SNOWMASS, COLO. — The pipeline of future cardiac surgeons is “essentially nonexistent”—and that fact will have serious downstream consequences not only for the surgical specialty but for cardiologists and all others who provide care for patients with heart disease, Dr. Andrew S. Wechsler warned.
“When I began my cardiac surgical training there were roughly 10 applicants per available position. Today there are basically more positions than applicants,” said Dr. Wechsler, professor of cardiothoracic surgery at Drexel University, Philadelphia.
Indeed, last year there were only 97 applicants for the 130 U.S. training positions, and only 68 of them were graduates of American medical schools. The quality of the applicants has dropped off, he added while speaking at a conference sponsored by the Society for Cardiovascular Angiography and Interventions.
The dramatic falloff in the applicant pool began about 4 years ago. It's a trend of particular concern because of the projected increasing demand for cardiac surgical services as the population ages, coupled with the fact that one-half of practicing cardiac surgeons are above age 53. Many are contemplating retirement as a consequence of decreasing reimbursement, mounting malpractice insurance costs, and declining job satisfaction.
Reimbursement for cardiac surgery today is, in real dollars, only about 30% of what it was 15 years ago. Cases have become far more complex, with a huge increase in the number of reoperations. The average yearly cost of malpractice insurance for cardiac surgeons practicing in Pennsylvania is $125,000. Surveys indicate only one-quarter of practicing cardiac surgeons would advise medical students to enter the field today, Dr. Wechsler said at the conference, cosponsored by the American College of Cardiology.
Cardiac surgery is currently performed at more than 1,400 U.S. hospitals, many of which have small-volume programs. Dr. Wechsler predicted that one consequence of the looming shortage of cardiac surgeons will be governmental pressure to reconsolidate cardiac surgical services to high-volume centers, with resultant closure of many smaller programs. Referring physicians are likely to find high-quality cardiac surgeons becoming less available.
Cardiac surgical educators have launched a number of initiatives to address the predicted shortage. Paid internships are being offered to medical students in an effort to capture their attention early in their education in the hope of steering them into this challenging field. New integrated training programs have been approved, including a 6-year program in cardiac surgery beginning right out of medical school. And vascular surgery is now accepted as a pathway to cardiac surgical training, noted Dr. Wechsler.
Former ACC president Spencer B. King III said that “we at the ACC have been worried about this [cardiac surgery workforce crisis] a lot.” Late last year the ACC and Society of Thoracic Surgeons agreed on a joint educational initiative that will focus on three broad areas: defining criteria for the appropriateness of revascularization; development of hybrid interventional cardiology/cardiac surgery procedures; and treatment of structural heart disease. “We interventional cardiologists are jumping into the area of structural heart disease with enormous enthusiasm, but how many interventional cardiologists have spent their career looking at the inside of hearts? That's where the surgeons live. So I think there are enormous opportunities for collaboration,” said Dr. King, the Fuqua Chair in Interventional Cardiology at the Fuqua Heart Center at Piedmont Hospital, Atlanta.
Surveys indicate only one-quarter of practicing cardiac surgeons would advise medical students to enter the field today. DR. WECHSLER