Please watch my short presentation given at the 2021 Annual Sessions of the Heart Rhythm Society on July 30, 2021. A 2.1 ampere-hour (Ah) battery capacity biventricular defibrillator (CRT-D) was recently shown to be the first to exceed patient survival in a chronic heart failure cohort. There is consensus that extended battery longevity (based on Ah) can reduce the costs and complications related to generator replacements. Our model revealed that increased utilization of extended longevity CRT-D battery technology (2.1Ah) leads to substantial annual reductions in major complications and costs of replacement procedures.
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. 
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  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 :
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.  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  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  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  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  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.
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.
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.
Thanks to all the faculty and attendees of the 2018 Lakeland Regional Health Cardiovascular Symposium! We appreciate the time away from family and hope the education proves to be worthwhile. You will find link to PDF’s of all lectures below; please note that faculty may have altered their presentations from these files.
Thanks again for attending and please let us know what you’d like to hear about next year. You can submit suggestions for next year by commenting here.
We hope you will join us for Lakeland Regional Health’s 2017 Cardiovascular Symposium. We believe that you will find this opportunity to learn from leaders in our profession both educational and inspiring. Speakers from University of Pennsylvania, Vanderbilt University, University of Pittsburgh, and University of South Florida as well as local faculty will be presenting state-of-the-art topics in cardiovascular disease.
Lakeland Regional Health is committed to delivering nationally recognized healthcare, strengthening our community and advancing the future of healthcare. The experienced physicians of our Heart Center place patients at the heart of all they do. We are Polk County’s pioneer in expert cardiac care and have been for more than three decades.
Upon completion of our Symposium, participants should be able to:
- Understand the latest research in managing patients with artificial hearts and/or ventricular assist devices.
- Describe the long-term impact of cardiovascular care on function in the elderly.
- Identify outpatients with pulmonary hypertension.
- Recognize and describe the pros and cons of rate versus rhythm control for atrial brillation.
- Identify and describe interventional cardiology technologies that are currently available to treat structural heart disease.
- Describe the latest methods for outpatient management and diagnosis of peripheral vascular disease.
- Describe the current inpatient and outpatient congestive heart failure care continuum.
- Understand survival rates and long-term complications of adults with congenital heart disease.
We look forward to seeing you in February. If you have any questions, please do not hesitate to contact us at 863.687.1190.
The Symposium offers 5.25 AMA Category 1 CME credits) and registration is free at 2017 Lakeland Regional Health Cardiovascular Symposium.
A defibrillator implant is a small device surgically implanted in the chest to maintain the heart’s electric rhythm. The surgery is very common: over 130,000 Americans receive a defibrillator implant every year.
If you or a loved one requires a defibrillator implant, you’ll undoubtedly have many questions—questions that can’t always be adequately explained in a forty-five minute doctor’s appointment. I recently published a complete, easy-to-understand guide to defibrillator implantation.
What Is a Defibrillator? begins with an explanation of how defibrillators work and the conditions they treat. I then 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. For readers having difficulty with medical terminology, there is a helpful glossary at the back of the book.
Patients, caregivers, and family members alike will benefit from these straightforward explanations. If you’re a candidate for defibrillator implantation, this book can help you approach surgery with a full understanding of the procedure and what it means to your quality of life.
What is a Defibrillator? is available in print and electronic versions at Amazon.com (http://www.amazon.com/What-Defibrillator-Cardiologists-Patients-Providers-ebook/dp/B011EXAQL4/ref=sr_1_4?s=digital-text&ie=UTF8&qid=1438283493&sr=1-4).
A recent article from The Advisory Board Company found a group of hospitals that had an advantage when it came to providing an excellent patient experience: specialty hospitals. An Advisory Board analysis of recent Hospital Compare data suggests that specialty hospitals dominate the rankings when it comes to patient satisfaction.
Patient satisfaction may not be the only benefit of a specialty hospital or “center of excellence.” We examined the demographics, complications, re-admissions, and accessibility of care in a community electrophysiology (EP) program to add to the body of knowledge of ‘real-world’ EP device implant complications. Two hundred and fifty consecutive patients who underwent device implantation by a single electrophysiologist in a new non-academic community hospital EP program starting from its inception in July 2008 were included for analysis. Standard procedures for implantation were used. Pacemakers, defibrillators, and generator changes were included; temporary pacemakers were excluded. Major complications were defined as in-hospital death, cardiac arrest, cardiac perforation, cardiac valve injury, coronary venous dissection, hemothorax, pneumothorax, transient ischemic attack, stroke, myocardial infarction, pericardial tamponade, and arteriovenous fistula. Minor complications were defined as drug reaction, conduction block, hematoma or lead dislodgement requiring re-operation, peripheral embolus, phlebitis, peripheral nerve injury, and device-related infection. This community cohort had similar ejection fractions but was older with worse kidney function than those studied in prior reports. There was one major early complication (0.4%) and seven minor early complications (2.8%). Left ventricular lead placement was successful in 64 of 66 patients (97%). This was the first community-hospital based EP program to examine device implant demographics and outcomes, and revealed an elderly, ill population with lower overall rates of complications than seen in national trials and available reports from single non-community centers. Contrary to current perceptions, these data suggest that community centers may subselect an elderly, ill patient population and can provide high-quality, cost-effective, and more accessible care.
“Specialty hospitals are under increasing scrutiny, but there may be a role for ‘niche’ hospitals that, while offering the full spectrum of general hospital care, can provide certain procedures at an exceptional level of quality and cost-effectiveness. Recent literature continues to document the paucity of data available on rates and predictors of ICD implantation in routine clinical practice.(24,25) The Ontario ICD Database (24) revealed major complications related to de novo defibrillator implantations in 4.1% of procedures. Adjusting our data to match their definition of major complications, our center had major complications in 1.0% of de novo defibrillator implantations (a 76% relative reduction in major complications). The cost of major complications among Medicare beneficiaries receiving implantable defibrillators was examined in 30,984 patients.(25) They found that 10.8% of patients experienced one or more complications resulting in an increase in length of stay by 3.4 days and costs by $7,251. Superiorly performing ‘niche’ hospitals that reduce major complication rates from defibrillator implants by 76% in the uS (conservative estimate of 100,000 yearly implants) could realize an estimated $60 million in cost savings while improving patient safety.” (Williams et al, 2010, full link to reference below)
Please take this one question poll about specialty hospitals:
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Please join us for the Sixth Annual Lebanon Valley Cardiovascular Symposium on Saturday May 30, 2015. It has been very well received by a broad swath of care providers in Pennsylvania. We continue to increase our attendance and registrant feedback was overwhelmingly positive! As you can see, we have a great lineup of faculty and topics for this year’s Symposium.
The 2015 Symposium (Saturday May 30, 2015) will feature Dr. Michael Ezekowitz (Director of Atrial Fibrillation Research & Education, Cardiovascular Research Foundation, Main Line Health) and faculty from the University of Pittsburgh, Jefferson Medical College, WellSpan (York Hospital) and The Good Samaritan Hospital. Topics will include Target Specific Oral Anticoagulants for Atrial Fibrillation, Outpatient Identification of Pulmonary Hypertension, Treatments for Venous Insufficiency, and more. This year we will also have our Electrophysiologists (Drs. Williams and Stevenson) debating rate versus rhythm control for atrial fibrillation.
The Symposium has grown into one of the largest Cardiovascular Symposiums in Pennsylvania and we will again be cosponsored by the PA Chapter of the American College of Cardiology! The Symposium offers 6.5 AMA Category 1 CME credits (including 2 hours patient safety and 10 MOC credits) and registration is free at www.gshleb.org/lvcs.
Abstract Presented at the Heart Rhythm Society 2014 Annual Sessions, May 8, 2014
Patient Awareness of High Frequency Jet Ventilation to Minimize Cardiac Motion during Interventional ProceduresAuthors:
Jeffrey L. Williams MD MS FACC FHRS, David Lugg BS RCIS, Robert Gray BSN RN, Rose Benson CRNA, Marie A. DeFrancesco-Loukas CRNA, Paul J. Teiken MD. Heart Rhythm Center, The Good Samaritan Hospital, Lebanon Cardiology Associates, Lebanon Anesthesia Associates, Lebanon, PA.
Introduction: High frequency jet ventilation (HFJV) is used to minimize pulmonary and hence, cardiac motion during interventional procedures. Patient awareness during routine use of HFJV has not been evaluated in this setting. A Bispectral index (Bis) value of less than 60 is generally accepted as appropriate level of sedation during general anesthesia. Methods: Seventy two consecutive patients underwent EP studies including ablation for supraventricular and ventricular arrhythmias (n=74) in an invasive EP laboratory using HFJV. Any EP studies where ablation was attempted were included for analysis. Patients underwent induction of general anesthesia with endotracheal intubation using inhaled positive pressure ventilation with sevoflurane in the EP laboratory prior to vascular access. HFJV was then provided by a commercial system with initial settings: ventilation rate at 100 cycles per minute and drive pressure at 20-25psi. Total intravenous anesthesia was then provided with dexmedetomidine and propofol as well as fentanyl and rocuronium titrated to Bis score. Results: The overall mean age of patients was 55±18 years (range=18-84years) and the overall mean Bis score was 40±5.3 (see Poster). No patient experienced awareness during the procedure. Conclusions: This first report of patient tolerance using high frequency jet ventilation in an invasive electrophysiology laboratory demonstrates that HFJV is well tolerated by patients with an average Bis score of 40±5.3 and no patient experienced procedural awareness.
Please join us for the Fifth Annual Lebanon Valley Cardiovascular Symposium on Saturday May 31, 2014. It has been very well received by a broad swath of care providers in Pennsylvania. We continue to increase our attendance and registrant feedback was overwhelmingly positive! As you can see, we have a great lineup of faculty and topics for this year’s Symposium.
The 2014 Symposium (Saturday May 31, 2014) will feature Dr. Henry Halperin (2010 AHA Distinguished Scientist Award Recipient, Johns Hopkins University) and faculty from the University of Pennsylvania, Lancaster General Hospital, WellSpan (York Hospital) and The Good Samaritan Hospital. Topics will include Outpatient Management of CHF, Cardiac Resynchronization Therapy, Novel Oral Anticoagulants for Atrial Fibrillation, and more. This year we will also have two of our Interventionalists (Drs. Tadajweski and Fugate) debating radial versus femoral artery access for cardiac catheterizations.
The Symposium has grown into one of the largest Cardiovascular Symposiums in Pennsylvania and we will again be cosponsored by the PA Chapter of the American College of Cardiology! The Symposium offers 5.25 AMA Category 1 CME credits) and registration is free at www.gshleb.org/lvcs.
I wrote What is a Pacemaker? Cardiologist’s Guide for Patients and Their Care Providers to fill a gap in available resources for patients who have undergone or are under evaluation for pacemaker implantation. Please consider this a resource for your patients, colleagues, friends, and family.
The fastest growing population segment in the United States, seniors commonly undergo pacemaker implantation. Although doctors’ offices typically provide short pamphlets on pacemaker implantation, there is rarely any comprehensive yet understandable reference material for the patients to obtain…until now. Explaining the “what, why, and how” of pacemaker implantation, this invaluable new guide provides an in-depth summary of pacemakers, from the initial patient evaluation and device implantation to the issues that could potentially arise during a long-term follow up.
- When your heart skips a beat (thehindu.com)
- These Pacemakers Adjust To Your Breathing So You Can Stay Active (gizmodo.co.uk)
- Why Stricter Standards Are Needed for Medical Devices (ankinlaw.com)