“It's hard to make predictions, especially about the future”

We appreciate the opportunity to reply to Dr. Gossman’s comments. It was less than a decade ago that the prevailing opinion was that too many cardiovascular specialists were being trained [1], and employment opportunities would eventually become scarce for cardiologists finishing their training. In contrast, we have witnessed a progressive reduction in the number of fellowship programs, a shrinking source of funding for trainees, the recent acceptance of a maximal 80-hr work week for all medical trainees, and a continued pandemic of cardiovascular disease, most recently fueled by the progressive aging of the American population. As a result, a shortage of cardiologists clearly exists and has the potential to reach crisis levels in the next decade [2]. A clinical cardiology fellow only needs to check his or her daily mail to witness the deluge of job offerings, ranging from private practice jobs in underserved rural areas to academic jobs in urban teaching hospitals, to realize that such a critical shortage of cardiologists already exists. While this may be comforting to the trainee, it is most discouraging for hospital administrators and for patients living in underserved locales. As a result of this crisis, executive workforces have been organized by such organizations as the American College of Cardiology to try to develop solutions. A Bethesda conference on workforce issues was held by this organization in October 2003. One possible solution may be the expanded use of physician extenders to lessen the workload for practicing invasive cardiologists. Many institutions (both academic and private) routinely use physician extenders in the cardiac catheterization laboratory, and confirmation that this practice is safe is an important requirement before widespread acceptance. Physician extenders can be trained to perform cardiac catheterization safely under the careful observation of a physician. We do not wish to imply that physician extenders are preferable to using fellows or attendings, only that they can be safely utilized to assist in the procedure. We rarely have encountered patients who have expressed any concern having a physician extender participate in their cardiac catheterization. Furthermore, completing the technical training to perform a procedure does not imply the physician extender is adequately prepared to supervise, properly interpret, or influence clinical management. The latter skills come from many years of extensive training that cannot be replaced by a short instructional and observational period. The physician extender can perform the technical aspects of diagnostic cardiac catheterization, however. The field of cardiology is currently at an important organizational crossroads. We are hopeful that our decision-makers can develop a variety of rational solutions to our workforce shortages. Our experience suggests that use of physician extenders, under properly supervised conditions, reduces the workload for overextended invasive cardiologists without compromising patient care.