Who will treat the aging population in 2020?

The workforce shortage in cardiology continues to increase without much prospect for a definitive solution. Unlike many other specialties where there are not enough candidates vying for fellowship training positions, there are a plethora of well-qualified applicants in cardiology. Many program directors acknowledge that they received well over 100 applicants for every open position last year. At the University of Florida, we have hundreds of applicants each year for only a handful of positions.

Growing demand for cardiovascular services is driving the problem. The U.S. population will grow from 285 million in 2000 to 335 million in 2020 — roughly like adding the population of England over 20 years! And we are getting much older. Here in Florida, our population currently is the oldest in the nation, and the Census Bureau indicates that by 2030 the entire nation will be as old as the population of Florida is now.

Carl J. Pepine

For a specialty expecting an increasing number of patients — at least 20 million more patients with heart disease by the year 2020 — this shortage is important to address now. The Bethesda Conference report last year said that about 40% of U.S. hospitals with 100 or more beds need cardiologists. A more recent survey by a major physician-recruiting firm, Merritt Hawkins and Associates, found that 48% of hospitals with 201 or more beds were recruiting cardiologists in 2005; 77% of all hospitals rated cardiologists “very difficult” to recruit. By contrast, family physicians and pediatricians were rated relatively easy to recruit.

Patients waiting longer

The report also found that more than 70% of cardiology patients have to wait longer than 14 days; 40% have to wait more than 21 days for a new patient visit. This explains why a recent American College of Cardiology survey found that the top request of members, both in private practice and full-time academic positions, was “get us some help.”

The workforce shortage is fueling an overall change in the field of cardiology. General physicians are calling themselves CV medicine experts, and cardiovascular surgeons are moving over to do CV medicine. Search firms tell me that internists are answering ads for echocardiography specialists.

This trend will require that multiple studies that have documented better patient outcomes when cardiology specialists are involved must be repeated to assess the quality of care delivered by this “new version” of a cardiology specialist.

Reciprocity agreements needed

Several suggestions have been made to address this shortage, including loosening the restrictions that currently prohibit recently retired CV specialists from practicing part-time in a state where they don’t hold a medical license. An alternate pathway, based on credit for years in practice without charges, perhaps could lead to “limited” licensure. Another proposal calls for instituting a shorter-track training program for cardiologists.

State medical boards and legislatures should be encouraged to support reciprocity agreements that could allow part-time physicians to practice in another state. Unfortunately, efforts to get the ABIM to support shorter training tracks have not been successful.

The Accreditation Council for Graduate Medical Education needs to increase the number of cardiology training programs and positions. Many believe that the size of our training programs and other teaching opportunities are not being allowed to change rapidly enough to meet anticipated CV health care needs.

Conversion program

Another suggestion recently proposed is development of a conversion program for internal medicine to cardiology. In this model, internists with interest in CVD could be given partial credit toward training (~one year) based on, for example, 10 years of a concentrated practice in caring for patients with CVD.

This would require a close working relationship with trained cardiologists as consultants. After an additional year or two of formal cardiology training, they might be eligible to take the board exam in cardiology. We should give these internists with experience in CVD an opportunity to specialize in cardiology; the ABIM, however, would have to approve this plan as well.

Many of us have been discussing this workforce shortage for several years, yet no solution has emerged. ABIM has not thrown its support behind a shorter training track. The ACGME has not increased the number of training programs or positions. States have not enacted reciprocity agreements for retired physicians.

As predicted several years ago, the burden of disease continues to grow with the rising rates of obesity and diabetes added to our aging population. Unless we find a solution soon, the health care needs of our aging population will not be met.