Manpower in cardiology II in western and central Europe (1999–2000)

In recent years surveys have been undertakenin certain European countries and in the USA to examine aspects of cardiological practice.1–10 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. 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 UEMS—Cardiology Section. These data were reviewed and completed if necessary by the national delegates of the UEMS—Cardiology 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. 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). The number of cardiologists in the non-EU/EFTA countries ranged from 11 (Turkey) to 120 (Lithuania), this is a mean of 62 cardiologists per million (59 in 1997) (Table 1b, Fig. 1b). Compared to the 1997 data the number of cardiologistsdecreased only in Turkey (Table 1b), whereas no data were available from Cyprus. In all othercountries the numbers increased from between 1.7% (Lithuania) to 25.7% (Estonia) (mean 11.8%). Number (per million inhabitants) and changes (diff %) in certified cardiologists in the EU/EFTA countries 1997 vs 2000 Number (per million inhabitants) and changes (diff %) in certified cardiologists in the EU/EFTA countries 1997 vs 2000 Number (per million inhabitants) and changes (diff %) in certified cardiologists in the non-EU/EFTA countries 1997 vs 2000 Number (per million inhabitants) and changes (diff %) in certified cardiologists in the non-EU/EFTA countries 1997 vs 2000 (a) Density of senior cardiologists (per 106inhabitants) in the EU/EFTA countries at the end of 1997 (□) and the beginning of 2000 (▪). (b) Density of senior cardiologists (per 106inhabitants) in the non-EU countries at the end of 1997 (□) and the beginning of 2000 (▪). (a) Percentage of female cardiologists in the EU/EFTA countries. (b) Percentage of female cardiologists in the non-EU/EFTA countries. Regarding the distribution of female cardiologists, Europe can be subdivided into threeareas: the countries of the Eastern part of Europe (Lithuania, Estonia, Romania) with an average of 70% female cardiologists, compared to a middle range consisting of Hungary, Turkey, Denmark andSpain with an average of 22% female cardiologists. The remaining third group of European countries, including most of the EU/EFTA and a few non-EU/EFTA countries has an average of 10% femalecardiologists. 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). 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. 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. 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 Density of cardiology training centres in the EU/EFTA and non-EU countries (per 106inhabitants) na=not available. Density of cardiology training centres in the EU/EFTA and non-EU countries (per 106inhabitants) na=not available. It should be noted that, depending on the country, between 0 to 75% of the training centres in the EU/EFTA countries and 0 to 92% in the non-EU/EFTA countries were designated only for part-time training in cardiology. In four EU/EFTA countries(Belgium, Denmark, Sweden, Switzerland) and in three non-EU/EFTA countries (Estonia, Lithuania, Romania) a large number of training centres provide only part-time training in cardiology. But in some countries, as in Belgium, it is changing and the number of training centres certified solely for part time training will decrease. 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. The relative commitment to outpatient andinpatient work varies markedly between different nations. Time devoted to outpatient work varies from 1–10% 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. 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 3 Other medical specialties managing cardiacpatients in the EU/EFTA countries GM=general medicine; IM=internal medicine; AN=anaesthesiology; RAD=radiology; INT=intensive care medicine; N=nurse; PM=paramedics (nurses, technicians, clinical physiologists); CS=cardiac surgeons; (+)=on a part-time basis. Most countries specializing in sport medicine, occupational health and work-related diseases perform ECGs, stress tests, and sometimes echo. Other medical specialties managing cardiacpatients in the EU/EFTA countries GM=general medicine; IM=internal medicine; AN=anaesthesiology; RAD=radiology; INT=intensive care medicine; N=nurse; PM=paramedics (nurses, technicians, clinical physiologists); CS=cardiac surgeons; (+)=on a part-time basis. Most countries specializing in sport medicine, occupational health and work-related diseases perform ECGs, stress tests, and sometimes echo. In Austria, Denmark, Finland, Germany, Greece, Iceland, Ireland, Norway, Spain and Sweden there are no legal minimum requirements for performing invasive diagnostic (coronary angiography, electrophysiological studies) and therapeutic (PTCA, ablation) procedures. It should be noted that in Austria, Denmark and Norway there are a restricted number of centres licensed to provide invasive procedures. In other countries (Belgium, France, Ireland, Italy) there exist minimum requirements for all invasive procedures, in the UK, for all except ablation, in Switzerland for PTCA and coronary angiography but not for electrophysiological studies or ablation, and in The Netherlands for PTCA only. In many countries there exist certain requirements for a physician to perform non-invasive procedures (most oftenregarding echocardiographic techniques). Theserequirements consist essentially of structured training, case load and in come cases examinations. Many countries have specific training regulations pertaining to certain procedures, most often for invasive techniques (Table 4). Minimal requirements for performing specified procedures as independent operators Echo=echocardiography; Coro=coronary angiography; PTCA=percutaneous transluminal coronary angiography; EPS=electrophysiological study; na=data not available. Minimal requirements for performing specified procedures as independent operators Echo=echocardiography; Coro=coronary angiography; PTCA=percutaneous transluminal coronary angiography; EPS=electrophysiological study; na=data not available. In most European countries the acute cardiacpatient can be hospitalized either in a coronary care unit (CCU) or in an intensive care unit (ICU) depending on the complexity of the disease and the need to be artificially ventilated. In a few countries these patients are admitted almost solely into the CCU (Iceland, Sweden, Norway), while in Belgium and Switzerland there exist almost only ICUs. Some of these are more specifically dedicated to cardiac patients, but only a small number of very large hospitals have an ICU completely dedicated to cardiac care. A cardiologist is most often in chargeof the CCU, but in the UK general physicians/internists work in and may direct CCUs. 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. 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 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 into—or already suffer—a 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 of our specialty in Europe to define recommendations for manpower planning. On the basis of these data, we that there will be an increased for cardiovascular specialists will cater for not diseases of the heart but also related A density of than to 50 cardiologists per million inhabitants is to be too while a density than to per million is necessary nor numbers a of UEMS regarding of Cardiology, Belgium, for more information, We all the and as well as the national delegates of the cardiology section of the UEMS for their