Thursday, June 07, 2007

Conquering Heart Disease is Multifaceted

An interesting question comes to mind when reading this study from the New England Journal of Medicine about how far we've come in twenty years treating heart disease: If we're doing such a good job with all of our public health initiatives and evidence-based treatment strategies, then why do we need more cardiologists? Why are we experiencing such a dearth of general cardiologists now and in the foreseeable future?

I think there's a lot of merit in this statement:
The looming critical shortage of cardiologists is due to a confluence of factors. The number of U.S. medical school graduates matching in internal medicine residencies has declined dramatically over the last 20 years. Fewer cardiologists are being trained today than a decade ago. An estimated 10% of cardiologists will retire in the coming decade. The baby boomers are reaching the age when cardiovascular disease rates climb sharply. The average patient load in cardiovascular medicine is declining, and maintaining those lower patient loads requires a greater number of physicians, Dr. Williams continued.
The road to cardiology requires a path through internal medicine, and where internal medicine training goes, so go budding cardiologists.

But I do not think this is the only reason the general cardiologists' numbers are declining.

I am aware of many, many residents who have completed their internal medicine residencies and are eager to enter cardiology fellowships but are unable to "match" in any cardiology fellowship position. I have seen graduating residents submit 50 to 70 letters to programs across the country without a single interview granted. This is where the REAL pruning of potential cardiology trainees occurs.

Fellowships are expensive for hospitals and academic programs. Funding sources have become limited as the squeeze to pare expenses continues in healthcare. So fellowship positions are often one of the first things reduced as a cost-cutting measure. Fellowships have historically also been partially funded by industry grants at times, but as the closer scrutiny of industry perks to medicine increase, these funds are more difficult for training programs to acquire. Competition for fellowship slots, then, becomes keen.

The training programs themselves are sometimes to blame. Some programs freely recognize that there may be some danger to "training their competition." Most trainees often like the city they're training in, so they look to stay nearby, making competition for patients near the training center higher if the new cardiologists chooses to practice outside the training center's immediate patient catchment area. Rural locations have fewer patients to treat, so geography may also limit the spread of cardiologists to more rural areas.

Training the new cardiologist also requires commitment from the academic faculty. As pay-for-performance initiatives drive productivity interests and are coupled with declining Medicare and insurer reimbursements, academician-teachers are being driven to become clinical revenue producers with less time to teach. It is hard to have a training program if there is no incentive to teach. Where's the Medicare reimbursement for this?

So if you want more cardiologists, not only must we make more fellowship positions, but we must also figure out how to compensate the folks doing the teaching so they're not penalized for doing so.


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