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P E R S P E C T I V E : 
P G P  S T A F F I N G
W E B  E X C L U S I V E   

4 February 2004  
  

Cardiology Workforce: A Shortage, Not A Surplus

An aging population and technological advances are creating
a shortage of cardiologists to meet current and future demand.

By W. Bruce Fye

ABSTRACT:

The United States faces a serious shortage of cardiologists as our population ages and the burden of heart disease grows. The problem is compounded by a cutback in the number of cardiology training positions a decade ago. Dramatic scientific, technological, and procedural advances fueled the growth of cardiology during the second half of the twentieth century. Patients benefited from access to specialists who transformed new knowledge into longer and better lives. Demand for cardiologists is strong and growing. An adequate supply of highly trained cardiologists is necessary to promote discovery and innovation and to help deliver state-of-the-art care to a growing number of cardiac patients.


Jonathan Weiner’s staffing model for benchmarking the nation’s physician workforce, based on patterns in prepaid group practices (PGPs), underestimates the need for cardiologists. Appropriately, he cautions against using this approach “to evaluate the adequacy of the current or projected U.S. physician supply.” It is especially difficult to predict future demand for cardiologists because many cardiovascular diseases are so devastating and the field is so dynamic. No one can deny, however, that the U.S. cardiovascular disease burden is great and growing steadily. Despite a dramatic decline in age-adjusted, heart-related death rates during the past two decades, cardiovascular disease still causes almost 40 percent of all U.S. deaths.¹ Moreover, the current “epidemics” of obesity, type 2 diabetes, and the metabolic syndrome are increasing the burden.

Since its invention as a specialty a century ago, cardiology has been defined mainly by its technologies and techniques. Powerful social and economic forces modulated (and usually fueled) its growth.² A decade ago, however, it appeared that the “managed care revolution” and the Clinton health reform plan would slow cardiology’s expansion by restricting access to specialists. In 1994 Weiner predicted that in 2000 “the supply of specialists will outstrip the requirement by more than 60 percent.”³ Warnings such as this and other factors led to a 20 percent reduction in the number of first-year adult cardiology trainee positions between 1994 (797) and 1999 (635).⁴ However, there is now evidence of a strong and increasing demand for cardiologists.

In 2001, as president-elect of the American College of Cardiology (ACC), I appointed a task force to evaluate the cardiology workforce. In its forthcoming report, the task force concludes that the United States is facing a growing shortage of cardiologists that will impede access to specialty care that is of proven benefit and will undermine our nation’s vital cardiovascular research effort. Weiner lists three approaches to estimating workforce requirements: (1) economic demand, (2) clinical need, and (3) PGP staffing. The task force focused on the first two.

There are many jobs for practitioner and academic cardiologists in most U.S. regions. About 40 percent of U.S. hospitals with 100 or more beds are seeking cardiologists, and about half of these institutions think that it is “very hard” to recruit them.⁵ A 2002 ACC survey revealed that job prospects for senior fellows were excellent and had greatly improved in the past five years. Recruiters were finding it very (76 percent) or somewhat difficult (21 percent) to fill cardiology positions. The ACC Practice Opportunity Line, a Web-based job database, had 597 listings as of January 2004.

Weiner also comments on physician distribution. Cardiologists, like other physicians, are not distributed equally across the nation. David Wennberg and John Birkmeyer estimated that in 1996 there were an average of 6.3 cardiologists per 100,000 U.S. residents, but the numerator varied from 2.7 to 11.3 across Hospital Referral Regions (HRRs).⁶ Many factors determine the market for cardiologists in specific locations, and there is no central mechanism to influence their distribution.⁷ With respect to physician ratios, Weiner notes “interesting variations” among the PGPs he studied (Kaiser Permanente, Group Health Cooperative, and HealthPartners). His Exhibit 2, for example, reveals that these PGPs employ about half as many cardiologists and almost twice as many hematologist-oncologists compared with national averages. Importantly, two-thirds of the PGPs he studied do not employ cardiothoracic surgeons (cardiology’s surgical twin). This makes one wonder how many patients received care from cardiologists not employed by these groups.

Elsewhere, I have argued that, on balance, several scientific, social, and demographic “demand catalysts” outweigh factors that might decrease demand for cardiologists during the next decade.⁸ These include (1) an aging population with more chronic cardiac patients living longer; (2) the “epidemics” of obesity and type 2 diabetes, leading to more cardiovascular disease; (3) evidence that heart patients have better outcomes if they receive at least part of their care from a cardiologist; (4) the demise of the gatekeeper model; (5) a better-informed public with growing expectations about their health care; (6) growing awareness among women that they are more likely to die from cardiovascular disease than cancer; (7) continuing technological and procedural innovations and their rapid diffusion into practice; (8) more widespread use of cardiovascular screening tests that result in more referrals and procedures; and (9) progressive subspecialization within cardiology, which results in more “internal” referrals.

Turning to clinical need, several studies have shown that patients with cardiac problems have improved outcomes if part of their care is provided by a cardiologist.⁹ Although Weiner claims that his study shows that “organized PGPs…provide high-quality, cost-effective care to a diverse insured population with considerably fewer physicians than are now available in the nation at large,” he does not include data or references to support this statement. Meanwhile, in cardiology, clinical trial results in patients with acute myocardial infarction, heart failure, or at high risk of sudden cardiac death are driving the demand for cardiologists, including procedurally oriented subspecialists.

Cardiology evolved during the past generation into several well-defined subspecialties such as interventional cardiology and clinical cardiac electrophysiology. This adds to the challenge of projecting the need for cardiologists. Percutaneous transluminal coronary angioplasty (PTCA), for example, was invented in 1977 as an alternative to coronary artery bypass graft (CABG) surgery for treating angina pectoris. The earliest technique employed a balloon-tipped catheter to open blocked vessels. The term percutaneous coronary intervention (PCI) is now used to denote several catheter-based techniques for opening blocked blood vessels.

Between 1979 and 1985 the number of PCIs performed in the United States skyrocketed from 2,000 to 82,000.¹⁰ This stunning growth reflected the fact that during this brief interval, many of the nation’s thousands of invasive cardiologists transformed themselves into interventionalists by attending brief demonstration courses or by being mentored by a colleague who had already done so. The clinical efficacy and reimbursement implications of PCI, coupled with the lack of formal training requirements in the 1980s, resulted in what I call the “ballooner-boomer” phenomenon.

Most physician workforce projections now reflect the impact of the baby-boomer generation, but cardiology workforce evaluations have overlooked the ballooner-boomer phenomenon. Within a decade most of the ballooner boomers active before 1985 will no longer perform interventional procedures. Meanwhile, the demand for interventionalists has been stimulated by a series of procedural innovations, technological advances, and clinical trial results. Although more than a half-million patients had a PCI procedure in 2000, there are only 213 accredited training positions in interventional cardiology today.¹¹ This sets the stage for a major demand-supply mismatch with important implications for patient outcomes.

One might assume that the most obvious solution to the growing shortage of cardiologists is to increase the number trained. The ACC task force report explains why this will be difficult. It includes several recommendations to help address the problem, but coordination among several organizations and regulating bodies will be necessary if the supply of cardiologists is going to meet the demand for their specialized services in the coming years.

NOTES

1. American Heart Association, Heart Disease and Stroke Statistics—2004 Update, 3, www.americanheart.org/downloadable/heart/1072969766940HSStats2004Update.pdf (21 January 2004).
2. W.B. Fye, American Cardiology: The History of a Specialty and Its College (Baltimore: Johns Hopkins University Press, 1996).
3. J.P. Weiner, “Forecasting the Effects of Health Reform on U.S. Physician Workforce Requirement: Evidence from HMO Staffing Patterns,” Journal of the American Medical Association 272, no. 3 (1994): 222–230.
4. American Board of Internal Medicine, “Summary of Workforce Trends in Internal Medicine Training, Academic Years 1994/1995 through 2001/2002, Number of First Year Fellows by Subspecialty,” www.abim.org/Workforce/Fellsubtrain.htm (9 January 2003).
5. Merritt, Hawkins, and Associates, “Summary Report: 2003 Survey of Hospital Physician Recruitment Trends,” www.merritthawkins.com/merritthawkins/pdf/2002_hospital_trends.pdf (21 January 2004).
6. D.E. Wennberg and J.D. Birkmeyer, The Dartmouth Atlas of Cardiovascular Care (Hanover, N.H.: Dartmouth College, 1999).
7. U.E. Reinhardt, “Dreaming the American Dream: Once More Around on Physician Workforce Policy,” Health Affairs (Sep/Oct 2002): 28–32.
8. W.B. Fye, “Cardiology Workforce: There’s Already a Shortage, and It’s Getting Worse,” Journal of the American College of Cardiology 39, no. 12 (2002): 2077–2079.
9. See, for example, P. Jong et al., “Care and Outcomes of Patients Newly Hospitalized for Heart Failure in the Community Treated by Cardiologists Compared with Other Specialists,” Circulation 108, no. 2 (2003): 184–191; A. Ahmed et al., “Association of Consultation between Generalists and Cardiologists with Quality and Outcomes of Heart Failure Care,” American Heart Journal 145, no. 2 (2003): 1086–1093; and M. Ansari et al., “Cardiology Participation Improves Outcomes in Patients with New-Onset Heart Failure in the Outpatient Setting,” Journal of the American College of Cardiology 41, no. 1 (2003): 62–68.
10. American College of Cardiology, Cardiovascular Specialists and the Economics of Medicine (Bethesda, Md.: ACC, 1994), 64, Figure 8.1.
11. Accreditation Council for Graduate Medical Education, “List of ACGME Accredited Programs and Sponsoring Institutions,” www.acgme.org/adspublic (8 January 2003).

Bruce Fye (Fye.bruce{at}mayo.edu) is a professor of medicine and the history of medicine at the Mayo Clinic College of Medicine in Rochester, Minnesota, and immediate past president of the American College of Cardiology.

Please click on the author's names to read related papers by Jonathan Weiner, Francis Crosson, David C. Goodman, Fitzhugh Mullan, Edward Salsberg and Gaetano Forte, and Stephen C. Schoenbaum.

DOI: 10.1377/hlthaff.W4.64
©2004 Project HOPE–The People-to-People Health Foundation, Inc.