Addressing Workforce Challenges Amid EP Services Growth

With the rapid increase of electrophysiology (EP) services within healthcare organizations nationwide, many organizations are facing challenges in finding and securing qualified physicians to accommodate the growth. In examining these workforce shortages, Corazon has identified some trends and possible strategies that may be helpful in addressing the physician shortage issue.

Much innovation has taken place within the field of EP over the last several years, and according to Millennium Research Group (MRG), the United States’ EP mapping and ablation device market will continue to grow strongly through 2016.¹ MRG estimates that atrial fibrillation ablation will be the fastest growing procedure type in this market, increasing at an average annual rate of 16%. This period of accelerated growth within the cardiology subspecialty is occurring during a time when healthcare as a whole is experiencing a significant physician shortage, projected well into the future for many clinical service lines. While the shortage is clearly an issue within cardiology and all of its subspecialties, the lack of EP physicians may be less severe, though recruitment and retention of electrophysiologists for both hospital organizations and practices is certainly not an easy task. 

AN OPTIMISTIC OUTLOOK 

Some statistics show that the cardiovascular specialist workforce will need to double between 2000 and 2050due to factors such as rapid growth in the U.S. population and an increase in the prevalence of cardiovascular disease.²  Combine these factors with an aging patient and physician population, and the result is a significant shortage of providers not able to keep pace with the demand. According to a 2009 study by the American College of Cardiology (ACC), there were 25,901 active cardiologists (full-time equivalent, or FTE), with a shortage of over 4400 cardiologist FTEs.² Of those active cardiologists, 64% were general cardiologists, 21% were interventional cardiologists, and only 7% were electrophysiologists.² 

The study also noted that more than 40% of the general cardiologists were age 55 or older, while only 20% of interventional cardiologists and 13% of electrophysiologists fell into the same age range. This would seem to indicate that retirement will have a less significant impact on the electrophysiology physician workforce than in other subspecialty areas. 

In addition to a smaller portion of the workforce facing retirement in the near future, the same study revealed about 750 physicians now graduate from general CVD training programs yearly, and nearly half go on to obtain further training in either interventional cardiology or electrophysiology. This could signify that the EP physician workforce will “replenish” itself at a manageable rate. 

Furthermore, while the overall demand for cardiologists continues to exceed the supply, a 2013 survey indicated that 40% of cardiology job openings are in general cardiology while only 15% are in electrophysiology.³ According to the ACC, current projections indicate that by 2025, electrophysiology “will reach equilibrium.”²

CHALLENGES UNIQUE TO EP

While those projections seem to indicate a more promising outlook for the physician workforce within electrophysiology than other cardiology subspecialties, electrophysiology does not remain unaffected by physician shortages. In fact, the shortages are significantly influenced by factors such as geographic location, a key issue in the distribution of EP physicians, and work/life balance. 

In 2009, the Heart Rhythm Society conducted a study identifying physician workforce trends in electrophysiology. The study provided a conclusion indicating that “overall, the current EP workforce is stable, with the exception of geographic dispersion.”⁴ The study data indicated that over the next five years, physicians “overwhelmingly plan to stay in the same location (76%) and no more than 12% of physicians plan to relocate beyond a 50-mile radius from the location of their current practice.”⁴ 

Further complicating the issue, many EP cardiologists, in order to ensure support of their service, choose to be members of large physician groups and look to live and work in urban areas with a higher population. This leaves some metropolitan areas saturated, while smaller communities experience shortages, which can in turn cause a lack of access to care for suburban and rural areas.   

In addition to exploring the mobility of the physician workforce, the study explored the workforce capacity of clinical electrophysiology specialists. The findings indicated that nearly two-thirds of the study’s respondents are at or exceeding their perceived workload capacity, and anticipate that they will face an increased workload due to factors such as longer procedural durations (i.e., longer workdays or workweeks); broader access to care, which can equate to increased travel time to more remote locations for procedures; and an aging physician workforce, which puts pressure overall on older physicians to work more at a time when they perhaps prefer to work less. The study indicates that this may lead to physician burnout, which can likewise contribute to shortages in the workforce supply. 

With 77% of the electrophysiologist population under 55 years old, Corazon’s recruitment division has been witnessing changing trends in the factors that are of importance to them in their practice and career. One of three doctors under the age of 50 are not interested in working longer hours for more money, and 71% of young doctors identify having family and personal time as an important factor in a desirable practice.⁵ 

The survey cited above reflected this trend as well, referring to other recent investigations that have highlighted the importance of work/life balance and speculated that fellows often seek employment in practices where call time is shared and practice management duties are limited. 

SOLUTIONS TO MITIGATE THE SHORTAGE

In providing consulting and recruitment at organizations across the country, Corazon has an invaluable understanding of barriers related to recruitment and retention of experienced EP physicians. In fact, while talent in this specialty can be difficult to attract, our niched knowledge of this specialty provides us the ability to speak in a knowledgeable and very detailed manner regarding a program’s strengths and growth potential — powerful information that anyone acting in the recruiter role must possess. 

An organization may be able to address the work/life balance issue by increasing efficiency within the practice with the utilization of part-time physicians as well as nurse practitioners and physician assistants. The ACC study indicated that many seasoned cardiologists would prefer to have an option to reduce their clinical activity as an alternative to retirement. In fact, more than 65% of cardiologists surveyed indicated that they either are or would be interested in working part time prior to retirement.² However, the availability of part-time opportunities seems to be limited. An organization may consider offering part-time opportunities to their physicians who are nearing retirement, or may consider bringing on a part-time physician in order to supplement the current clinical staff. The addition of part-time physicians may be a way to satisfy a desire for work/life balance amongst the younger, full-time physicians.

A program can also increase efficiency, thereby creating more opportunity for work/life balance, through the use of mid-level and allied health professionals. The cardiology workforce study states that non-physician practitioners are significantly underutilized by private and academic practices.² The Heart Rhythm Society also addressed the need for larger numbers of well-trained allied professionals who would require only physician supervision and could help manage the increasing population of device patients within their study.⁴ While the availability of cardiology-trained physician extenders is limited, the ACC’s study indicated that the larger problem is that many cardiologists are unfamiliar with providing care with the team care approach, and that this knowledge gap needs to be bridged by educational programs.² The study also recognizes the opportunity to increase efficiency through the use of administrators to help benefit practice workflow. 

CONCLUSION

With electrophysiology services consistently growing and predictions estimating this trend will continue well into the future, current and long-term physician shortages in the EP specialty are very real. Hospitals and practices that consider EP as a significant driver of volumes and revenue for the cardiovascular service line must proactively address what could evolve into a hindrance to program viability in the coming years. While studies suggest that the impact of industry-wide shortages may not be felt as greatly within EP as with other cardiology subspecialties, challenges to secure EP talent certainly have the potential to remain a stumbling block for many organizations. 

However, with forward-thinking diligence and a strategy in place to plan for accelerated program growth, early retirements, unexpected turnover, or other recruitment/retention challenges, hospitals and practices can ensure that their EP program potential will not be negatively impacted by staffing issues. While additional challenges to physician recruitment and retention will still exist, Corazon believes that organizations working to recognize those challenges and consider alternative ways to address them will be best positioned to take full advantage of all the possibilities that exist in the EP marketplace nationwide. 

References

1. US Market for Electrophysiology Mapping and Ablation Devices to Reach Value of Over $1.6 Billion by 2016. Millennium Research Group. Published June 12, 2012. Available online at http://mrg.net/News-and-Events/Press-Releases/Electrophysiology-Mapping-Ablation-Devices-061212.aspx. Accessed March 2, 2013.
2. Rodgers GP, Conti JB, Feinstein JA, et al. ACC 2009 survey results and recommendations: addressing the cardiology workforce crisis. A report of the ACC board of trustees workforce task force. J Am Coll Cardiol. 2009;54:1195-1208. 
3. Leah Lawrence. Workforce Wake-Up Call: A Physician Shortage or a Job Shortage? CardioSource. Published Fall/Winter 2003. Available online at http://www.cardiosource.org/News-Media/Publications/CardioSource-WorldNews-Focus-on-FITs-and-Early-Career-Cardiologists/2013/Fall-Winter/Cover-Story.aspx. Accessed February 23, 2013.
4. Deering TF, Clair WK, Delaughter MC, et al. A Heart Rhythm Society Electrophysiology Workforce study: current survey analysis of physician workforce trends. Heart Rhythm. 2010;7:1346-1355. 
5. Workforce Trends. CardioSource. Available online at www.cardiosource.org/en/Practice-management/Hospital-and-Practice-Solutions/Workforce-Trends. Accessed February 23, 2013.

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The Physician Perspective

The importance of securing an electrophysiologist for the program before buying any EP/ablation equipment cannot be understated. This advice is particularly relevant amid growing support for focal impulse and rotor modulation (FIRM), a new electromapping technique for atrial fibrillation (AF) ablation. This technique involves targeting the rotors rather than the pulmonary veins, and uses proprietary software to quickly locate the origin of the AF which, when ablated, can cure the problem without the need for pulmonary vein isolation (PVI). 

Although there are few head-to-head trials of the FIRM technique versus standard PVI, initial results suggest it may be safer and less time-consuming, with relatively equal efficacy. Other new technologies include a pressure force ablation catheter (Biosense Webster, Inc.) and the Rhythmia^™ Mapping System (Boston Scientific). Most EP trainees are exposed to various mapping and ablation technologies during their fellowship, including systems from Stereotaxis and St. Jude Medical, as well as Medtronic’s cryoballoon. However, over the course of their EP training, each doctor finds themselves gravitating toward one or two systems for 95% of their cases.  Understanding what system or approach the EP prefers (FIRM vs PVI) is critical to ensuring good stewardship of limited hospital capital resources. 

Disclosure: Ouside the submitted work, Dr. Kinder reports board membership with HRS Consulting Services, consultancy with Corazon, Inc., and honoraria and payment for development of educational presentations including service on speakers’ bureaus from St. Jude Medical, Boston Scientific, and Medtronic.