because of the ABIM’s unwillingness to support the concept for one subspecialty.

We clearly need a change in the number of cardiology training programs and positions, a number regulated by the Accreditation Council for Graduate Medical Education (ACGME). At the University of Florida, we have only a handful of positions open each year but we receive hundreds of applications.

The Bethesda Conference report was clear about this looming problem. About 40% of U.S. hospitals with 100 or more beds need cardiologists. They have openings but can find no one to fill the positions.

In contrast to our trainees, according to ACC President Pamela Douglas, MD, our educational systems, training programs and their funders “are very slow in reflecting the change in care patterns in CV diseases and are not adjusting training opportunities to meet the evolving market — the health care needs of our population.”

Unless we find a way to train more cardiovascular specialists and find a way to make use of our retired colleagues who are eager to fill in part-time, the health care needs of an aging population will be seriously compromised.