Downsizing cardiology. Getting the process started.

F ew Americans dispute that health care in the United States has become too expensive. Many believe that a substantial fraction of the high cost can be attributed to an excess of specialists who order too many expensive tests and treatments. Not surprisingly, cardiologists figure prominently among those identified as "the problem." All major educational organizations concerned with internal medicine, including the Association of American Medical Colleges (AAMC), the American Board of Internal Medicine (ABIM), the American College of Physicians (ACP), the Association of Professors of Medicine (APM), and the Federated Council of Internal Medicine (FCIM),* as well as a myriad of health policy and governmental groups, agree that the workforce in cardiology needs to be reduced. Not everyone agrees with this premise. Most cardiologists believe that their management of most complex clinical problems achieves better outcomes in a more cost-effective manner than that of other physicians. Unfortunately, data to support this opinion are lacking. Studies are needed to identify the unique contribution of cardiologists and to protect that contribution as the delivery of health care is reformed. But, important as they would be, future studies are unlikely to change the conclusion that there are too many cardiologists. Why is this? And what should be done? In the United States there are currently more than 16 000 practicing cardiologists' and approximately 2600 trainees in cardiovascular disease programs; between 1988 and 1992 the number of training positions increased by one third.2 During this same period, the proportion of health care provided by health maintenance organizations (HMOs) with capitated payment plans has increased dramatically, changing the demand for cardiologists. Even where HMOs fail to take hold, fee-for-service practices are influenced by capitated