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
APPROPRIATE NUMBER OF CARDIOLOGY FACULTY FOR THE FUTURE
Over
the past 20 years, there has been a substantial increase
in the number of full-time and part-time faculty members
in academic cardiology divisions throughout the United
States. The major impetus for this increase in faculty
was the emergence of subspecialty disciplines within
cardiovascular divisions as a result of advances in
technology. The areas that required specialized training
and developed into subspecialties were echocardiography,
nuclear cardiology, clinical/interventional electrophysiology,
coronary/valvular interventional cardiology, heart failure/transplant
cardiology, preventive (risk factor modification) cardiology
and vascular medicine. Certificates of added qualification
are or will be granted by the Cardiovascular Board of
the American Board of Internal Medicine for electrophysiology
and interventional cardiology, since these subspecialties
require an additional year of fellowship beyond the
standard 3-year cardiology fellowship training program.
To
staff these new disciplines, full-time academic cardiovascular
divisions needed more attending physicians to provide
clinical services, conduct research and train the next
generation of subspecialists. In addition, cardiology
fellows who were tracking to become "general cardiologists"
needed a liberal exposure to these specialized areas.
The
Association of Professors of Cardiology has been monitoring
the number of full-time cardiology division faculty
in academic medical centers since 1992. Table
1 shows the number of faculty members per institution.
Between 1992 and 1997, the number of faculty per institution
grew from 15.71 to 18.17 (Table
1).
Another
stimulus for the increase in the number of cardiology
division faculty during the past 20 years is the increased
emphasis on the research mission of academic medical
centers. Many cardiology divisions actually changed
their name from "cardiology divisions" to
"cardiovascular divisions" after incorporating
vascular medicine and vascular biology into their academic
mission. Research faculty in cardiology divisions sought
to participate in the revolution in molecular biology
and molecular genetics as it applied to cardiovascular
disease. The advances in molecular biology stimulated
increased recruitment of basic science faculty to academic
cardiovascular divisions. Many division chiefs in academic
cardiology sought to develop programs for the training
of MD investigators in molecular and cellular biology.
Many of these newly trained individuals remained on
the faculty of their respective institutions or were
recruited to academic centers elsewhere. Other stimuli
for the growth of research faculty included expansion
of clinical trials and technology development and assessment.
Unfortunately,
a recent study has shown that faculty at medical centers
in competitive markets publish fewer scientific articles
compared to clinical investigators in less competitive
markets (1). The junior
faculty members in the highly competitive markets had
greater clinical responsibilities and, hence, less protected
time for research.
The
question that can now be asked is "how many faculty
do we really need?" The answer is at present unclear.
The total number of board certified or eligible cardiologists
in the U.S. has grown considerably during the past 25
to 30 years. In 1970, there were 4,616 clinically active
cardiologists practicing in the United States, or 2.2/100,000
population. By 1993, the number of cardiologists in
the United States had risen to 14,125, or 5.7/100,000
(2). Today in the United
States, there are approximately 7.0 cardiologists per
100,000 population. Despite the well known constraints
of managed care, the number of patients seen by cardiologists
continues to grow. Contrary to intent, it is possible
that despite managed care, the referral of patients
with cardiovascular disease to cardiologists by primary
care physicians might continue to increase. Americans
clearly want freedom of choice of physician including
access to cardiologists. Additionally, as the American
population ages, cardiovascular-related illness will
increase. An increasing emphasis on quality and increasing
population at risk for cardiovascular disease might
thus lead to a greater demand for cardiologists, thereby
placing pressure on academic cardiology divisions to
train more cardiologists. However, given the conflicting
forces, it is impossible to predict accurately whether
the demand for cardiologists will increase, decrease
or remain the same in the future.
Similarly,
the number of faculty members needed for the provision
of high quality specialty care, state-of-the-art research
and training of the next generation of general cardiologists,
subspecialty cardiologists and internal medicine residents
is unknown. Certainly, there will be increased utilization
of nurse practitioners and physician assistants in response
to cost-cutting and cost-effective care norms. Of interest
are data provided by the American Board of Internal
Medicine showing that the number of first-year cardiology
fellows decreased from 858 to 736 between 1992 and 1996
at a time when the number of full-time faculty members
per academic training institution actually increased
(see Table 1) (3).
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