SURVEY REPORT
ACC 2009 Survey Results and Recommendations: Addressing the Cardiology Workforce CrisisA Report of the ACC Board of Trustees Workforce Task Force
George P. Rodgers, MD, FACC, Chair, ACC Board of Trustee Workforce Task Force,
Jamie B. Conti, MD, FACC, ACC Board of Trustee Workforce Task Force,
Jeffrey A. Feinstein, MD, FACC, ACC Board of Trustee Workforce Task Force,
Brian P. Griffin, MD, FACC, ACC Board of Trustee Workforce Task Force,
Jerry D. Kennett, MD, FACC, ACC Board of Trustee Workforce Task Force,
Svati Shah, MD, MHS, FACC, ACC Board of Trustee Workforce Task Force,
Mary Norine Walsh, MD, FACC, ACC Board of Trustee Workforce Task Force,
Eric S. Williams, MD, FACC, ACC Board of Trustee Workforce Task Force and
Jeffrey L. Williams, MD, MS, FACC, ACC Board of Trustee Workforce Task Force
Key Words: ACC survey report • workforce • physicians, cardiologist • nonphysician practitioner • professional practice
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Table of Contents
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- 1 Introduction......1195
- 2 Methods......1196
- 3 Results......1197
- 3.1 Current Supply......1197
- 3.1.1 International Medical Graduates......1197
- 3.1.2 Women......1198
- 3.1.3 Underrepresented Minorities......1198
- 3.1.4 Subspecialty Choice......1201
- 3.2 Current Demand......1201
- 3.2.1 Retirement and Workforce......1202
- 3.2.2 Practice Efficiency......1202
- 3.2.2.1 Employment of Nonphysician Practitioners......1202
- 3.2.2.2 Alternative Work Schedules......1203
- 3.2.3 Projections......1203
- 3.2.3.1 Demand Drivers......1203
- 3.2.3.2 Supply Drivers......1203
- 4 Recommendations......1204
- 4.1 Advocacy......1204
- 4.2 ACC Initiatives......1205
- Acknowledgments......1206
- Appendix 1. ACC/MedAxiom Cardiology Practice Survey Methodology......1206
- Author and Peer Reviewer Disclosures......1206
- References......1207
- Related References......1207
- Related Resources......1208
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1. Introduction
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The prevalence of cardiovascular disease (CVD) is increasing by 1% to 2% per year, and will continue to do so over the next 2 decades (1). The American Heart Association predicts that by 2020, at least 20 million more people in the United States will be afflicted with heart disease than there were in the year 2000. The U.S. population is projected to increase across all age groups over the next 2 decades with the most rapid growth amongst those age 65 and older. Between 2000 and 2010, growth in the population age 65 to 84 years has been about 1% annually. Between 2010 and 2020, this jumps to 3.3% annually. Since age is a significant factor in the risk for CVD, the need for CVD care will rise substantially as the population ages. Several studies have shown that cardiovascular (CV) specialists have played a pivotal role in the improvement of CV mortality (2,3). Although CV mortality rates should continue to fall, deaths from heart disease are projected to increase 128.5% from 2000 to 2050. Using the death rate alone as a rough estimate of workforce needs, these statistics suggest a doubling of CV specialists is necessary between 2000 and 2050. Thus, there will be an inadequate supply of CV specialists to care for these new CV patients.
The American College of Cardiology's (ACC) focus on workforce issues is not new. In 2001, under the leadership of Dr. Bruce Fye, the College led the nation in identifying workforce shortages as a concern. Years of effort in this arena resulted in the publication of the 35th Bethesda Conference: Cardiology's Workforce Crisis: A Pragmatic Approach (4), which outlined several reasons for the anticipated shortage: 1) The incidence and prevalence of CVD was projected to increase substantially in the future owing primarily to demographic and lifestyle trends in the United States. This is related to the increasing age of the population, obesity, type 2 diabetes, and the incidence of the metabolic syndrome. 2) As CV mortality decreases due to prompt and optimal care, the size of the population of patients with chronic CVD, especially heart failure, is increasing. 3) Additionally, adults with congenital heart disease are now surviving to an older age and contribute at least an additional 1 million to the number of patients in need of care. 4) The number of physicians training to be CV specialists decreased by about 20% during the 1990s in direct response to the government prediction in the 1980s that the demand for highly technical specialties would dramatically diminish as more patients were cared for by generalists. 5) As a result, the size of CV training programs decreased and the output of cardiologists decreased from 800 to 710 per year.
In addition to the resultant decrease of cardiologists in the "pipeline," cardiologists may retire early, for a variety of reasons including increasing cost of malpractice insurance, billing issues, documentation requirements, reimbursement and financial considerations, and work-life balance. Even if efforts began today to rectify the training shortage, a significant difference in the output of board-eligible CV specialists would not be seen for 5 years.
In view of this anticipated workforce shortfall, the ACC and the American College of Cardiology Foundation (ACCF) asked The Lewin Group* and the Association of American Medical Colleges (AAMC) to conduct another workforce study of cardiologists to better understand the factors affecting the supply of and demand for cardiologists. In particular, the study was intended to provide answers to the following questions: - What is the appropriate methodology for tracking CV workforce trends over time?
- What factors influence physicians to enter the field of cardiology, subspecialize within cardiology, pursue part-time work, retire, and remain in the workforce?
- How would the cardiology community respond to the infusion of nonphysician practitioners and/or additional cardiologists into the workforce?
- What impact do international medical graduates have on the cardiology workforce?
- What impact would incremental reductions of income have on the cardiology workforce?
- How will the composition of the workforce change over time with respect to women and underrepresented minorities?
- What can the ACC do to maximize the efficiency of the cardiology workforce?
This report presents the results of this workforce study, a synthesis of its findings related to these questions, and recommendations for workforce change and development.
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2. Methods
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Following the published results of the ACC 35th Bethesda Conference (4), a task force was created to further evaluate CV workforce issues and make recommendations. The ACC and the ACCF contracted with The Lewin Group and the AAMC to conduct an analysis of the factors affecting the cardiology workforce. A variety of methods were used. - • Current supply and projections of future supply over the next 20 years were based on analysis of the American Medical Association (AMA) Masterfile, analysis of retirement patterns in the AAMC Over 50 Survey, and data on residency training programs and subspecialization trends.
- • Demand data were obtained from the ACC Academic Practice, Pediatric Practice, and Private Practice surveys that asked practices to identify the number of positions they are currently seeking to fill with CVD specialists.
- • The Lewin Group's Physician Supply and Demand Model, which has the capability to project supply of and demand for physician services under alternative scenarios, was used to project CV specialist workforce needs over the next 20 years.
- • Quantitative analysis of specialty choice based on observations of internal medicine program graduates in the AMA Masterfile between 1991 and 2004
 was performed to understand subspecialty choice. A multinomial logistic regression model was used to model the influence of factors such as compensation and length of training on the choice between practicing internal medicine or subspecializing in 1 of 9 subspecialties.
- • The Lewin Group relied heavily on national databases including the Medicare Part B analysis file, a United Health Group commercial claims database known as the Research Data Mart File, the National Ambulatory Medical Care Survey, the National Inpatient Sample, physician specialty surveys, AMA Socioeconomic Statistics, the National Residency Match program database, and Medical Group Management Association Physician Compensation and Production Survey, as well as physician survey data and focus groups.
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3. Results
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3.1 Current Supply.
The challenges of assessing and predicting workforce needs begin with determination of the size and characteristics of the current supply of cardiologists—their numbers, types of clinical activity, geographic distribution, and how long they intend to remain clinically active. Supply is also directly affected by the number of new entrants into the workforce from the CVD training programs.
To assess the current supply of cardiologists in the United States, The Lewin Group/AAMC CV workforce study began with the AMA Masterfile. Because the goal is to identify active cardiologists, and there can be a lag between retirement or level of activity and its designation in the Masterfile, the numbers of cardiologists were adjusted. The adjustment algorithm was derived from an independent activity survey performed by the AAMC and specialty societies, of cardiologists over age 50 years, to estimate likelihood of retirement or clinical activity change. Based on the adjusted data, there are currently 25,901 active cardiologists, 64% of whom are general cardiologists (based on board eligibility or certification; see Fig. 1).
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Figure 1 Current Supply: Number of Active Board-Certified or Board-Eligible Cardiologists by Specialty, 2008
Lewin Group analysis of the American Medical Association Masterfile with adjustment for underreporting of retirements. Reprinted from the Cardiovascular Workforce Assessment (5).
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It is important to note that more than 40% of general cardiologists are age 55 years or older (Fig. 2). Given the size of this group, their decisions about timing and type of retirement (as well as their opportunities for continuing clinical activity) will have an important impact on the cardiology workforce. Not surprisingly, the percentages of board-certified interventional cardiologists and electrophysiologists over age 55 years are less, 20% and 13%, respectively. About 30% of pediatric cardiologists are over age 55 years. This information does not reflect practicing non–board-certified individuals.
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Figure 2 Number of General Cardiologists by Age and Sex, 2008
Lewin Group analysis of the American Medical Association Masterfile with adjustment for underreporting of retirements. Reprinted from the Cardiovascular Workforce Assessment (5).
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The geographic distribution and concentration of cardiologists vary widely. Indeed, some have suggested that maldistribution is a more important workforce challenge than the total number of physicians (Fig. 3).
The most quantifiable factor affecting workforce is the number of new cardiologists entering the workforce via the 179 CVD training programs approved by the Accreditation Council for Graduate Medical Education (ACGME). Following a decline in the early 1990s, the number of CV trainees has increased by a modest amount recently but remains below historic high levels. About 750 physicians now graduate from general CVD training programs yearly. Nearly one half now obtain further training in interventional cardiology or clinical cardiac electrophysiology.
The number of approved training positions in CVD programs is established by the ACGME, based on criteria principally related to the educational resources (e.g., faculty and patient base) and quality of the programs. Many quality training programs have the educational resources to increase the number of trainees. However, the financial resources are limiting, due largely to the "freezing" of the number of Centers for Medicare and Medicaid Services-funded post-graduate positions by the 1997 Balanced Budget Act. A proposal to increase the number of Centers for Medicare and Medicaid Services-funded positions is under consideration.
3.1.1 International Medical Graduates
International medical graduates (IMGs) comprise about 30% of the total cardiology workforce though this varies to a small extent across the subspecialty areas. The Lewin Group/AAMC analysis of IMGs who trained in CV medicine in the United States between 1999 and 2000 and between 2002 and 2003 suggests that 97% remained in the United States after the completion of training. Additionally, a survey of fellows finishing CV medicine in New York State from 2001 to 2007 found that less than 5% of IMGs left the country at the end of training. IMGs make up about the same proportion of the cardiology workforce as they do for internal medicine and its subspecialties overall. The proportion of IMGs in cardiology has remained relatively stable over the period from 1995 to 2007. The Lewin Group's quantitative model analyzing the factors influencing subspecialty choice among internal medicine program graduates in the AMA Masterfile found that IMGs were relatively unaffected by specialty compensation level or length of training in deciding on cardiology as a career. Length of training was a more important factor driving subspecialty selection in other groups. However, analysis of the AAMC/Specialty Society Over 50 Survey indicates that IMGs are more likely to remain active in practice longer than U.S. graduates and to work full time to an older age. Why this is has not been addressed nor have the determinants of work satisfaction in the IMG group. Although the supply of IMGs to the U.S. cardiology workforce has been stable in recent decades, it is conceivable that changing economic and regulatory conditions both in the United States and globally may substantially affect this in the future. Thus, improving economic conditions and increased demand for cardiovascular services in the home countries of IMGs such as India or a worsening economic environment in the United States might diminish the attractiveness of the United States as both a training and a career destination for IMGs. Additionally, as IMGs represent a potential economic loss to their native country, it is conceivable that regulations in the United States or in countries providing IMGs may be altered to ensure that a greater proportion of IMGs return home to pursue their lifelong careers after training here.
3.1.2 Women
Women comprise a very small proportion of all cardiologists—about 12% of general cardiologists (Fig. 2) and less than 10% of interventional cardiologists and clinical cardiac electrophysiologists. Pediatric cardiology is an exception, where nearly 30% of pediatric cardiologists are women. A substantial pool of potential female candidates for a career in CV medicine currently exists. About 50% of medical students and internal medicine residents are women. Focused efforts have significantly increased the representation of women in subspecialty training in cardiology over the past 10 years from 10% in 1996 to 18% in 2004 (6,7).
The 2008 ACC survey report, A Decade of Change in Professional Life in Cardiology (6), has shed light on several issues that impact the choice of a career in cardiology for women. As seen across a broad spectrum of professional women, fewer women than men in cardiology are married or have children. In addition, the majority of women in cardiology continue to experience discrimination. More women (69%) reported having experienced discrimination during their career compared with 22% of men (p = 0.0001). Women reported that the discrimination was because of sex (65% versus 1% of men, p = 0.0001) or parenting responsibilities (27% versus 1% of men, p = 0.0001). Men and women reported similar levels of discrimination from racial (10% of men versus 9% of women) and religious reasons (8% of men versus 4% of women).
For both female and male trainees, work-life balance is an important factor in career and job decisions. In the 2008 survey (6), 80% of women and 82% of men reported working full time; this represents an absolute decrease of 6% for women and 13% for men compared with a similar survey in 1996 (8). Occupational exposure to radiation is an issue for both men and women. However, female cardiologists reported making more changes in their training and careers to reduce radiation exposure. The majority of women did not perform fluoroscopic procedures while pregnant. Furthermore, one fourth of women specifically selected career tracks to reduce their radiation risk.
Importantly, the survey demonstrated that overall satisfaction with cardiology as a career has remained high for both men and women. Women's career satisfaction appears to have increased from 80% in 1996 to 90% currently, now equaling the level reported by men (8).
3.1.3 Underrepresented Minorities
Representation of minorities in health care professions has not kept pace with the changing demographics of the general U.S. population, thereby potentially creating even greater health care disparities in delivery and outcomes. These disparities are equally if not more pronounced in CVD. In an effort to increase diversity in America's health professions' education training programs, the Sullivan Commission on Diversity in the Healthcare Workforce released its findings in September 2004 (9). This report emphasized the need for leadership, commitment, and accountability at the highest levels to give urgency and focus to the problem, and included many strategies for increasing representation of minorities in the health care profession, including making health professions' education more affordable for minority students and shifting from student loans to scholarships. Germane to CVD, one of the charges of the ACC Board of Trustees Workforce Task Force was to address issues related to workforce diversity. Therefore, a more detailed assessment of issues related to minorities in the CV workforce was conducted.
Despite constituting approximately one quarter of the U.S. population, underrepresented minorities, including black, Hispanic, and Native American individuals, account for only 6% of practicing physicians as suggested by data collected by AAMC. In 2006 to 2007, black and Hispanic fellows represented about 13% of internal medicine residents and 10% of cardiology fellows. Barriers to pursuing careers in health care encountered by under-represented minorities include burdens in financing education and lack of mentorship. Studies have shown that underrepresented minority physicians are more likely than non-Hispanic white physicians to work in facilities and communities designated as health professional shortage areas, thereby potentially improving access, quality of care, and patient satisfaction for minority patients (10) (Figs. 4 and 5). There is a higher percentage of black trainees in cardiology fellowships than in the other internal medicine subspecialties, though this percentage remains consistently lower than those in the internal medicine graduate population as a whole. Although cardiology previously attracted a share of Hispanic fellows similar to the proportion of Hispanic residents completing internal medicine training, in the last several years the percentage of Hispanic internal medicine residents has increased while the proportion of Hispanic cardiology fellows has not increased.
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Figure 4 Distribution of Black Cardiologists and Population by Core-Based Statistical
Cardiologists are nonpediatric (either as a primary or secondary specialty), active U.S. medical doctors practicing in the United States. Black population is Hispanic and non-Hispanic black population 15 years of age or older. Reprinted from the Cardiovascular Workforce Assessment (5). CBSA = core-based statistical area.
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Figure 5 Distribution of Hispanic Cardiologists and Population by Core-Based Statistical Area
Cardiologists are nonpediatric (either as a primary or secondary specialty), active U.S. medical doctors practicing in the United States. Population is 15 years of age or older. Reprinted from the Cardiovascular Workforce Assessment (5). CBSA = core-based statistical area.
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In exploring reasons underlying these disparities, our assessment found that program directors had few formal programs for attracting underrepresented minorities. Although an indicator for race/ethnicity was not available in the specialty choice analyses, we used an indicator for historically black colleges/universities (HBCU) as a proxy for black internal medicine program graduates. Regression results indicated that internal medicine graduates who attended HBCU are more sensitive to length of training relative to others when they make their subspecialty choice decisions, resulting in HBCU graduates being more likely to remain in primary care than their counterparts. While the underlying reasons may be difficult to tease out, these differences may be attributable to financial barriers that may make it more difficult for HBCU graduates to complete longer training programs.
3.1.4 Subspecialty Choice
Many factors enter into the complex issue of choosing a specialty including length of training, compensation, declining reimbursement, and work-life balance. Recent surveys have highlighted the importance of work-life balance and have speculated that fellows often seek employment in larger practices where call time is shared and practice management duties are limited.
We used a discrete choice regression approach to model the factors influencing the subspecialty choice among internal medicine program graduates. Data from the AMA Masterfile on the choices made by all internal medicine graduates between 1991 and 2004 were used to estimate the model. The model allowed internal medicine graduates completing their residency in this period to choose to practice primary care in internal medicine or to choose to pursue fellowship training in 1 of 9 internal medicine subspecialties. Figure 6
displays the number of internal medicine graduates pursuing primary care; Figure 7
displays the number of internal medicine graduates pursuing subspecialty medicine.
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Figure 7 Number of Internal Medicine Graduates Pursuing Cardiology and Selected Other Subspecialties
Reprinted from the Cardiovascular Workforce Assessment (5). Card = cardiology; Gastro = gastroenterology; IM = internal medicine; Neph = nephrology.
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3.2 Current Demand.
Current and projected demand estimates were based on multiple sources of data and a number of factors. Surveys of academic and private practice administrators were used to determine current and short-term (3-year) needs. Long-term projections were derived using multiple factors including, but not limited to, the services provided by cardiologists and the effects of competition from noncardiologist health care providers managing CV conditions (e.g., hypertension and hyperlipidemia). Subgroup analysis was also performed for general cardiology, interventional cardiology, clinical electrophysiology, and pediatric cardiology.
According to practice surveys, the overall demand for cardiologists in total and each of the 4 secondary specialty subgroups far exceeds the supply, currently and in the short term (Table 1). While data from the National Residency Match Program suggest an adequate supply for adult and pediatric cardiologists (with the ratios of applicant to available fellowship position for adult and pediatric CVD training at 1.8 and 1.3, respectively), overall demand remains far greater than the current number of fellows completing training annually.
Longer-term demand is subject to the influence of many different forces and is more variable within subgroups. The demand for cardiologists can be impacted by a wide spectrum of forces ranging from external forces to the natural development of the specialty. Economic and societal factors such as economic growth and health insurance policy changes can positively or negatively affect the demand for cardiologists. CVD prevalence and thus demand for clinical care are increased by the aging of the population, the growing prevalence of obesity and type 2 diabetes, and the improved survival of cardiovascular patients as attributable to optimized medical management, mortality benefits of device interventions, and improved congenital surgical outcomes. Furthermore, as advances are made in cardiovascular diagnostic and therapeutic technologies, there will be a growing need for cardiologists adept at those specific skills. An alternative way to evaluate the utilization of and, indirectly, demand for cardiology services is to analyze trends in payments to cardiologists. This analysis shows that nonevaluation and nonmanagement (i.e., procedural) services are growing at a faster rate than evaluation and management services. However, payments for general cardiology services are growing faster than those for adult cardiology subspecialties for both the Medicare population and the privately insured population under the age of 65. Finally, payments to pediatric cardiologists per member per month grew 8.8% annually between 2003 and 2006, representing substantial increases in recent demand.
Some of these methodologies may not apply to pediatric cardiology due to the small sample size in our survey. Of note, 30% or nearly 800 pediatric cardiologists are expected to retire within the next 10 years. In addition, the increased survival rates in patients with complex congenital heart disease and the emergence of fetal cardiology over the past 2 decades has dramatically increased the number of patients with chronic disease cared for by pediatric cardiologists or adult congenital heart disease specialists. While we currently do not have data about the trends/patterns regarding subspecialization in pediatric cardiology, there is no doubt that geographic disparities will be a tremendous issue in the appropriate care and management of congenital heart patients. If all these assumptions are correct, we will be short of pediatric cardiologists in 2025.
3.2.1 Retirement and Workforce
A significant portion of practicing cardiologists are of, or near, retirement age. Forty-three percent of general cardiologists, 31% of pediatric cardiologists, and 21% of interventional cardiologists are over the age of 55 years. Retirement rates will thus play a critical role in the supply of cardiologists in the near future. While over 50% of cardiologists, even those older than 75 years, remain clinically active in some fashion, multiple factors contribute to early retirement. Personal health issues, lack of professional satisfaction, and insufficient reimbursement are the most often cited reasons for early retirement. On-call responsibilities and increased regulation in medicine, including requirements for recertification, may also play a major role in the timing of retirement. While the current economic recession may force many older cardiologists to delay retirement, reduction in clinical activity is becoming a growing alternative to retirement. More than 65% of current cardiologists surveyed, regardless of age, indicated they either are working part-time or would be interested in doing so prior to retirement.
Based on analysis of the AAMC/Specialty Society Over 50 Survey, the workforce assessment indicated there was a gap between cardiologists' interest in working part-time and the availability of part-time opportunities. Among those age 50 and older, relative to other medical specialists, cardiologists have a similar level of interest in working part-time, but are less likely to find those types of opportunities. The cost of malpractice insurance, in some areas, may play a role in the availability of part-time practice.
Since a large percentage of cardiologists remain in good health even in their seventh and eighth decades of life, with only 11% between the ages of 60 to 69 years reporting fair or poor health and 19% of those 70 years and above reporting the same, there appears to be great potential to utilize this 80% to 90% of older cardiologists in the workforce. Addressing the gap between desire for and availability of part-time work among cardiologists might well result in later retirements and significantly contribute to ways to address the growing cardiologist workforce deficit.
In summary, the Lewin/AAMC report indicated that age, health status, professional satisfaction, and financial status were key factors in cardiology retirement decisions. Whereas anecdotal evidence suggests the current recession may delay retirements by some cardiologists, health care reform with potentially greater regulation and emphasis on outcomes could have opposite effects not really quantifiable at present.
3.2.2 Practice Efficiency
The current and anticipated shortage of cardiologists calls for a careful analysis of methods to provide patient care more efficiently. There is substantial variation in cardiology practice characteristics related to clinical staffing (e.g., number of physicians, utilization of part-time physicians and/or nonphysician practitioners) and practice operation and management (e.g., multispecialty versus single specialty, number of offices, use of part-time or outreach offices, ownership type, practice setting). Data from the 3 ACC surveys—adult private practices, pediatric practices, and academic practices—were analyzed to elucidate the effects of practice characteristics on clinical productivity.
3.2.2.1 Employment of Nonphysician Practitioners
All practices were asked to report either the number of relative value units as a standard metric of work per full-time equivalent (FTE) physician or gross revenues per FTE physician. These practices were further asked whether or not they employed nonphysician practitioners (nonphysician professional providers). Although state regulations differ with regard to scope of practice of nonphysician practitioners and may thus have influenced practices' employment of these individuals, data were not stratified according to state.
Overall, larger private practices were more likely to have nurse practitioners (NPs) or physician assistants (PAs) with 90% of practices with more than 10 cardiologists reporting employment of nonphysician practitioners. However, among practices using NPs and PAs, the ratio of nonphysician practitioners to physicians was much higher in the smaller practices.
Some groups surveyed found that nonphysician providers generate one third of the relative value units of an FTE cardiologist, and NPs and PAs generate gross revenues 3 to 4 times greater than their incomes. Such favorable economics suggest that greater utilization of nonphysician practitioners can enhance practice efficiency. Many practices surveyed did not indicate any use of nonphysician practitioners. Moreover, larger practices on average had lower ratios of nonphysician practitioners per physician than smaller practices employing NPs and PAs. There are many opportunities then for increased utilization of nonphysician practitioners.
3.2.2.2 Alternative Work Schedules
There appears to be a gap between cardiologists' interest in working part-time and availability of part-time opportunities for cardiologists. In the 2008 published survey, A Decade of Change in Professional Life in Cardiology (6), only 9% of female and 6% of male cardiologists reported working part-time. Compared with a similar survey a decade ago, the number of women who are working less than full time is unchanged, but the number of men in part-time practice appears to have doubled.
3.2.3 Projections
3.2.3.1 Demand Drivers
Our study evaluated 5 major drivers of demand: demographics, lifestyle, economic growth, expansion of insurance coverage (health system reform), and technological advances. Without question, the increase in population over 64 years old due to the baby boomers will affect the demand for CV services in the near future. In the age group of 65 to 84 years, there was a 1% increase per year in the decade between 2000 and 2010. Between 2010 and 2020, there will be a 3.3% increase per year in this age group due to the baby boomer generation.
Lifestyle will no doubt be a major driver as well. Although American society has reduced the effects of secondary smoke and there has been an overall slight decrease in cigarette smoking, an even greater problem looms. Recent National Health and Nutrition Examination Survey data have determined that the prevalence of adult and childhood obesity exceeds 30% in many regions of the United States (11). This trend will likely result in an increase in type 2 diabetes and, therefore, coronary artery and peripheral vascular disease. A conservative estimate would be a 1% to 1.5% increase in demand for CV services per year based on demographics and lifestyle issues alone.
Historically, economic growth drives an increase in demand for specialty health care. Once the U.S. economy significantly recovers, the demand for CV services is very likely to increase. Health care policy will also have a major effect on the demand for these services. Overall expansion of insurance coverage will drive further demand for services.
Finally, technological advances have traditionally driven demand. This is especially seen in the electrophysiology and interventional cardiology subspecialties. Over the last 5 years, there has been an increase in demand for services of 2% to 9% per year due to economic growth and technological advances. Prevention will decrease demand for CV services. Furthermore, strict adherence to appropriate use criteria and regulatory requirements may further decrease demand. However, these strategies are difficult to implement and to predict. A conservative estimate would suggest at least a 1% increase per year due to these factors.
Health system reform initiatives and changes in the U.S. economy make it difficult to predict future demand for CV services. In following these demand drivers, some important surrogates will be measured in an ongoing process: wait times for appointments to see CV specialists, status of CV physician incomes, internal medicine and pediatric resident applicants for CV fellowship training, CV specialist versus primary care delivery of services, technology utilization, and open CV physician positions.
3.2.3.2 Supply Drivers
The Lewin Group utilizes a proprietary physician supply and demand model. In discussing the supply of cardiologists, it is probably most useful to consider FTE cardiologists as the preferred metric.
In the evaluation of cardiologist supply projections, there are 3 fundamental participants—FTE cardiologists, new entrants (graduating cardiology fellows), and attrition of cardiologists. There are certain scenarios in which the supply of cardiologists could significantly shift in the future. The first major shift could occur in fellowship training.
Provided there is no reduction in the current overall number of funded CV fellowship positions, the validation and widespread adoption of an ACC-proposed shortened track pilot (see Section 4.2. ACC Initiatives) could result in a modest increase in individual CV fellowship class sizes and graduates. Such a program would also help mitigate the debt burden of trainees, which may influence career decisions, and also would permit earlier entrance of interventional and electrophysiology trainees into their subspecialty training programs. However, whether and when this pilot may be undertaken remains unclear.
Another important driver of supply could be advocacy for an increase in funding to full implementation of already existing ACGME-approved but unfilled positions. Utilizing the demonstrated capacity that exists today could perhaps result in a 5% to 10% increase in fellowship trainees over the next 5 years. Extensive interviews with internal medicine residents as well as cardiology fellows revealed that work-life balance continues to be a major factor for both men and women entering active practice in cardiology. This inevitably will lead to a decrease in hours worked and, therefore, a decrease in productivity. A conservative estimate is that this could account for approximately a 10% decrease in supply. A fourth major opportunity for increasing the CV workforce would be to delay retirement. The recent negative impact of the U.S. financial markets on the savings and retirement funds of many physicians may force physicians to further delay their retirement. However, this study used a conservative estimate based on a 1-year delay in retirement to generate projections.
Recent surveys indicate that nonphysician practitioners are significantly underutilized by private and academic practices. Although this represents a great opportunity to improve the efficiency of care delivery, cardiology-trained nonphysician practitioners are relatively limited in number. Some state regulations may limit the scope of practice for nonphysician practitioners. However, the larger problem appears to be that many cardiologists are unfamiliar with providing care with the professional assistance of nonphysician practitioners (the team care approach). Not only is this approach important in chronic disease management but in extending many other facets of care (especially prevention and patient education) that physicians traditionally provide. Educational programs will be needed to bridge this knowledge gap.
A great opportunity for increasing productivity lies in creating more efficient and more professional practice management within practices. Practice administrators provide such expertise. The use of electronic medical records and other software tools can further increase practice workflow and improve efficiency in the delivery of care. Inclusion of nonphysician practitioners in the practice would greatly contribute practice productivity as discussed in the preceding text. Reasonable estimates were that these factors together may result in a 10% increase in productivity for the workforce as a whole.
These demand drivers are inevitable, and these estimates of their effect on the CV workforce are somewhat conservative. Current projections indicate that by 2025, electrophysiology and pediatric cardiology will reach equilibrium. Interventional cardiology, however, will maintain the present deficit of approximately 1,900 physicians through 2025. The greatest concern, however, is with general cardiology. Currently there is a deficit of approximately 1,700 general cardiologists. If none of the supply shifts and interventions are accomplished, there could be an increase in the deficit of general cardiologists to 16,000 by 2025 (see Fig. 8). If all of the supply-side shifts and interventions are accomplished, the best case scenario would be an 8,000 FTE general cardiologist deficit by 2025.
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4. Recommendations
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The recommendations for improving the CV workforce fall into 2 broad categories: advocacy and professional society initiatives.
4.1 Advocacy.
Clearly, there is a need to increase the supply of CV specialists. This is especially true in regards to general cardiology. Advocacy to increase governmental funding of more fellowship training positions in general cardiology is imperative. Similarly, there is a need for more nonphysician practitioners. Thus, there is a need for increased funding to train more nurses and physician assistants to meet these demands. Advocacy for multiple issues that will significantly improve practice efficiency and professional satisfaction is also needed. These include subsidies for electronic medical records, decrease in regulatory hassle, and an improvement with regard to tort reform.
Underrepresented minorities (especially blacks and Hispanics) comprise approximately 25% of the U.S. population, yet only 6% of the CV workforce. Increasing the percentage of this population in the CV workforce will require intervention at several levels. The shortened fellowship track and loan forgiveness programs would be a positive incentive at the governmental level to attract more underrepresented minorities into cardiology fellowship programs. However, there is also a problem of "pipeline"; thus, interventions at the middle school, high school, and college levels is also necessary to increase the number of under-represented minorities entering medical school. Advocacy through governmental and charitable programs will be very important in improving the delivery of care to underserved populations. It is more critical than ever to increase the cultural proficiency of the general cardiology profession as the patient population continues to become more diverse. Regardless of the background of the cardiologist, it is important that cardiologists receive cultural proficiency education in residency and fellowship training, as well as continuing education in this area. For example, the National Alliance for Hispanic Health has developed a provider education project on cultural proficiency including a manual for providers and teaching sessions to increase cultural proficiency. Finally, irrespective of race or sex, there is a need for increasing attention to mentorship at the college and medical school level to encourage students to pursue careers in cardiology. Academic institutions and advocacy groups need to recognize and support such development of mentors in cardiology.
4.2 ACC Initiatives.
The ACC can improve the CV workforce situation at many levels. The ACC has established a work group to develop recommendations for the redesign of CV fellowship training to include a pilot proposal for a paradigm that would permit completion of internal medicine and CV fellowship training in 5 rather than the current 6 years. Several educational programs have been initiated that will be important in alleviating some of the workforce issues. An educational program has been developed to assist NPs in gaining more proficiency specific to cardiology care. This will accelerate the availability of cardiology-trained nonphysician practitioners. Also important is the development of team-based education around team-based care. Surveys found that nonphysician practitioners are underutilized. Best practices in optimal utilization needs to be taught to the cardiology community. The cardiology community can further benefit from the development of education and best practices that address programs for delayed retirement, improvement of practice workflow, and adoption and implementation of electronic medical records. The ACC's initiatives to streamline the recertification process may improve retention of older cardiologists. Work-life balance is critically important to the recruitment of new fellows into the specialty and the retention of older physicians and women cardiologists in the workforce. Clearly, there is an opportunity for the College to demonstrate best practices in innovation for part-time and call arrangements that improve work-life balance. Education is important for cultural proficiency and outreach of academic programs to under-represented minorities.
Finally, through the ACC's newest membership category, practice administrators, as well as our partnership with major cardiology practice consulting firms, the College has an opportunity to develop programs to educate the cardiology community in creating optimal practice efficiencies and improving the delivery of quality CV care.
Table 2
summarizes the conclusions and recommendations of this report.
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Author and Peer Reviewer Disclosures
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The authors and peer reviewers of this document reported no relationships with industry or other entities that were relevant to this topic.
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Staff
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American College of Cardiology Foundation
John C. Lewin, MD, Chief Executive Officer
Charlene L. May, Senior Director, Science and Clinical Policy
Dawn R. Phoubandith, MSW, Director, ACCF Clinical Documents
Lisa R. M. Chambers, MBA, MHA, Associate Director, Member Strategy
Erin A. Barrett, Senior Specialist, Science and Clinical Policy
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Related References
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- 1 Cooper RA, Getzen TE, McKee HJ, et al. Economic and demographic trends signal an impending physician shortage. Health Affairs 2002;21:140–54.
- 2 Council on Graduate Medical Education. Council on Graduate Medical Education Sixteenth Report: Physician Workforce Policy Guidelines for the United States, 2000–2020. 2005;1–48.
- 3 Deal CL, Hooker R, Harrington T, et al. The United States rheumatology workforce: supply and demand, 2005–2025. Arthritis Rheum 2007;56:722–9.
- 4 Foot DK, Lewis RP, Pearson TA, et al. Demographics and cardiology, 1950–2050. J Am Coll Cardiol 2000;35:1067–81.
- 5 Fye WB. Cardiology workforce: a shortage, not a surplus. Available at: http://content.healthaffairs.org/webexclusives/index.dtl?year=2004. Accessed June 1, 2009.
- 6 Fye WB. Cardiology workforce: there's already a shortage, and it's getting worse! J Am Coll Cardiol 2002;39:2077–9.
- 7 Fye WB. President's page: women cardiologists: why so few? J Am Coll Cardiol 2002;40:384–6.
- 8 Fye WB. Cardiology's workforce shortage: implications for patient care and research. Circulation 2004;109:813–6.
- 9 Fye WB. Evidence for expanding physician supply. Ann Intern Med 2005;142:472–3.
- 10 Johnson NJ, Sorlie PD, Backlund E. The impact of specific occupation on mortality in the U.S. National Longitudinal Mortality Study. Demography 1999;36:355–67.
- 11 Koenig L, Siegel JM, Dobson A, et al. Drivers of healthcare expenditures associated with physician services. Am J Manag Care 2003;9 Spec No 1:SP34–42.
- 12 National Alliance for Hispanic Health. Quality Health Services for Hispanics: the Cultural Competency Component. 2001; 1–109.
- 13 National Resident Matching Program. National Resident Matching Program, Results and Data: 2008 Specialties Match. National Resident Matching Program 2-1-2008; 1–65.
- 14 Reede JY. A recurring theme: the need for minority physicians. Health Aff (Millwood) 2003;22:91–3.
- 15 Steinwachs DM, Collins-Nakai RL, Cohn LH, et al. The future of cardiology: utilization and costs of care. J Am Coll Cardiol 2000;35:1092–9.
- 16 The Lewin Group. Physician Supply and Demand: Projects to 2020.10-1-2006; 1–35.
- 17 Weiner JP. Forecasting the effects of health reform on U.S. physician workforce requirement. Evidence from HMO staffing patterns. JAMA 1994;272:222–30.
- 18 Williams JL. Projecting the general cardiology workforce shortage. Am Heart Hosp J 2007;5:203–9.
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Related Resources
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- American Association of Medical Colleges Center for Workforce Studies Chart: Number of Residents by Cardiovascular Training by Academic Year, 1994-2006
- American Board of Internal Medicine Candidates Certified: All Candidates
- American Board of Internal Medicine Candidates Certified by Country (Non-US)
- American Board of Internal Medicine Candidates Certified by US State/Territory
- Bureau of Labor Statistics Employer Costs for Employee Compensation Press Release (March 2008)
- May 2008 National Occupational Employment and Wage Estimates
- Modeling and Forecasting Health Care Consumption (1994)
- National Resident Matching Program Results 2004–2008 Specialties Matching Service
- Number of Candidates Certified Annually by the American Board of Internal Medicine (1936–2006)
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Acknowledgments
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The authors wish to thank Dr. W. Bruce Fye for his guidance and insight on CV workforce issues related to his vast experience in this area including his work on Bethesda Conference 35. In addition, the authors wish to acknowledge Paul Hogan, Ellen Bouchery, and Tim Dall of The Lewin Group and Edward Salsberg and Clese Erikson of AAMC—the groups that conducted the research and statistical analysis for this report.
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Appendix 1
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ACC/MedAxiom Cardiology Practice Survey Methodology
Cardiology Practices:
Private Practice administrators were identified using the following methods. - MedAxiom, a subscription-based service provider and information resource for cardiology practices and their administrators, provided 3 lists totaling 6,998 contacts. The lists comprised:
- • Names and e-mail addresses of all 224 MedAxiom practice administrator members.
- • Practice names, postal addresses, and practice administrator contact names for 6,304 unique practice locations.
- • E-mail addresses for 470 practice administrators.
- The Chair of the American College of Cardiology's Task Force on Workforce, Dr. George Rodgers, MD, FACC, distributed an e-mail to the ACC Board of Governors (BOG) asking them to reach out to ACC member physicians to encourage practice administrator participation.
- The research was conducted using an on-line survey tool. During the week of January 8, 2007, the survey link was distributed to contacts on the MedAxiom lists through both e-mail and standard U.S. postal delivery. Reminder e-mail letters and U.S. postal mail letters were distributed to nonrespondents the week of January 26. Dr. Rodgers's e-mail request to the BOG was distributed the week of January 29.
- There were 354 unique responses; 135 resulting from the e-mail solicitation representing a 19.4% response rate and 99 resulting from the U.S. postal mail solicitation representing a 1.6% response rate. Dr. Rodgers's request solicited an additional 119 responses.
For the Pediatric Practices, we used a 2-phased approach to identify and inquiry administrators. Phase I:
- Survey invite went out to 1,053 pediatric cardiologists (ACC members) to provide the name and contact information for the person in their practice with in-depth knowledge with workforce issues
- Survey live October 1 to November 30, 2007
- 154 members completed the survey—response rate of 15%
- A total of 128 contact names and addresses were collected through this mechanism
Phase II:
- Survey went out to 128 key pediatric practice decision makers identified in phase I
- Survey live December 14, 2007 to January 15, 2008, required 15 to 20 minutes to complete
- Number of completed surveys: 71
- Response rate approximately 56%
Academic Practices:
E-mail invitations were sent to 110 chiefs of cardiology at academic institutions around the country. The online survey was live May 11 to June 5, 2007. There were 27 unique responses representing a 25% response rate.
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Footnotes
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This document was approved by the American College of Cardiology Board of Trustees in August 2009.
The American College of Cardiology requests that this document be cited as follows: Rodgers GP, Conti JB, Feinstein JA, Griffin BP, Kennett JD, Shah S, Walsh MN, Williams ES, Williams JL. ACC 2009 survey results and recommendations: addressing the cardiology workforce crisis: a report of the ACC Board of Trustees Workforce Task Force. J Am Coll Cardiol 2009;54:1195–208.
Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org). For copies of this document, please contact Elsevier Inc. Reprint Department, fax 212-633-3820, e-mail%20reprints{at}elsevier.com.
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology. Please contact healthpermissions{at}elsevier.com.
* The Lewin Group is an independent research firm not affiliated with the ACC. 
 A full description of the methodology is in the Cardiology Workforce Assessment published by the Lewin Group and the AAMC in 2009 (5).
 Details of the methodology used in conducting the ACC/MedAxiom practice survey are described in Appendix 1.
 By design, there is a 3-year lag in the data. The study was commissioned in 2007. Thus, 2004 was the last full year that data were collected.
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References
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1. Foot DK, Lewis RP, Pearson TA, et al. Demographics and cardiology, 1950–2050 J Am Coll Cardiol 2000;35:1067-1081.[Free Full Text]2. Ayanian JZ, Landrum MB, Guadagnoli E, et al. Specialty of ambulatory care physicians and mortality among elderly patients after myocardial infarction N Engl J Med 2002;347:1678-1686.[Abstract/Free Full Text] 3. Ahmed A, Allman RM, Kiefe CI, et al. Association of consultation between generalists and cardiologists with quality and outcomes of heart failure care Am Heart J 2003;145:1086-1093.[CrossRef][Web of Science][Medline] 4. Fye WB, Hirshfeld JW. Cardiology's workforce crisis: a pragmatic approach. Presented at the 35th Bethesda Conference, Bethesda, Maryland, October 17–18, 2003 J Am Coll Cardiol 2004;44:215-275.[Free Full Text] 5. The Lewin Group, Association of American Medical Colleges Cardiology Workforce Assessment http://content.onlinejacc.org/cgi/content/full/j.jacc.2009.08.001/DC2 2004Accessed September 10, 2009. 6. Poppas A, Cummings J, Dorbala S, et al. Survey results: a decade of change in professional life in cardiology: a 2008 report of the ACC women in cardiology council J Am Coll Cardiol 2008;52:2215-2226.[Free Full Text] 7. Graduate medical education JAMA 2005;294:1129-1143.[Free Full Text] 8. Limacher MC, Zaher CA, Walsh MN, et al. The ACC professional life survey: career decisions of women and men in cardiology: a report of the Committee on Women in Cardiology. American College of Cardiology. J Am Coll Cardiol 1998;32:827-835.[Abstract/Free Full Text] 9. Sullivan LW, Bednash G, Benjamin RM, et al. Missing persons: minorities in the health professions: a report of the Sullivan Commission on Diversity in the Healthcare Workforce. The Sullivan Commission http://www.jointcenter.org/healthpolicy/docs/SullivanExecutiveSummary.pdf 1998Accessed July 15, 2009. 10. Physician Diversity Fact Sheet. Association of American Medical Colleges http://www.aamc.org/newsroom/pressrel/2006/physician_diversity_facts.pdf 1998Accessed August 4, 2009. 11. National Center for Health Statistics: the Third National Health and Nutrition Examination Survey (NHANES III, 1988–1994), 2005 http://www.cdc.gov/nchs/nhanes.htm 1998Accessed July 15, 2009.
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Top
Table of Contents
1. Introduction
