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Cardiologist shortage on the horizon
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Outrage over the concealment of long waiting times at VA medical centers recently led Congress to allocate an additional $5 billion for the VA to hire additional doctors and an additional $10 billion to pay for veterans care in the private sector to reduce waiting times. However, Congress did not act to increase the supply of trained physicians, including cardiologists, highlighting concern about a growing crisis in the supply of physicians. The VA may be a microcosm of a much larger looming shortage in our workforce. The question remains: Where will these additional physicians come from?
Cardiologist supply changing
L. Samuel Wann
Although there have been moves to expand medical school enrollment and increase support for primary care graduate medical education (GME), there has been little movement to increase government support of cardiology fellowship training. Most cardiology fellowships are funded from hospital profits and indirect GME payments received from Medicare. The VA, the Armed Forces, Medicaid and research grants also provide a relatively small amount of financial support to train cardiologists. To a certain extent, cardiology fellows and other advanced trainees may justify their hospital-paid salaries by providing useful services to these hospitals. Accreditation of training programs in CVD is rigorously controlled by the Accreditation Council for Graduate Medical Education (ACGME) and certification of individuals by the American Board of Internal Medicine (ABIM).
A shortage of cardiologists has been predicted since the early 1990s, when implementation of the managed care model of health insurance waned. But there has been little subsequent change in number of GME programs, or additional funding for trainee positions. We now have an aging population covered by Medicare needing more medical care, and the Affordable Care Act promises that more young patients will also be able to afford advanced CV health services.
Population aging
Due in some measure to the effectiveness of public health efforts to reduce cigarette smoking and promote other healthy lifestyle changes, and dramatic advances in health care and medical technology, for which we are justifiably proud, the US population continues to age rapidly. The mortality and morbidity from CVD has declined dramatically during the past few decades, although CVD and cancer remain the most common causes of death. In surviving, however, our aging population paradoxically requires ever more medical care.
The number of individuals aged 65 years and older is expected to grow by nearly 50% in the United States during the next decade. Our cardiologists have also gotten older: 43% of general cardiologists were older than 55 years in a recent American College of Cardiology survey. Retirement of baby boomer cardiologists will worsen the shortage of cardiologists available to care for their fellow baby boomers as they enter a prime CVD age group.
Factors of concern
Confounding expert predictions of an absolute shortage of cardiologists is the clear evidence of geographic maldistribution of CV practitioners. Although few cardiology positions are unfilled in major metropolitan areas and wealthy suburban communities, acute shortages exist in many smaller cities and rural communities. The overall numbers of CV interventions performed have plateaued or declined during the past few years, but expectations have risen that patients with acute MI will receive prompt revascularization, even if they live outside major metropolitan areas, and that advanced cardiac care, including sophisticated interventions, will be available to patients with HF, valvular disease and arrhythmias in their community or regional hospitals. There is now high demand in smaller communities for recently trained interventional cardiologists and electrophysiologists.
Also difficult to predict is the role of cardiologists in delivering primary care to patients with advanced CVD. In an era of accountable care, hospitalization may be seen as economically undesirable. Our hospital-centric model of organizing physicians, based in some measure on building and subsidizing outpatient networks to gain referral for profitable procedures in the hospital (“market share = profit margin”), may shift focus to the community setting, where prevention and care of chronic illness dominate. This environment may spur demand for generalist cardiologists to interact with primary care physicians, physician assistants and nurse practitioners, while continued demands for long, intense and continuing training and minimum procedure volumes to maintain competence could result in fewer, but busier, CV proceduralists.
Other concerning factors affecting the future supply of cardiologists include the fact that only one-fifth of CV specialists are women, although they now make up slightly more than half of medical school graduates. Hispanics and African Americans are also under-represented in cardiology. The length of cardiology training, the plethora of sub-subspecialty board examinations and, most recently, concern about the arduous nature of the ABIM maintenance of certification (MOC) requirements to maintain board certification may discourage some for entering or remaining in cardiology. Uncertainty about future ability for cardiologists to generate incomes needed to pay back loans incurred during medical school may also discourage young physicians from entering cardiology. There is some support for shortening the general cardiology-training track after medical school from the current 6 years to 5 years by eliminating one of the 3 years now required for general internal medicine training. This move may be counterbalanced on the other end by our rigorous training standards. The soon-to-be-released Cardiovascular Core Cardiology Training (COCATS) recommendations update will outline the detailed needs for extensive training in the many and growing subspecialty areas of cardiology.
Workforce needs
How will individuals — cardiologists and others — be trained to meet these future demands for CV care? The Institute of Medicine (IOM) of the National Academy of Sciences recently issued a scathing report on GME in the United States, with recommendations nearly on the scale of the Flexner Report of a century ago. Most US GME is now funded by payments from Medicare and Medicaid to hospitals using opaque formulae that have not been substantially revised in nearly 20 years. About $15 billion in public funds supported GME last year. The IOM was especially critical of the lack of accountability of our current hospital-based GME system and a failure to match community and society needs with the type, content, location and number of training positions offered. The IOM proposed gradual implementation of a simpler, more transparent, goal-oriented system of GME funding that includes focus on nonhospital-directed care delivery, emphasizing training of physicians, both primary care and subspecialists, to be better prepared to operate as members of a larger health care team using advanced technology to deliver better, as well as more, care for patients, measure the effectiveness that care and communicate better with patients and with other members of the health care team. The far-reaching and controversial recommendations of the IOM will undoubtedly be a subject of considerable discussion in the months and years ahead.
As with the stock market, looking at past performance to predict future cardiology workforce needs may not accurately anticipate the future environment for cardiology practice. Little did we know in 1977, when Andreas Gruntzig, MD, performed the first coronary angioplasty, that percutaneous CV therapies would be developed into a worldwide standard of care for heart patients, requiring new and innovative training programs for tens of thousands of cardiologists. Programs to reduce cigarette smoking have also had a dramatic effect on the incidence of CVD, as has the development of statins and other drugs. New technologies, new management tools and new developments in the larger health care workforce will all affect the need for cardiologists. Nurse practitioners, health aides, pharmacists, dietitians, psychologists and other non-physicians and team care will make individual physicians more productive. “Team-based” care may well reduce the number of cardiologists needed to deliver high-quality care to more patients. The physician-centered paradigm of cardiac care will likely shift to meet demands for CV care in a manner that is more economically acceptable and sustainable.
The cardiologist of the future
The cardiologist of the future will be called on not only to perform appropriate and effective diagnostic and therapeutic procedures with a high degree of skill and competence, but to also operate as part of a team working in the community setting to reduce and mitigate risks of heart disease, reducing the need for hospitalization and expensive care. One thing is for sure: Our future workforce will be different than our current one.
L. Samuel Wann, MD, MACC, FESC, is a cardiologist at Columbia-St. Mary’s Healthcare in Milwaukee. He is also Section Editor of the Practice Management and Quality Care section of the Cardiology Today Editorial Board. He can be reached at Wisconsin Cardiovascular Group, 2350 N. Lake Drive, Milwaukee, WI 53211; email: samuelwann@gmail.com.
Disclosure: Wann reports no relevant financial disclosures.