Cardiovascular medicine is paradigmatic of the aforementioned issues. This field has had explosive growth in terms of the number of its practitioners [4] and therapeutic advances [5], but it is also under intense pressure to shrink its ranks [6]. We offer a proposal for achieving the seemingly disparate goals of providing high-quality, specialist cardiovascular care while increasing the relative supply of generalists.

Definitions

Generalists are physicians who are dedicated to providing primary care; that is, "first-contact, continuous, comprehensive care ... to a population undifferentiated by gender, disease, or organ system" [7]. We take "primary care provider" and "generalist" to be synonymous; we include within this group family practitioners and general internists and exclude subspecialty-trained internists, such as cardiologists.

Just as generalists are heterogeneous, so too are cardiovascular specialists. We use "cardiologist" and "cardiovascular specialist" interchangeably to apply only to those physicians who have completed an approved postresidency fellowship and have passed the American Board of Internal Medicine (ABIM) certification examinations in internal medicine and cardiovascular disease. The form of postresidency training may differ depending on whether the trainee is pursuing a clinical or an investigative career (Table 1)

Current Environment

According to the Policy Statement of the Association of American Medical Colleges [8], specialty practice has attracted more medical school graduates than has primary care because of

"the increasing ability of the non-generalist practitioners to diagnose and treat many heretofore untreatable conditions, the inherent appeal of the astonishing technological advances ... in several specialized areas, the desire to gain mastery over a well-defined and circumscribed field, [and] the prospects for greater financial rewards."

Many of these reasons contribute to the attractiveness of cardiovascular medicine [9]. Economic opportunities for specialists are supported by wide-spread public desire to seek the care of specialists for specific conditions [10]. The demand for access to specialists is also cultivated by professional societies for specialists, which attempt to blunt the ability of managed care to reduce reliance on specialist services through direct advertising to the public. Such efforts are supported by evidence that the care provided by cardiologists may be better than that provided by internists and family practitioners for some conditions [11]. In 1993, Borowsky and colleagues [12] reported that cardiologists were more likely than noncardiologists to refer their patients for "clinically necessary" coronary angiography. Ayanian and coworkers [13] reported in 1994 that cardiologists were more likely than generalists to prescribe therapies of proven efficacy for acute myocardial infarction. Lower mortality rates have been reported [14, 15] for patients who have had acute myocardial infarction when care is provided by a cardiologist rather than a generalist. Cardiologists also have more accurate perceptions of the value of modifying cardiovascular risk factors [16].

However, other data show that cardiologists rely heavily on testing and procedures that increase costs with little health benefit [17, 18]. An editorial that accompanied a report on the Medical Outcomes Study [18] concluded that

"one way to gain some control over escalating health care expenditures is to pay attention to the mix of physicians providing health care ... . Given the inexorable fact that our nation must limit its expenditures on health care, it is time to increase the proportion of physicians entering generalist disciplines [19]."

This call has been heard loud and clear, despite the paucity of data on the effects that such a shift would have on quality of care [20] and the acknowledged profound effect it would have on academic medical centers [21, 22]. Proposals differ with regard to how the goal of increased reliance on generalists is to be attained and what the final, steady-state, relative number of generalists and specialists ought to be [23-28].

Proposal for Training in Cardiovascular Care

Any proposal to alter the relative number of generalists and cardiovascular specialists encounters two hurdles. First, no consensus has been reached about the ideal target number of cardiovascular specialists. In most instances in which manpower requirements are discussed, staffing patterns for health maintenance organizations are extrapolated to populations [29, 30]; this prompts the question of whether such staffing patterns are optimal, in terms of either clinical outcomes or economics. Uncertainty about the need for physicians today implies even greater uncertainty about these needs in the future because of the fundamentally incalculable interplay of population demographics, changing patterns in the natural history of major cardiovascular illnesses, technological innovation, and the effect of health reform on physician behavior and practice. In addition, changes to the present system of postgraduate training will not appreciably affect the ultimate physician mix for years because of the length of the medical school and postgraduate training process and the large pool of specialist physicians already in clinical practice.

To increase the supply of generalists, reduce growth in the number of cardiovascular specialists, and preserve access to high-quality cardiovascular care in the face of inherent uncertainties in projected physician workforce requirements, we propose two complementary actions: 1) decrease the number of trainees in cardiovascular disease and 2) develop a 5-year generalist/cardiovascular specialist training track.

Decreasing the Number of Trainees in Cardiovascular Disease

Although the optimal number of cardiovascular specialists is unknown (and probably unknowable), it is agreed that current training patterns have led to an oversupply [31]. Paradoxically, this may decrease the quality of cardiovascular care: As specialized services become widely practiced, the ability of individual specialists to develop and maintain their expertise is limited. Even now, most cardiologists who perform coronary angioplasty do fewer procedures per year than the number recommended by the joint expert panel of the American College of Cardiology and the American Heart Association [32].

As discussed at the 25th Bethesda Conference [33], "any reduction in subspecialty training should be based on the quality of the education experience alone and not on ... ‘across the board’ reductions." The Residency Review Committee, with input from the ABIM and the American College of Cardiology, should actively raise the standards of fellowship training programs with the intention of disqualifying more marginal programs.

Generalist/Cardiovascular Specialist Clinical Training Track

Along with a reduction in the number of cardiovascular training positions, we propose the creation of a 5-year generalist/cardiovascular specialist training program (Table 1). The first 2 years of the program would consist of standard training in internal medicine. The final 2 years would resemble a typical cardiology fellowship, with abbreviated rotations in the coronary care unit, exercise laboratory, noninvasive imaging laboratory, catheterization suite, and more. The middle year would combine internal medicine and cardiovascular medicine in a flexible way that may differ from institution to institution. The intention is to emphasize the nonprocedural aspects of preventing and treating vascular disease. Some programs may include formal training in the pharmacologic management of atherosclerosis, thrombosis, hypertension, and dyslipidemia; others may provide a conventional senior residency year with enriched elective time devoted to cardiovascular issues. Trainees would be Board eligible in internal medicine after the third year and would maintain a longitudinal outpatient primary care practice during the 5 years of the program.

Trainees would not qualify for ABIM certification in cardiovascular disease and should not be eligible for Board certification, even if they seek another year of cardiovascular training elsewhere, because this would subvert the intention of the training program. The final product of this training path would be a Board-eligible internist with a commitment to and solid training in primary care who also possesses special skills for evaluating and managing prevalent cardiovascular illness. This generalist/cardiovascular specialist would neither be trained in nor expected to perform catheterization procedures or advanced imaging studies, such as nuclear myocardial perfusion scanning or transesophageal echocardiography.

The incentive to lengthen training by 2 years without the promise of subspecialty certification must come from a personal commitment to providing longitudinal, nonprocedural primary care and cardiovascular principal care and from the need to reduce the number of training positions in traditional cardiovascular fellowships. We expect that generalist/cardiovascular specialists would be attractive to multispecialty group practices and health maintenance organizations, with or without formal recognition of their advanced cardiovascular training. They would function as primary care providers and provide longitudinal clinical care for many patients with cardiovascular diseases, such as congestive heart failure or coronary artery disease, without referral to a cardiologist. We think that patients will welcome the enhanced cardiovascular competence of their physicians in the context of longitudinal and comprehensive care, especially as access to traditional specialists becomes more circumscribed.

Financial support for fellowship training programs currently comes from federal funds for graduate medical education, clinical income from faculty practices, public and private grants, and philanthropy. The new track, insofar as it substitutes for traditional training positions, would not increase the total amount of support necessary and should be at least as attractive as the traditional track to faculty and government. Faculty members may be more inclined to underwrite the training of persons who would not enter into direct competition to provide tertiary services. Government agencies should respond positively to attempts at increasing the supply of generalists. We also believe that funding the generalist/cardiovascular specialist training track may be attractive to managed care organizations, which may partner with academic medical centers in their markets to train generalists with expanded expertise in cardiovascular medicine.

We propose that the 5-year generalist/cardiovascular specialist clinical training track be implemented on a pilot basis in a few academic institutions that have recognized academic excellence in cardiovascular disease and are willing to support the pilot program financially. A working group of a minimum of five centers could draft specific guidelines for curriculum and training requirements and measurable end points of success. If the pilot program is successful, ongoing funding could be sought from government agencies and managed care organizations. The pilot centers would continue to have standard cardiovascular training programs.

Discussion

Top Discussion Author & Article Info References

Gabriel [34] suggested that "one of America's foremost health-care challenges is to control medical-care costs while keeping the decrease in beneficial outcomes, technical quality, access, and service to the barest minimum." We believe that the real goal should and can be the achievement of necessary cost savings with a simultaneous increase in beneficial outcomes. The proposed generalist/cardiovascular specialist training track is one means to that end.

Shrinking existing training opportunities in cardiovascular disease and creating a new 5-year generalist/cardiovascular specialist program will yield several important benefits. First, reducing the size of present programs will directly promote the shift toward fewer specialists and more generalists, although it will take years for the effects of smaller training cohorts to be felt. Second, the shift within training programs toward the development of physicians who are well versed in and committed to the practice of preventive cardiology in a primary care setting will create a flexible pool of practitioners who can fill the unpredictable future needs of the health care system. Although there seems to be a need for more generalists, rapid advances in the understanding and management of cardiovascular diseases add to the fund of knowledge needed to deliver high-quality cardiovascular care. The generalist/cardiovascular specialist can achieve this balance. Third, innovative training opportunities will also foster the role of the departments of medicine within academic medical centers. These departments may use this new pathway as an opportunity to integrate various clinical subspecialties in a cohesive group practice; this may be advantageous in the rapidly changing medical marketplace. If it is successful, this template may also be used to create similar training programs in other procedure-oriented medical subspecialties, such as gastroenterology and pulmonary medicine. Finally, decreasing the number of training berths that lead to certification in cardiovascular disease and opening an alternative path for persons interested in providing longitudinal, nonprocedural care will aid academic medical centers that have been producing highly trained subspecialists only to have them enter the community and threaten the viability of their training centers [35].

Despite these apparent benefits, some potential difficulties may be encountered in the institution of this new training pathway. It must be made clear that the positions created should substitute for traditional training positions and not add to the overall pool. The temptation to expand programs by adding this new pathway must be resisted. The generalist/cardiovascular specialist may also face misunderstanding and skepticism about his or her qualifications until this pathway becomes more firmly established and widely recognized.

This proposal is not intended to undermine the commitment to clinical research and scholarship embodied by the current ABIM requirement for 1 year of investigative work as part of the path to Board certification in cardiovascular disease. We believe that it complements and extends the recent position paper of the ABIM Task Force on Subspecialty Internal Medicine, which called for (as do we) more rigorous training for specialists and fewer fellowship training positions [36]. Expanding the number of training pathways (not the number of positions) available is intended to further "the ultimate goal ... [of] maximization of quality of life for all, balanced against the United States' very real resource limitations" [37].

Conclusions

The proposed generalist/cardiovascular specialist training track may improve the balance between generalists and cardiovascular specialists while also providing the highest-quality patient care. Such a program could serve as a model for innovative training programs in other subspecialties and could help support the group practice needs of academic institutions.