Cardiovascular manpower: the looming crisis.

Less than 10 years ago, conventional wisdom taught that there was an oversupply of specialists in a managed care environment and that the majority of needs in cardiovascular prevention and care could be provided by generalists. Healthcare planners called for a reduction in specialty training,1–4 and a number of cardiovascular training programs went through a period of downsizing. The demand for subspecialty care has not diminished and, with the continued needs for cardiovascular practitioners in the community and in academic medical centers, most training programs that downsized in the early 1990s have reversed the trend and increased the number of trainees. We agree with others5–7 that despite these changes, the current number of training positions is inadequate to meet the future demand for cardiovascular care and that a manpower crisis is imminent. Manpower needs in the treatment of cardiovascular disease are driven by three fundamental factors, as follows: (1) the prevalence and incidence of cardiovascular disease, (2) expanded strategies in the management of cardiovascular disease necessitating new responsibilities for healthcare providers, and (3) the impact of new technologies in the treatment of cardiovascular disease. During the past decade, significant changes and advances have occurred involving each of these three areas that are currently contributing to an increasing shortage of manpower in cardiovascular disease. Left unchecked, the current problem will soon escalate and evolve into a major crisis, limiting our ability to treat and prevent the continued epidemic of cardiovascular disease—the No. 1 cause of death and disability in the United States today.8 Increasing Burden of Cardiovascular Disease In the latter half of the 20th century, major demographic changes in the US population have resulted in the increasing prevalence of risk for cardiovascular events. Most notable among these is the aging of the population and the increasing numbers of elderly patients with chronic disease.6 It is estimated that nearly 10% of individuals 75 years and older have chronic heart failure, and 10% of those 80 years and older have atrial fibrillation.8 Based on 1997 data, 10.7% of US men and 14.7% of women were over the age of 65. It is estimated that 16.5% of the population will be 65 and older in the year 2020 and that this will increase to 20.5% by 2040.9 A number of major risk factors increase with aging, including hypertension, diabetes, obesity, and the metabolic syndrome, all of which will continue to fuel the prevalence of cardiovascular disease in an aging population. The second most notable trend in the past few decades has been the accelerating increase in overweight and obesity, which is not limited only to the elderly. Almost two thirds of the US population is considered overweight (body mass index [BMI] 25), and nearly one third are frankly obese (BMI 30).10 Nearly 40% of adult Americans, age 18 or older, report no regular physical activity.8 Both obesity and lack of exercise are risk factors for coronary heart disease, and obesity is a frequent precursor of diabetes, a recognized coronary heart disease equivalent that has increased in prevalence by 33% in the 8-year interval from 1990 to 1998 (4.9 to 6.5%).11 This increase in the prevalence of diabetes and its associated atherosclerotic vascular disease has occurred