Cardiologists pump up efforts to avert shortage

The schedule at the office of cardiologist John Hayes, MD, is jam-packed. His staff at Wisconsin's Marshfield Clinic double-books his schedule and squeezes in patients at the end of the day just to keep up with demand.

All 22 cardiologists who work at Dr. Hayes' multisite clinic face the same pressures.

"People are pretty much maxed out. There's only so much you can do in a day," said Dr. Hayes, who is chair of the clinic's cardiology department. "You want to make sure people don't have to wait too long, particularly since many things we do are urgent."

Dr. Hayes is looking to hire five more cardiologists now and three more over the next three years in anticipation of population growth in the region as well as an increase in the number of older patients and the number of patients with obesity-related heart disease -- two factors not unique to Wisconsin.

"When you talk to colleagues in other parts of the state or the country, everyone has the same pressures of trying to fill positions," Dr. Hayes said. "It's an ongoing stress to say the least. You feel you could accomplish so much if you had the critical number of people to do it."

While there are anecdotal reports of regional shortages, a study that appeared in the Journal of the American College of Cardiology in 2000 estimated that this cardiology shortage would become widespread during the 2010s and 2020s as heart disease strikes the aging baby boom generation at the same time baby boomer cardiologists are retiring.

And a 2003 Merritt, Hawkins & Associates survey found that 40% of hospitals with 100 or more beds were seeking cardiologists, and half found they were "very hard" to recruit.

Dr. Hayes, who has never had an easy time recruiting, said the situation is getting much worse.

"We're in a rural area in the upper part of the Midwest, and by that situation alone it's hard to attract good candidates," he said. "But with the shortage, the market has become very competitive, and over time it seems to be getting more and more difficult to recruit cardiologists. I don't see any end in sight."

A battle plan

To combat this problem, theAmerican College of Cardiology has developed a multipronged strategy to increase the production of cardiologists.

The most controversial recommendation is one seeking to shorten training for general cardiologists from six years to five. A short-track residency, the ACC believes, would help meet the expanding need for long-term management of chronic heart disease.

"We need to figure out ways to make general clinical cardiology more attractive. One way to do that is to take away one year of training that's not necessarily pertinent," said W. Bruce Fye, MD, past president of the ACC.

Residents in cardiology programs now spend three years in internal medicine, followed by three years in cardiology. They then can opt for an additional year in a subspecialty.

The ACC would like to add an alternative five-year program that eliminates the third year of internal medicine and cuts out training in the high-tech cardiology procedures.

The money saved by cutting out that year could be used to train more cardiology residents or fellows, according to the ACC. More cardiologists would be turned out over time, and such a program would attract medical graduates who might be turned off by either the length of the six-year program or the high-intensity lifestyle of a proceduralist.

But the cardiologists' gain would be the internists' loss, Dr. Fye conceded. Residents would spend two years in internal medicine instead of three, leaving internal medicine residencies short on third-year housestaff who handle the bulk of patient care.

Making changes rarely simple

Steve Fihn, MD, MPH, a past president of the Society of General Internal Medicine and a professor of medicine and health services at the University of Washington School of Medicine, has not seen the ACC's recommendations.

Still, he said to be successful in getting support for a five-year general cardiology residency, the ACC would need to show what additional skill set these residents would be acquiring that they wouldn't get in internal medicine.

"Presuming they don't take on technical skills, what's left is a lot of basic general internal medicine," Dr. Fihn said. "They might be more proficient at interpreting cardiological information, but what exactly are we talking about in terms of the content?"

The ACC has initiated talks with a teaching institution to pilot this model, but it won't get off the ground without the American Board of Internal Medicine granting board eligibility to graduates.

Lynn Langdon, senior vice president and chief operating officer for the ABIM, said making one change within the complicated health care system is rarely simple. Before the ABIM would approve a change for any program, the board, which includes representatives from all of the branches within internal medicine, would seek guidance from relevant member societies and the pertinent resident review committees of the Accreditation Council for Graduate Medical Education.

"Such a decision would not be made by cardiology alone," she said.

The ACC plan also calls for increased federal funding to expand first-year residency slots and the development of training models for practicing internists who want to become board-certified in cardiovascular disease.