Received April 19, 2002;
accepted July 10, 2002
* Corresponding author. Division of Cardiology, University Hospital Vrije Universiteit Brussel, 101 Laarbeeklaan, 1090 Brussels, Belgium
pierre.block{at}az.vub.ac.be
Key Words: Manpower in cardiology in Europe Organization of practice Training and accreditation in cardiology Cardiology and other specialties Manpower planning
1. Introduction
In recent years surveys have been undertakenin certain European countries and in the USA to examine aspects of cardiological practice.110 The first systematic survey of cardiology manpower in Europe was published in 200111 and depicted the situation at the end of 1997. At that time it was apparent that important differences existed within Europe, and it was anticipated that such differences could become even more marked with time in the absence of manpower planning.
In comparison with the first survey, this paper examines more extensively the status at thebeginning of the year 2000 and why manpower in cardiology might become of increasing importance in the near future.
2. Methods
As in the first survey, the data were obtained by asking presidents and secretaries of the national scientific and professional organizations of the countries of the European Union and the European Free Trade Area (EU/EFTA), as well as a number of non-EU/EFTA member countries of the European Society of Cardiology and of the UEMS (European Union of Medical Specialists)Cardiology Section, to answer a detailed questionnaire. Before publication, a summary of the information obtainedfor each country was sent to each respondent for approval, correction and/or completion. All organizations in the EU/EFTA countries replied. Among the non-EU/EFTA countries 9/11 (82%) replied. No information was received from Russia or Ukraine. Small countries such as Luxembourg were notincluded because of their very low number of cardiologists. The data were evaluated separately for the EU/EFTA countries and the associate member countries of the UEMSCardiology Section. These data were reviewed and completed if necessary by the national delegates of the UEMSCardiology Section. Although we obtained much more concise information than during our first survey, we recognize that for some countries the data are still incomplete. Nevertheless they provide a useful snapshot of the manpower situation in cardiology in Europe for the year 2000 and allow comparison with the situation at the end of 1997. The questionnaire is included in the Appendix.
3. Results
3.1. Density of certified cardiologists
3.1.1. EU/EFTA countries
The number of cardiologists in the EU/EFTAcountries (mean: 58 per million inhabitants) ranged from seven in Ireland to 210 in Greece (Table 1a), compared with a mean of 54 cardiologists permillion in 1997 (Table 1a, Fig. 1(a)). The mean value drops down to 43 cardiologists per million when the extreme values of Greece and Italy (maximum), and Ireland and UK (minimum) are excluded. Compared to the 1997 data, in 13/16 countriesthe number of cardiologists increased by 1.5%(Portugal) up to 60% (Austria), mean 17.8%(Table 1a). Only in France, Spain and Irelanddid the number drop from between 12.5 to 37.5% (Table 1a).
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3.3. Training in cardiology in Europe
3.3.1. Cardiologists in training
The total number of cardiologists in training in 11/17 EU countries ranged for which we have the information from 1.5 to 17 per million, mean: 7.6 When the highest (25 per million) in Greece and the lowest number (1.5 per million) in Finland are excluded, the number of cardiologists in training (7.2 per million) has not changed significantly since the last survey.
Compared to the 1997 data the number oftrainees has increased in six EU/EFTA countries (Austria, Belgium, Finland, Norway, Spain, The Netherlands). In three the number has remained almost unchanged (France, Sweden, Ireland) and in one (Greece) the number decreased, although it still has (relatively) the highest number of trainees.
The total number of cardiologists in training among 7/11 non-EU/EFTA countries ranged from5 and 16.5/million (mean: 7.1). In the non-EU/EFTA countries, the number of trainees increased in three (Hungary, Lithuania, Romania), decreased in one (Israel) and remained unchanged in one (the Czech Republic).
3.3.2. Certified cardiologists in 1999
In the EU/EFTA countries (seven of the 17 countries for which we have information) the number of cardiologists who certified in 1999 and finished their training in cardiology ranged from 0.4 to 4.5/million inhabitants, with a mean of 2.3 cardiologists completing their training in 1999. For six of 11 non-EU/EFTA countries for which we have information, similar numbers of cardiologists (1.5 to4.2 cardiologists/million (mean 3.5)) finished their training in 1999.
3.3.3. Duration of training in cardiology
These data relate to training specifically in cardiology and do not take account of the duration of training in the common trunk (basic training in internal medicine). Cardiology training most often comprised between 2 and 4 years. We have to be aware that in some countries the curriculum will change and could already have changed in 2002. Data are available for 13/17 EU/EFTA and for 8/11 non-EU/EFTA countries. Regarding the specific training in cardiology in the EU/EFTA countries, it is of 2 years duration in three EU/EFTA countries (Austria, Iceland, Sweden) and in three non-EU/EFTA (Lithuania, Poland, Czech Republic)countries; 3 years in five EU/EFTA (Belgium,Norway, Spain, Finland, Italy) and three non-EU/EFTA (Hungary, Israel, Turkey) countries; it is also3 years in Austria and Germany, but 1 year may have been included in the common trunk of internal medicine, which is 5 years; 4 years in five EU/EFTA (France, Greece, Italy, Switzerland, TheNetherlands) and two non-EU/EFTA (Cyprus,Estonia) countries.
These differences in training duration are often (but not always) related to differences in requirements, with often a higher degree of specialization in those countries with a longer training period.
3.3.4. Training centres in cardiology
The total number of training centres per million inhabitants ranged in 11/17 EU/EFTA countries from 0.4 to 7.5 per million (mean: 3.0 per million), and in 8/11 non-EU/EFTA countries from 0.7 to 7.6 centres per million, (mean: 4.3; Table 2).
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3.4. Management of cardiac patients
Manpower analysis not only consists of looking at numbers, but also in analysing certain operational aspects of the specialty, and the interactionsbetween cardiology and other medical specialties, which in certain respects may vary very considerably from one country to another.
3.4.1. Commitment to outpatient and inpatient work
The relative commitment to outpatient andinpatient work varies markedly between different nations. Time devoted to outpatient work varies from 110% in Northwestern European countries to 50% in others such as France, Germany and Greece. Inpatient, hospital-based practice accounts forapproximately 10% of the workload in France and Greece, compared to 90% in Norway and Sweden, and almost 100% in The Netherlands.
In many countries the cardiologist combines a private predominantly outpatient practice outside the hospital with more technologically orientated activity inside hospital, as for example in Belgium and Denmark.
3.4.2. Management of cardiac patients by cardiologists and other medical specialties
It is clear that not all patients who suffer from cardiovascular diseases are referred to cardiologists. We therefore analysed who, other than cardiologists, treat cardiac patients in European countries. Table 3portrays the discrepancies within EU/EFTA countries regarding interactions between cardiology and other specialties that also provide cardiological diagnostic facilities such as resting and stress ECGs, and echo-Doppler studies. The provision of cardiologic procedures by non-cardiologists happens chiefly, but not only, in those countries with fewer cardiologists.
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The ICUs that also cater for cardiac patients, in all countries where they exist, are managed bya specialist in intensive care medicine, who isvery frequently also qualified as a cardiologist, internist or as anesthesiologist. When the responsible physician is not a cardiologist with an interest in intensive care, a cardiologist must, in almost all countries, be involved in the activities of the ICU.
In most EU/EFTA nations, there is no specific category of emergency cardiologist nor does there exist a special admissions unit for acute cardiology. Only very large and university hospitals have a cardiologist or an internist with a special interest in acute cardiac disease; if such an interest is pursued, the training takes place at the end of the course. In some countries emergency cardiologyis provided by general practitioners. These have usually acquired a special competence in emergency medicine, but they have to refer to the cardiologist of the ICU, CCU or the cardiologydivision of the hospital in more complex cases.
3.6. Continuous medical education (CME), accreditation and recertification in cardiology
The situation in this field is changing rapidly in Europe and the data presented are those currentat the beginning of 2000. Continuous medicaleducation exists now in all European countries, but operates on a voluntary basis in the majority.
Continuous medical education is mandatoryin Belgium, Iceland, Ireland, The Netherlands, Switzerland, UK, as well as Estonia, Hungary, Lithuania, the Czech Republic. It will becomeobligatory in France, Germany, Poland, Romania and Turkey. Where CME is obligatory, the accreditation of these activities is, in most countries, the responsibility of the scientific and professionalorganizations. Whereas in the EU/EFTA countries, only exceptionally are the Universities involved in this process (only Iceland), the system is more frequently seen in the non-EU countries. Only in Belgium does the government (National HealthInsurance System) also control accreditation but it will also become the case in Italy. Recertification until now exists only in The Netherlands, Estonia and Lithuania.
Since the creation of the European Accreditation Council for CME (EACCME) at the start of 2000 to facilitate recognition of CME credits throughout Europe, the cardiology section of the UEMS together with the ESC has created the European Board for Accreditation in Cardiology (EBAC) which accredits internationally orientated educational events in Cardiology.11
4. Discussion
This second survey aims to address more specific questions about the situation of the specialty of cardiology in Europe than was undertaken inthe first survey.12 Unfortunately we did receive incomplete data from Italy and Portugal and some important items of information are missing for a number of other countries. It shows how difficult it remains in many countries to collect accurate and complete information on the professional aspects of cardiology, despite the existence in all of them of professional and/or scientific organizations and despite the fact that each country has officialdelegates in the Cardiology Section of the UEMS. It is also worth noting that for many questions it was difficult to obtain precise information and that certain data relate more to the estimations of our correspondents than on truly objective figures. This is especially the case for some topics relating to the commitment to in- and outpatient care, the interactions between cardiologists and other medical specialties, even if for some countries (Belgium, France) more accurate information exists.
In general the survey was once more characterized by the tremendous heterogeneity, not only between the EU/EFTA and the other countries, but also within the EU/EFTA countries. Therefore if we would like to achieve a European level of manpower in cardiology, harmonization between the countries relating to several issues will be of the utmost necessity.
Some healthcare providers and professionalorganizations question the need and feasibility of manpower planning. In many countries projects already exist and in a few early attempts are underway. Some form of manpower planning has recently been undertaken, most often at the request of, and undertaken by, the government as in France,Ireland, The Netherlands, Norway, the UK as well as in Cyprus, Estonia, Poland, Romania and the Czech Republic. Manpower planning is intended to start in Belgium and Switzerland. At the present time in The Netherlands there is a shortage of cardiologists, demonstrating that manpower planning is a difficult and risky task.
Manpower planning is indeed a very complex task, which necessitates firstly a clear idea as to the optimal number of specialists in cardiology. When considered in association with the rate of attrition from retirements and death this may allow more accurate predications of the required number of trainees needed year on year. Other aspects that need to be taken into consideration include the degree of diagnostic and therapeutic capabilityexpected of specialists, and for which funding must be found. The role and tasks of other physicians such as the internist, regarding the managementof patients with heart diseases must be defined. Finally, the optimal number of cardiologists might vary according to the prevalence and type of cardiovascular diseases, which vary in the different parts of Europe.
A number of questions arise. What is the optimal number of cardiologists? Should we make recommendations for Europe as a whole, or should we define it for each country separately on the grounds of specific needs and/or priorities in the healthcare sector?
We have to be aware that at present, even having excluded Greece with 210 and Italy with 166 cardiologists per million inhabitants, there is a very large variation in the density of cardiologists in Europe, ranging from seven to 76 per million 106inhabitants. It is obvious that these very different numbers correspond to very large differencesregarding the role and the tasks of the cardiologists across Europe. If we really want to harmonizecardiology in Europe, we have not only to define the optimal numbers of cardiologists, but also the optimal extent of the activity of the cardiologist.
A Task Force of the AHA/ACC in charge of these affairs proposed, a number of years ago, 50 cardiologists per million inhabitants as being optimal.13 But in two recent papers14,15 they estimated that this number would be too low. It is necessary to take many factors into account, including the ageing of the population and the improved management of patients with cardiovascular diseases resulting in a higher prevalence of the disease. These factors increase the number of patients with atrial fibrillation, chronic coronary heart disease and heart failure. New sophisticated diagnostic and therapeutic procedures, some very time consuming and increasing the workload, require a high degree of skill. All these factors will result in the need for more cardiologists and quite possibly more subspecialization.15 Nevertheless it appears to usunrealistic to propose uniform guidelines formanpower planning within the EU. If manpower planning is recognized as desirable and even necessary, it has to be done on a national level, taking into consideration local needs and priorities, the local organization of the cardiology sector, as well as the financial resources devoted to the health sector and more specifically to cardiovasculardiseases.
Although manpower is an issue primarily ofnational concern, it is appropriate that the cardiology section of the UEMS, in conjunction with the European Society of Cardiology, should make some general recommendations in the field, as did the American College of Cardiology.16,17 In the few countries with a very high number of cardiologists, and/or with a rapid rise in the number of cardiologists, as in Belgium and especially in Greece, measures should be taken to control and eventually restrict the number of trainees. On the other hand the more numerous countries with very few cardiologists (less than 30 per million inhabitants) should be aware that they could run intoor already suffera lack of cardiologists for the optimal, or indeed adequate, management of their patients with heart diseases. In these countries more training facilities have to be created or cardiologists imported from abroad. Studies have confirmed that trained cardiologists provide more effective cardiological care than general physicians, andrelying on internists or general physicians without sufficient or appropriate training is not, in our opinion, the solution to the problem of manpower deficiencies.18,19
These data provide a concise portrayal of the current state of our specialty in Europe andmay help to define further recommendations for manpower planning. On the basis of these data, we believe that there will be an increased requirement for cardiovascular specialists (who will cater for not just diseases of the heart but also related vascular disorders). A density of less than 40 to 50 cardiologists per million inhabitants is likely to be too low, while a density greater than 70 to 80 per million is probably neither necessary nor cost-effective. Precise numbers do, however, remain a matter of debate.
NEW UEMS QUESTIONNAIRE regarding MANPOWER AND RELATED ASPECTS IN CARDIOLOGY IN THE EUROPEAN COUNTRIES1999/2000
Project Director: Prof. P. Block (Brussels-Belgium)
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To send
To Prof. P. BLOCK: Department of Cardiology, Laarbeeklaan 101, 1090 Brussels, Belgium, Tel.: +32-2-477-6842, fax: +32-2-477-6840, E-mail: Pierre.block@az.vub.ac.be (secretariat: Brenda.mees@az.vub.ac.be).
Also for more information, contact Prof. P. Block.
Acknowledgments
We thank all the National Cardiac Societies and Professional Organizations as well as the national delegates of the cardiology section of the UEMS for their contribution.
References