Cardiovascular workforce in the 21st century.

Access to healthcare will likely again become a major issue for the US government and for the medical profession as the rate of increase in healthcare expenditures steepens. The number and distribution of physicians is a major factor driving healthcare utilization and thereby costs. Another factor is the disease burden in the population as a whole. Cardiovascular diseases are the leading cause of morbidity and mortality in our society, and with the predictable large increase in the elderly population over the next one to three decades, they will undoubtedly continue to be a dominant healthcare issue. Thus, the paper by Wieslander and associates, in this issue of the Journal, attempts to answer an important question: will there be a sufficient number of adequately trained cardiovascular specialists to meet the anticipated demands? These authors conclude that, at least for some aspects of cardiovascular care (ie, noncoronary endovascular procedures), the answer is no. In fact, they believe there will likely be a critical shortage. They make a number of assumptions in reaching this conclusion. The first assumption is the large increase in numbers of patients needing endovascular procedures. Without doubt, the population is aging. As the baby boomers reach their golden years, there will be a steep increase in the number and percentage in the population over 65 years of age, beginning in 2010. But will there be a corresponding increase in the incidence and prevalence of atherosclerotic lesions that need invasive treatment? The answer here is less certain. The competing impact of diabetes, obesity, and smoking on the one hand, with healthier lifestyles, better pharmaceuticals, and better medical management of cardiovascular risk factors on the other, makes predictions risky. In addition, the impact that managed care and other payment schemes will have on procedural utilization rates is unknown, but it is unlikely to be inflationary. The second assumption is that there will be large increases in utilization rates for endovascular procedures in the future, both in total and as a percentage of all cardiovascular procedures. It is true that there has been a dramatic increase in catheter-based procedures over the past 5 to 10 years driven by new technology and patient demands. But the durability of most of these procedures is less than ideal and, in many cases, less than the open surgical procedures that they replaced. Does it make sense to place stents in coronary or peripheral arteries only to have to perform an open procedure 1, 2, or 3 years later when the often repeat dilation and stenting procedures are finally declared a failure? The greatest number of endovascular procedures and the greatest percentage increase in their performance has been by the interventional cardiologists who are rapidly increasing their interest in noncoronary arterial lesions. The appropriateness and necessity of many of these peripheral interventions have been questioned, and the same can be said for endovascular procedures performed by other specialty groups, including vascular surgeons. Unfortunately, good data on this subject are lacking, but the wide variability in utilization rates throughout the country suggests that indications are just as variable. As criteria for both endovascular and open vascular procedures become standardized, the predicted increase in utilization rates may not occur or could even decline. Furthermore, most health economists believe that the number of procedures performed in a population is driven as much by the number of physicians who perform them as by the number of patients who need them. Third is the assumption that there will be insufficient numbers of specialists available to meet the increased workload brought on by the increased population. The ratio of specialists to patients for promotion of optimum utilization of services is not known. There will surely need to be more physicians trained, but the question just how many and what types is the nexus of the paper of Wieslander et al. The authors cite a possible scenario whereby there will actually be fewer practicing cardiovascular specialists in 2010 than in 2000. This is on the basis of a projected annual retirement rate of 5%, which in turn is based on an American Medical Association survey of mostly nonsurgeons. For some reason, the authors dismiss as too low the 2.3% and 2.4% rates of conversion to senior member status (their proxy for retirement) from the American Association for Vascular Surgery and the Western Vascular Society, respectively. And although it might have been true a few years ago that physicians were retiring earlier, I believe that economic pressures (reduced reimbursements and decreasing investment income) have begun to force physicians to work more rather than fewer years. With a more conservative annual retirement rate of 3.3%, the authors calculated a 14.4% increase in the cardiovascular workforce in the year 2010 and a further increase of 32% by the year 2030. The fourth assumption is that there is a current deficit of 638 endovascularly trained surgeons, that only a small percent of vascular surgeons are performing endovascular procedures, and that only a small number of vascular fellowship programs provide adequate endovascular training. Here again, I believe the situation is rapidly changing. From the Division of Vascular Surgery, University Hospitals of Cleveland. Competition of interest: nil. Reprint requests: Jerry Goldstone, MD, University Hospitals of Cleveland, Division of Vascular Surgery, Lakeside 6121, 11100 Euclid Ave, Cleveland, OH 44106 (e-mail: jgoldst77@aol.com). J Vasc Surg 2002;35:1301-2. Copyright © 2002 by The Society for Vascular Surgery and The American Association for Vascular Surgery. 0741-5214/2002/$35.00 0 24/9/123761 doi:10.1067/mva.2002.123761