A recent publication from the National Center for Health Workforce Analysis  predicted a shortage of 7080 cardiologists by 2025. Another publication reported recruitment incentives for cardiologists are at “unprecedented levels.”   I decided to revisit a paper I published in 2007 (JLW AHHJ 2007) predicting a general cardiology workforce shortage. [1]

I developed this model to project the need for general Cardiologists from 2005-2050 using Matlab (Mathworks, Inc., Natick, MA). The growth in need for General Cardiologists was estimated by incorporating the effect of retirement, prevalence of heart disease, and patient per physician load. At the peak demand in the year 2038, the model projected a need for 62,452 General Cardiologists. Current training durations would result in 29043 General Cardiologists and Fast-Tracking (e.g., third year of Internal Medicine training counted as first year of cardiology) would result in 32533 General Cardiologists. There was evidence of an impending shortage of General Cardiologists that will peak in 2038 resulting in only 46.5% of the projected need for General Cardiologists. This may result from a complex cascade of declining US medical graduates and those matching in Internal Medicine residencies, combined with an increasingly complex cardiovascular disease patient requiring the care of multiple, distinct cardiovascular specialists.

Baseline Data for Modeling the Cardiologist Workforce:

The 35th Bethesda Conference [2] revealed that only 120 of 173 Clinical Cardiac Electrophysiology (EP) spots and 229 of 269 Interventional spots are filled per year.  These baseline partial fill rates were used to assess the effect completely filling these subspecialty fellowship positions would have on overall number of General Cardiologists. In 2001, there were 2160 total trainees and 709 first year fellows.  In the baseline conditions of the model, the number of first year fellows was taken as 709, 2nd year fellows numbered 726, and 3rd year fellows numbered 725.

There are an estimated 6 cardiologists per 100,000 U.S. residents.  This was used as the basis for calculating the number of cardiologists in the US at 16800 in 2005.

Determining Growth in Need for General Cardiologists: 

Effect of Retirement:  I estimated that 10% of Cardiologists would retire by 2015.  Thus, the model uses 1%/year increase in need due to retirement.

Effect of Prevalence of Heart Disease (HD):  Heart disease deaths indicate a need for cardiologists however, prevalence of HD is more important than death in determining workforce requirements.  In this model, it was assumed the prevalence of HD will grow by 1.7%/year until 2030.  As the baby boomer population passes away, the prevalence of HD will decrease by 0.58%/year from 2030-2040 and 0.39%/year from 2040-2050.

Effect of Decreasing Physician-Patient Load:  The average physician’s patient load in cardiovascular medicine declined by over a third from 1980-1995.  There are a higher proportion of patients who require the care of more than one cardiovascular specialist (e.g., a General Cardiologist, Electrophysiologist, Interventionalist, and/or Heart Failure Specialist).    For every 10% decrease in average patient load, 20% more physicians are required. The model uses 2%/year increase in demand due to decreasing physician-patient load.

Effect of Cardiovascular Subspecialty “Fast-Tracking”:  

1.The 8th Working Group of the 35th Bethesda Conference suggested a means to allow a 5-year short-track to train general cardiologists. The trainee would complete 2 years of general internal medicine then 3 years of cardiology.  This short-track would increase the number of general cardiologists, free up more money for additional trainees, and permit trainees to begin paying on student loans.  However, they did not discuss the possibility of “Fast-Tracking” for Interventional or Electrophysiology Fellowships for those who have already completed a 3-year Internal Medicine residency.
2. In this model, “Fast-tracking” would comprise 2 years of a General Cardiology Fellowship then 2 years of either Interventional or Electrophysiology training. This concept of “Fast-Tracking” was incorporated into the model to assess its effect on the General Cardiology Workforce numbers.

Growth in Need for General Cardiologists from 2005-2050 :

Gen Cardiology Workforce Model

Projections of Cardiology Workforce from 2005-2050. This model incorporates a decrease in heart disease prevalence by 0.58%/year from 2030-2040 and 0.39%/year from 2040-2050.  Current training duration (blue line) and Fast-Track (red line) would still result in deficit when compared with model projection of need for General Cardiologists (green line).  At the peak demand in the year 2038, there is a projected need for 62,452 General Cardiologists.  Current training durations would results in 46.5% (n=29043 total cardiologists) the projected need and Fast-Tracking would result in 52.1% the projected need for General Cardiologists (n=32533).

Current training duration (blue line) and Fast-Track (red line) would still result in deficit when compared with model projection of need for General Cardiologists (green line) from 2005-2050.  See Figure.  At the peak demand in the year 2038, current training durations and Fast-Tracking would result in 46.5% (n=29043) and 52.1% (n=32533) the projected need for General Cardiologists. Doubling the number of General Fellows trained and incorporating Fast-Track for EP and Interventional fellows would help offset the predicted shortage in General Cardiologists (green line) by year 2020.  However, this would result in an oversupply in General Cardiologists by the year 2050.

 

How accurate was my model predicting the cardiology workforce as of 2015?

The Association of American Medical Colleges (AAMC) publishes a biannual report on the most current data available about active physicians and physicians in training. [3]  The AAMC estimated 22038 active cardiologists whereas my model predicted 20515 active cardiologists in 2015.  Certainly, care delivery models and market forces (e.g., 2008-2009 recession leading to decreased retirement rates) have affected the cardiology workforce projections.  My estimates of the prevalence of heart disease continue to be accurate. In 2012, The Trust for America’s Health [4] found that at present growth rates “the number of new cases of type 2 diabetes, coronary heart disease and stroke, hypertension and arthritis could increase 10 times between 2010 and 2020—and double again by 2030.”  Finally, it is difficult to get an accurate trend in cardiologist patient loads over time. The recent Medscape Cardiologist Compensation Report 2016 [5] reported that only a quarter of cardiologists have seen an influx of patients due to the Affordable Care Act (ACA) while three-quarters have not.

Is there an impending shortage of general cardiologists? I suspect my model is accurate though has overestimated the shortage of general cardiologists we can expect moving forward. Several reasons included delayed retirement of current cardiologists, the move towards primary-care directed delivery, and the use of physician extenders.  That being said, there have been a host of studies examining the cardiology workforce using a variety of analyses that all point to a shortage of cardiologists moving forward.

It is clearly difficult to place a number on any “shortage” of cardiologists however, there is a common theme to the various studies looking at the future cardiology workforce.  The most recent study [6] reported a shortage of 7080 cardiologists by the year 2025.  “Projections were developed using the Health Resources and Services Administration’s (HRSA) Health Workforce Simulation Model (HWSM), an integrated microsimulation model that estimates current and future supply and demand for health care workers in multiple professions and care settings.” The 2009 American College of Cardiology Board of Trustees Workforce Task Force [7] reported a deficit of 16000 cardiologists by 2025 and best case scenario of 8000 cardiologist deficit with pointed interventions. The CV workforce model I developed estimated a deficit of 17865 general cardiologists by the year 2025.

Summary:

It continues to be reasonable to estimate a general cardiologist shortage by the year 2025. There is consensus of a likely deficit in the general cardiologist workforce using a disparate set of studies including those looking at practice-level demand, prevalence of CV disease, and implications from recruitment incentives for general cardiologists. Regional variation is to be expected but health systems should be cognizant of the likelihood of a general cardiologist shortage in the near- to mid-term.

References:

1  Williams JL, “Projecting the General Cardiology Workforce Shortage,” American Heart Hospital Journal, V. 5 (Fall 2007), pp. 203-209.

2  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;44:215–75.

3  American Association of Medical Colleges, “2016 Physician Specialty Data Report,” Accessed online at https://www.aamc.org/data/workforce/reports/457712/2016-specialty-databook.html.

4  ”F as in Fat: How Obesity Threatens America’s Future”; Trust for America’s Health Issue Report, Sept 2012; Robert Wood Johnson Foundation. Accessed at http://healthyamericans.org/report/100/.

5 Peckham C, “Medscape Cardiologist Compensation Report 2016,” April 1, 2016. Accessed at: https://www.medscape.com/features/slideshow/compensation/2016/cardiology#page=15

6  U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Workforce National Center for Health Workforce Analysis, “National and Regional Projections of Supply and Demand for Internal Medicine Subspecialty Practitioners: 2013-2025,” December 2016. Accessed online at https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/projections/internal-medicine-subspecialty-report.pdf.

7  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.

 

 

 

 

This is the final podcast in the What are Palpitations? series and we will be discussing how patients can adjust to living with heart rhythm disorders. We will start with adjusting to life after being diagnosed with heart-rhythm abnormalities. Next, we’ll talk about the quality of life in heart-rhythm patients and how do arrhythmias affect you and your family. Arrhythmias in children and young adults can be challenging and we’ll spend time on this issue. Finally, we’ll examine patients that have palpitations without arrhythmias.

Please check back with the Heart Rhythm Center as we begin the new series What is a Defibrillator?

This is the eleventh podcast in the What are Palpitations? series and we will be discussing the postoperative care following EP studies. We will cover care of the vascular access sites including showering/bathing restrictions. Other activity limitations including driving issues will be addressed. Finally, the first followup appointment after the EP study will be explained as well as lifestyle limitations that may be recommended.

Please check back with the Heart Rhythm Center for the final podcast in the What are Palpitations? series: Psychosocial Impact of Arrhythmias.

This is the tenth podcast in the What are Palpitations? series and we will be discussing the complications that can occur during or after EP studies. We begin the discussion with an explanation of the types of complications and their treatment. We will end by discussing special EP studies and ablations that may have higher rates of complications and lower success rates.

Chest Radiograph Appearance of Large Pericardial Effusion after Cardiac Perforation. (A) Immediately following the implantation of a pacemaker, the chest x-ray (CXR) shows a normal appearance of the cardiac silhouette. (B) At two weeks postoperative, the CXR (performed because the patient reported symptoms of chest pressure) shows an enlarged cardiac silhouette. The patient responded to pericardiocentesis with no lead repositioning. (Figure originally published by Williams and Stevenson 2012.)

Please check back with the Heart Rhythm Center for future podcasts:

  • Postoperative Care after an EP Study (and possible ablation)
  • Psychosocial Impact of Arrhythmias

This is the ninth podcast in the What are Palpitations? series and it focuses on the preparations necessary before proceeding with an electrophysiology study including elements of the preoperative workup. We will discuss the electrophysiology laboratory where the procedure is performed and steps involved in performing the procedure. We’ll talk about what happens if your doctor cannot find or ablate the arrhythmia as well as postoperative care. Finally, we will discuss advanced treatment options for atrial fibrillation. A brief outline includes:

  1. Preoperative risk assessment
  2. Use of contrast agents during EP studies or ablations
  3. Thyroid issues
  4. Allergies
  5. Registration and check-in
  6. Informed-consent process
  7. The procedure room
  8. The EP study
  9. How does the doctor place catheters inside the heart?
  10. What happens if my doctor cannot successfully find an arrhythmia?
  11. What happens if my doctor cannot successfully ablate the arrhythmia?
  12. Immediately after the EP study
  13. Day after the EP study
  14. Advanced treatment options for atrial fibrillation

Please check back with the Heart Rhythm Center for future podcasts:

Possible Complications of Electrophysiology Studies and Ablations
Postoperative Care after an EP Study (and possible ablation)
Psychosocial Impact of Arrhythmias

This shows a typical office visit for a defibrillator check (called interrogation). The programmer (A) has all the software necessary to check and program the defibrillator (or pacemaker). Many devices allow wireless interrogations but many still require a wand (B) that is held over the pacemaker to communicate with the device. Part of the shared decision making process is ensuring patients understand the long-term followup required after device implantation.

What is a Defibrillator? Cardiologist’s Guide for Patients and Care Providers can be used as a Shared Decision Making (SDM) tool as mandated by Medicare’s recent Decision Memo for Implantable Cardioverter Defibrillators (https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=288). The Medicare memo states the “a SDM encounter prior to initial ICD implantation is a critical step in empowering patient choice in their treatment plan. While ICDs have remained a common treatment option for many years, the strength of evidence for an ICD benefit is different for different patient populations.” This SDM encounter mandates an evidence-based decision tool that discusses more than just the risk and benefits of defibrillator implantation. What is a Defibrillator? is a 216-page, evidence-based SDM tool that addresses all aspects of how defibrillators work and the conditions they treat. We discuss how doctors determine whether patients are good candidates for defibrillators and provides an overview of the implantation process. Potential complications both before and after defibrillator implantation are discussed, as is surgical recovery and follow-up treatment. There are extensive discussions on the long-term care and follow-up required including the psychosocial aspects of defibrillator implantation. Particular emphasis is placed upon possible device advisories as well as end-of-life issues including possible deactivation of defibrillators. For readers having difficulty with medical terminology, there is a helpful glossary at the back of the book. Patients, caregivers, and family members involved in the Shared Decision Making process will benefit from the straightforward explanations. If you’re patients are candidates for defibrillator implantation, this book meets the requirements of the SDM decision tool and helps your patients approach surgery with a full understanding of the procedure and what it means to their quality of life. Please message me if your practice or facility is interested in bulk discount pricing as well as customized editions that feature your logo on the cover as well as an introduction from your Heart Rhythm Center director or CEO of health system.

This is the eighth podcast in the What are Palpitations? series and it focuses on the treatment options for arrhythmias. We will be discussing everything from lifestyle modifications that may help reduce arrhythmias as well as medications that are often used in arrhythmia treatment.  A brief outline includes:

  1. Lifestyle
  2. Can exercise cause heart-rhythm problems?
  3. Medications
  4. Anticoagulation
  5. Ablation
  6. Cardioversion
The Vaughan-Williams Classification (Classes 1, 2, 3, and 4) is a system used to classify antiarrhythmics based on their mechanism of action. This Table describes the different classes of antiarrhythmics and how they are used, as well as side effects.

Please check back with the Heart Rhythm Center for future podcasts to include:

  • The Electrophysiology Study and Ablation Procedure
  • Possible Complications of Electrophysiology Studies and Ablations
  • Postoperative Care after an EP Study (and possible ablation)
  • Psychosocial Impact of Arrhythmias

This is the sixth podcast in the What are Palpitations? series and it focuses on the common ventricular arrhythmias that many patients may experience. We will be discussing premature ventricular contractions (called PVC’s) which are very common and thankfully usually quite harmless. We will also be discussing various types of ventricular tachycardias; many are easily treated though some may require defibrillator therapy. A brief outline includes:

  1. Premature ventricular contractions
  2. Ventricular tachycardia
  3. Non–coronary disease VT
  4. What are defibrillators?

Please check back with the Heart Rhythm Center for future podcasts to include:

  • Treatment Options for Arrhythmias
  • The Electrophysiology Study and Ablation Procedure
  • Possible Complications of Electrophysiology Studies and Ablations
  • Postoperative Care after an EP Study (and possible ablation)
  • Psychosocial Impact of Arrhythmias

 

This is the sixth podcast in the What are Palpitations? series and it focuses on atrial fibrillation. We will be discussing the most common arrhythmia seen in clinical practice. The listener will be introduced to the mechanisms, causes of, and treatments for atrial fibrillation. There are extensive explanations about the noninvasive and invasive treatments available for atrial fibrillation. A brief outline includes:

  1. Normal electrical activation versus atrial fibrillation
  2. Signs and symptoms
  3. Causes of atrial fibrillation
  4. Understanding your risk of stroke
  5. Is there a difference between atrial fibrillation and ventricular fibrillation?
  6. Is there a cure for atrial fibrillation?
  7. What is atrial flutter?

Please check back with the Heart Rhythm Center for future podcasts to include:

  • What Are the Common Ventricular (Bottom-Chamber) Tachycardias?
  • Treatment Options for Arrhythmias
  • The Electrophysiology Study and Ablation Procedure
  • Possible Complications of Electrophysiology Studies and Ablations
  • Postoperative Care after an EP Study (and possible ablation)
  • Psychosocial Impact of Arrhythmias

 

This is the fifth podcast in the What are Palpitations? series and it focuses on what are the most common supraventricular (top-chamber) tachycardias (SVT). We will be discussing a variety of the more common SVT seen in clinical practice and clinical scenarios are used to introduce the listener to these types of arrhythmias.  A brief outline includes:

  1. Premature atrial contractions
  2. AV-node reentrant tachycardia
  3. AV reentrant tachycardia
  4. Atrial tachycardia
  5. Atrial flutter
  6. Atrial fibrillation (will be discussed in great detail in podcast 6)
Electrocardiograms of Common Arrhythmias. Panel A, shows normal sinus rhythm, which is the heart’s baseline rhythm; the tall, narrow spikes are the QRS complexes. Panel B shows what a supraventricular tachycardia (in this case, atrioventricular nodal tachycardia) looks like; notice how narrow the QRS complex is. Panel C shows atrial fibrillation with the very irregular-appearing QRS complexes. Panel D shows ventricular tachycardia; note the very wide QRS complexes, especially when compared to the narrow QRS complexes after the VT stops. The main difference between SVT and VT is the wide QRS complexes, but some SVTs may have wide QRS complexes (this is called aberrancy). Panel E shows atrial flutter, which has a “sawtooth” appearance of the baseline between QRS complexes. Atrial flutter is treated using the same techniques and medicines as those for atrial fibrillation.

Please check back with the Heart Rhythm Center for future podcasts to include:

  • What Is Atrial Fibrillation?
  • What Are the Common Ventricular (Bottom-Chamber) Tachycardias?
  • Treatment Options for Arrhythmias
  • The Electrophysiology Study and Ablation Procedure
  • Possible Complications of Electrophysiology Studies and Ablations
  • Postoperative Care after an EP Study (and possible ablation)
  • Psychosocial Impact of Arrhythmias