EDITORIALS
Who Is a Cardiologist? FORREST
H.
ADAMS,
MD,
FACC
Los Angeles, California
In the October 1,1974 issue of this Journal, the Advisory Committee of the American College of Cardiology on “Adult Cardiovascular Training and Manpower Requirements” presented its findings and recommendati0ns.l They represented the results of a study conducted between July 1971 and November 1973 of all 10,690 physicians in the United States with a declared primary or secondary commitment to adult cardiology as well as the 329 cardiovascular training programs. The Advisory Committee is greatly indebted to the many doctors and other persons who helped make this study possible and a success. For the first time, we have data that furnish an estimate of present and future manpower needs for cardiologists as well as a description and identification of cardiovascular training programs in the United States. Using the log-diary technique, we were able to obtain detailed information about cardiologists’ professional activities, and from this have identified four types of cardiologists described in considerable detail in the report. Each of the .four types-internist-cardiologist, clinical-cardiologist, cardiac-specialist and academic-cardiologist-seems to have a special role in our present health care system. Nevertheless, the cardiologists surveyed in this study probably care for only a small proportion of all patients seeking care for cardiovascular problems; primary care physicians see the majority of such patients. Setting aside for the moment the tremendous problem of maldistribution of cardiologists, one must ask: Is the present laissez faire system of training of cardiologists, knowing the roles they eventually perform, in the best interests of the consumer-the patient with a cardiovascular problem? Isn’t the patient entitled to know the qualifications of the physician treating his cardiovascular problem? Under desirable circumstances, who should see and care for the patient with aortic stenosis, acute myocardial infarction, hypertensive encephalopathy or pulmonary embolism? Who should read the electrocardiograms for From the Department of Pediatrics, Division of Cardiology, University of California, Los Angeles School of Medicine, Los Angeles, Calif. Address for reprints: Forrest H. Adams, MD, Department of Pediatrics, Division of Cardiology, University of California, Los Angeles School of Medicine, Los Angeles, Calif. 90024.
hospital X; who should be in charge of the coronary care unit of hospital Y; and who should perform the cardiac catheterizations and coronary arteriograms in hospital Z? What should be the training and qualifications of these doctors? ’ In his presidential address of October 1972 to the American College of Surgeons, Dr. W. P. Longmire, Jr.2 indicated that the practice of surgery in the United States should, with certain specific exceptions, be limited to those “by reason of his training and experience be certified by a surgical American Specialty Board, approved by the American Board of Medical Specialties-or, on the basis of training obtained outside of the U.S., have satisfied the training requirements for Fellowship in the American College of Surgeons.” It is clear that Dr. Longmire believes that only qualified doctors should practice surgery. Currently, the best and accepted method of determining specialty qualification is to require that the individual train in an approved center and later pass a nationally administered board examination. Should not these standards also pertain to cardiologists? Our study has shown that only 55 percent of all physicians with a declared primary or secondary interest in adult cardiology are certified in internal medicine and about 10 percent are certified in cardiovascular disease! Even among cardiac specialistswho are younger and the product of more formal training, require special skills or expertise and are more apt to see patients in consultation-the percent certified in internal medicine and in cardiovascular disease was not much higher. Are these current findings in the best interests of the patient? How can the patient determine that the doctor treating his cardiovascular problem is qualified to do so? We now have some criteria by which care for patients with cardiovascular disorders can be measured. The specialty and subspecialty boards are a case in point. The recent publications of the Inter-Society Commission for Heart Disease Resources3 are another. Still more specific guidelines have been published as “Norms for Use in the Peer Review of Selected InHospital Cardiovascular Diagnosis” 4 (and treatment). These criteria for standards, competence and performance should help us in any evaluation. Re-
May 1975
The American
Journal of CARDIOLOGY
Volume
35
761
EDITORIALS
cently, the American College of Cardiology and the American Heart Association with the help of experts have designed a Physician Self Assessment and Education Program5 available at a nominal fee. Preliminary interest in this program has been good. Finally, the majority (19 of 22) of the specialty boards of the American Board of Medical Specialties have formally approved the concept of voluntary periodic recertification examinations; one member board, the Ameri-
can Board of Family Practice, will make periodic recertification mandatoryP Some form of National Health Insurance is close at hand! Licensure, standards of care and evidence of continuing professional competence will almost certainly be a part of the legislation. Professional members of the cardiovascular community need to give serious thought to the various ramifications of, “Who is a cardiologist?”
References 1. Profile of the cardiologist: training and manpower requirements for the specialist in adult cardiovascular disease (Adams FH, Mendenhall RC, ed). Am J Cardiol 34:389-456, 1974 2. Longmire WP Jr: The surgeon, the system and patient care. Bull Am Coll Surgeons 57:9, 1972 3. Reports of the Inter-Society Commission for Heart Disease Resources: Cardiovascular Diseases-Guidelines for Prevention and Care. Washington, D. C., U. S. Government Printing Office,
762
May 1975
The American Journal of CARDIOLOGY
No. 1727-0035, 1974 4. Norms for use in the peer review of selected in-hospital cardiovascular diagnoses. Am J Cardiol 33:697-704, 1974 5. Self Assessment and Education Program of American College of Cardiology and American Heart Association. Bethesda and New York, 1974 6. AMA Newsletter 6: No. 7, February 18, 1974
Volume 35
Who Is a Cardiologist? FORREST
H.
ADAMS,
MD,
FACC
Los Angeles, California
In the October 1,1974 issue of this Journal, the Advisory Committee of the American College of Cardiology on “Adult Cardiovascular Training and Manpower Requirements” presented its findings and recommendati0ns.l They represented the results of a study conducted between July 1971 and November 1973 of all 10,690 physicians in the United States with a declared primary or secondary commitment to adult cardiology as well as the 329 cardiovascular training programs. The Advisory Committee is greatly indebted to the many doctors and other persons who helped make this study possible and a success. For the first time, we have data that furnish an estimate of present and future manpower needs for cardiologists as well as a description and identification of cardiovascular training programs in the United States. Using the log-diary technique, we were able to obtain detailed information about cardiologists’ professional activities, and from this have identified four types of cardiologists described in considerable detail in the report. Each of the .four types-internist-cardiologist, clinical-cardiologist, cardiac-specialist and academic-cardiologist-seems to have a special role in our present health care system. Nevertheless, the cardiologists surveyed in this study probably care for only a small proportion of all patients seeking care for cardiovascular problems; primary care physicians see the majority of such patients. Setting aside for the moment the tremendous problem of maldistribution of cardiologists, one must ask: Is the present laissez faire system of training of cardiologists, knowing the roles they eventually perform, in the best interests of the consumer-the patient with a cardiovascular problem? Isn’t the patient entitled to know the qualifications of the physician treating his cardiovascular problem? Under desirable circumstances, who should see and care for the patient with aortic stenosis, acute myocardial infarction, hypertensive encephalopathy or pulmonary embolism? Who should read the electrocardiograms for From the Department of Pediatrics, Division of Cardiology, University of California, Los Angeles School of Medicine, Los Angeles, Calif. Address for reprints: Forrest H. Adams, MD, Department of Pediatrics, Division of Cardiology, University of California, Los Angeles School of Medicine, Los Angeles, Calif. 90024.
hospital X; who should be in charge of the coronary care unit of hospital Y; and who should perform the cardiac catheterizations and coronary arteriograms in hospital Z? What should be the training and qualifications of these doctors? ’ In his presidential address of October 1972 to the American College of Surgeons, Dr. W. P. Longmire, Jr.2 indicated that the practice of surgery in the United States should, with certain specific exceptions, be limited to those “by reason of his training and experience be certified by a surgical American Specialty Board, approved by the American Board of Medical Specialties-or, on the basis of training obtained outside of the U.S., have satisfied the training requirements for Fellowship in the American College of Surgeons.” It is clear that Dr. Longmire believes that only qualified doctors should practice surgery. Currently, the best and accepted method of determining specialty qualification is to require that the individual train in an approved center and later pass a nationally administered board examination. Should not these standards also pertain to cardiologists? Our study has shown that only 55 percent of all physicians with a declared primary or secondary interest in adult cardiology are certified in internal medicine and about 10 percent are certified in cardiovascular disease! Even among cardiac specialistswho are younger and the product of more formal training, require special skills or expertise and are more apt to see patients in consultation-the percent certified in internal medicine and in cardiovascular disease was not much higher. Are these current findings in the best interests of the patient? How can the patient determine that the doctor treating his cardiovascular problem is qualified to do so? We now have some criteria by which care for patients with cardiovascular disorders can be measured. The specialty and subspecialty boards are a case in point. The recent publications of the Inter-Society Commission for Heart Disease Resources3 are another. Still more specific guidelines have been published as “Norms for Use in the Peer Review of Selected InHospital Cardiovascular Diagnosis” 4 (and treatment). These criteria for standards, competence and performance should help us in any evaluation. Re-
May 1975
The American
Journal of CARDIOLOGY
Volume
35
761
EDITORIALS
cently, the American College of Cardiology and the American Heart Association with the help of experts have designed a Physician Self Assessment and Education Program5 available at a nominal fee. Preliminary interest in this program has been good. Finally, the majority (19 of 22) of the specialty boards of the American Board of Medical Specialties have formally approved the concept of voluntary periodic recertification examinations; one member board, the Ameri-
can Board of Family Practice, will make periodic recertification mandatoryP Some form of National Health Insurance is close at hand! Licensure, standards of care and evidence of continuing professional competence will almost certainly be a part of the legislation. Professional members of the cardiovascular community need to give serious thought to the various ramifications of, “Who is a cardiologist?”
References 1. Profile of the cardiologist: training and manpower requirements for the specialist in adult cardiovascular disease (Adams FH, Mendenhall RC, ed). Am J Cardiol 34:389-456, 1974 2. Longmire WP Jr: The surgeon, the system and patient care. Bull Am Coll Surgeons 57:9, 1972 3. Reports of the Inter-Society Commission for Heart Disease Resources: Cardiovascular Diseases-Guidelines for Prevention and Care. Washington, D. C., U. S. Government Printing Office,
762
May 1975
The American Journal of CARDIOLOGY
No. 1727-0035, 1974 4. Norms for use in the peer review of selected in-hospital cardiovascular diagnoses. Am J Cardiol 33:697-704, 1974 5. Self Assessment and Education Program of American College of Cardiology and American Heart Association. Bethesda and New York, 1974 6. AMA Newsletter 6: No. 7, February 18, 1974
Volume 35
