Ira S. Nash

The Generalist/Cardiovascular Specialist: A Proposal for a New Training Track

The physician workforce of the United States has the highest ratio of specialists to generalists of any developed western nation [1]. The economic forces that are reshaping the U.S. health care delivery system have prompted intense examination of physician mix [2], and calls are being made to increase the supply of generalists and train fewer specialists [3]. However, important and historic reasons explain why specialists dominate health care delivery in the United States. In addition, a growing body of data suggests that specialists may provide higher-quality care for some conditions, raising important issues of access to appropriate care. 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) Table 1. Cardiovascular Training Tracks 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

Reassessing normal blood pressure

Blood pressure should be evaluated and treated in the context of overall cardiovascular risk

Resident burnout [2]

TO THE EDITOR: Smith and colleagues (1) provided much-needed information about the characteristics of erythema migrans caused by Borrelia burgdorferi that will grow in BarbourStoennerKelly culture. In addition, they commented on erythema migranslike lesions in the southeastern United States, which are associated with Amblyomma americanum, or lone star ticks (2), and suggested that another agent, perhaps even from the Borrelia genus, may cause the infection. For this statement, they gave three references, one of which is a study by Campbell and associates that was sponsored by the U.S. Centers for Disease Control and Prevention (3). In fact, Campbell and associates concluded quite the opposite, that is, that these tick biteassociated annular rashes were not caused by B. burgdorferi or related spirochetes. The state epidemiologist who initiated the study and I, as the clinician who supplied most of the patients, declined authorship because of the exclusion of relevant data and the lack of objectivity. We published our objections in the Journal of Clinical Infectious Diseases (4) and Missouri Medicine (5), including data excluded by Campbell and associates, and reiterated our opposite conclusion: that atypical B. burgdorferi or related spirochetes were completely compatible with data gathered in the study. Now that increasing evidence is implicating these Lyme-like lone star tickassociated rashes as borreliosis, it would be a terrible mistake to give credit to Campbell and associates. In fact, on 31 March 1996, after the Campbell studys publication, Dr. David Dennis of the Centers for Disease Control and Prevention, a coauthor, was quoted in the Kansas City Star as saying that these rashes could be caused by tick spit for all we know. For factual reasons, one should avoid giving credit for properly implicating borreliosis to those who actively and, in my opinion, inappropriately opposed the concept.

Economic Costs Associated with Atrial Fibrillation

As the population ages, the incidence and prevalence of atrial fibrillation (AF) is expected to increase, resulting in significant societal and economic impact. By 2050, AF is projected to affect 15.9 million individuals in the United States. Atrial fibrillation results in a variety of adverse outcomes, including a fivefold increased risk of stroke, impaired quality of life, decreased work productivity, and increased rates of hospitalization. In 2005, there were 470,000 U.S. hospitalizations secondary to AF. In 2004, over 9 million working days were lost because of AF. Costs of AF and its associated complications are enormous. In 2006, costs attributable to AF-associated stroke equaled

Ethnic differences in electrocardiographic amplitude measurements.

12 billion. In addition,

Contemporary awareness and understanding of cholesterol as a risk factor: results of an American Heart Association national survey

41,000 to

Do Cardiologists Do It Better

105,000 per patient was spent on aggregate and individual AF care. Because of its increasing prevalence, numerous complications, and large costs, AF presents a significant challenge for patients, clinicians, and health care policymakers. Finding strategies to best care for these patients will become increasingly important.

Contemporary Awareness and Understanding of Cholesterol as a Risk Factor Results of an American Heart Association National Survey

BACKGROUND There is controversy regarding ethnic differences in electrocardiographic (ECG) patterns because of potentially confounding socioeconomic, nutritional, environmental and occupational factors. METHODS We reviewed the first 1000 medical files of a multi-ethnic community, where all individuals shared similar living conditions. Only healthy adults age 15 to 60 years were included. Wave amplitudes were measured manually from the standard 12 lead ECG. Minnesota coding was used. RESULTS ECGs from 597 subjects were included in the study: 350 Saudi Arabians, 95 Indians, 39 Jordanians, 17 Sri-Lankans, 39 Filipinos, and 57 Caucasians; 349 were men. The mean±SD of Sokolow-Lyon voltage (SLV) in men was significantly different among ethnic groups (2.9 ± 0.86, 2.64 ± 0.79, 2.73 ± 0.72, 3.23 ± 0.61, 2.94 ± 0.6, 2.58 ± 0.79 mV; P=0.0006, for Saudis, Indians, Jordanians, Filipinos, Sri-Lankans, and Caucasians, respectively). SLV was similar among ethnic groups in women. The prevalence of early transition patterns was also different among ethnic groups in men but not women (15.8%, 34.6%, 17.9%, 21.7%, 35.3%, 26.8% in Saudi, Indian, Jordanian, Filipino, Sri-Lankan, and Caucasian men, respectively, P=0.037). T wave amplitude was significantly different among ethnic groups in selected leads. CONCLUSIONS ECG wave amplitude differs with ethnic origin even when other factors are similar. Using SLV of 3.5 mV as a criterion may overestimate the incidence of left ventricular hypertrophy in some ethnic groups. The pattern of high R wave in lead V1 is common in healthy adults in certain ethnic groups. T wave height differs with ethnic origin and sex.

Working group 8: Defining the different types of cardiovascular specialists and developing a new model for training general clinical cardiologists

Results: Interviews were completed with 1163 adults 40 years and older. A national probability sample of 1114 was created. Of the final sample, 28.5% were 65 years or older, 56.1% were women, and 86.5% were white. Although 91.2% of respondents stated that it was “important to them personally to have a healthy cholesterol level” (77.6% extremely or very important), 51% did not know their own level. Only 40.2% were aware of national guidelines for cholesterol management, and 53.1% either did not know or overestimated the correct desirable total cholesterol level for a healthy adult. When asked what sources of information they relyon themost, 66.8%identifiedphysicians,while only 3.7% rely primarily on the Internet.