PROCEEDINGS
OF THE 30TH BETHESDA CONFERENCE. THE FUTURE OF ACADEMIC
CARDIOLOGY. BETHESDA, MARYLAND, OCTOBER 26-27, 1998.
JACC Vol. 33, No. 5, April 1999:1091-1135
30th
Bethesda Conference:
The Future of Academic Cardiology*
Task
Force 4: Faculty
Joseph
S. Alpert, MD, FACC, Co-Chair,
Carl V. Leier, MD, FACC, Co-Chair
THE
FACULTY OF THE ACADEMIC CARDIOLOGY DIVISIONS IN THE
21st CENTURY
Age-adjusted
cardiovascular mortality has declined by 50% over the
past 50 years. This remarkable accomplishment has been
driven by the research and teaching of academic faculty.
However, cardiovascular disease still accounts for 50%
of morbidity and mortality in the U.S. Since cardiovascular
disease is particularly prevalent in the elderly, the
number of patients who will require cardiac care will
increase in the 21st century. The rapid progress in
understanding molecular and cellular pathophysiology
provides unprecedented opportunities to bring improved
care to patients.
Although
the profile of the academic cardiology faculty varies
considerably between institutions, certain principles
and aspects pertain to all. Advances in cardiovascular
research require major participation by academic cardiologists.
Important basic science work is often performed in cardiology
sections. Academic cardiologists frequently play a critical
role in translating basic science advances into clinical
applications. Depending on faculty interest, available
resources and financial support, divisions will vary
with respect to their activities in basic, translational
and clinical trial research; but each division will
have to participate in research to bring current cardiovascular
advances to patients, trainees and their community.
The
academic cardiologist is essential in the cardiovascular
educational process. He/she must remain committed to
teaching trainees various problem-solving concepts and
approaches, as well as critically appraise current practice
and advances in the field. The faculty of cardiology
divisions must foster a research environment and offer
the highest standard of clinical care. An adequate number
of patients is crucial to this mission. Fiscal support
for time spent performing both teaching and research
must be identified.
The
impact of the socioeconomic forces and changes over
the past decade on academic cardiology faculty has been
remarkable. The daily activities of most academic faculty
have been modified considerably; in general, time and
effort formerly dedicated to research, scholarship and
professional development have been shifted to patient
care duties. In brief, academic faculty are now expected
to perform research and to teach as before while increasing
their clinical workload to nearly the same level as
our colleagues in nonacademic practice and at a far
lower remuneration. This represents a serious threat
to the stability of academic divisions and to the survival
of academic cardiology.
This
section of Bethesda Conference #30 focuses on many of
the problems of academic faculty in cardiology (e.g.,
inadequate salaries, job insecurity, promotion and tenure,
depressed morale), potential solutions for such problems
and a prospectus for a successful future for academic
cardiology faculty and divisions.
THREATS
TO SALARY STABILITY, JOB SECURITY AND MORALE
There
can be little doubt that academic specialists in general,
and cardiologists in particular, have felt the world
closing in on them both financially and with respect
to job security. Trainees lament that their options
are limited compared to the past, and faculty feel threatened
at every turn from decreasing reimbursement, increasing
overhead, enhanced documentation requirements and restricted
access to primary care colleagues. In many academic
centers, faculties have experienced "rightsizing,"
falling compensation or threats of both.
How
this situation has come about is not difficult to ascertain.
From 1988 to 1993, there was double-digit inflation
in the cost of health care to employers and government
agencies. This escalation in cost could not be sustained
if company and government budgets were to be balanced.
This led to a demand for decreasing health care costs.
The result of this demand was the rapid growth of managed
care. Implementation of managed care carries a number
of direct consequences for all physicians and particularly
for academic practices where the costs of teaching and
research have been borne in part by clinical revenue.
The number of dollars available for a unit of clinical
work (e.g., clinic visits, electrocardiograms or angioplasty)
is decreasing rapidly. Second, as more and more patients
are managed by primary care physicians and access to
specialists becomes limited, the number of services
provided by specialists decreases. This leads to a diminished
need for cardiologists in managed care markets, as noted
in California and other regions of the country with
high managed care penetration. This has occurred at
the same time that there has been significant growth
in the number of cardiology fellows.
A
few examples will highlight the concerns. Figure
1 shows the stages in market development for managed
care in a geographic region. In early markets, the number
of catheterizations performed per 1,000 covered commercial
lives (age <65 years) is approximately 2.4, with
$90+ available per covered member per month. Under these
market conditions, one cardiologist who performs cardiac
catheterization would need about 18,000 covered lives
to stay busy full time. As can be seen, as the managed
care market "matures," the changes become
dramatic. At end stage, where there are fully integrated
systems taking full risk capitated contracts, the number
of catheterizations falls to only 1 per 1,000 insurees,
dollars available are cut in half and 58,000 people
are needed to keep a single catheterizing cardiologist
busy. Thus, there is a perceived diminished need for
cardiologists. This, coupled with the fact that there
is rapidly decreasing reimbursement, has led to considerable
anxiety on the part of cardiology faculty and fellows.
These
changes have forced academic units to begin to cost-account
faculty time in terms of research, teaching and clinical
services. The goal is to make each component pay for
itself, since clinical revenue can no longer subsidize
teaching and research.
One
consequence of decreasing reimbursement is an increase
in the amount of work performed by faculty to help maintain
economic stability. This has resulted in the shift to
more clinical and less research faculty in departments
of medicine and divisions of cardiology. Faculty are
being asked to increase their clinical workload to emulate
their colleagues in private practice but without the
same personal remuneration. Figure
2 shows concrete examples of what the Division of
Cardiology at Duke has done over the past 6 years. From
1992 to 1997, charges which can be taken as a surrogate
for patient care activity (price increases over this
time have been in the 1% to 3% per year range) have
increased an average of 8.3% per year for a total increase
of 49.8%. Therefore, with approximately the same number
of faculty, Duke cardiologists did 38% to 45% more clinical
work over a span of 5 years. Over that same period of
time, total receipts fell 6.3%. These results are typical
of those observed across the country and are obviously
very disheartening to cardiology faculty. In many academic
institutions this has led to flat or decreasing salaries
and even decreases in faculty size. If we look nationally
at the trends in salaries for cardiology at academic
centers, the recent past has shown little growth in
compensation and, in some cases, actual decreases.
These
changes have led divisions of cardiology to reassess
the role and appropriate size of their faculty and their
mission. Programs have now limited the number of recruits,
and in some cases downsized. To meet our tripartite
mission of teaching, research and clinical care, it
will be necessary to find new revenue streams and to
decrease expenses. In the past, divisions of cardiology
have been financial generators for departments of medicine.
This model is rapidly changing as cardiology income
declines.
All
of these forces have resulted in declining faculty morale.
This situation has contributed to increased faculty
turnover in recent years. To preserve the mission of
academic cardiology, it is essential that we improve
the morale of our faculty. However, it would sound foolish
to inform faculty that "all is well." Nevertheless,
academic life is still filled with many positive experiences:
the intense satisfaction of the faculty member who has
just won her hard-earned RO1 grant, the pleasure of
hearing that your promotion has been approved and the
joy of interacting with eager and enthusiastic medical
students and house staff. We as faculty need to develop
a level of personal equanimity that enables us to accept
the bad news around us and put it into appropriate perspective.
Academic cardiology will survive; our patients, our
profession and our nation require it. We must remember
that we practice the most advanced and sophisticated
medicine in the world, that cardiovascular research
plumbs new and exciting depths almost on a daily basis
and that our students are as intelligent and dedicated
as ever. We can and will overcome present circumstances.
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