A Closer Look at the Cardiology Workforce Shortage

What Some of the Nation’s Experts Have to Say

By Suvarna Sheth

SAN FRANCISCO – The cardiology workforce shortage isn't anything new, but a recent survey finds the current 3,000-person shortage could reach a staggering 16,000 by the year 2050.

"Our guess is that the deficit in number of cardiologists is probably going to widen and even double in 20 years," says Dr. George Rodgers, chair of the task force that designed the survey and a cardiologist in private practice in Austin, TX.

Some of the nation's top cardiologists are skeptical about the number, but the consensus is there is a shortage of cardiologists in the workforce today. 

"I'm not a good statistician to predict more accurately," says Dr. Robert Bonow, chief of cardiology at Northwestern University Feinberg School of Medicine, "other than to echo the sentiment there's going to be a shortfall, whether it's 16,000, 12,000 or 20,000—there's going to be a shortage."

According to Rodgers, much of the current shortfall is attributed to massive downsizing that took place in the field during the mid-1990s.  At that time, a nationwide assessment found the bulk of cardiovascular problems could be taken care of by primary care physicians. 

"It turns out, this was wrong," Rodgers says, "primary care physicians don't want to manage acute heart attacks, and patients don't want to be handled without their cardiologists." The problem is that many institutions were stuck with limited funds and resources well through the end of the 1990s.

Bonow says there was also a significant downsizing of cardiology training programs at the time.  "Today, some of those programs have ‘right-sized'- but not all," Bonow says.  Still, more cardiologists are in training now then 1992.  Northwestern's cardiology program went from five fellows to three and now is back up to seven per year.

Rodgers says the shortage of general cardiologists is about 3,000 today based on positions that haven't been filled yet.  Going after these positions are only about 800 fellows that have just finished their training.  "That's all the cardiologists we create every year— about 800 to fill the gap," Rodgers says.

It's not a pipeline issue, according to Rodgers, because every year there is 1,200 internal medicine residents who are applying for positions in cardiology—but only 800 of them get into fellowship programs.

"There are 400 internal medicine residents that are turned away every year," Rodgers says.  "There are plenty of people interested in a career in cardiology, but more funding for fellowship positions is required."

Bonow agrees.  "The applicant pool is not the issue," he says, "it's that the number of training slots is not sufficient."

The case in cardiac surgery, however, is different.   According to Bonow, there's going to be a real under-supply of cardiac surgeons because the training programs are going unfilled.

"It's the opposite of what's happening in cardiology—where you have a huge applicant pool," Bonow says.   "Programs in cardiac surgery aren't getting enough applicants."

Bonow is certain that this is going to be a problem because there's going to be a need for cardiac surgeons with the aging population—"you can't do everything with catheters— and there may not be enough surgeons to go around in the very near future," he says. 

In order for there to be more fellowship positions, Bonow says someone will have to pay for it – either the government or other internal sources within the various institutions.

But fellowship funding is only part of the problem.  The real issue is that the cardiology workforce shortage is going to continue because of the aging population.

"With growth of patients with diabetes and metabolic syndrome at younger ages, there's going to be a rise in the amount of patients with cardiovascular disease, and right now, there's probably not enough cardiologists to take care of them," Bonow says.

The fact is, Americans are living longer with cardiovascular disease and requiring more specialized care than before.   More baby boomers are clicking into the 65 and over range, and there has been a 1% growth per year over the last decade in that population.   Over the next two decades, the growth in that population is projected to be 3.3% per year.

"Cardiology has actually been very successful in keeping people alive," Rodgers says, "but unfortunately, we can't cure the disease so we have many more people than we use to that are still alive with heart disease today. "

Another reason for the cardiology demand is that a significant number of cardiologists are near, or heading towards retirement.  Forty-three percent of the current cardiology workforce, 31% of pediatric cardiologists, and 21% of interventional cardiologists are over the age of 55 years.  Retirement rates are therefore projected to play a critical role in the supply of cardiologists in the near future.

If half of today's cardiologists decide suddenly they don't want to work anymore, "then suddenly you have a drop in a quarter of the entire cardiovascular workforce," Rodgers says, "that would be what's known as an extinction level event."

And then there is the healthcare reform wildcard. If the 47 million Americans who currently don't have access to healthcare become suddenly eligible for insurance, that is going to in turn increase the demand for doctors across the board, from primary care doctors to cardiologists.

It's not certain if healthcare reform will help or hinder the situation.  "It depends on how it all plays out," Bonow says.  "It's not clear that the healthcare reform is going to create more incentive to become a cardiologist because it's quite possible that reimbursement cuts may act as less of a financial incentive."

But that could go many ways.  "Right now, I'm skeptical," Rodgers says, "the winds are not moving in our direction and maybe it's going to take things getting worse before it gets better."

While the cardiology community is aware of the impending crisis, there are some experts that are weary of the projections.

"The only thing I would say is that all projections at the moment are very problematic," says Dr. Bruce Fye, a cardiologist at Mayo Clinic in Minn., "because so many important factors are uncertain, the economy, health care reform, etc.," he says.

Fye was once actively involved in researching and writing about the issue as chair of the 35th Bethesda Conference which examined the origins and implications of the cardiologist shortage in 2004.

"If you read my introduction to the 35th Bethesda Conference report," Fye writes in an e-mail response, "you will see that I was skeptical of projections then and remain skeptical about predictions."

Fye also says there is a "great deal of caution" about over hiring that will likely make it harder than usual for trainees to find jobs.  But, he says this is a short term problem.

What solutions are on the horizon?  While it may take longer to create more fellowship positions, a faster solution involves creating a team-care environment using non-physician practitioners, like physician assistants and nurse practitioners to help out the cardiology care team.

"There's clearly an undersupply of physician assistants and nurse practitioners and we can use them more," Bonow says.

A more controversial idea brewing at the American Board of Internal Medicine is to redesign the fellowship program with a shortened track so it takes five years instead of six years of training to become a cardiologist.

"Shortening the track for training would help," Bonow says, "because it will reduce the amount of money required to support the salaries of individuals in training."

However, Rodgers says it's going to require a lot more work and perhaps a "paradigm shift" on how internal medicine and cardiology education is practiced to accomplish that.

In the end, cardiologists have been aware of the looming crisis, but there haven't been any solid solutions to the problem yet.

"There's got to be some national discourse about what's needed to provide the best care for an aging population and and also a population that's developing more obesity, diabetes, and cardiovascular disease among young people," Bonow says.