ACC survey finds critical shortage of cardiologists now and in the future

Updated: A critical shortage of cardiologists exists today, and will only grow more severe in the future, according to a new report from the American College of Cardiology. The report finds a current shortage of more than 1,600 general cardiologists and nearly 2,000 interventional cardiologists. By 2025 the shortage of general cardiologists could grow to 16,000, and by 2050 the number of practicing cardiologists will need to double.

But not all experts agree that simply increasing the number of cardiologists is the best way to address the underlying problem, and several experts expressed skepticism about the finding that there is currently a shortage in interventional cardiologists.

The full report appears in the September 22, 2009 edition of the Journal of the American College of Cardiology.

“We have a significant shortage of 3,000 cardiologists in the workplace today, and all indicators are that it’s going to get worse if we don’t do something,” said George Rodgers, chair of the ACC Board of Trustees Workforce Task Force and a cardiologist in private practice in Austin, TX, in an ACC press release. At an ACC press conference Rodgers said that assessment of the current shortage was based on an examination of the marketplace demand for cardiologists. “We decided,” Rodgers said, “to let the marketplace decide what the need is.”

The report states that the current shortage is due to a decision in the early 1990s to reduce the number of cardiology training spots by 25% under the assumption that primary care practitioners would take on a larger role in treating heart disease. Other factors contributing to the shortage include a shortage of women and minorities in cardiology, an aging population of cardiologists (>40% of cardiologists are over 55 years of age), and underutilization of non-physician providers.

The report notes that approximately 750 physicians graduate each year from cardiology training programs, half of whom go on to further training.

William Boden, the PI of the COURAGE trial, agreed that there is a growing crisis related to the increasing prevalence of cardiovascular disease, but cautioned that simply increasing the number of cardiologists was not the best solution:

The greatest unmet need is in preventive cardiology and general clinical cardiology. We need to invest more resources there and undertake meaningful healthcare reform such that there are increased incentives to physicians to treat patients to multiple targets for BP, LDL, HDL, BMI, and HgbA1C as we achieved over the long haul in COURAGE.  This is fundamentally the only way to treat a systemic disease–that is, with aggressive systemic treatment and lifestyle intervention–not simply catheter-based intervention. PCI is here to stay, but it treats the more advanced stage of CAD. We need to prevent or forestall the CAD progression and induce regression, if we can. Critics of COURAGE said that the optimal medical therapy was “too good”, or that OMT is “not achievable in the real world”. Rather than lamenting that OMT is hard to achieve, it seems that we need to re-commit to this approach–but also to provide the clinical docs taking care of these patients to have some financial skin in the game, so that they too can participate economically as our procedural brethren have done over the past 2 decades.

Editorial Comment:

There can be little doubt that the lethal combination of aging baby boomers, the obesity epidemic, and the growing success of medical and interventional therapies for CV disease (resulting in more and more survivors of major events) is going to produce a flood of cardiovascular disease in the coming decades, and cardiologists in great numbers will be needed to care for these people. However, that doesn’t mean that the message conveyed by the ACC report should be accepted without scrutiny. It is disturbing that the determination of a current shortage of cardiologists– and in particular, interventional cardiologists– was based on an assessment of the marketplace demand for interventional cardiologists. Employing the same logic it would be easy to conclude that there are “critical shortages” of cosmetic surgeons or, for that matter, drug dealers or malpractice lawyers.

Interventional cardiology, in particular, has been utilized as a seemingly endless font of revenue for many institutions, so it is hardly surprising that institutions compete to build interventional cardiology programs. But, as we learned from William Boden’s COURAGE trial, an aggressive use of interventions is not necessarily always in the best interest of either the patient or the healthcare system. Now if the ACC is acting in the capacity of a cardiologists “union” then it is appropriate for them to seek the most number of jobs at the highest possible salary for their members. But if the ACC is acting in the capacity of a “college” then it has a different responsibility.

The coming “flood” of cardiovascular disease threatens our entire future in much the same way hurricanes threatened New Orleans prior to Katrina. After Katrina flooded New Orleans, thousands of construction workers found work rebuilding the city. But surely it would have been far better if before Katrina the city had reinforced its levees and prevented the disaster in the first place. Similarly, prior to the flood of CV disease we should be devoting resources to prevention, primary care, and population-based efforts to fight obesity and diabetes. More interventional cardiologists may help relieve symptoms, but they will do nothing to prevent the flood from occurring.

Many years ago, when I still smoked, I asked a cardiologist friend if he minded if I had a cigarette during a meal. “Go right ahead,” he told me, “it’s good for business.” Similarly, the coming flood of CV disease might be perceived by some more cynical than myself as being “good for business.” The ACC, and other health organizations, should make every effort to combat that perception.

Here is the press release from the American College of Cardiology:

New Survey Reveals Critical Shortage in Number of Cardiologists Available to Care for Growing Number of Americans with Heart Disease
ACC issues report to sound alarm and outline important solutions

Despite the fact that heart disease remains the leading killer of Americans, there aren’t enough cardiologists to care for these patients, according to a report released today by the American College of Cardiology (ACC). This finding is especially concerning given that the demand for cardiology services is only expected to increase amid an aging baby boomer population, the escalating obesity epidemic and as more people are living longer with chronic heart disease. In fact, based on the new data, authors project the number of practicing cardiologists will need to double between 2000 and 2050 in order to adequately take care of anticipated new cases of heart disease.

“We have a significant shortage of 3,000 cardiologists in the workplace today, and all indicators are that it’s going to get worse if we don’t do something,” said George P. Rodgers, M.D., F.A.C.C., chair of the ACC Board of Trustees Workforce Task Force and a cardiologist in private practice in Austin, TX.

If current trends persist, Dr. Rodgers says there will be 16,000 too few cardiologists in 2050. These estimates are based on the analysis of a survey of employers within private and academic practices—those who hire cardiologists and are keenly aware of the market needs and willing to pay for cardiologist services—to assess whether and how many open positions there are to meet demand and provide quality care, as well as other observed trends in cardiovascular care.

“Patients are surviving heart attacks and are living better and longer with heart disease, which is a good thing, but they will need ongoing cardiac care and surveillance,” Dr. Rodgers said. “Without boosting our supply of cardiologists, we may threaten the incredible progress we have made to date.”

According to ACC, the mortality and morbidity related to heart disease has been reduced by 29 percent over the past 8 years.

The full report, published in the September 22, 2009, issue of the Journal of the American College of Cardiology, also outlines factors that influence physicians to become a cardiologist, the underrepresentation of women and minorities in the field, as well as the lack of an adequate number of training spots and funding.

The current shortage stems from a decision by policymakers in the early 1990s that, with the ushering in of managed care, assumed the family practitioner would be the main gatekeeper for people with heart disease. This resulted in a 25 percent cut in the number of cardiology training spots.

“In reality, we now know family practitioners aren’t comfortable managing complex cardiology patients, and there is considerable evidence that patients with heart attacks, coronary artery disease and chronic heart failure have better outcomes if they are under the care of a cardiologist,” said Dr. Rodgers. “Cardiology ranks among the most highly selected specialties by internal medicine residents, but there aren’t enough spots available and the budget has been set at the current level since the Balanced Budget Act in 1997.”

In addition to the expected demand for cardiology services over the next 20 years and the lack of training opportunities and funding in cardiology, several other issues are fueling experts’ concern:
· More than 40 percent of all cardiologists in the current workforce are over the age of 55 and may retire early for a variety of reasons (e.g., malpractice insurance costs, cuts in reimbursement, arduous call schedules with no opportunity to “wind down” closer to retirement).
· There is an underrepresentation of minorities and women in cardiology; while African Americans and Hispanics comprise 25 percent of the U.S. population, they only represent 6 percent of cardiologists in active practice, and women only comprise 12 percent of cardiologists.
· Non-physician providers are underutilized even though they could help to work up, screen, educate and discharge new patients
· Proposed Centers for Medicare & Medicaid Services cuts in the range of 25 to 42 percent may hinder access to services that have improved countless lives by diagnosing and treating cardiovascular disease

The report offers suggested solutions, including expanding the number of fellowship positions, establishing better work-life balance, reducing known “hassle factors” that may encourage early retirement, creating incentives for underrepresented minorities to consider cardiology, as well as encouraging a team-based approach to cardiology care that leverages the skills and expertise of other non-physician providers (e.g., nurse practitioners, physician assistants).

“We need to advocate for more training spots and funding for cardiovascular specialists and, in the meantime, find creative and more effective ways of delivering care,” said Dr. Rodgers. “Team-based care is a major opportunity for improving the current and future workforce crisis.”

ACC is actively promoting team-based care by working with non-physician providers and practice administrators and through the development of a curriculum and workshop to educate cardiologists about how to work effectively with other providers.

The Workforce Task Force was started by ACC following the 35th Bethesda Conference in 2004. The present survey was conducted by ACC and the American College of Cardiology Foundation with the Lewin Group and the Association of American Medical Colleges to better understand the factors affecting the supply of and demand for cardiologists, the magnitude of the shortage and projected trends.
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The American College of Cardiology is leading the way to optimal cardiovascular care and disease prevention. The College is a 36,000-member nonprofit medical society and bestows the credential Fellow of the American College of Cardiology upon physicians who meet its stringent qualifications. The College is a leader in the formulation of health policy, standards and guidelines, and is a staunch supporter of cardiovascular research. The ACC provides professional education and operates national registries for the measurement and improvement of quality care. More information about the association is available online at www.acc.org .

The American College of Cardiology (ACC) provides these news reports of clinical studies published in the Journal of the American College of Cardiology as a service to physicians, the media, the public and other interested parties. However, statements or opinions expressed in these reports reflect the view of the author(s) and do not represent official policy of the ACC unless stated so.

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